Conclusions and recommendations
1. Having a baby is
the most common reason for admission to hospital in England. In
2012, there were nearly 700,000 live births, a number that has
risen by almost a quarter in the last decade. There has also been
an increase in the proportion of 'complex' births, such as multiple
births or those involving women over 40. Maternity care cost the
NHS around £2.6 billion in 2012-13. The Department is ultimately
responsible for securing value for money for this spending. Since
April 2013, maternity services have been commissioned by clinical
commissioning groups, which are overseen by NHS England. Maternity
care is provided by NHS trusts and NHS foundation trusts.
2. There is confusion around the Department's
policy for maternity services, what it wants to achieve and who
is accountable for delivery. Having clear
objectives and accountabilities is crucial in a devolved delivery
chain like the NHS. Stakeholders told us they were confused as
to the current policy objectives and whether Maternity Matters
removed the policy framework. In addition, some of the Department's
main objectives for maternity services, such as continuity of
care for women by midwives, are described only as aspirations
not objectives. The Department and NHS England struggled to articulate
to us who is accountable for even the most fundamental areas of
maternity care, such as ensuring the NHS has enough midwives.
At local level, it is unclear how commissioners are ensuring maternity
services meet the Department's policy objectives, or how they
are holding trusts to account. Over a quarter of trusts lacked
a simple written service specification with their commissioner
last year.
Recommendation: The Department should set
out clearly its objectives for maternity care, explicitly stating
who is accountable for their implementation and how success against
its objectives will be measured.
3. The Department has not demonstrated whether
its policy objectives for maternity services are affordable.
There is evidence from stakeholders that many maternity services
are running at a loss, or at best breaking even, and that the
available funding may be insufficient for trusts to employ enough
midwives and consultants to provide high quality, safe care. The
Department has recently introduced a new payment framework for
maternity care. However, the evidence we received suggests that
the Department had only limited assurance that the new tariff
payments would provide sufficient income to providers to deliver
the Department's objectives. Stakeholders believed more could
be delivered for less money with better outcomes if there were
more midwife-led birth centres available. The payment framework
was one factor inhibiting the increase in such birth centres.
Although there has been a welcome increase in midwives there is
still a national shortage of some 2,300 midwives required to meet
current birth rates. Pressure on staff leads to low morale and
nearly one third of midwives with less than 10 years' work experience
are intending to leave the profession within a year. Over half
of obstetric units do not employ enough consultants to ensure
appropriate cover at all times. Evidence suggests quality of care
is less good at weekends.
Recommendation: The Department should assess,
through a detailed costing exercise, the affordability of meeting
its policy objectives, and work with NHS England and Monitor to
review whether the current tariffs for maternity care are set
at the right level. The department should ensure the financial
incentives enable the best and most appropriate services to be
developed at the lowest cost.
4. The clinical negligence bill for maternity
services is too high. Clearly victims
of poor care need to be properly compensated, but clinical negligence
costs have spiralled and reduce the money available for frontline
care. Maternity cases account for a third of total clinical negligence
payments and the number of maternity claims has risen by 80% over
the last five years. The rate of babies who are stillborn or die
within seven days of birth in England compares poorly with the
other UK nations and some European countries. Some £480 million,
nearly a fifth of trusts' spending on maternity services, is for
clinical negligence cover, equivalent to £700 per birth.
The NHS Litigation Authority has recently produced helpful research
on the causes of maternity claims, such as mistakes in the management
of labour.
Recommendation: The Department and NHS England
should build on recent research to address the main causes of
maternity clinical negligence claims and to stop so many claims
coming forward. They should also investigate the variations in
performance between trusts to see how services can be improved
so that fewer tragic mistakes occur.
5. Women want more choice about where to give
birth. The number of midwifery-led units,
where midwives take primary responsibility for care, increased
from 87 in 2007 to 152 in 2013, but only 11% of women gave birth
in these units in 2012. Research by the National Federation of
Women's Institutes and the NCT suggests that only a quarter of
women want to give birth in a hospital obstetric unit, with care
led by consultants. However, 87% of women still gave birth in
this setting in 2012. Women who have a low risk pregnancy should
be able to choose where to give birth and such a large disparity
between what women want and what women receive in terms of choice
of place of birth is unlikely to be driven by clinical need alone.
Over a quarter of maternity units had to close to admissions for
half a day or more between April and September 2012. While such
short-term closures of maternity units can safeguard the quality
and safety of care when demand might outstrip capacity, they further
restrict the level of choice available to women.
Recommendation: NHS England should build
on recent research to investigate the factors that affect women's
choice of place of birth, including closures of maternity units,
and what inhibits women from exercising choice in practice.
6. The NHS has failed to address persistent
inequalities in maternity care. The NHS
has had a specific objective to promote public health with a focus
on reducing inequalities in maternity care since 2007. However,
the latest available data (from 2010) on women's experiences showed
black and minority ethnic mothers were less positive about the
care they received during labour and birth than white mothers.
They were also significantly more likely to report shortfalls
in choice and continuity of care. The Department intended to address
inequalities through improved early access to maternity care,
but data also show regional and demographic inequalities in the
proportion of women receiving an antenatal appointment within
12 weeks of conception.
Recommendation: NHS
England should set out what it intends to do to reduce inequalities,
take the appropriate action as a matter of urgency, and report
annually on progress.
7. Local maternity networks are an important
way of sharing good practice and reducing variation, but they
are not obligatory and those that do exist tend to be less well
developed than other NHS networks. Maternity
networks bring together commissioners, providers and other stakeholders
(including users of maternity services) in a local area with the
aim of achieving the best possible outcomes for women and babies
and tackling variations in outcomes. Despite recommending the
creation of maternity networks in its 2007 maternity strategy,
the Department has not made it compulsory for commissioners and
providers to create them and a quarter of trusts are still not
part of a network. In addition, less than 40% of trusts are part
of a maternity network with a paid coordinator, compared with
90% for neonatal networks.
Recommendation: NHS
England should actively manage the development of maternity networks
across the NHS, and set out what arrangements it will put in place
to ensure the sharing of good practice between, as well as within,
networks to improve quality and eradicate unacceptable variations
across the country.
8. The Department lacks the data needed to
oversee and inform policy decisions on maternity services.
The Department's main source of data for assessing performance
against its strategy is the Care Quality Commission's survey of
women's experiences carried out once every three years. The Department
seemed to be unaware of other relevant research, for example from
the National Federation of Women's Institutes and the National
Childbirth Trust, that it could be using to supplement its understanding
of the performance of maternity services. The NHS is in the process
of implementing a new 'dataset', comprising over 100 data items
covering all the maternity care received by every woman. But collection
of this data will only be mandated from 1 April 2014, almost five
years later than planned and there are no minimum requirements
for the IT systems that will support collection of the data.
9. Recommendation:
The Department and NHS England should make better use of
existing and emerging data, and of research, to monitor progress
against its policy objectives and to inform decisions.
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