Written evidence from the Royal College
of Midwives (CFI 29)|
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 in maternity services and
provide professional leadership for one of the most established
of all clinical disciplines.
2. The RCM welcomes the opportunity to submit evidence
to this inquiry, and have responded only to those points on which
we have most to contribute.
RCM believes that the Health and Social Care Bill contains powers
for the NHS Commissioning Board over GP-led commissioning consortia
that will be helpful in ensuring the Board is able to deliver
on its priorities. We welcome this.
RCM is pleased that the Committee highlighted the need for GP-led
consortia to draw upon the specialist expertise of other clinicians.
The Department of Health has explicitly stated that consortia
will need additional help when commissioning maternity care, so
we see the involvement of midwives and obstetricians in this as
will need to work together at times on certain aspects of care,
for example of commissioning a home birth service; we welcome
the Committee's interest in how this might be done, and outline
below some of our own thinking on how this could happen for maternity
care at the sub-regional level.
the natural tension between, on the one hand, the need to commission
to deliver choice and, on the other, the need to use financial
resources efficiently, the RCM spells out how new powers in the
Health and Social Care Bill would enable the Department of Health
to ensure that choice trumps cost-cutting.
on local accountability, the RCM believes that existing Maternity
Service Liaison Committees should be incorporated into the new
structures as a way of enhancing accountability.
NHS COMMISSIONING BOARD
3. The Committee expressed concern about the level
of authority the NHS Commissioning Board will have over commissioning
consortia in the delivery of outcomes.
4. This is particularly important in the case of
maternity care. When the Government announced in its response
to the consultation on last summer's NHS white paper, Equity
and Excellence: Liberating the NHS, that maternity
care would be commissioned by GP-led consortia rather than by
the NHS Commissioning Board, it stated: "we will expect
the Board to give particular focus to promoting quality improvement
and extending choice for pregnant women."
5. It is crucially important therefore, from our
perspective, that the Board has the tools it needs to drive forward
improvements in outcomes in maternity care. We believe that there
is scope within Clause 22 for the Board to instruct consortia,
but we would feel a higher level of reassurance if Ministers were
invited to clarify that the Board will be able to step in and
act, particularly on maternity issues.
6. In addition to this the RCM seeks reassurance
that the Department itself will use the powers it will have under
Clause 16 (the standing rules) and Clause 19 (the mandate) to
direct improvements in certain areas.
7. The RCM agrees that whilst commissioning most
NHS care will be done by GP-led consortia, it is important to
recognise that GPs are generalists, not specialists. There is
a pressing need to ensure that those with specialist knowledge
of certain areas of care are involved fully in the commissioning
8. We would recommend that for maternity care, this
process involves not just those we represent (ie midwives) but
their colleagues, the obstetricians. It is important to recognise
the need for both these professions to be involved in decisions
about the commissioning of maternity care provision. Midwives
are the specialists in normal birth.
9. The RCM believes that maternity networks could
engage midwives and other maternity clinicians in the commissioning
process and, in so doing, provide consortia with valuable information
and advice. It is our experience that where Primary Care Trusts
have actively involved midwives and other related clinicians in
the commissioning process, this has brought about demonstrable
improvements in the quality of local maternity services.
10. For example, commissioners in Blackburn have
worked closely with midwives, obstetricians, trust managers and
service users on the reorganisation of maternity services. The
resultant reconfiguration will result in both safer and more effective
care for women at high risk, through the consolidation of obstetric
services in Burnley and an expansion of midwife-led care, via
midwife-led units at Blackburn, Burnley and Rossendale. The effectiveness
of this reconfiguration was undoubtedly enhanced because commissioners
engaged with midwives as the experts in normal birth.
11. A maternity network would be ideally placed to
engage with clinicians in all the maternity units in its catchment
area. The RCM is therefore concerned that Government thinking
around maternity networks is that they should evolve organically
without any imposed purpose or authority. The RCM appreciates
that whilst it is possible for networks to develop in this way,
we are concerned that any such development will be patchy and
will result in some provider units not participating fully in
the activities of the network. Networks must be given some power
and authority if they are to be active participants in the commissioning
12. Maternity networks could also access information
and clinical expertise by agreeing a network-wide maternity dashboard,
as described by the Royal College of Obstetrics and Gynaecology
(RCOG). 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
then commissioners would have ready access to the performance
of various providers and could use the information to discuss
variability between providers in the network. Such discussions
are a vital way of driving up clinical standards.
13. There is a clear argument, supported by the Government
that maternity care as a special case. In its response to the
consultation on last summer's NHS white paper, Equity and Excellence:
Liberating the NHS, the Department of Health decided that
maternity care should, after all, be commissioned by GP-led consortia,
rather than by the NHS Commissioning Board, as suggested in the
14. The Department did make clear that "maternity
services need a different approach to reflect their special nature
and circumstances. While responsibility for commissioning maternity
services should sit with GP consortia, we will expect the Board
to give particular focus to promoting quality improvement and
extending choice for pregnant women."
15. We believe that this strengthens the case for
specific input from maternity professionals in the commissioning
of maternity care.
16. We have recommended to the Department of Health
and we now recommend to the Committee that some GP pathfinders
are used to test different approaches to commissioning maternity
care so that lessons can be learnt and best practice rolled out.
17. The ability to deliver service improvement across
an area larger than a consortium is an issue that has been of
concern to the RCM since the health service proposals were first
published. This is because extending choice of place of birth,
as well as antenatal and postnatal services, will require changes
to the configuration of maternity services for a population base
far bigger than the likely size of any individual GP-led consortium.
18. Northeast London offers us an example. In this
part of the capital, where five trusts provide services for around
1.5 million people, clinicians and NHS London have collaborated
to ensure that women are able to receive the choice they need
from five obstetric hospitals, five alongside midwife-led units,
three freestanding midwife-led units and shared home birth services.
19. It is very difficult to plan a range of maternity
services like this over a small geographical area. A homebirth
service might only look after 3% to 5% of women, a midwife-led
unit maybe 20%, with the rest using the major hospital. If GPs
are to commission maternity services they would in all probability
need to come together as a consortium of consortia to ensure viable
20. This feels overly bureaucratic and leads the
RCM to conclude that an outpost of the NHS Commissioning Board
would operate at a more appropriate population level. A network
of maternity services could then be commissioned on a logical
basis depending on the size and needs of the population. These
could be the same maternity networks that the Secretary of State
suggests in the consultation and could work together with the
regional outposts (the commissioners) to ensure uniformity of
standards and so on across the network. This is akin to something
like cancer services where you have a more centralised approach
with hubs and spokes within a network arrangement.
21. This is our suggestion of how this might work,
but it would be useful for the Department to set out how it best
thinks this kind of process might happen. The RCM simply does
not believe that the Department should adopt a laissez faire approach
to this, with no guidance on best practice.
22. Choice tends to mean something different, and
the RCM would argue - more meaningful, for maternity services,
compared to other types of care. This is because pregnancy is
not an illness requiring treatment, where the scope of patient
choice is limited by the knowledge of the clinician about the
best course of treatment. Most healthy women should be able to
make a range of choices over where and how she gives birth.
23. Choice for women accessing maternity care is
something the Coalition Government is committed to delivering,
as set out in the NHS White Paper, Equity and Excellence: Liberating
24. Choice in pregnancy is broad, but the most important
aspect from the perspective of commissioning is the need for all
areas to give local women access to, of course, consultant-led
obstetric care in a hospital maternity unit, but also care in
a midwife-led unit, and access to a home birth service.
25. Clause 16 of the Health and Social Care Bill
establishes something called the standing rules. Under the bill,
the Department would be empowered to use these standing rules
to set out how consortia should commission services; using these
standing rules would therefore enable the Department to enforce
choice across England by requiring consortia to commission a range
of choices for women in every area - obstetric care, midwife-led
care, and a home birth service.
26. The RCM would like ministers to confirm that
they will use the standing rules in this way to turn its policy
of choice in maternity care into a reality.
27. The RCM agrees with the Committee that the current
arrangements in the bill on local accountability are weak. It
is legitimate, given the amount of public money spent and the
importance so many people attach to the health service, that these
arrangements are robust.
28. The RCM has a suggestion that it would like to
put to the Committee. We would like to see Maternity Service Liaison
Committees (MSLCs) given a formal role alongside the new maternity
networks, which will bring together providers of maternity care,
to guarantee input from service users. MSLCs are independent,
advisory bodies, usually at trust level, that advise on the development
of maternity care locally; this is just the kind of existing structure
that should be incorporated into the new systems. There is no
need to reinvent the wheel.
29. The barrier to this suggestion being adopted
is the reluctance amongst ministers to set out a model for these
new maternity networks. A good illustration of this reluctance
is the following statement, made by Anne Milton MP, Parliamentary
Under Secretary of State for Public Health, during a Westminster
Hall debate on maternity services:
"The important thing for central Government,
and it is what we are doing, is to move away from being centrally
very prescriptive. If I were to guess, I would say that networks
will be on a regional level, but their size will depend on various
things." [HC Deb, 1 February 2011,
30. The RCM does not propose some grand, new bureaucracy.
The Government has decided to create maternity networks. Our proposal
simply seeks to ensure that these networks enjoy the benefit of
user input, and we seek to achieve this using MSLCs, which already
exist and have already proven their worth.