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!


Of Priests, Bishops and Midwives

Today I am returned from the service of celebration of the 20th Anniversary of women being ordained at St Asaph Cathedral, Wales. To remind us that we are still radical we had a small picket of people calling upon us to adhere to the scriptures ‘that women should keep silence in churches’. We were there because we had been there 20 years ago when our good friend Kath Southerton was ordained as one of the first women priests in Wales. We took our 2 year old daughter who is photographed in the arms of the presiding Bishop Alwyn.

It is significant for me that we were there 20 years ago and it is significant that I was there today, because this is part of the struggle we face as women to be treated as of equal value with in the world including within our faiths. And misogyny and discrimination remain and most particularly in the two areas of my life I am most passionate about: the maternity system which deals exlusively with women birthing and in the Church whose starting point is God’s love for all regardless of gender and creed and status in life.

Bishop Rachel, first woman Bishop in England gave the sermon. She took as her readings the story of Ruth(!) and the resurrection story of Mary Magdalene in the garden. These were both women, she said, whose context was shaped by the decisions of others.

In the story of Ruth we have a woman whose context is shaped by the decisions beyond her control. A Family of two parents and their sons migrate for work to a neighbouring country. The sons grow up and marry two local girls. This is in a culture where marriages are financial and social contracts where women are commodity as much as people. Tragedy strikes and the Father and sons die leaving the women without the protection of a legally recognised (male) head of household and means of living. Naomi, the mother in law decides to return to her own people where she maybe able to afford some living and protection amongst family and tribes people. Her daughters she releases to return to their families where they would be married off (perhaps as second hand) to another man/family. Ruth looks at the choices she has – shaped by her context and the decisions of others. None of the choices are easy but she chooses to take the risk of going with Naomi, setting aside her own culture and nationality to, in effect, become a daughter of Naomi – her people, her God – taking the risks of an all female household. All ends well for Ruth as with some more courage (and the cunning and audacity of the two women) she marries a wealth relative of Naomi – Boaz – becoming one of the very few women to be named as an ancestor of Jesus in Matthews Gospel. Rachel said that this was a woman taking life changing chances in a context limited by the decisions of others – this is the context of all – men women and children – but very much so for children and women.

Bishop Rachel is the first woman Bishop, but over the last 20-25 years since women were ordained priests in the British Anglican Church there have been many women as clever, as wise as suited to the role of Bishop who have not been ordained due to the ongoing discrimination of the Anglican Church. This will continue to be the case for many years until Women Bishops are the norm. The context of women priests is framed by the decisions of others’, individual women priests face this truth as they follow the path of their vocation.

And so I want to say to my daughters and to my female friends out there. We operate in a context framed by the decisions of others. This can empower us (such as anti discrimination legislation, some maternity laws and the mentoring of women ahead of us) but the decisions can also be limiting – many women I know, myself included have injured ourselves against the glass ceiling – and historically this has often been the case. Our efforts are in the context of a millennia of patriarchy – if we think our steps forward are very small we have to set them in this context – the story of Ruth set in the second millennium BC reminds us of this.

And sisters and daughters, if you have worked hard, you are talented and qualified but you don’t achieve what you should, do not blame yourself (as we so often do!), look at the context shaped as it is by the decisions of others. If you seek to bring about change to benefit women – and I think here of the midwives, birth workers, maternity activists and mothers themselves and you fail ( as I have) or your victories are not great and soon eroded, or you burnout ( as I have), then do not blame yourselves, remind yourself that you have been taking life enhancing action, taking life changing risks in a context that is shaped by the decisions of others.

Today we celebrated 20 years for the women who made it to ordination in the Welsh Anglican Church, whilst remembering the many more who worked, campaigned who suffered much and received little in the years before and since. Today we celebrated with the first woman Anglican Bishop of England celebrating in a few days the consecration of the first woman bishop in Wales, commemorating 20 more years of missed opportunities for the gifts and talents of women in Wales.

Today I also remember the many women priests of birth, the midwives and the doulas, who have empowered and enabled women to make their own healthy choices for birth. I celebrate we who have campaigned so women can choose a birth at home, in water, in a midwifery led unit, with a midwife she knows and trusts, to have impartial information and support whatever her decision. Our successes and failure speak of courageous selfless women taking life changing risks in a context shaped by the decision of others. Sisters we do what we can, we do not blame ourselves for what we can’t and we call on our daughters to stand on our shoulders to take the work forward. Amen

Freestanding Midwifery Led Units in Shropshire: at the sharp end of the debate

Notes from ‘Questions at the Shropshire CCG Board meeting’ 13th December 2016

Those who know me well will understand the commitment of turning out before 8am to drive somewhere (and back) on my own for the first time – I got lost with the help of two SATNAVs today but just managed to slip in on time to the Public Board Meeting of the Shropshire CCG.  I was there because the brilliant Gill George campaigner for the Ludlow Maternity Unit and small hospital had encouraged mothers and others to attend and ask questions:  she wanted a commitment from the CCGs to ensure their contract with the Shropshire and Telford Hospital Trust (SaTH) maintained the freestanding midwifery units (FMU) and all the maternity care they provide to local women in a large county.

The front row was taken by a cluster of Mums with their babes and toddlers – giving a dour meeting a lightness of touch and sense of humour that was much needed.

The first part of the meeting was questions from the public, and the first part of this (clearly planned) were questions from the Mums.  The first Mum stood up saying she represented a small fundraising charity for local midwifery units and all the Mums in the area as there were concerns that the maternity services at the Midwifery Led Units (MLUs) were going to be cut and indeed threatened.  They wanted the Midwifery units to be open 24/7 and offer the postnatal care and breastfeeding support they currently do.  SaTH have announced they will close the MLUs – of which there are three – Ludlow, Bridgnorth and Oswestry – at night, this will also end Postnatal stays and 24 hour breastfeeding support.

Her actual words were that the Units were going to be turned into Birthcentres – clearly implying this was a bad thing.  It is a shame that such a term in this area has become synonymous with cuts to the very services that Birthcentres represent to many of us in other parts of the country.

She described her own ordeal of being transferred by ambulance across Shropshire to hospital but not making it and having to give birth in a layby en route.  She believed that this would happen more often if the services of local MLUs were reduced so women had to travel significantly further during labour.  We know that the least safe place to birth is at the road side.

She described how in just a few days her Save Ludlow Maternity Unit Facebook page had got 1100 members and that there was a successful march in Ludlow on 3 rd December.

She gave 4 reasons for keeping the MLUs:

  • Research shows that most women labour during the night (Thank you Alison for that painstaking work over decades!)
  • Most Midwives live a significant distance from the MLUs, so there could be delays if women arrive in full labour at the unit before the on-call midwife can make an appearance.  And what if more than one woman births on the same night?
  • What would be the impact on breastfeeding rates if the units reduce their care?
  • Finally, she described how constant threats to the service and lack of investment in it reduced midwives’ morale.  Good midwives will leave the service was her message.

A second Mum stood and spoke.  She quoted the NICE  Intrapartum Care Guideline reminding the CCG board that planned birth for low risk women in an obstetric unit raised the rate of C-Sections in this group. That MLUs reduced instrumental delivery, raised normal birth rates and so on.

She also described the important role in breastfeeding the MLU in Bridgnorth had provided.  She described how they supported her breastfeeding and she only went home once she was confident.  She had found this invaluable.

Gill George then stood up and asked some incisive questions demonstrating she knew the politics and financial situation in detail.  She along with the Mums asked the board for the same thing:

We want the CCG to commit to funding for continuation of the current rural maternity service and units (Bridgnorth, Ludlow and Oswestry) and to get this written into their contract with the hospital trust – due to be signed by 23rd December. (We also want them to guarantee consultation before they allow any change to the service – but mostly we oppose the cuts!).

I always say that asking the question is more important than the answer you receive.  On this occasion it really was not the case.  The CCG iterated its position that safe good quality maternity services were a priority.  The dire financial position of the Hospital Trust and the CCG was stated but we were told that SaTH had not approached the CCG about reducing or changing its maternity structures. This was a significant point because SaTH have already announced that they are closing the MLUs at night in effect changing the service provision.

The speaker pointed out that there was an issue that women were choosing to birth at Hereford and have their postnatal care at Ludlow – but the tarrif money for the postnatal care had not been retrieved.  I recalled a similar difficulty between Calderdale and Bradford and decade or two ago!

Gill George pressed for rural maternity services to be in the contract signed on 23rd December and that there would be public consultation before any changes were made.  And what would be the chances of this being signed off on 23rd?  ‘Optimistic’ came the sad faced reply.

Here I am inserting Gill George’s notes of the answers to her questions at this point which she kindly sent to me on reading this blog:

Q: Will rural maternity services be in next year’s contract with SaTH (the hospital trust)?
A: Yes.
Q: At the current level of service?
A: We’re in discussions with SaTH.
Q: Are you expecting this to be possible?
A: I’m very optimistic.

This was from the Head Honcho of Shropshire Clinical Commissioning Group, in a meeting this morning. It’s possible that we’re getting there. We also got something that came very close to a clear commitment that would be consultation on any ‘substantive change’ to maternity services.

The floor was opened to further public questions – most of which were about cuts to services.  This is clearly a well rehearsed session with the players all knowing each other and their roles.  There is a sense of frustration from the public side as they fight to keep valued health services and exasperation on the board side desperately trying to balance books with one of the lowest budgets per head of population in the country.  There is a massive deficit and the prognosis is £15 million pounds worth of cuts to be found in 2017/18 by the CCG.  There was a short stunned silence at that point: there is no choice was the message we will have to cut valued services – there is no money.

The chair of the board said at one point to the public – you are the electorate you need to elect a Government that provides money for the NHS you want.  This said in a county that returns Conservative MPs and has the lowest financial settlement per head of population.

Finally I stood up and as light relief invited the board and everyone present to the SaTH supported conference – Implementing the National Review in Rural Areas:  Better Births in Shropshire and beyond #SaTHFMU

I mentioned its impressive speaker line up (including Baroness Cumberlege, Prof Dennis Walsh, Cathy Warick and Kathryn Gutteridge).  I left programmes on the table and the response was that someone from the board would probably be there.  Listening to the discussion it could be a good thing.  Here is the link if you want to join us:  https://www.facebook.com/photo.php?fbid=1372545286097059&set=gm.151748551970104&type=3&theater

Meanwhile in the foyer the local reporter was interviewing the Mums about what they said.  No opportunity wasted by these Mums to ensure the survival of their community maternity care.

A CCG with no money, with services costing more than their budget, a Hospital Trust with no money and running at a deficit (as are the majority of hospital trusts in England): the quality of all health services are threatened – A&E waiting times grow, dementia and other care is not getting the investment needed, Maternity care in rural areas threatened.  There are no easy choices here for the CCG Board and I would not be in their shoes for half of all England with no power but to dispense the national Government agenda of cutting heath service costs to this population – dressing it as efficiency does not wash.

In this context it can feel easier to cut low tech low cost services to protect the high cost, high tech, highly qualified services.  But as Alan Brace points out in my blog : Why is it so Difficult to Implement Continuity of Carer, it maybe the low cost services people actually need and it won’t save money to funnel more people into high cost services who only needed a low cost service.  This is the case with Maternity care in special degree – why send healthy young women across a vast county to birth in a high cost obstetric unit when they can more cheaply and safely birth at home or in a midwifery led unit? But if you have made a capital investment in a new Obstetric unit as SaTH has done – it has to be paid for by a higher throughput of women.  Read Belinda Phipps analysis in my blog: One to One Midwifery: How things can Change, of why Trusts may not save money by promoting midwifery led care.  In Austerity NHS, medical-based evidence may come second to a real terms reduction in NHS budget and whoever shouts loudest wins – so shout!

To support those campaigning locally for Shropshire MLUs join the Facebook group : https://www.facebook.com/groups/1219003658173471/

To join in a positive discussion about Freestanding Midwifery Led Units in rural areas and implementing the National Maternity Review for rural populations come to the fantastic Conference Chaired by Baroness Cumberlege 13th February for just £35 at the Shropshire Conference centre.  More info here: https://www.facebook.com/events/151748521970107/


I’ve Had Enough Of Hearing About Jeremy Corbyn.

I don’t re-blog blogs and I don’t want to be party political here.  But this blog is an exception because ultimately it discerns the Corbyn phenomena as a  strong desire for change – he just happened to get in the way of it!  Whatever your political persuasion this blog has a message about making change happen. And that politics and change-making should be about making things better for people – especially the most vulnerable: the sick the young, the very old, the poor, the refugee.  And of course those of us in maternity know how very important change for the benefit of women babies and families is important at this time.

Hold on to your seats for this roller coaster blog!

Right, that’s it, I’ve had enough. I’ve sat on my hands for long enough. I’ve spent months looking at conversations and threads on the internet about Jeremy Corbyn, about ho…

Source: I’ve Had Enough Of Hearing About Jeremy Corbyn.

“In case you sue us”. A discussion on consent.

Guest blog by Emma Ashworth

I had a mole removed yesterday.  Just a simple procedure, done in the GP clinic on a smooth running, efficient weekly service.

Before the doctor went anywhere near me with a scalpel, I was asked to sign a consent form because, of course, even when I ask someone to cut a piece off me, we all need to be very clear about what exactly I have requested, and what they have agreed to do.  I’m quite fussy about consent forms.  I like to know what I’m signing.  I like to read all of the details and to ensure that I clearly understand what is being offered and what the potential risks may be.

Consent forms can often be long and complicated.  This one wasn’t – it was a small piece of text on an A5 sheet of paper and the consent wording was along the lines of, “I agree that I have been fully informed of all of the risks, which may include bleeding, pain and scaring”.  It reminded me of a self-discharge form that I was asked to sign in hospital once.  It stated that, “I have been made fully aware of all of the risks of self-discharging”.  However, the reason that I was self-discharging was that I had been in the hospital for two days without seeing a doctor once, my symptoms had gone and I was clearly low priority, as otherwise I would have already have had a discussion with the doctor, which would have meant that I was, in fact, fully aware of any risks of leaving.  I hadn’t, so I wasn’t.  I declined to sign that form and left anyway.

In AD 579, Emperor Justin II was in need of emergency surgery.  No surgeon would even attempt the procedure because they were too worried about being blamed for it if it went wrong.  Emperor Justin handed the surgeons the scalpel himself to clearly show his request for the surgery, and promised that there would be no retributions if they failed.  In fact, he died, so it’s a good job that they did!  This very early example of consent being gained for the surgeons’ protection rather than the patient’s, is now being repeated time after time in our hospitals and clinics.  The time pressures on clinicians is such that it is extraordinarily difficult for them to walk us through the pros and cons of different options, and so often reduced to the effects of the paternalism endemic throughout history, where the likes of Henri de Mondeville in the late 13th Century stated, “patients […] should obey their surgeons implicitly in everything appertaining to their cure”, and even the Hippocratic texts which recommend, “concealing most things from the patient, while you are attending to him.”

While the lack of information sharing nowadays is almost always for entirely different reasons (a lack of time, not desire for control), we do see responses from medical staff when we ask for more information which perhaps many might get huge value from reflecting on. In my experience, impatience is the usual reaction, which again is likely to be because of time constraints, but sometimes there is perhaps a paternalistic throw back. For instance, I was once in a meeting with a consultant who was in discussions with a doula client.  She had plenty to ask after much preparation between us.  After she had gone through a number of her questions, the doctor asked in rather frustrated tones, “You seem to know an awful lot about this. Who have you been talking to?”

My client responded, “Well, my doula”

To which the doctor snapped back, “No, I meant which professionals?”.

So, to go back to my own minor surgery yesterday. I read the consent form and I pointed out that to sign to say that I was fully informed of the potential risks, without them all being laid out, was not full consent. The doctor replied that there was a list, look, right there, and anyway it’s just, he said, so that you won’t sue if there’s any issues.  I explained that I meant that the wording itself implied that there were other risks that weren’t listed – I couldn’t blanket consent to say that I know everything – and, importantly from his perspective, he was unlikely to be protected if, say, he hit a tendon and caused me to lose function in my hand.

The next day I happened to be in the same GP surgery again for a physio appointment. Because my wound had bled quite badly, I asked the receptionist if she would be able to get me a replacement dressing from the nurse.  “Oh no”, she replied, “you’ll have to have an appointment for that”.

“Why?” I asked. “It’s basically like changing a plaster, I can just do it myself”.

“Well,” she responded, “you might sue us if it’s been bleeding so I need to make sure that the nurse sees you to protect ourselves.”

Is this really where we have gone with obtaining consent? I cannot change my own simple dressing because I might sue for some minor bleeding that I’d already signed to say that I understood might happen?.  On the one hand, are health professionals trying to desperately cover themselves with extensive notes, and consent forms which may or may not be adequate, and on the other hand completely unable to give people in their care the time to actually talk things through properly? What does obtaining consent mean? When women in the throes of labour are bullied in caesareans with long speeches about the dangers of continuing with their vaginal birth, and then they are given complex consent forms with risks such as “death” as they’re being wheeled towards the theatre, can we really say that they’re consenting?  And in the end, who, if anyone, is being protected here?

Consent is not as simple as signing a consent form. Food for thought for both health carers and the people in their care.



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!

Continuity of Carer: Summary for CCGs and the National Maternity Review

The hardworking, well informed and  persistent midwifery campaigner and strategist Brenda van der Kooy has once again helped us all by providing a useful summary of the research on continuity of carer and the financial and health advantages to the NHS.  She balences this against the higher cost of this care compared to the fragmented/factory model maternity/midwfery care as we have it now.  She says that for those who want continuity of carer and its benefits for themselves, their friends and their family – this, basically is what you need to tell the National Maternity Review.

Implementing Continuity of Carer

Since the recognition of the importance of ‘continuity of care’ in the Changing Childbirth Report 1993, many case loading pilots have been undertaken. Although virtually all have not continued and national rollout has not occurred, their evaluations have added to the robust evidence that ‘continuity of carer’ improves outcomes for mothers and babies and the women who experienced this care valued it very highly.

Improved outcomes that were measured include:

  • higher normal birth rates,
  • lower intervention rates,
  • reduced preterm births,
  • reduced admissions to Special Care Baby Units, and
  • increased breast feeding rates which leads to:
    • reduction of necrotising enterocolitis in babies;
    • reduction of otitis media and lower respiratory infections in babies, and
    • reduction of breast cancer in mothers.

These provide significant direct financial savings for the NHS. It has been suggested that many other medium and long term health and social benefits will also result from the outcomes of an optimal pregnancy, birth and early weeks experience for mothers and babies.

The reasons for cessation of the case loading pilots were:

  • withdrawal of or inadequate funding;
  • midwife burnout from carrying too large caseloads, and
  • difficulty recruiting further midwives into an underfunded, overstretched model.

Case load midwifery care is the only model that can provide ‘continuity of carer’ and it does cost more than the fragmented care provided by the current shift pattern model. This is in order to pay midwives appropriately for the significant on call commitment required for when their caseload of women give birth and to cap their caseload to a sustainable and safe number of women. This investment is also required to reap the ongoing life time savings from the improved health and wellbeing of mothers and their children as identified in the NHS Five Year Forward View.

The simplest way to provide this investment and for it to act as a lever for maternity providers to innovate and provide continuity of midwifery carer is to introduce a national ‘continuity tariff’. This paid to any provider who can prove that a woman was attended throughout her pregnancy, labour and the early weeks by her named midwife (or her back up).

The implication of not addressing this resource shift at national level to implement ‘continuity of carer’ will be that the opportunities for improved physical, mental health and well being for mothers and their children will continue not to be realised along with the failure to reap the significant potential ongoing financial savings.

Brenda van der Kooy RGN, RM, PGCEA, MSc Advanced Midwifery Practice

Midwifery Consultant


DoH (1993) Changing Childbirth: Part 1: Report of the Expert Maternity Group, London: HMSO

Sandall J, Soltani H, Gates S, Shennan A, Devane D.; Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3.

Sandall, J., Davies, J., & Warwick, C. (2001). Evaluation of the Albany midwifery practice: final report, March 2001. Florence Nightingale School of Nursing & Midwifery, King’s College. Available online at http://openaccess.city.ac.uk/599/

Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study BMJ 2009;338:b2060

Renfrew MJ, Pokhrel S, Quigley M et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF UK; 2012. Available from: http://www.unicef.org.uk/Documents/Baby_Friendly/R

Building Great Britons Conception to Age 2: First 1001 Days All Party Parliamentary Group

February 2015

NHS Five Year Forward View October 2014

Wesson N, Carter N.; The Search for Continuity. AIMS Journal Vol: 26. No: 3. 2014

When labour needs to start

A different way of approaching the baby’s birth. Useful techniques but also a different way of thinking about how birth begins and making a birth easy.


There are several situations when it is preferable that labour start sooner rather than later. These include-

  • prolonged pregnancy (although the WHO recognises than normal human gestation at term is 38-42 weeks many women, especially older mothers have pressure put on them to accept induction from 40-40+10 days, due to a potential increased risk of stillbirth)
  • Elevated blood pressure (gestational hypertension at term)
  • Women with type 1 or 2 diabetes at term
  • rupture of membranes at term without labour

Although some women are happy to accept induction, others would prefer labour to start naturally or are planning to birth at home so do not want o go into hospital for induction.

I have been offering a ‘Starting labour’ one to one session(in NorthWest and Wales, UK)  for the past few years and have had good results (the majority of women going into labour within 24 hours) although some people have…

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You have the right to choose where you give birth!

Elizabeth Duff, Senior Policy Adviser at the NCT shared this with me recently after a case where a GP was apparently choosing the place of birth for the women in their care!

“It was confirmed in Parliament this year that Maternity Matters™ (2007) remains maternity policy for the current government. It says:

The national choice guarantees four national choice guarantees will be available to all women and their partners. By having these guarantees, women and their partners are given the opportunity to make informed choices throughout pregnancy, birth and during the postnatal period:

  1. Choice of how to access maternity care. When they first learn that they are pregnant, women and their partners will be able to go straight to a midwife if they wish, or to their General Practitioner. Self-referral into the local midwifery service is a choice that will speed up and enable earlier access to maternity services.
  2. Choice of type of antenatal care. Depending on their circumstances, women and their partners will be able to choose between midwifery care or care provided by a team of maternity health professionals including midwives and obstetricians. For some women, team care will be the safest option.
  3. Choice of place of birth. Depending on their circumstances, women and their partners will be able to choose where they wish to give birth. In making their decision, women will need to understand that their choice of place of birth will affect the choice of pain relief available to them. For example, epidural anaesthesia will only be available in hospitals where there is a 24 hour obstetric anaesthetic service.

The options for place of birth are:

  • birth supported by a midwife at home
  • birth supported by a midwife in a local midwifery facility such as a designated local midwifery unit or birth centre. The unit might be based in the community, or in a hospital; patterns of care vary across the country to reflect different local needs. These units promote a philosophy of normal and natural labour and childbirth. Women will be able to choose any other available midwifery unit in England.
  • birth supported by a maternity team in a hospital. The team may include midwives, obstetricians, paediatricians and anaesthetists. For some women, this type of care will be the safest option but they too should have a choice of hospital. All women will be able to choose any available hospital in England.”

If you have to stand up to get your rights respected, there’s also a Birthrights fact sheet that might help you prove your point.

Excellent training: find out when Dianne’s near you

Dianne Garland’s training has been widely praised by midwives. I think she’s a super hero and love her study days! She has a really woman centred approach, there’s lots of practical professional advice and plenty of time to practice problem solving. Dianne also shows videos to highlight how birth varies around the world.

Her study days are run throughout the year all over the country. You can usually book a place but occasionally spaces are limited to the organisation who’s booked her. Many are also open to doulas as well as midwives and students.

2014 dates

13th Nov. – East Kent – awaiting details
18th Nov. Manchester – open to externals -Chris.Mckay@UHSM.NHS.UK]
21st Nov. Scunthorpe – open to externals -kimsheppard@nhs.net jane.stoney@nhs.net
9th December – South Bank uni – not open to externals

January – February – India awaiting details
March – Blackpool – awaiting details
20th March – Peterborough –open to externals – info@barefootbirthpools.co.uk
March –Uni. Of York – awaiting details
March Uni of Hull – awaiting details
March – Barcelona – awaiting details
30th May – Dartford Kent- open to externals – Dianne@midwifeexpert.com
Sept. Bracknell – awaiting details

If you can’t see a date that suits you Dianne is always keen to hear from you, you could host your own day. There’s no limit on numbers, and she will talk you through any details of costs/ venue and lecture requirements on request. Study days can be run by a wide range of organisations: trusts/ RCM local branch/ student unions, antenatal / doula educators… and they may generate useful income for the host.

Dianne is an international renowned speaker and has taken her valuable advice to Cyprus, America, Israel, Austria, Croatia, India and China!

Lastly, if you want something a little different, Dianne can tailor a study day and will check exactly what you need in advance. Click on www.midwifeexpert.com for some of her glowing testimonials and to get in touch directly.

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