HC 1048-III Health CommitteeWritten evidence from the Royal College of Midwives (PH 36)

1. The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of practising midwives in the United Kingdom. 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 we also provide professional leadership for one of the most established of all clinical disciplines.

2. The RCM welcomes the opportunity to contribute to the Health Committee’s examination of public health. Our response is based on the views and opinions of RCM members, lay representatives and officers.

3. Maternity care is very important in delivering improvements in public health. As the Public Health White Paper, Healthy Lives, Healthy People, states, “The health and wellbeing of women before, during and after pregnancy is a critical factor in giving children a healthy start in life and laying the groundwork for good health and wellbeing in later life.”

4. Indeed, midwife-led care can make an important contribution to the wellbeing of childbearing women. Women who access midwife-led care tend to report high levels of satisfaction with the service they receive, because they are made to feel empowered. The sense of wellbeing that this engenders is known to be important in contributing to the future health of the newborn child. Midwifery-led care also leads to higher rates of breastfeeding—a critical public health intervention.

5. We would also like to state specifically that we welcome the Government’s commitment to narrowing health inequalities through improving the health of the poorest, fastest. We support also the adoption in the White Paper by the Government of the Marmot Review’s advocacy of proportionate universalism.

6. The RCM supports an explicit public health role for the Secretary of State. We welcome the proposal that public health will be embedded in the Secretary of State’s mandate for the NHS Commissioning Board. We would go further and recommend that the mandate also recognises the crucial public health role played by midwifery services and ensures that this public health function is effectively delivered through adequate antenatal and postnatal provision. This can also be enhanced by mandating for schemes that are midwife-led and which enhance continuity.

7. We note the reference to the announcement in the Coalition agreement that the Department of Health (DH) will strengthen the role and incentives for GPs and GP practices on preventive services. We would not wish to dispute the critical role that GPs play in both primary and secondary care prevention. We would simply point out that when it comes to the preventive aspects of maternity care, that midwives are as important to mothers and babies as GPs are. Could the DH therefore look at strengthening the role and incentives for midwives?

8. We welcome too the establishment of a new public health budget, ring-fenced within the overall NHS budget. We criticised the previous Government for raiding public health budgets when the NHS faced cost pressures in the past, so we view this as a welcome development. However, we also note the stated hope that the DH will “work to ensure that funding for public health is not squeezed by other pressures”, which strikes us as falling somewhat short of being a copper-bottomed guarantee that the budget will in fact be ring-fenced.

9. Indeed, an early sign of this risk has been the removal of government funding for National Breastfeeding Week (19–25 June). It is widely acknowledged that breastfeeding offers babies the best possible start in life, and this withdrawal of funding can only really be seen from the perspective of cost-cutting. This is a bad sign, and we look to the Committee to highlight this example.

10. Since public health is as much a function of maternity services, health visiting and GP services as it is a specialist function in itself, the question will arise what is covered by ring-fencing and what sits outside the public health budget? While recognising that further work is needed in order to properly cost the public health budget this only reinforces the importance of clarifying how public health functions are defined and where responsibility rests for commissioning, funding and providing those functions.

11. The RCM supports the recognition of the vital role that local government can have in leading on public health. We recognise the logic of giving lead responsibility to local government, since many of the functions it oversees—such as education, housing, planning and transport—have a significant impact on the health and wellbeing of local communities. Indeed, we support, in principle, the establishment of Health and Wellbeing Boards and recognise the potentially valuable role they can fulfil in bringing together local government, the NHS and public health to take a rounded view of the needs of local populations. Accordingly we agree that Health and Wellbeing Boards are the appropriate body for bringing together ring-fenced public health and other budgets.

12. Whilst we agree with the proposal to embed public health within local government, we are concerned that the Government intends to “keep to a minimum” the constraints as to how local government decides to fulfil its public health role and spend its public health budget. Our anxiety stems from the fact that determination of these issues will now be in the hands of elected representatives, the majority of whom will have been elected on a manifesto that may or may not include public health issues. This could lead to considerable variation in the availability and quality of public health services if prioritisation is left to local politicians. It may also lead to instability in local authorities where political power regularly changes hands or in councils where no one party is in overall control.

13. If left to the vagaries of local government politics there is a real danger of a public health postcode lottery developing—when what is needed is for public health to be a priority in every area. Directors of Public Health (DsPH) will be an important check to preventing public health slipping down a local authority’s list of priorities and we welcome the proposal that they act as the strategic lead of public health in local communities and that they will be responsible for the health improvement functions of local authorities. We think however that further safeguards are needed in order to maintain the professional independence of DsPH.

14. The RCM supports in principle the allocation, by Public Health England (PHE), of ring-fenced public health budgets to local authorities, as stated above. We do however have some reservations relating to our other concerns about the political priorities and knowledge and understanding of public health issues of local politicians.

15. Another important consideration is the extent to which Health and Wellbeing Boards are able to access appropriate clinical advice and expertise. However, we are not clear how the new boards will access professional midwifery advice; given the importance of maternity care, as acknowledged by the Public Health White Paper, we see this as a significant omission. The White Paper proposes that membership of local boards should be expanded to include local clinicians and the RCM would therefore recommend that Heads of Midwifery (HOMs) should be represented on all Health and Wellbeing Boards. Similarly, professional midwifery advice will also be crucial for the effective operation of Joint Strategic Needs Assessments (JSNAs) and the joint health and wellbeing strategies.

16. On commissioning, the RCM has some concerns regarding the services listed as coming under the aegis of PHE for the purposes of funding and commissioning. Our chief concern is that there are clear funding and commissioning routes and that, as with GP-led commissioning, there is input from midwifery services for those services—such as smoking cessation and obesity—that require input from midwives. There also needs to be greater clarity around how certain services are defined, in order to ensure that the right organisations are funding and commissioning those services. For example, the RCM is as yet unclear how screening services are defined and what, if any, distinction will be drawn between routine scanning services and national screening programmes. It is vitally important that these definitions and distinctions are quickly established in order to ensure that there is clarity as to those elements that form part of national tariffs and those services that fall within the remit of PHE.

17. In terms of commissioning public health services from the voluntary and independent sectors, we would question whether this is inherently beneficial to health improvement programmes. That is not to say that voluntary and independent providers don’t have an important contribution to make in providing some health and wellbeing services. But it is important to ensure that the provision of health and wellbeing services is commissioned and organised not on the basis of a competitive free-for-all but rather so as to maximise opportunities for integration and cooperation between NHS, local authority, public health, voluntary and independent providers. Our starting point would therefore be to identify, via the JSNA and health and wellbeing strategy, where there are gaps in service provision or where existing providers have demonstrably failed to deliver services of an acceptable standard and quality; it would then be possible to consider whether there is a role for voluntary and independent providers to provide the capacity to deliver in these areas and to contract accordingly.

18. For primary care services it will be important for the NHS Commissioning Board to ensure that commissioning decisions are underpinned by a combination of recommendations contained in relevant NICE quality standards, by research evidence produced by the public health observatories that will come under the control of PHE and by the recommendations of relevant professional organisations, such as the Association of Directors of Public Health.

19. In terms of ensuring that public health expertise informs NHS services commissioned by GP consortia, the most effective source of advice will be from local DsPH. These people however themselves need to have mechanisms in place for hearing the advice of experts.

20. The RCM supports the creation of a Public Health Outcomes Framework as an accountable, transparent framework for measuring the effectiveness and impact of public health activity. We believe that the framework should also promote joint working where local organisations share common goals. For the framework to do this effectively, it is important that all partner organisations are able to access comprehensive and rigorous health, demographic, social and economic data. In this respect it is important that PHE has the requisite funding to resource and support the public health observatories that it will be managing.

21. The RCM would in principle support linking a proportion of health improvement funding to progress on elements of the Public Health Outcomes Framework, so long as the agreed performance measures were stretching but also measurable, realistic and achievable.

22. The RCM supports the ring-fencing of public health funding, nationally and locally. Furthermore, we support in principle the proposal to develop a health premium as a means of incentivising local authorities to make progress on health improvement priorities and reduce health inequalities. The RCM believes that the overriding factor in designing the health premium is the extent to which interventions offer the greatest long-term benefits. We also believe that the premium should incentivise reductions in inequalities. We would therefore recommend that health premiums are developed that focus on early intervention as the most effective means of ensuring every child gets the best start in life and of reducing health inequalities. Accordingly health premiums could be used to incentivise progress on outcomes such as breastfeeding or smoking cessation.

23. On the question of the regulation of public health specialists, it is relevant to say that the Nursing and Midwifery Council (NMC) currently regulates midwives, health visitors, children’s nurses and occupational health nurses, all of whom undertake roles with a strong public health component. The RCM would therefore strongly recommend that the NMC is best suited to provide a system of voluntary regulation for public health specialists.

June 2011

Prepared 28th November 2011