Commissioning: further issues - Health Committee Contents

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.


—  The 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.

—  The 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 a necessity.

—  Consortia 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.

—  On 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.

—  Finally, 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.


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 process.

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 process.

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 white paper.

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 services.

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 the NHS.

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, c235WH]

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.

February 2011

previous page contents next page

© Parliamentary copyright 2011
Prepared 5 April 2011