The new suffrage movement

Friday night: I have just arrived back from watching Suffragette at the fantastic Llanfyllin Community Cinema.  I say I have arrived back but first I hadto make my way to the wetlands – my place of solitdue and thought – to sob my heart out.

That film recalled to me the immense bravery, tenacity and courage of the women of the suffrage movement and especially the suffragettes.  It reminded me of the suffering women under went to gain basic human rights.  The awful suffering.

And confronted with that, who am I to complain about the slings and arrows that might come my way for campainging for quality, humane maternity care?  How can I justify hanging back when I know it is time to step up to the challenge. When the lives of women and babies, families and communities depend on it.

I have indeed struggled for the last 2 years with a kind of slow burn exhaustion, I am indeed overworked and have a family to care for.  But so did these women and that is when it takes real courage and fortitude.

So again and now I step up to the challenge, I carve out the time, I pick up my pen and my laptop and I do my bit.  Thankyou film makers for recalling me to myself, thankyou to all those who are working for change and are so supportive, thankyou brave and courageous women who showed us the way: yours are the shoulders we stand on.

 

 

 

 

 

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!
Capture

Infant Loss, Inequality and why things should change

I went to a workshop  a couple of weeks ago about ‘Inequality and Infant Loss: Identifying the gaps in women’s networks’.

I learnt that the UK rate for infant mortality is 4.1 per thousand. But for Caribbean Women it is 9.7 per thousand, for Pakistani women it is 7.4 per thousand, for African women 7.4 per thousand and for teen mothers 5.4 per thousand births.

I also learnt that in Bradford and Airedale the only risk group that get caseloaded midwifery are the teen parents.  Their normal birth rate is 94%.

The highest risk groups in our city do not get caseloaded midwifery and we know this is affecting outcomes.  And outcomes are not just statistics but human beings lost and unnecessary grief and suffering.

One to One Midwifery came to Bradford and Airedale offering women caseloading care on the NHS with evidence of great outcomes elsewhere. They are being prevented from operating in our area because our local CCGs are both refusing to commission them or pay the invoices on non contracted activity.

At the same time local Trusts tell us that they cannot at this time deliver one to one midwifery care even to the most vulnerable and at risk groups in our city – except teen parents – who need it most.

These UK infant mortality rates reflect our experience in Bradford district over several years and I am saddened and disappointed that the people who have the power to make a difference – without paying extra  – are currently choosing not to do so.

Is there any one there who will answer?  Who will do something that will make a difference?

One to One Midwifery: How things can change

Belinda Phipps CEO of the biggest UK wide charity for parents NCT sets out the barriers to achieving one to one midwifery care on the NHS and how it can change to enable the maternity care we all want.

The question is:  why is it proving so difficult for CCGs and Providers to deliver one to one care, and why is there so much opposition to commissioning other providers to deliver the care?

In addition to the answer given below she has offered to work with CCG commissioners here and in other parts of the country because she says there are ways and means of working within the NHS rules, inappropriate as they are at the moment, to give acute hospital providers the flexibility they need to deliver one to one/personalised, continuity of CARER.

Belinda Phipps, CEO of NCT over to you:

I think you know that it is proving difficult for the NHS itself to offer or to buy in proper one to one care with a midwife you know and trust because

1)      The health service including commissioners don’t accept/understand how important continuity of carer is to women and what health benefit/cost reductions this can bring over all to the NHS. If you want to help them understand add your voice to this campaign   http://www.m4m.org.uk/

2)      The heath service cannot, with in its current system rules accommodate case-loading in a sustainable way that is acceptable to most midwives

3)      Fairness is an important NHS value and a service that is “unfairly” better and reaches only a minority of women is difficult for commissioners to take on.

I think first we need to change NHS rules:-

In England the new risk based PbR (Payment by Results) will not work any better than the old activity based one.  We need a system that is truly based  on results ie outcomes for the woman and her baby.  We need to pay when women are satisfied with their care and when babies and mothers come through pregnancy and labour whole and healthy with the mother feeling ready to start her role as mother.

The old PbR (Payment by Results) system paid by activity.  The more activity you did as a hospital, the more you got paid, the more complex activity you did the more you got paid. It was based on the principle that C-Section costs more than a normal birth so the payment for this would be higher, using the principle that the price of an activity is the same as costs, because the NHS is non profit making.  However the actual cost of a C-section for instance is not known and the payment for it does not necessarily bear any resemblance to what the procedure actually costs in reality.

However, in reality, in an Acute Trust 85% of costs are fixed which means that a per treatment cost as above 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 rate means they cannot cut costs because so much of it is fixed so start to have 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 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 is not only on being safe during intervention however necessary or unnecessary they are.

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 alighted 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.

NCT ONE TO MDIWFERY HOW THINGS can change 1

It starts to address this problem of women being left alone in labour and stressed midwives caring for may women because the rostering pattern almost never matches the number of women in labour.  It can’t be done like this, so the system needs changing.

NCT 121 midwifey blog 2

I am happy to offer whatever support I can though I think NCTs optimum skill is getting attention paid to these rules so they change for the better and make it possible for women to have a midwife they can get to know and trust who is there fore the pregnancy, labour and birth and afterwards.   if you want to help join us http://www.nct.org.uk/get-involved/become-nct-member

Best wishes

Belinda

Belinda Phipps

Chief Executive

Thankyou Belinda!

And don’t forget the Airedale Mums Petition for One to One Midwifery http://www.thepetitionsite.com/593/491/398/support-one-to-one-midwifery-care-for-the-women-of-bradford-and-airedale/

Women are voting with their feet for one to one midwifery care

Midwife 4 ME:

Women in West Yorkshire choosing one to one midwifery care

Scores of women throughout West Yorkshire and beyond have been voting with their feet in the last few weeks as news got round that One to One midwifery (Northwest) Ltd had set up in West Yorkshire.  One woman said “I referred myself to them because I wanted to be guaranteed a homebirth without staffing issues”.  Another said she had seen four different midwives postnatally and had seen different midwives ante-natally and through her birth.  This time she wanted to have the support of the a midwife who knew her.

At present local Commissioners are not supportive of the choices these women are making:  saying “We are not commissioning One to One midwifery at present.  We recognize that caseloading midwifery is in the NHS mandate but although it is a commissioning stance, it is not a priority for the CCGs ( GP commissioning groups) amongst its wider commissioning priorities.”  The CCGs say that it’s patient engagement exercise last year did not reveal this as a priority for patients generally or the mothers they consulted.

Ruth Weston, Co- chair of the MSLC says:  “We do not know who the CCGs consulted with but we do know this did not include the MSLC, NCT or Airedale Mums.   More consumer and Voluntary sector groups are being contacted for whether they were consulted.”

In the meantime, several consumer organizations have been writing to the local CCG Commissioners requesting, in the light of medical evidence, that women’s healthy choice is respected and paid for when they seek a care provider offering one to one midwifery care.   Airedale Mums have also set up a petition at

http://www.thepetitionsite.com/593/491/398/support-one-to-one-midwifery-care-for-the-women-of-bradford-and-airedale/

Beverley Beech, Chair of AIMS ( www. aims.org) wrote to the CCG Commissioners saying:

“The Government has made it clear that there should be more community based care and the Birthplace Study showed that women and babies were safer birthing at home or in free-standing midwifery units.  In their recently published NHS Mandate it states:
 “Ensure every woman has a named midwife who will make sure she has personalized one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”
The One to One midwifery service provides precisely this service.  I understand that nearly 100 women have referred themselves to One to One in the last month alone, and more are trying to do so every day.  This group has a team of extremely skilled midwives and it is puzzling that your group is not enthusiastically embracing this service.  Not only does it improve the quality of care to women and babies, reduce mortality and morbidity but also saves an enormous amount of money (see references 1-34).    I do wonder just how much evidence of quality care and benefit is needed before action is taken?  One would have thought that this would be a no-brainer and I would, therefore, appreciate it if you can explain to me why you are not supporting this service.”

The full text of letter with 34 citations is given at the end of this blog.

Local Campaign Group Airedale Mums wrote:

” It has come to our attention that an amazing opportunity could be opened up for the women of the district through the commissioning of private care provider One to One Midwifery.  Airedale Mums have met and corresponded with One to One Midwifery and we were very impressed by their model of care and record of normal birth in the Wirral. Several of our members attended the Open Day in Bradford last month and were further enthused by the transparency of information and the excellent attitude of all the One to One representatives.

We have also been asking questions at the MSLC over recent months about how the Commissioners and Acute Trusts are going to handle the requests of women who would formerly have chosen Independent Midwifery care – no solutions have been put forward.

For this reason we have been utterly baffled to discover there is high level opposition to this service from the Area CCG’s.  Bradford may have taken steps to introduce Midwifery led intrapartum care, but our district is way behind the game when it comes to case-loaded antenatal and postnatal care.  Many of the women who engage with Airedale Mums have seen up to 12 midwives for antenatal care alone.

The prospect of a family being given named Midwife care throughout pregnancy, birth and the postnatal period (up to six weeks) is no longer a halcyon dream.  Not only that, but this care can, and IS being provided at the same tariff as comparably less successful models being used within the NHS.”

Women of Yorkshire and the UK in general it is time to vote with our feet, our pens and our voices for the care we need.  It is being offered to us here on a plate, but if we do not write those emails to our MPs  and local GP commissioners, if we do not sign the petitions, if we do not start voting with our feet and referring ourselves ( do we have to be pregnant to refer ourselves in?!) into to One to One Midwifery and Neighbourhood Midwives even if they cannot currently provide our care, then we will be doomed to suffer another generation of fragmented, factory, care leaving us and our daughters traumatised, alone and angry.

You can join the campaign by doing three easy things:

  1. Signing the petition:http://www.thepetitionsite.com/593/491/398/support-one-to-one-midwifery-care-for-the-women-of-bradford-and-airedale/
  2. Writing to your local MP and your local CCG Commissioner. You can write to your MP asking her/him to forward your letter to the local commissioner.  A good framework for a letter is given above by Airedale Mums and Beverley Beech.
  3. You can go to  www.M4M.org.uk and sign up to the national campaign which has a lovely postcard to save you the hassle of writing a long letter.

If you want to do more, contact me or Airedale Mums if you live in West Yorkshire, if you live elsewhere contact M4M (  Midwifery 4 Me) or AIMS.  Now is the time to act.

Full Text of Beverley Beech’s Letter complete with 34 citations:

Dear Mr Pue

I am dismayed to hear from our members the difficulties they have been having in being able to refer themselves to One to One midwifery practice, and very disturbed by the reluctance of your Commissioning Group to commission these services.

The Government has made it clear that there should be more community based care and the Birthplace Study showed that women and babies were safer birthing at home or in free-standing midwifery units.  In their recently published NHS Mandate it states:

 “Ensure every woman has a named midwife who will make sure she has personalized one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”

The One to One midwifery service provides precisely this service.  I understand that nearly 100 women have referred themselves to One to One in the last month alone, and more are trying to do so every day.  This group has a team of extremely skilled midwives and it is puzzling that your group is not enthusiastically embracing this service.  Not only does it improve the quality of care to women and babies, reduce mortality and morbidity but also saves an enormous amount of money (see references 1-34).    I do wonder just how much evidence of quality care and benefit is needed before action is taken?  One would have thought that this would be a no-brainer and I would, therefore, appreciate it if you can explain to me why you are not supporting this service.

Yours sincerely
Beverley A Lawrence Beech
Hon Chair
Association for Improvements in the Maternity Services

The following documents support the statements that are made in this letter:

  1. Only 1 in 5 women will be attended at any point in their labour by a midwife they have met before:

Redshaw M, Heikkila K. Delivered with care: a national survey of women’s experience of maternity care 2010. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2010. Available from: https://www.npeu.ox.ac.uk/files/downloads/reports/Maternity-Survey-Report-2010.pdf

  1.  Only one in 10 will have a midwife they have met before, while in other places nearly 1000 of them will be left alone in labour or after the birth when they are frightened

Healthcare Commission. Maternity services review 2007 Data tables for 148 trusts in England. Available from: http://webarchive.nationalarchives.gov.uk/20101014074803/http:/www.cqc.org.uk/aboutcqc/howwedoit/involvingpeoplewhouseservices/patientsurveys/maternityservices.cfm

3. Over 1 in 4 women will have a caesarean operation.NHS Information Centre. NHS maternity statistics, England: 2011-2012. Available from: http://www.ic.nhs.uk/statistics-and-data-collections/hospital-care/maternity/nhs-maternity-statistics-england-2011-2012; http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1941

  1. 8 in 1000 babies die at or around the time of birth.  Sands. Preventing babies’ deaths: what needs to be done. Sands; 2012. Available from: http://www.uk-sands.org/fileadmin/content/Media/PREVENTING_BABIES_DEATHS_REPORT_2012LR02.pdf
  1. One in ten women will become depressed following the birth.  Just over 1 in 3 women will appraise their experience as ‘traumatic’ and 2 in 100 women will develop post tramatic stress disorder (PTSD).  Alder J, Stadlmayr W, Tschudin S, et al. Post-traumatic symptoms after childbirth: what should we offer? J Psychosom.Obstet Gynaecol. 2006;27(2):107-12.
  1. Tyler S. Commissioning maternity services. A resource pack to support Clinical Commissioning Groups. Available from: http://www.commissioningboard.nhs.uk/files/2012/07/comm-maternity-services.pdf

The way a woman is supported and cared for during her pregnancy and birth, and in the days and weeks following, profoundly affects her and her partner’s ability to parent their baby

7.            Allen G. Early intervention: the next steps. London: The Early Intervention Review Team; 2011. Available from: http://dwp.gov.uk/docs/early-intervention-next-steps.pdf

  1.   Odent M. The scientification of love. Free Association Books; 1999.

9.            Solter A. Tears for trauma: birth trauma, crying, and child abuse. 1996. Available from: http://www.primalspirit.com/pr2_1solter_tears.htm

10.       The way that a baby develops in utero and in the weeks after birth is influenced by the quality of care that parents receive   Field F. The foundation years: preventing poor children becoming poor adults. The report of the Independent Review on Poverty and Life Chances . London: Independent Review on Poverty and Life Chances; 2010. Available from: http://povertyreview.independent.gov.uk/final_report.aspx

11.       Quality maternity services should be defined by the ability to provide a safe transition to parenthood and a positive and life enhancing experience.  Midwifery 2020 UK Programme. Midwifery 2020: delivering expectations. Edinburgh: Midwifery 2020 UK Programme; 2010. Available from: http://midwifery2020.org.uk/documents/M2020Deliveringexpectations-FullReport2.pdf

  1. Providing a model which ensures that women can be seen in a community setting where appropriate and focuses on the needs of the woman and her baby and enhances the woman’s experience.  Royal College of Obstetricians and Gynaecologists EAG. High quality women’s health care: a proposal for change. London: RCOG; 2011.
  1. One in five women is left alone in labour.  Care Quality Commission. Maternity services 2010. Available from: http://www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/maternity-services-survey-2010
  1.   10-15% of women suffer from postnatal depression.  National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical management and service guidance. National Clinical Practice Guideline Number 45. London: The British Psychological Society and The Royal College of Psychiatrists; 2007. Available from: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11004
  1. 8% of babies are born prematurely.  Office for National Statistics. Preterm births data (2007, Accessed 26 March 2013). Available from: www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-50818

16.       69% of new mothers start breastfeeding exclusively, but a week after birth, only 46% are doing so.  Health and Social Care Information Centre. Infant feeding survey 2010. Health and Social Care Information Centre (IC); 2012. Available from: http://tinyurl.com/afu6yb2

17.   The birth rate increased by 22% between 2001 and 2011.  Royal College of Midwives. State of maternity services report 2012. London: RCM; 2012.

  1.  More older first-time mothers are giving birth.  HM Government. General Household Survey. Available from: http://data.gov.uk/dataset/general_household_survey
  1. There is an acute shortage of midwives.  Front Line Care: the future of nursing and midwifery in England. Report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England 2010. London: The Prime Minister’s Commission on the Future of Nursing and Midwifery in England; 2010. Available from: http://cnm.independent.gov.uk/wp-content/uploads/2010/03/nursing_midwifery_report.pdf

20.       There is no financial incentive to provide continuity of midwifery care, but the improved outcomes demonstrated by this service generate significant savings.  van der Kooy B. Continuity of care: the elusive key to improved maternity outcomes . Pract Midwife 2013;16(4):16-7.

21. Centralisation of maternity care in fewer, very large impersonal obstetric units create increased travel time for women in labour.  NCT. Location, location, location: making choice of place of birth a reality. London: NCT; 2009.

22.  . Student midwives have a high drop out rate because after qualification they are unable to practise in the way that they wished.Centre for Workforce Intelligence. Workforce risks and opportunities: midwives. Education commissioning risks summary from 2012. Woking: Centre for Workforce Intelligence; 2012. Available from: http://www.cfwi.org.uk/publications/midwives-workforce-risks-and-opportunities-education-commissioning-risks-summary-from-2012

23.       Fewer women having the support they need to have straightforward births

Downe S, McCormick C, Beech BL. Labour interventions associated with normal birth. British Journal of Midwifery 2001;9(10):602-6.

24.       Fewer women having one-to-one midwifery care in labour in obstetric units. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400.

25.       The required ratio of one midwife to 28 women is not being met.  Smith H. Daily Hansard debate 17 Jan 2012. Midwife and maternity services. Available from:

http://www.publications.parliament.uk/pa/cm201212/cmhansrd/cm120117/debtext/120117-0004.htm

26.   Each woman should have a named midwife they can get to know and trust and who they will see during their pregnancy, birth and after their baby is born.  Association of Radical Midwives. New vision for maternity care. Hexham: The Association of Radical Midwives; 2013. Available from: http://www.midwifery.org.uk/wp-content/uploads/2013/02/The-Vision-2013.pdf

27.  To provide care in line with the evidence will require the establishment of maternity networks with most care based in the community.   NCT. Innovative, integrated and in the interest of families: the Maternity Network approach. London: NCT; 2010.

Good evidence demonstrates improved outcomes from midwifery case-loading models providing continuity of community-based care

28. McLachlan HL, Forster DA, Davey MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG 2012;119(12):1483-92.

29. Milan M. Independent midwifery compared with other caseload practice. MIDIRS Midwifery Digest 2005;15(4):439-49.

30. Improved birth outcomes generate significant financial savings.  NHS Institute for Innovation and Improvement. Delivering quality and value. Focus on: caesarean section. Coventry: NHS Institute for Innovation and Improvement; 2006. Available from: http://www.institute.nhs.uk/quality_and_value/high_volume_care/focus_on%3a_caesarean_section.html

31. Increased breastfeeding rates have the potential to save the NHS £40m a year.  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/Research/Preventing_disease_saving_resources.pdf?epslanguage=en

32. Payment by Results is not well-suited to promoting continuity and co-ordination of care.  Appleby J, Harrison T, Hawkins L et al. Payment by Results: how can payment systems help to deliver better care? London: King’s Fund; 2012. Available from: http://www.kingsfund.org.uk/publications/payment-results-0

33.Independent midwives need to have insurance and guaranteed access rights to support women giving birth on NHS premises.   Independent Midwives UK. Current situation with regard to the forthcoming requirement for mandatory Professional Indemnity Insurance. 2012. Available from: http://www.independentmidwives.org.uk/files/pii_update.pdf

34.  Midwifery led care when compared with models of medical led care and shared care was associated with several benefits for mothers and babies, and had no identified adverse effects.  Hatem M, Sandall J, Devane D, Soltani H and Gates S.  Midwife-led versus other models of care for childbearing women, The Cochrane Collaboration, http://apps.who.int/rhl/reviews/CD004667.pdf

Because it is not an ideal world . . . .

This week I have had a lot of ‘in an ideal world . . ‘ comments from people talking about midwifery staffing and one to one care.

And I want to say I am fed up of it, I want it to stop and it needs to challenged!

To say that in ideal world we want gold standard one to one midwifery care, is to consign that notion to impossibility.  One to one care IS happening on the NHS now in Liverpool (the Wirral) and elsewhere.  Small puddles in the desert they may be but nevertheless demonstrations of the concept of real world gold standard care.

Yesterday I was at a meeting about where things went badly wrong in maternity service, and the report states that staffing had been an issue on the night and it was clear there was big lack of continuity of care – but it was deemed unchangeable – in comparison to changing the policy to ensure many more women will have a medical birth to ‘save’ this happening again.

In an ideal world was the medical directors comment, and I said “No, its not about an ideal world its about saving women’s lives’

Sisters brothers, comrades in arms, one to one midwifery care, gold standard continuity of carer that provides dignity and time and respect to every woman, saves women’s health, sanity, and their lives.  This kind of midwifery ensures baby gets mothers milk and fathers get support and guidance, this kind of support is called social care and it makes a big difference to families and communities.  And its not for an ideal world because in an ideal world we would not need it – gold standard midwifery care is for the real world because we need it to meet the challenges of healthy birthing and parenting.

Our mantra should be ‘Its not an ideal world  – that’s why we need gold standard one to one midwifery care!