Written evidence from the Royal College
of Midwives (COM 45)
1. The Royal College of Midwives (RCM) is
the trade union and professional organisation that represents
the vast majority of practising midwives in the UK. It is the
only such organisation run by midwives and for midwives. The RCM
is the voice of midwifery, providing excellence in representation,
professional leadership, education and influence for and on behalf
of midwives. We actively support and campaign for improvements
to maternity services and provide professional leadership for
one of the most established of all clinical disciplines.
2. We welcome the opportunity to submit
evidence to this important inquiry, especially as the granular
detail of the policy is still being formed by the Department of
Health.
SUMMARY OF
KEY POINTS
— NHS maternity services are set to be
commissioned separately from most other NHS services, directly
by the NHS Commissioning Board, not by GP consortia.
— NHS maternity services should be commissioned
by planned maternity networks at the regional level; commissioning
via regional outposts of the NHS Commissioning Board would be
unnecessary duplication.
— Experience has taught us that engagement
with the full range of clinical staff by commissioners produces
the best results.
— Maternity dashboards should be used at
a regional level by maternity networks to compare the performances
of a range of local providers; maternity networks should be empowered
to request and require any relevant information from any provider
of NHS services.
— New maternity networks should be legal
entities, with specific powers set out in statute; experience
has taught us that without such powers, some providers will not
cooperate with these new networks.
— Midwives play a vital role in public
health, from breastfeeding, to smoking cessation, to child protection,
to combating obesity; the new local directors of public health
must ensure that they engage with the work of maternity networks
as much as they do with GP consortia.
— Quality of care is so important to maternity
services; systems must be put in place that compel providers to
deliver on high quality care and not just throughput and activity.
INTRODUCTION
3. In future, NHS maternity services will
be commissioned separately from most other NHS services. As set
out in the NHS white paper, maternity care will be commissioned
not by GP consortia but instead by the new NHS Commissioning Board.
4. Our evidence will therefore necessarily
be specific to maternity care and not focus on the planned GP
consortia. Given that our submission will address quite a niche
aspect of the overall commissioning policy landscape, we will
focus solely on what we consider to be the key elements of future
commissioning as they affect NHS maternity services. The Committee's
more general questions are perhaps more pertinent to those set
to be directly involved in or affected by GP consortia.
5. We welcome the Committee's view, expressed
in its calling notice for evidence, that its inquiry "can
contribute to the debate about the implementation of the policies
for commissioning outlined in the Government's White Paper, Equity
and Excellence: Liberating the NHS." We welcome this
assertion as we are keen to influence the policy's implementation,
most specifically with regard to giving maternity networks (a
white paper innovation) a commissioning role and also establishing
such networks in law.
MATERNITY NETWORKS
AND COMMISSIONING
6. The RCM believes that maternity networks
could and should commission maternity services on behalf of the
NHS Commissioning Board. While the exact relationship between
the Board and maternity networks still needs to be determined
in detail, it would seem an unnecessary duplication to have maternity
networks and, simultaneously, regional outposts of the Board responsible
for commissioning maternity services. We would anticipate that
such networks would be accountable to the Board for this function
in just the same way that GP consortia will be for their functions.
7. The exact makeup, roles and responsibilities
of maternity networks are still very much fluid, but we will in
this submission set out ways in which we think maternity networks
could contribute to more effective commissioning.
CLINICAL ENGAGEMENT
WITH COMMISSIONING
8. Currently it is the job of primary care
trusts (PCTs) to commission maternity care for women in their
area. It is our experience that where PCTs have involved midwives
and other clinicians in the commissioning process, a real sea
change in the quality of care has occurred.
9. Blackburn is an example where this has
happened, with commissioners working very closely with managers,
service users, midwives and obstetricians. The resulting reconfiguration
of services offered by East Lancashire Hospitals NHS Trust has
resulted in obstetric services consolidating in Burnley, with
an alongside midwife-led unit delivering 1,500 women annually.
Blackburn will have another midwife-led unit, delivering 1,000
women annually, with a small midwife-led unit in Rossendale, handling
300 births per year for a geographically isolated community.
10. Importantly, the commissioners did not
read "clinicians" simply to mean "doctors".
They engaged with midwives as well. This is important as too often
clinicians are seen as only medical staff, and midwives are the
experts in normal birth.
11. The RCM recommends that maternity networks
follow a similar approach, with full clinical engagement in all
aspects of their work.
12. The Committee asks, "how will commissioners
access the information and clinical expertise required to make
high quality decisions about the shape of clinical services?"
It is clear that the challenge will be less acute for maternity
networks than it will for GP consortia as networks will be responsible
only for one area of care. As far as maternity networks are considered
therefore, securing the direct involvement principally of midwives
and obstetricians will ensure that commissioners access proper
clinical expertise. The value of this approach in east Lancashire
was borne out by the example above.
13. In terms of accessing information, we
recommend that maternity networks are given the power to require
any and all providers to produce any relevant information. Maternity
networks could agree a network-wide maternity dashboard as described
by the Royal College of Obstetricians and Gynaecologists. Dashboards
are now widely used by providers to collect and review information
relating to activity, outcomes, staffing and user satisfaction.
If such a dashboard was used across a network, commissioners would
have ready access to the performance of various providers and
could use the information to discuss variability between providers
in the network.
ACCOUNTABILITY FOR
COMMISSIONING DECISIONS
14. The Committee asks, "What legal
framework will be required to underpin commissioning consortia?"
This question is relevant not only to GP consortia, but also to
maternity networks.
15. The RCM recommends that the link from
the NHS Commissioning Board (which will have responsibility for
commissioning maternity care across England) right down to the
provider level should be along the following lines: individual
care providers will be accountable to a maternity network, which
will have powers and duties set out in statute, which will commission
care from those providers on behalf of the Board, to which the
networks will be directly accountable.
16. The RCM believes that maternity networks
must be constituted as legal entities if they are to have sufficient
authority to secure the cooperation of all maternity care providers
within the network's catchment area. We are concerned that as
NHS trusts attain foundation trust status and as more independent
and private-sector providers enter the market, it will become
increasingly difficult to foster the degree of collaboration necessary
to promote the standards and quality of care that we would want
all women to receive. This will be a challenge for maternity networks
even if they are established in statute; it will be nigh on impossible
if they are not.
17. This is not a theoretical concern, but
one backed up by practical experience. An informal maternity network
already exists, facilitated by NHS South Central. Whilst this
network delivers several benefits—for example, an opportunity
to share information, provide mutual support, standardise protocols
and pathways, and so on—foundation trusts have often been
reluctant to share information and they have restricted the extent
to which even senior staff can participate in collaborative enterprise.
18. And it is important to get maternity
care right. Whilst this area of care consumes only about 2% of
the overall NHS budget, obstetric-related claims for medical negligence
account for 46% of all payouts—almost £1.4 billion
of the £3 billion paid out under the Clinical Negligence
Scheme for Trusts (CNST). Indeed, of the 100 largest payouts made
under the CNST, 79 related to obstetrics.
PUBLIC HEALTH,
COMMISSIONING AND
MATERNITY CARE
19. The white paper states that the public
health responsibilities of PCTs will pass to local authorities,
which will each employ a Director of Public Health jointly with
a new Public Health Service. These directors will be responsible
for ring-fenced public health budgets.
20. Local directors will no doubt seek to
establish good working links with GP consortia, but the RCM would
like to see them also encouraged or required to work closely too
with maternity networks. Midwives play a vital role in promoting
good public health.
21. This public health role is recognised
explicitly in the white paper: "Pregnancy offers a unique
opportunity to engage women from all sections of society, with
the right support through pregnancy and at the start of life being
vital for improving life chances and tackling cycles of disadvantage".
22. Specific examples of the impact that
midwives can have are encouraging pregnant women and family members
to quit smoking and promoting breastfeeding. Midwives are also
heavily involved in two of the most critical public health issues
of today: protecting children and reducing the impact of obesity.
Midwives will often be the first health or social services professional
to have contact with a family and their role in preventing harm
cannot be overestimated.
23. Developing the public health work of
midwives may benefit from involving directors of public health
in the commissioning of services from maternity care providers.
PROMOTING QUALITY
MATERNITY CARE
24. The white paper outlines a number of
ways in which future payment systems for the delivery of NHS care
will reward quality and outcomes in addition simply to activity
levels. Examples from the white paper include the development
of quality standards by NICE as well as the CQUIN payment framework.
25. Maternity care is not a service that
is best assessed simply by throughput, which is what is chiefly
rewarded under Payment by Results.
26. Indeed, the final report of the Midwifery
2020 project states this clearly. This project was commissioned
jointly by the Chief Nurses of the UK's four health departments,
to set the direction for midwifery and identify the challenges
that need to be overcome.
27. In its vision, Midwifery 2020's final
report states: "There will be an increased focus on measuring
the quality of healthcare across the whole maternity pathway.
The best indicators of quality will reflect: person centredness,
safety, effectiveness, efficiency, equity and timeliness."
28. We therefore welcome the move towards
greater reward for quality care and better outcomes.
29. Additionally, there are desired policy
outcomes for maternity care contained within the white paper (eg
extending choice for pregnant women) that require payment systems
to drive their implementation on the ground. Commissioning arrangements
will have to incorporate the need to include financial drivers,
rewarding trusts that genuinely offer a home birth service and
the option of birth in a midwife-led unit. Exactly how these choices
are guaranteed by all-important funding streams will need consideration
and implementation.
CONCLUSION
30. The commissioning arrangements for NHS
maternity services are set to be different from those of most
other NHS services. They will be commissioned directly by the
NHS Commissioning Board and not by local GP consortia. We welcome
this.
31. To make this commissioning arrangement
work however the job of commissioning services at the local and
regional level should rest not with the Board directly, but with
the white paper's other innovation, maternity networks.
32. Experience has taught us that commissioning,
if it is to work, must involve engagement by commissioners with
the full clinical team. As maternity networks will have a narrow
range of services to commission (unlike GP consortia) this should
be easier for them to accomplish.
33. Maternity dashboards offer a template
of exactly how maternity networks can monitor performance from
across a wide range of providers. To make this work however all
providers must be required to provide any and all information
and assistance that is required; to this end, maternity networks
must be legal entities, with specific powers in law.
34. Public health promotion is an essential
component of the workload of an NHS midwife. It is fundamental
to what she does. New local directors of public health must engage
with maternity networks therefore as well as with GP consortia.
35. Maternity care is about so much more
than throughput and activity levels. Quality of care is highly
valued by women using the service. To this end, we must see commissioners
putting in place systems that encourage and reward providers who
provide a high-quality service.
October 2010
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