What you can do to save midwifery as an independent profession in the UK.

By Ruth Weston and Emma Ashworth

Independent Midwives are in the NMC firing line, and most of the campaigning that you might see is about this. However, the NMC (Nursing and Midwifery Council), which made this decision, did so without a practicing midwife on the board, and the ramifications of the decision affects every midwife in the UK.

For instance, the NMC have stated, “A registered midwife can only attend a woman during a birth if she has appropriate indemnity cover. The midwife cannot avoid this legal requirement by attending the birth in a ‘non-midwife’ capacity… The only exception to this is when a midwife attends a birth in a personal capacity to support a family member or close friend for whom they have not previously provided midwifery services”. “Services” includes emotional and physical support, meaning that midwives are being banned from attending the births of their grandchildren, or their own babies in the case of male or lesbian midwives if they’ve so much as listened in, or supported their partner through morning sickness.

The NMC is removing the midwifery committee, which advises the NMC on midwifery matters. Its replacement will have no budget and delegatory powers and it is unclear who will be on it and what its role will be within the NMC. As the NMC – the NURSING and Midwifery Council – has overwhelming numbers of nurses compared to midwives, and the way it is now being set up means midwives will be regulated by a completely different professional – one geared to nursing sick people rather than caring for healthy women -without their own voice being heard at all.

There is a huge risk that this will toll the death knell to midwifery as an independent and autonomous profession. becoming subsumed into the nursing profession as another branch of nursing.  This is certainly the way the NMC and the Government legislation is treating midwifery at present and would mean Midwives would lose the status of being THE professional experts in the normal maternal pathway and key care provider. This is not inevitable but as a profession and as parents we must rise up and clearly and strongly oppose  the removal of the midwifery code, the midwifery committee and lack of representation for mothers and midwives at the NMC. The profession has never been in more jeopardy, and never has the care of women and their babies been so much at risk since the formation of the profession of midwifery.  It falls to us to do something about it..

What can I do?
1) There have been several petitions. The writer of this one admits that if it had been less rushed it would be better worded, however, if we want Parliament to take note of the voices of women, midwives and their families then this is a good petition to start the ball rolling, so please do support it. https://petition.parliament.uk/petitions/178561

2) Share your story of how midwives have helped and supported you. What impact will the lack of access to IMs have on you?  Share on:

Facebook, Save Independent Midwifery page: https://www.facebook.com/groups/443681876022589/

Send to Birthplace Matters who is preparing stories and letters to the NMC through  birthplacematters at yahoo.co.uk

Send them to the saveourmidwvies.co.uk website.

Don’t forget to include permission to share.

3) Tweet!  Use the #savethemidwife hashtag with your messages about how this affects you. You can  tag Jackie Smith of the NMC using @JackieSmith_nmc, and BBC Watchdog (@BBCWatchdog)

4) Write to your MP. The website saveourmidwives.co.uk has important template letters which answer the cut-and-paste responses that most MPs are sending. Find your MP here: http://www.parliament.uk/mps-lords-and-offices/mps/

5) Join IMUK, the Independent Midwives’ professional body, as a supporting member. It only costs £20: http://www.imuk.org.uk/professionals/join-imuk/

6) Make a complaint to the NMC. E-mail complaints@nmc-uk.org. They have less than 20 working days to respond. It is important to mention that it’s a formal complaint to ensure that you go straight to Stage 2 of their complaints process. If you don’t like the reply, simply respond back, say you’re not satisfied, why, and then appeal the complaint response, escalating to Stage 3.

7) Many women and Midwives across the UK are using their passion, creativity and skills to support independent midwives and to challenge midwifery regulation to do its work better.  Do what you can with the people you can, and watch this space as more developments are in the pipeline.  Thank you!


This is NOT “Public Protection”

The Nursing and Midwifery Council (NMC’s) decision to stop Independent Midwives (IMs) from practicing is, in their words, for public protection.

IMUK have clearly stated that they feel that their indemnity policy is sufficient. The NMC have stated that they believe it’s not. They also say that they not in a position to state what would be enough. This in no way supports IMUK and in turn this does not support the public who want or need the services of an IM. This is not “public protection”.

But does medical liability insurance protect the public in any way, even if it is “sufficient”, as IMUK believe?

The definition of malpractice, or medial liability insurance (MLI) is a policy which, “protects health care providers against patients who sue them under the claim that they were harmed by the physician’s negligent or intentionally harmful treatment decisions.” (reference: http://www.investopedia.com/terms/m/malpractice-insurance.asp)

There is nothing in that definition which is protecting the public. MLI protects the practitioner. This is not “public protection”.

So, what does MLI actually offer? In the case of IMs, in the unlikely situation that an IM makes an error which causes harm to a mother or baby, the indemnity means that if the parents decide to sue the midwife, the midwife will be able to call upon her policy to pay damages to the parents (after a significant amount of legal wrangling which may take years, and in the meantime the mother or child will receive nothing other than the regular state provided care).

If the injury was not caused by an error by the midwife (or the baby is born with a condition which is unrelated to birth, including some cases of cerebral palsy), the parents will have no recourse from the IM’s indemnity policy and will need to rely on the state provision.

If the state provision is not sufficient for the baby or mother who is damaged by an error, it is not sufficient for those for whom there is no one to “blame”. This is not “public protection”.

In addition to this, there is no evidence at all that MLI changes practice. MLI does not mean that practitioners try harder to not make mistakes, nor that they make fewer mistakes. In other words, the same number of mistakes happen whether or not the practitioner holds insurance. This is not “public protection”.

MLI does not protect the public, so let’s stop pretending that that is what this is about.

Save the NHS – Waterbirth!

“A woman in birth is at once her most powerful, and her most vulnerable.” Marcie Macari

There are some areas of maternity care which are so valuable, so game changing, that it is remarkable that they are not the default offering for women in labour.  At our most vulnerable time we can be supported to be our most powerful.  Labour and birth in water can transform childbirth, and at the same time it fulfils a vital requirement of our health service: to save money.

Jeremy Hunt continues to force the NHS to make “efficiency” savings, and the NHS has an obligation to provide the best care that it can. Given that waterbirth firmly ticks both of these boxes, it is essential that all trusts ensure that they are providing a sufficient number of birthing pools to be able to offer them to all women who wish to use water.

Tell me more about these cost savings

In summary, water labour and birth compared to land labour and birth reduces the number of interventions or complications that women experience. Some interventions and complications cost the NHS money immediately (such as caesareans, forceps, transfer to the hospital from an out of hospital birth, chemical pain relief) and some also create costs on an ongoing basis due to follow up care (eg caesareans, perineal damage, birth trauma).

Let’s back that up with some research.  Looking at caesarean sections, an Italian study in 2014 found that the women in their study who birthed in water had a 94-99% spontaneous vaginal birth rate, in a country where the caesarean birth rate is 38%! A follow on evaluation of Birthplace 2011 showed a reduction in risk of caesarean birth by 20% for first time mothers. The same review also showed that the number of women who were transferred to hospital having planned an out of hospital birth was also significantly reduced for women who laboured in water.

A 2004 observational study over a 9 year period found that waterbirths reduced the risks of perineal tearing, episiotomies and reduces the mother’s blood loss. This leads to NHS cost reductions in follow up care for tears or cuts, and for treatment for anaemia – and leads to a reduction in women coping with new parenthood without being able to sit comfortably (something that we all need to do a lot of as we feed our newborns), and reduces the number of women coping with pathological exhaustion on top of normal postnatal tiredness.

This is just a very small summary of the evidence that is available, because there are hundreds of studies which show the benefits of waterbirth to women, and to the NHS, which we will continue to blog about over the coming months.

Let’s put this into practice!

Aquabirths came about because of my passion for supporting women in birth, and because to be able to ensure that women have access to a pool if she chooses to birth in a hospital or midwife led unit, trusts need to be able to afford the capital cost of installing them. The original investment will be repaid by saving just a couple of women from an unwanted caesarean, and the human cost of an unwanted caesarean is priceless. Aquabirths fitted pools are available from £2900 including plumbing components, and are discounted even further when 2 or more are ordered. They’re manufactured in one piece to make fitting as easy as possible, and Aquabirths will do the installation if required.  The pools are easy to repair in the very unlikely situation that they’re damaged, due to their fibreglass construction rather than plastic, and they also come with an industry-best 10 year warranty.

Ongoing care is made easy and cheap by the fact that the baths are manufactured in one piece, making cleaning and hygiene control quick and effective. All plumbing components are standard parts, so they’re easy to replace if required, although this is very rarely needed, just like it’s almost never the case that you need to replace plumbing in your own home.

In a follow up post I’m going to talk some more about access to birth pools. At the moment, many trusts have a policy which means that many women are not eligible to use them unless they’re classed as “low risk” (a term which I should also cover at some point!). I’ll just leave this post with one final thought. “High risk” women are often denied access to a pool, but told to take a bath, and the same women are denied access to a pool, but instead offered heroin (diamorphine) in labour without being told what they’re being given. It’s time to take another look at labour and birth in water and the benefits of it to women, babies,

…and trust finances.

Aquabirths are running a special offer of a free birth couch (currently £795, normal price £950) with every Canberra, Venus or Heart-shaped Birthing Pool. Use code SB161102  when ordering the Pool.


NMC Consultation – Respond before 17th June and here’s some help with doing it.

Guest Blog by Rachel Gardner of Forging Families

Dear Friends,

This is the most important thing I have ever written, and I implore you to read it and act upon it by answering these two questions in this government questionnaire.

This is not about labour or conservatives, this is about midwives and women and birth and about saving women’s choice in birth and about saving the midwives who support these changes.

Please get involved and get others involved. The deadline is 17th June. ACT NOW.


This questionnaire is here:


It is for professionals and the public but is worded in such a way that most members of the public would not fully understand what is being asked.

There are two questions that you MUST answer. The rest of the questions you can skip but the first two please respond too, and then submit your questionnaire to the government.

Question 1 is:

Do you agree that this additional tier of regulation for midwives should be removed?

This question is referring to the role of Supervisor of Midwives. Supervisor of midwives role is to protect women’s choice, and women’s choice regarding their birth is one the most important things in maternity. Supervisors of Midwives support women choosing birth outside of ‘policy’ or outside of specific guidelines.
Without the role of Supervisor of Midwives the potential is for Trusts to refuse to care for women choosing care outside box guidelines and there will be no protection or support for midwives providing care in these instances.

This would be a catastrophe for maternity care and for women and for choice in birth.

Midwifery supervision brings challenge to Trusts when advocating for the safety of women. This is a healthy level of challenge ensuring Trusts management maintain women’s safety as the focus of their care, enabling women’s choices to be listened to and respected. SoMs also work collaboratively across trusts sharing best practice, completing external investigations and providing “fresh eyes” on midwifery practice. All this has the potential to be lost with the removal of the regulatory function of Supervisors of Midwives.

Do we agree with this happening? No, no no!

Question 2 is:

Do you agree that the current requirement in the NMC’s legislation for a statutory Midwifery Committee should be removed?

Considering the NMC stands for Nursing and Midwifery Council there is poor representation by midwives in the council. If the midwifery Committee is to be removed from the NMC the voice of midwives will become weaker than ever. Someone has to protect the function and role of a midwife or it will be lost forever. Allied health professionals are not just nurses in the same way as midwives are not just nurses. This is like physiotherapists being regulated by radiographers. It just doesn’t make sense. The professions although within health are completely different.

Should we remove midwives from the Nursing and MIDWIFERY Council? No, no, no!

NMC Consultation: Midwifery Committee Concerns

Guest Blog By Beverley Lawrence Beech and Emma Ashworth of AIMS

Last week I wrote about the proposed changes to the NMC that the DoH is currently consulting on.  While they work on removing Supervision, they are trying to slip in the removal of the midwifery committee at the same time.

This is how the NMC describes the Midwifery Committee:

The Midwifery Committee advises the Council on:

· any matter affecting midwifery, such as policy issues affecting midwifery practice, education and statutory supervision of midwives,

· responding to policy trends,

· research, and

· ethical issues affecting all registrants.

The Midwifery Committee’s recommendations and subsequent Council decisions influence midwifery development in the UK, which affects the lives of individual women and their families under the care of UK midwives.

(for full text, click here)

The consultation states, “Although the NMC regulates two professions, nurses and midwives, the NMC is only required by its legislation to have a statutory midwifery committee to advise the NMC Council on matters relating to midwifery. It has no similar requirement to have a statutory nursing committee and none of the other healthcare professional regulators have a comparable statutory committee. The government has a policy objective to streamline and rationalise regulatory legislation.

However, let’s look at how the NMC is made up.  For every 1 midwife there are more than 12 nurses.  The other healthcare professional regulators do not need to have their own representatives because they are their own representatives, not lost in the noise of another profession. Of course it did not have a requirement to have a statutory nursing committee, the government was forced into legislating for a statutory midwifery committee as a result of the protests from midwives and lay groups who felt that without a statutory requirement midwives would just be absorbed into the nursing profession.

Let’s look at some more history.  When in 1983 the government proposed a single ‘nursing’ professional council, despite opposition from midwives, AIMS and other groups, they amalgamated the Central Midwives Board into the UK Central Council for Nursing, Midwifery and Health Visiting which, in 2002 became the Nursing and Midwifery Council.  The midwives fought for a separate Midwifery Council but lost, although as a sop to their concerns, a review in five years was promised.  It never happened.

Since 2002 the Midwifery Committee has been gradually reduced so that there are now only seven members, of which only two are practicing midwives, and in recent years  its support staff have been withdrawn, the dedicated office closed down,  and there is now only one midwife on the main Nursing and Midwifery Council.

A few years ago the NMC was awarded a £20m government grant for the NMC to address ‘the problems it faces in terms of administration and management’.  But this is but one of the problems.  As far as midwives and users of the service are concerned there is a far greater problem -the dichotomy between nursing and midwifery practice.

Over recent years, too many excellent practising midwives (most of them independent midwives) have been reported to the NMC, and some have been struck off.  Unfortunately, midwives are no longer judged by their peers.  AIMS members have observed hearings where, for example, a community midwife was judged by a labour ward manager who, clearly, was not up to date with the research and, from his questions, had no concept of the principles of informed consent.

Take the case of Beatrice Carla for instance.  AIMS members observing the case soon realised that this case was not only about Ms Carla’s individual practice, but encapsulated the struggle between midwifery evidence, knowledge and skills, and accepted medical evidence, protocols and policies. This struggle was very apparent among the panel members. Perhaps the most worrying aspect of this case was that while the Chair of the panel, Professor Paul Lewis, who was an exemplary Chair, showing fairness, care, courtesy and regard towards all concerned, he had repeatedly to draw the attention of the other panel members to the research evidence on maternity/midwifery care.  It is a serious issue that the NMC has failed, and is continuing to fail, to address.

Until midwives have their own Midwifery Council and allegations of failure in practise are judged by expert midwives these injustices will continue and women will be deprived of skilled midwives who really understand the meaning of normal, undisturbed, physiological birth, informed consent and women-centred care.  The removal of the midwifery council from the NMC leaves midwifery practice being judged by those who are in an entirely different role.  Would doctors accept their cases being considered by nurses?

The real fear is that the changes will lead to midwives being forced to become obstetric nurses, losing the autonomy that has been fought so hard for, for so many years.

There is a General Medical Council and a General Dental Council, so why is it not possible to have a General Midwifery Council?

Please, respond to the consultation and raise these concerns.  Your response is desperately needed.

Consultation link: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/518039/NMC_regulation_consultation_document_A.pdf

What is so difficult about Implementing Continuity of Carer?

Here is the script for the AIMS talk I gave at York University on Saturday 21st November. What do you think?

What is so difficult about delivering continuity of carer?

We thought we had made it in 2013 when the NHS mandate stated that maternity services must
“ensure that every woman has a named midwife who will make sure she has personalised, one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”

We have the empirical data now, how birth reduces miscarriage before 24 weeks, reduces prem labour and still birth. We know midwifery care from someone you know and trust care reduces the perception of pain, we know that intervention and instrumental deliveries are reduced and so on. And we know that women who have it want it again – they know the difference and want that relationship. We also know that it does not need to be just one midwife – one midwife is really important but actually two or three midwives is quite do-able for a woman to trust and relate to. Sandall talks of up to six midwives in her research being very clear about that: this is NOT 121 care she told a conference. But it is also not a parade of strangers walking in and out of your birth room with no connection to you, no investment in your wellbeing.

WE had the evidence, we had the policy, but implementation has got stuck every step of the way.

I think a good analysis of the nature of our dilemma is summarised in this clip from Yes Minister. The Department of Administration is implementing a national integrated databased. Jim Hacker the new incoming Minister is trying to ensure there are safeguards for individual liberties built into the database. But he is struggling to get anything to happen. He decides to go and talk to his opposite number who had held the post before the election. Here goes:

So what are the tactics of obstruction? :
1.  Administration is very new – there are alot of other things you should be getting on with
2.   Are you sure this is the right way to achieve it?
3.   It is not the right time – for all sorts of reasons
4. Practical Problems
• Technical problems
• Political problems
• Legal problems
• Administrative problems
5.   It is too late – there is not enough time before the next election

‘They will stall at every stage and will do nothing unless they are chased up.’

I would suggest this is why we are struggling to delivery continuity of carer. There are a range of technical financial and practical difficulties to be overcome. But if we sit down and work them through there will be a solution. However, this does not happen, challenges are thrown at us mixed together in a mishmash of politically motivated, genuine difficulty, emotional stuff and indifference to the issue.

Using Yes Minister as our starter for 10 let us look at some of the genuine barriers to implementation and what some key strategists say about them, look at a positive example of change and the key factors that could work elsewhere, before looking at what went wrong in Yorkshire – to think what could be done better. Finally what we can do.

Practical Problem: Strategic Finance: The money is not there to sustainably deliver this kind of care.

A couple of years ago Beverley Beech invited me at short notice to a consultation meeting at the House of Lords with Baronness Cumberledge and miraculously I could go! There I met Belinda Phipps then CEO of NCT. We had a good conversation – especially after I admitted that I had planned my question on the train down! My big question was – why are providers and the CCGs seeking to block any shift towards caseloading when the evidence base is so strong. I took notes on her answers turned them into a blog post with her approval and you can find it today on Born Stroppy. I would commend it for reading but here is an exert:

… in reality, in an Acute Trust 85% of costs are fixed which means that a per treatment cost … does not work because the building, equipment and staff need to be available even if the C-Section is not done. So there maybe little difference in cost for a Trust between a 15% C Section rate and 25% C- Section rate in terms of costs to them. But they rely on the income – often to fund the fixed costs for other services, – and so any fall in the election CS rate means they cannot cut costs because so many of the costs are fixed. This can result in financial problems
This means a ratchet mechanism operates which drives the C-section rate up irrespective of clinical need.
The new PbR system allocates women at booking to a risk category ( low medium and high) of course there is now an incentive in monetary terms to allocate women to a higher risk category to raise income levels thereby delivering more women into the Consultant led system.

What would work is a payment of x per birth ( where x is total cost of maternity in UK minus necessary admin costs not borne by providers divided by number of births) with a deprivation payment per woman for those from the most deprived postcodes ( bit like the pupil premium). This should be paid per birth and the provider take the risk. Effective providers would benefit by making sure they did all the preventative work they could, to keep births simple. There would have to be a rule that says the woman chooses the midwife and then irrespective the provider cannot refuse care (they would have to pay for others to provide complex care if that became necessary). However this would require the NHS to break its mental rule of cost=price at a treatment level.
This would also work better than the block contract approach.
Another option is to give the woman the budget – and I like that option too.

In concert with this, the capital changes have to be changed from a charge on space (as now) to a charge on people (a capitation charge) so the payment has to be made irrespective of treatment location which would remove the drive to treat people inside buildings in acute trusts unless this was clinically necessary.

You know I think CNST (the NHS litigation insurance payment system) and its equivalents in other countries needs to change so that prevention and watchful waiting is rewarded with lower fees. And that the focus of CNST should stop being solely about being safe during intervention – without regard for how necessary or unnecessary it is.

Then there is the whole business of care being carried out in organizations where the governance and the building is aligned. They don’t need to be! and a system set up across trusts with the service and governance aligned rather like clinical networks with teeth would probably work better, certainly for maternity.

Case-loading without the rule changes above is only a partial solution to this dilemma and is difficult to sustain because of the above.

It is a huge chunk of stuff to take in – so spend some time on the blog – but it is absolutely clear that there are some big barriers to caseloading, here in the often archane structures of the NHS. which align buildings with healthcare, and pays for activity rather than health. This means cutting your C-Section and raising your HB levels may not save you money – even though on paper it should. It may explain that whilst Birthplace say FMUs work financially, they are still being closed down.

These issues are real but CAN be tackled and overcome – in the case of Birmingham Women’s below the finance issue was turned on its head as the Provider and CCG acknowledged that capacity and finance should DRIVE them to low risk women having homebirths and births in MLUs.

But first let us listen to the voice of a Strategic Finance director in Wales tackling big financial principles behind the financial policies:

Alan Brace Finance and Procurement Officer, Aneurin Bevan University Health Board, Wales. Health is a devolved responsibility in Wales.

Alan started with a photo of the gaping jaw of a crocodile: with costs going up and funding going down and the gap between the two widening. Our new focus he said is not the 5 million pounds we were planning for but just 1.1 million pounds to spend. And differently in Wales to England – the cuts come earlier and harder here.

Listen to this: Alan said: People get tired of the pressure to save money all the time. Traditional cost cutting strategies destroy value in health. And he said – I don’t want a job where all I do is cut peoples budgets. More than this he said: Ill health costs the NHS money – alot of money. – so how do we DO value in healthcare?

He was NOT talking about maternity specifically at any point during his talk but listen to his questions/comments:
How do we do value in health care?

Do we use expensive staff for low level work? Do we do tests not because they are clinically necessary but because it is protocol? Compliance with care Processes rather than focussing on what is needed can prevent improvements to care – and ill health costs the NHS money. Here are cost reductions that do not require cuts in quality – quite the reverse they may improve outcomes.

He said as an NHS we focus too much on the technical ability of clinicians but really we should be focussed on outcomes – the difference the care is making not on the Doctors ability. For instance Matin Kinik measured the variation amongst surgeons showing outcomes and results – and the variation was disturbingly great. Should we not be asking ‘what difference will this procedure make to the patient?’ And ‘what techniques have the best outcomes for patients’? Because ill health costs the NHS money.
We don’t know what makes the difference to patients says Brace. We tend to cut low cost care thinking we are protecting high value care- but maybe we are not. Low cost care was actually what was needed. On Radio 4 a couple of weeks ago a GP commented that a practice had got rid of their asthma nurse to save money and found that their costs actually went up because they were now referring into hospital far more often. Brace himself, gave the example of his elderly infirm mother whose health improved under the care of careworkers and deteriorated markedly in the care of highly trained, highly paid nursing staff.

And so we need meaningful cost knowledge so we can make proper value judgements – and we don’t have that knowledge at the moment, we don’t know the true cost of what we do.

Ill health costs the NHS alot of money, so improving care to reduce ill health will reduce its costs. And we need to use the most efficient practices and the low cost staff to do that.

This analysis is done in Wales in the context of the Eniron Bevan Commission set up by the Welsh assembly and reporting to the health minister. It looks at all reforms to ensure that the NHS remains recognisable to the principles of its founder – publically owned and free at the point of care.

When we turn his perceptive gaze upon maternity care: do we find healthy women in high cost facilities being cared for by over qualified expensive staff – and having worse outcomes there than healthy women cared for in dirt cheap homes or in MLUs by much cheaper staff? Are we subjecting healthy women to a barrage of tests and measurements which efficiency and evidence do not support – Michel Odent in Birth And Breastfeeding says so. Does medical process trump what is needed and wanted by women in the care of women in many institutions? Are we focussing on the qualifications of the clinician rather than asking what difference are they making to the outcomes? Are we cutting low tech cheap staff delivering breastfeeding support and continuity of carer thinking this protects the high value Obstetric unit – without analysing the true cost benefit of doing so. Does cutting continuity of carer and breastfeeding support really save the NHS money in the short medium or long term?

Being me I did put my hand up and say – this would all apply admirably to maternity care where midwifery led care is shown to promote normality and save lives and cut NHS budgets. He smiled wryly: in maternity the fight for restructuring care was not financial but in other places. A culture for instance that sees a unit ‘downgraded’ to midwifery led, and turkeys very definitely refusing to vote for Christmas. Nevertheless, Alan Brace has surely given us a moral and economic argument for implementing caseloading relationship care. The barriers to change are not necessarily here.

So let us inch our way closer to the political and cultural issues that enable or prevent continuity of carer by looking at how policy has changed in Birmingham as FMUs and a homebirth service have been set up with sustainable funding.

The story of the Homebirth team at Birmingham Women’s from the NCT Birth place Conference in June 2015

The information here is culled from 3 talks at the NCT Birthplace Conference in Birmingham in June: from Dr Tracey Johnston, Consultant Obstetrician and until recently Clinical Director, at the Birmingham Women’s Hospital, Diane Reeves Accounting Officer for Birmingham South Central CCG; Sarah Noble Midwife lead for Birmingham Homebirth Service
A homebirth team had been mooted for a long time in Birmingham, Dr Tracey had been involved in several failed attempts to set up a homebirth team: the barriers had been too great. But now these barriers were coming down:

• Finance and tariff issues. Significant change:- introduction of more granular tariff
• Lack of published evidence-Birthplace study endorsed the safety- published 2011 BMJ And the lead clinician was clear that the Birth Place Survey had provided the incontrovertible evidence that enabled them to convince their colleagues.
• Interaction of evidence with clinical commissioning – lack of pathway from evidence to implementation. Need for leadership to do this.
• Increasing population, young city, high birth rates issues of capacity – In the circs would it not be easier to do more of the same?
• Under-used home birth service because not dedicated – on call midwives pulled into labour ward leading to women not satisfied (promised service not happening). Not promoted as a result.
• GPs wary and unconvinced about having such a service:

There are some points worth unpacking further:
1: The finance issue: the pct had turned down the HB team proposals several times over several years but the argument was now turned on its head from ‘we can’t afford to’ to ‘we cannot afford not to’:
Tracey said: ‘the birth rate increase projections give us a capacity and financial time bomb, and therefore we should not be clogging up expensive obstetric beds with healthy low risk women – the safest and cheapest place for them is home!’
2. The HB team was not given an bottomless budget, but given start up costs and the maternity tariff, with 3 years to break even. AT 240 births it is a realistic target with a realistic turnaround time in terms of increasing HB numbers in the population. In their first year they were on track to sustainability in the three years. So this is not another Airedale MAMs or Better Start programme in Bradford: in Birmingham the funding is there forever and sustainability is built into the scheme with a saving to the Trusts being made.
3. Interesting are the objections from the GPs and how this was tackled – remembering that the CCG is a membership organisation. GP survey was circulated in July 2013 and 42 surveys completed. The main concerns were, medications, GP attendance, Transfers into hospital, new baby checks. The Key concern seemed to be that they would be landed with situations beyond their competency: they would be called out to a birth or be involved in night transfers or have to do the baby checks. They were worried that they would be responsible if things went wrong when they had no control over those things. It was Clear that most GPs had little expertise in this area and were unaware of latest research on homebirth and other research findings as well as good practice – like what midwives do.
Tackling the concerns of the GPs with real information, peer to peer advocacy for GP colleagues brought the GPs on side. And 12 months into the service none of the GPs concerns have been realised.
4. Tellingly the CCG lead Dianne Reeves, the GP board lead and the hospital clinical lead ( Tracey Johnston) were all women with personal experience of homebirth (one of them against clinical advice) and so they worked together to convince their peers, and increase homebirth in the area as a public health good as well as a real option for women. I think that here, Personal experience, emotional connection to the issue as well as robust clinical evidence gave these people a commitment to its availability for other women. Could this be what is missing in our Yorkshire commissioners and clinical leads?

Key success factors here
• Evidence, data, choice and capacity issues created a mandate – ie the combination of the medical evidence, the choice agenda in public health policy and the hospital capacity issue – too many babies being born for the Obstetric Unit to cope with.
• Enthusiastic provider team (MWs and OBs), enthusiastic (female) GP commissioners- with a desire to improve choice and reduce interventions for low risk women.
• Non recurrent spending requirements- initial pump priming ie To get the results and the savings long term, initial investment had to be made.
• Work to promote it to GPs- Peer to peer education seemed to be key. Plus educational events, GP networks
• MSLC support – the MSLC kept raising this issue over years ( I get the impression that they were fed up of raising it by the end) but it kept it on the agenda until all the elements were in place. This is a message to the battle weary MSLC reps amongst us.
• “Big social conversation” engagement events- reaching diverse communities. Community participation not a top down approach. Making sure the service meets women’s needs.
• Strong leadership from CCG Commissioners – who were female, mothers and had personal experience of homebirth. It is a strategic thing.

And Dianne Reeves stated that they were Commissioning for Quality all round here

• Intra-partum transfer review and benchmarking – ensuring that transfer rates do not exceed the Birthplace average
• Continuity of care is important: 3 or fewer midwives through whole package of care. The head of the HB team said that they decided not to do 121 midwifery but team care due to staff lifestyle balance – but the standard is that women meet 3 or fewer midwives during the entire pathway. This actually meets the criteria of continuity in the Sandall Research.
• Breastfeeding rates 75%. Current rate at discharge is 80% so high BF rate is expected and being delivered
• Incident reporting and monitoring – this has to be as rigorous as in a unit
• Diversity of users – not just for hippies. Sighs.

Message to everyone out there:
• Build sustainability into your business plan
• Strong cross professional leadership needed. Key here was GP leadership.
• If it fails this time around keep pushing: its time will come.

In this example, the key elements for success were:

• Clinicians – doctors with personal experience/sympathy in key positions
• Evidence of high quality – Birthplace
• Financial and capacity imperative –
• Careful and painstaking teamwork bringing key gatekeeping groups on board ( eg GPs and women and their families).
• Long term Financial sustainability built into the package

Interestingly – and pertinent to our discussion- women are at the end of the process, they are being persuaded to make this choice now the HB service is in place. Evidence rather than demand is the driver in promoting the service to women – demand is being created for the good health of women and babies – which also saves the NHS money!

So my question, in the light of this example –

What is missing in Yorkshire (and elsewhere) when it comes to implementing the strong evidence for continuity of carer in clinical practice?

Pause for discussion and questions.

So in the light of all this positive stuff: What went wrong in Yorkshire?

That has been my question for the last 2 years. What is missing in Yorkshire – not the evidence, not the finance – is it the leadership? Is it the vision?

Here is an account I wrote 2 years ago about what happened whilst I was chair of the MSLC in the thick of it. Remember, we are trying to tease out the learning points from this negative experience. See what you make of it – what is missing in Yorkshire?

Women and organisations serving the most vulnerable women in our area were throughout my tenure as MSLC chair (2009- 2013) saying at every MSLC meeting: we need personalised care, we want personalised care, we are concerned that the Trusts are saying they cannot deliver it, we are concerned that independent midwifery is not going to be an option for those of us who are willing and able to pay for it and so our choice of having continuity of midwife carer will be entirely gone. There was no response from the outgoing PCT nor the incoming CCG. The Trusts said basically (and I am paraphrasing here) with all due respect ‘no way can we deliver this kind of care’, One Trust despite all the evidence said that women did not want this kind of care when asked. I have the minutes, letters and emails to back me

As chair of the MSLC I invited IMUK and One to One Midwives to talk about their models of care and what they could offer the NHS. I spent months setting up a meeting between One to One Midwives and the PCT/CCG at the time to discuss the possibility of this care in the poorest wards of the city, with the most vulnerable women, where infant mortality is unacceptably high. I was stone walled, patronised and ignored. They only engaged with me seriously when I started publishing the letters and emails they had sent me on my blog in May/June 2013 . . . .

All change

Then, on April 1st the world changed – and after 20 years it really felt like that! I missed it because I was on holiday!. I came home to a pile of emails. One to One (North West) Ltd had set up in Bradford. Due to the amount of interest generated, an information day had been planned. The women’s networks were hot with the news – at last independent midwifery on the NHS, at last the quality of care we had all been wanting and waiting and working for over so many years! I turned up late to the ‘drop-in’ session to find well over 100 women there complete with babes and toddlers. Tea, coffee and water had run out and there was a desperate need for a microphone! No one, least of all One to One had anticipated this interest. It was the Who’s Who of women and midwives in our region: NCT teachers, doulas, La Leche League leaders, student and experienced midwives, a couple of commissioners squashed in alongside some breastfeeding mums and burgeoning bumps. The place rocked. We were excited – at last women could choose mother centred care on the NHS and it would not cost the NHS any more money. Indeed as the invoicing was retrospective it would save CCGs money, with all the future benefits and savings that One to One’s excellent results show.

In the weeks that followed, the One to One presence in Bradford went from one midwife to five, driven by the number of referrals coming in. Women told me of their relief that at last they had a midwife who listened to them, supported them and worked out a pathway that enabled their wants and needs to be met – woman centred care!

But the good times did not last for long. One of the Trusts in our area and the CCGs were absolutely furious that One to One had begun working in the area without invitation. Although the issue had been raised at MSLC meetings, although I had written many times and asked for meetings about the delivery of continuity of carer, particularly to the 300 most vulnerable women in the area, we were told that this advent was a complete surprise, they had no notion it was going to happen. To tell the truth, I had had no notion that it was going to happen on April 1st but I had been saying for months, even years, that this was going to happen at some point. No one was listening!

So there was a huge row. Heated meetings between CCGs and One to One (North West) Ltd. The CCGs refused to pay invoices. Without any consultation with the women involved (where is the woman centred-ness in all this?), for reasons I cannot understand, and flanked by providers (which in itself surely constituted a conflict of interest), the regional division of NHS England backed up the CCG/provider alliance against women’s choice, and against One to One Midwifery (North West) Ltd. They said that women were free to refer themselves into the service, and One to One were free to deliver it, but the CCGs did not have to pay the bill! Have you heard anything so ludicrous? I run a business – that is not how business works, if it is OK for women to choose a service then it is OK for the service provider to be paid.

At a stormy MSLC meeting in July women were told:

• That they were mistaken in their choices.
• Why would a woman want to choose this service when they had so many options already available to them.
• Women do not know what they are choosing.
About One to One Midwifery they said:
• how dare they come in and destabilise our service provision.
• how dare they come here and not ask our permission first.

My only response could be, “Women should have a right to make the choice of their carers. Women do not have the choice of one to one midwifery care in the current provision. Don’t women have a right to choose their care?” I just had to repeat it over and over again – because they were not listening.

The two ordinary mothers there – both of them attending for only the second time: were intimidated by the attitude of the provider and CCG representatives. One mother said nothing at the meeting but facebooked me to say:

“I felt very intimidated after the meeting and it caused me quite a bit of stress.
I don’t really understand what the meeting is for if service users can’t describe their experience of the service, it’s providers and how they felt about it. . . . As a service user who would be described as high risk with ‘alternative”’choices, I am very attracted to what the One to One midwives are offering as I already know Bradford and Airedale cannot accommodate all of my needs, for example a named midwife.
I was at the One to One open day in Bradford the other week and the impression I got was One to One wanted to listen to my needs and accommodate me. I did not get this impression from the MSLC meeting, more that I had to fit in with what the care providers are offering, like it or lump it. Doulas and all. There was no room for discussion and the meeting was not the place for it. – you can quote me on that”

Providers and commissioners did not want to listen to what women wanted, they did not want to hear the reasons why women wanted to choose One to One midwifery care. At the MSLC meeting their voice was devalued even more when commissioners and providers said that they did not want to hear the voices of the kind of women that come to the MSLC! The CCGs are currently on the lookout for ‘ordinary women’ who do not go to MSLC meetings. They want to find out if women really do want One to One care in our district. There apparently is not enough evidence to prove women want women-centred care and they are not going to act on the medical evidence such as the Cochrane review alone – not for this clinical decision anyway.

I was told by the CCGs that:

• They don’t want a dead baby on their hands.
• Local care pathways between One to One and Trusts had not been set up and would not be set up. Both Trusts have care pathways for women with independent midwives and one Trust has set up specific care pathways with women with One to One midwives.
• Care pathways are a condition of being commissioned but being commissioned is the only way these pathways can be set up – a circular argument to keep out competition.
• I have a dossier of cases of women who say they been bullied by one of the Trusts because they have chosen One to One midwifery rather than the Trust to deliver their care.
• One to One midwives have been victimised and verbally abused by employees of some providers when attending births or hospital appointments with women.
• Both NHS providers say they cannot and will not deliver one-to-one care to women by 2015 if at all – and say that women are telling them they are happy with their care.
• then they said it is a national project and so our CCGs cannot do anything until the whole nation agrees to do something.

And there was I thinking that the CCGs were set up to be closer to their population and to commission on behalf of that population for the good of that population – not for the good of the providers. And there was I thinking that the Government policy was about choice, about women being able to make the healthy choice of having one mother one midwife care. It hurts, it hurts mightily because I really did not want my experience of care 20 years ago to go on being repeated today. I wanted my daughters to have a better quality of care than I received from the NHS.

Where things are at now

I am not on the inner circle now and exhausted had to take a step back for a while. It is very interesting as I am at the hub of a maternity network – how little I get to hear!. But here are some key points.

1. Solicitors letters have gone back and forth for years. The Commissioners continued to refuse to pay 121 Midwifery Northwest, Monitor and NHS England did sod all to ensure payment or continuation of the service women were demanding and One to One eventually had to withdraw from Yorkshire.

2. Local women were going to their GPS asking to be referred to One to One Midwives for quality care and their GPs were turning them down. It took some digging and an FOI to get the letter from the Commissioners – which basically raised a list of serious concerns all of which would be met by passing a CQC inspection which they did. Not one GP checked with CQC regarding safety of practice. The CCG letter was a cynical roose I believe to ensure no GP would refer a woman to One to One. GPs told women (and the letter implied) that they could be responsible for paying for the service out of their own budgets – GPs did not know that their referral OBLIGED the CCGs to pay – hence the letter to put them off!

3. Monitor received complaints from a local service user group about anti-competitive practice – tributes here to Airedale Mums once again. They agreed with the complaints and letters went back and forth but NOTHING ACTUALLY HAPPENNED TO CHANGE ANYTHING.

4. Meanwhile every month at my homebirth group women complain that they still cannot choose One to One midwifery. Most don’t complain about their current midwives per se but they are not getting relationship care, nor are the midwives!

5. One further thing about this saga. As I say, I had spent months trying to get a meeting with the CCGs leads trying to bring together people for a conversation about delivering continuity of carer to the most vulnerable women in Bradford – the ones at greatest risk of losing their baby for instance. I had not got anywhere. When One to One arrived in Bradford and were having a significant impact senior managers demanded a meeting with me to discuss various conflicts of interest. I probed and discovered that they were saying that I had been advocating for 121 Midwifery because I was being paid by them – not because quite stupidly I might want implementation of medical research for the betterment of women and babies – Lord No! I wrote a letter refuting this and calling it out and sent it to everyone I could think of – all the MPs, Beverley Beech Belinda Phipps, if I had an email address I sent it. It ended that line of personal attack on me. Notice the tactic of ‘don’t play the issue play the woman’! – That is an episode in Yes Prime Minster called ‘man over board’

I did however agree to the meeting. I took in a colleague from the MSLC who would become the new Chair. I was to play bad cop (as they already had the black hat firmly on my head) and she was to play good cop. It worked like a dream for the future of the MSLC. When it came to One to One Midwifery the Commisioner wanted her say and I was all ears: She lambasted One to One Midwifery but then said that by the end of 2015 they would ensure that this care was delivered to women in Bradford and if the local providers could not do it they would commission an outside service. That was 18 months ago. We are still waiting.

So I went to the 2015 BRI AGM and asked for the details of this fantastic service which women had been promised by the end of 2015 and so should surely be celebrated. That was September 16th – I received the response this Tuesday 17th November, 2 months later. And here it is:

From an acute provider perspective we have discussed models of personalised care over a long period of time. We have taken note of the evidence, the outcome of the stakeholder event  held at the Trust last year and also the commissioners’ views

 Following the evaluation of the MAM project in Airedale our commissioner asked us to pilot an alternative personalised care model as although the Airedale pilot evaluated well from the women’s perspective there were unexpected pressures on the MAM team.

 This new project in Bradford Better Start area focuses on enhancing ante/postnatal care, continuity of care, all women in the project knowing and seeing the community midwife regularly.  Caseloads are much smaller than usual and The midwife is the key  care coordinator and contact for all women on the caseload.

 Continuity of care throughout ante and postnatal periods is a focus (which tends to become lost in projects including intrapartum care)  We are aiming for a maximum of 2 midwives ante/postnatally.

 We are  not aware that a case loading option involving intrapartum care  was promised to all women and we need to do the pilot to evaluate the model and plan sustainability. As we have highlighted previously there are no Trusts in the UK where ‘one to one’ style care is a universal offer as it is complex and expensive to roll  to roll out across a whole service; there still needs to be a core hospital based services and this has to be staffed as well as the case loading teams. This is why we have decided to use the chosen model as a pilot.

So what went wrong in Yorkshire? Lots of things that is for sure. And that question is one for our discussion – alongside the more positive question: what do we do differently in Yorkshire to get a different scenario? But in the light of the previous stuff we can pull out some ideas:

• A lack of vision and leadership over several years – we don’t have peer to peer mentoring on this issue within and across professions
• This is not a priority for CCG commissioning, nor local Trust provision. This has not been something to be worked towards.
• Key people do not believe this is deliverable and so despite the great need chose not to engage with anyone with a different view point
• There was a lack in partnership working therefore across sectors, people who should be working together are viewed as competitors, women’s demands for this care are seen as threats – labelling ordinary women as hippies and ‘those kind of women’ once more devaluing our input so that they don’t need to regard it.
• Geraldin Butcher at the RCM conference said: New Zealand Midwifery only flourished after identifying with women and actively involving women in decision making.

And if Monitor had teeth and NHS England had backbone and the NHS mandate was a serious piece of policy to be implemented rather than a ‘nice to have’ maybe things would have been different. And if we had vision and leadership from those with most power and influence in the system rather than kicking it into the long grass with another Maternity Review – things may have shifted because good quality maternity care – continuity of carer- is an investment in health that saves the NHS money whilst saving baby’s lives and women’s health. Remember ill health costs the NHS alot of money!

So what do we need?

We need cando leadership– looking at the barriers to change whether it be GP attitudes, Midwives burnout or financial constraint- and instead of using them as reasons for inaction, sit down and work out a way to overcome the barriers. Example after example I have found across the UK shows that with the right attitude barriers to implementing new and improving services – including continuity of carer – have a solution: The biggest barrier is the willingness of leaders to take this challenge on.

What needs to change and what can we do?

We need vision and leadership in Yorkshire and so we need to seek out allies and friends in Trusts and CCGs and other organisations and we need to recruit clinicians, commissioners and HOMs with vision and commitment to making this happen. We need to find the Diane Reeves, the Tracey Johnstones and so on, of Yorkshire – we need people to stand up to the plate and play their part as we play ours. We need visionary midwives with ideas and plans and strategies, with courage and audacity to make them happen. We need MSLC Chairs and reps who just keep the subject on the agenda month after month, year after year, passing the baton down to the next generation until it happens.

And we need activists, many many activists, mothers, doulas, birthworkers who keep asking for care they don’t get, keep complaining, keep writing letters, keep asking questions at public meetings, keep raising the issue in ‘consultations’ and Reviews, keep organising and marching at demos. People who will talk to women about good birth and good care in supermarkets, in toddler groups, at the school gate, in the cafes and pubs, on Radio, on TV in social media and in the newspapers. Women and men who ensure that the demand for quality maternity care is never off the agenda and that every mother father and grandparent knows the difference between the care they are getting and what they should have.

I was in despair really writing the end of this talk because what difference can I make? After all the effort I and others have put in – what has been the result?: Our daughters getting the same care as we had! Then I watched Chicken Run and watched Ginger try over and over and over again to escape the chicken farm – not just herself you understand – that would have been relatively easy – but EVERY CHICKEN ON THE FARM!. And after every failure there was always another plan, another idea. She was tough and she persevered – but boy! did I cry her tears when she sat wondering what they were going to do next.
I have no big promises and prizes to offer you today, but I am not giving up – and I hope you won’t – because our daughters deserve better and so do we!