NHS: Maternity Care

Baroness Cumberlege Excerpts

Thursday 5th February 2015 Lords Chamber

[Baroness Cumberlege (Con)]

My Lords, my interests are in the Lords’ register. In addition, I am a vice-president of the Royal College of Midwives, and patron of the NCT and of Independent Midwives UK. Like others, I thank the noble Lord, Lord Harrison, for initiating this debate and for the briefing that I have had from other bodies, not least the Women’s Institute, of which I used to be a very active member.

The NHS Five Year Forward View states:

“Having a baby is the most common reason for hospital admission in England”.

For women with low-risk pregnancies, research shows that,

“babies born at midwife-led units or at home did as well as babies born in obstetric units, with fewer interventions. Four out of five women live within a 30 minute drive of both an obstetric unit and a midwife-led unit, but research by the Women’s Institute and the National Childbirth Trust suggests that while only a quarter of women want to give birth in a hospital obstetrics unit, over 85% actually do so”.

That document goes on to say that the NHS will commit to a commission to review future models for maternity units to report next summer—I will be watching that—and to recommend how best to sustain and develop maternity units across the NHS. It will ensure that tariff-based NHS funding will support the choices women make, rather than constraining them. It will make it easier for groups of midwives to set up their own NHS-funded midwifery services.

I really cannot tell noble Lords how delighted I was when I read that. This is such fresh thinking. It rides the wave of what women and midwives want: giving choice to women as to how they want their care provided, and to midwives as to how they want to work. Of course, this is just the beginning. The noble Lord, Lord Harrison, and other noble Lords clearly set out the immediate problems facing maternity services. The first concerns workforce issues and the shortage of midwives. One solution is to attract back into the service those thousands of midwives already qualified—some with a great deal of experience—who have chosen not to work in the current system, often because it is too dysfunctional, fragmented and rigid. The second is to stop the loss of newly trained midwives, who characteristically leave in their first two years after qualifying.

How are we going to achieve that? The NHS needs to enable midwives to offer a service to women that supplies genuine continuity throughout pregnancy, birth and antenatal care. Midwives who work with a caseload and who really get to know their women and their families—and especially the fathers of the babies—find the work rewarding, particularly when they have some control over their work/life balance. Then they stay in the service.

As the Five Year Forward View states, different models are needed. We already have some but they are very fragile and nascent and they need support. These different midwives want to work for the NHS. I should like to cite two models. One is Neighbourhood Midwives—a social enterprise, employee-owned and not-for-profit organisation based in the community. Midwives follow the women and work flexibly over 24 hours. This is possible because they are not needed to staff labour wards and clinics on 12-hour shifts. Likewise, Independent Midwives UK is a membership organisation that represents and supports 70 self-employed midwives, with a further 60 associate members. IMUK is a public benefit registered company with a very high-powered board. It has come a long way in its struggle to secure clinical indemnity, which it now has, and as a consequence I think it is destined to grow.

Both those organisations—and there are other, similar models—are pioneers, but they are up against the deep reluctance of the NHS to award them contracts. However, this coming year’s planning guidance, signed off by NHS England’s board in December, states that for 2015-16 commissioners should review the choices that are locally available for women. This may include choice about how women access maternity care, the type of care they receive, where they give birth and where they receive their antenatal and postnatal care.

Many of us may think that we have heard similar rhetoric in the past, but I think that this goes beyond rhetoric. For the first time, this spells action. I believe that many CCGs will want to implement this guidance, but can my noble friend tell me what will happen if they do not? If they do commission these services, that will enable groups of midwives to set up their own NHS-funded service based in the community and funded directly from a tariff or, in the future, from personal budgets. They will work in partnership with the trusts to offer a complete care pathway, but it will mean that both sectors can plan and manage their own staffing levels, and this will dramatically increase the offer and provision of a very reliable home birth service. It will also increase the use of free-standing birth centres. Working in group practices in the community will increase midwives’ autonomy, improve their clinical skills, and enhance their experience and confidence across the whole care pathway.

Caseload midwifery is seen as the gold standard of care, yet providing women with a midwife whom they can get to know and trust is still the exception rather than the rule. However, we know that this model of care improves outcomes, reduces interventions, saves money, improves women’s experience of birth and improves midwives’ job satisfaction, skills and commitment. What is now needed are commissioners who are brave enough to enable this model of care to be provided in a sustainable and innovative way. Does my noble friend agree? Does he see this as a way forward, and has he suggestions as to how the Government could encourage commissioners to commission such services?