House of Commons - Health Committee

Commissioning - Health Committee Contents

Memorandum by NCT (COM 118)

COMMISSIONING, INCLUDING A PROPOSED MODEL TO REMOVE THE PERVERSE INCENTIVES IMPOSED BY PAYMENT BY RESULTS IN MATERNITY SERVICES

1. Executive summary

1.1 Payment by Results has a negative effect on maternity services. Under the current system, more is paid to a Trust where more interventions are performed. This contradicts other government policy that aims to reduce the medicalisation of birth and increase normality, such as the National Service Framework for Children, Young People and Maternity Services.[27]

1.2 By paying the tariff in this way, there is a perverse incentive towards interventions, and commissioners will see that any moves to reduce these will result in a loss to the Trust.

1.3 This system only acts to exacerbate the rising rates of caesarean section that so much work, such as the NHS Institute for Innovation and Improvement's "Self-improvement toolkit" on reducing caesarean section rates,[28] is aiming to curtail.

1.4 Instrumental births are associated with longer stays in hospital, which will lead to increased use of resources.[29]

1.5 Interventions in births are associated with increased "downstream" costs, the need for which will be reduced as normal birth rates are allowed to rise.[30]

1.6 The NCT recommends a system whereby one price is set for a birth. This will reward a service for making fewer interventions, and will allow commissioners to take decisions that will achieve movement towards higher normal birth rates, in keeping with government policy.

2. About the NCT

2.1 The NCT is the foremost charity working for parents in the UK. We support thousands of people each year through pregnancy, birth and early parenthood.

2.2 We have a membership of 104,000, and operate a branch structure to allow the UK office a comprehensive view of services for parents from both a national and local perspective.

2.3 The NCT believes that maternity and early parenting services should be designed around parents' needs.

2.4 The NCT believes that the normal physiological processes of birth and breastfeeding can make a major contribution to the health and well-being of women and babies but are threatened by pressures of modern society and need protection and promotion.

3. Factual information relating to the Inquiry

3.1 Payment by Results is a system intended to recompense services within the NHS for the delivery of care. It was introduced in 2003, in order to "pay NHS Trusts and other providers fairly and transparently for services delivered, while managing demand and risk."[31] Since this time, it has been growing increasingly complex in order to accommodate the various services available via the NHS.

3.2 In terms of maternity, there are nine levels of payment, depending on the complexity of the procedure.[32] These are as follows:


Description	Tariff

Normal delivery 19 years and over with complications	£1,881
Normal delivery 19 years and over without complications	£1,174
Normal delivery 18 years and under with complications	£1,921
Normal delivery 18 years and under without complications	£1,177
Assisted delivery with complications	£2,288
Assisted delivery without complications	£1,728
Caesarean section 19 years and over	£2,579
Caesarean section 18 years and under	£2,654
Caesarean section with complications	£3,626

3.3 This table highlights the misnomer of Payment by Results, as results are not accounted for. Payment is made by activity.

3.4 It is universally accepted that outcomes are better for women and for babies when interventions in labour are kept to the minimum necessary.[33], [34] For this reason, the Department of Health prioritises working towards normal births—those with no interventions—for women with low risk pregnancies.[35]

3.5 For the past three decades, the normal birth rate has been falling, while the caesarean section rate has risen. This medicalisation is the reverse of the intention of the Department of Health in the National Service Framework for Children, Young People and Maternity Services.

4. Recommendations

4.1 The left hand side of the chart below—using real figures from a Trust—demonstrates the disincentive for normal births, with interventions achieving a profit and normality a loss. With figures like this, it will be clear to any commissioner that initiatives intended to fulfil government commitments to increase normal births will achieve a loss for the service.

4.2 The NCT proposes a system that pays an equal amount for each birth, so rewarding by results, rather than by activity. This equal tariff will remove the disincentive for normal births by making normality profitable. Therefore, commissioners will be enabled to take steps that will encourage normal births without adversely effecting the financial viability of the service.

4.3 The right hand side of the chart shows how an equal tariff incentivises normal births. As the trust adjusts its profile to achieve more normal births, it will achieve more "profit".

4.4 A significant advantage to this model is that the trust benefits further as its normal birth rate increases. As this happens, women and their families will also benefit. Additionally, there will be no extra cost to the health service, as the total tariff will equal its current level. This is more desirable than a model that would aim to add to the tariff for normal deliveries, which would be more costly to the health service, and would retain the price incentive for interventions.