Maternity services in England - Public Accounts Committee Contents

1  The management of maternity services

1. On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and NHS England about maternity services in England. We also took evidence from the National Childbirth Trust (NCT), the Royal College of Midwives, and a consultant obstetrician.[1]

2. Maternity is a unique area of the NHS as the services support predominantly healthy people through a natural life event that does not always require doctor-led intervention. Having a baby is the most common reason for admission to hospital in England and, in 2012, there were almost 700,000 live births. The number of births has increased by almost a quarter in the last decade, placing increasing demands on NHS maternity services. Over recent years there has also been an increase in the proportion of 'complex' births, such as multiple births and those involving women over 40 or women with obesity or pre-existing medical conditions, meaning care often requires greater clinical involvement.[2]

3. Maternity care cost the NHS around £2.6 billion in 2012-13. The Department has devolved the commissioning, provision and regulation of maternity services, but it remains ultimately accountable for securing sufficient resources for healthcare from the Treasury and for achieving value for money for this spending. Since April 2013, maternity services have been commissioned by clinical commissioning groups which are overseen by NHS England. Prior to this, services were commissioned by primary care trusts. NHS trusts and NHS foundation trusts provide maternity care to women.[3]

4. In 2007, the Department set out its policy for maternity services in its strategy document Maternity Matters. Its aims include to improve performance against quality and safety indicators and to promote public health with a focus on reducing inequalities. The Department intended to achieve its aims by: offering women choice in where and how they have their baby; providing continuity of care from midwives; and ensuring an integrated national service through networks and agreed pathways of care.[4]

5. Stakeholders told us they were confused about whether Maternity Matters was still the current policy. During our hearing, the Department confirmed that Maternity Matters, and subsequent ministerial commitments such as the 'named midwife' guarantee, remain government policy. However, we note that a number of the individual objectives, such as continuity of care, have been expressed by the Department in aspirational terms, with a lack of clarity about what they mean in practice and how they will be achieved. Additionally, it is not clear who we should hold to account for important aspects of maternity care. For example, the Department and NHS England struggled to articulate to us who is accountable for ensuring the NHS has enough midwives.[5]

6. To achieve its policy objectives, and to hold trusts to account, the Department expects local commissioners of maternity services to guarantee national policy commitments through contractual service specifications with trusts. However, over a quarter of trusts did not have a written service specification with their commissioner in 2012-13. NHS England told us that it is mandatory for clinical commissioning groups to have a service specification for maternity services in 2013-14 and that every group would have a service specification in place by the end of the financial year.[6]

7. The Department funds most maternity care delivered by the NHS through the 'payment by results' framework. Under this system, commissioners pay providers fixed prices for each unit of care. We heard from the Foundation Trust Network that funding is inadequate to cover costs. As a result, many maternity services run at a loss, or at best break even, and are cross-subsidised by other services within trusts. The Department and NHS England did not know whether this was the case and did not seem aware of the Foundation Trust Network's research.[7]

8. In April 2013, the Department introduced a new payment system for maternity care. Rather than paying for each individual activity undertaken, the Department has aggregated the funding to create 'tariffs' for the three sections of the maternity care pathway—antenatal, birth and postnatal. However, the Department implemented these new pathway tariffs with only limited assurance on whether they provide sufficient income to providers to deliver the Department's policy objectives. NHS England told us that it would change the pathway approach if it did not work as intended.[8]

9. We explored whether trusts have sufficient funds to employ the recommended levels of midwives and consultants to provide high quality, safe care. The National Audit Office noted that there were around 21,000 midwives in 2012 and that the number of long-term vacancies reported by maternity units at September 2012 was around 700. However, a calculation based on a widely recognised benchmark for midwife staffing levels suggested a total shortfall of some 2,300 midwives. Following our hearing, we received evidence from the Royal College of Midwives, suggesting that the benchmarks for midwife staffing levels may be financially unachievable under existing funding frameworks. The Royal College noted that the pathway tariffs do not reflect a fully staffed system, because they are based on the average cost of providing services two years previously when, as now, the system was short of midwives.[9]

10. There is also a shortage of consultants, with only 47% of hospital trusts achieving recommended standards in consultancy presence. Standards of care and outcomes vary across the country, and the evidence we heard suggested poorer levels of care at weekends leading to higher levels of complications occurring.[10]

11. The Department's main source of data on the performance of maternity services is the Care Quality Commission's survey. This survey seeks views from a large sample of over 25,000 mothers, but covers just one month in every three years. NHS England noted that trusts have also recently started using the 'friends and family' test to assess people's experience and understanding of the services they receive.[11]

12. From April 2014, trusts will be required to record over 100 data items for every woman receiving maternity care, covering demographic information and details of all the care received.[12] These items will be brought together into a national maternity 'dataset'.[13] This dataset was supposed to be introduced almost five years ago in 2009.[14] The Department explained that the delay had been caused by concerns about the burden that collecting data would place on NHS staff as the original proposal had been for a dataset of more than 1,000 items.[15]

13. The Department told us that it expected electronic data systems would facilitate the collection of the new maternity dataset.[16] However, the National Audit Office found that local data systems are often poor and in 2013 almost one in five maternity units did not have an information system linked to its patient administration system.[17] Although collection of the new dataset will be mandated from 1 April 2014, the Department told us that there are no minimum requirements for the IT systems that would support it.[18] It is not clear to us what assurance the Department has that trusts will purchase IT systems that support connectivity with other parts of the system.[19]

1   C&AG's report, Maternity services in England Session 2013-14, HC 794, 8 November 2013 Back

2   Qq 90, 167, 267, C&AG's Report, paras 1, 3, 4 Back

3   Qq 27, 30-31, C&AG's Report, paras 2, 7-9 Back

4   Qq 2-3, C&AG's Report, paras 11, 12 Back

5   Qq 22, 33-34, 53-61, 65, Memorandum to the Committee from the Royal College of Midwives, November 2013 Back

6   Qq 61-62, 146-149 Back

7   Qq 23-27, 35-44, 79, C&AG's Report, para 2.8, Email to the Committee from the Foundation Trust Network, November 2013 Back

8   Qq 44, 196, C&AG's Report, para 2.14 Back

9   Qq 29, 32, 35-37, 42-44, 66, 125, 133-34; C&AG's Report, para 1.31, Memorandum to the Committee from the Royal College of Midwives, November 2013; Email to the Committee from the Foundation Trust Network, November 2013 Back

10   Qq 19, 124, 125, 132; C&AG's Report, paras 1.13 and 1.22 Back

11   Q 67, 69; C&AG's Report, para 2.7 Back

12   Qq 70-71, 75 Back

13   Ibid  Back

14   Qq 69, 73, 108; C&AG's Report, para 2.7 Back

15   Qq 76, 108 Back

16   Q 76 Back

17   Qq 76, 103; C&AG's Report, para 2.7 Back

18   Q 103 Back

19   Q 103-114 Back

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Prepared 31 January 2014