Today saw the publication of Julia Cumberlege’s Maternity Review, Better Births. Commissioned in the wake of the Kirkup investigation into the deaths of babies at Morecambe Bay, its remit was to improve the outcomes of maternity services in England.
I’ve had a look and there’s some good stuff in there. The personal maternity care budgets have been grabbing the headlines, but there are some recommendations that have been overlooked. These include:
- Thorough, open, multi-team investigations when something goes wrong, such as a baby dying
- A national, standardised process for investigating mistakes
- Collection of data on the quality and outcomes of maternity services, so that maternity teams can measure their own performance and compare it against other maternity teams
- Multi-professional working, with teams of midwives and obstetricians working together in the best interests of mother and baby
These all represent a huge step forward. One of the big problems at Morecambe Bay was the lack of communication between midwives and obstetricians, and an apparent “them” and “us” mentality. There was also an unwillingness to investigate when things went wrong, so that the same things kept going wrong, time and time again.
It’s very important that people are able to learn from their mistakes. The aviation industry was able to slash the number of air accidents by adopting an open approach to errors: encouraging staff to report their own mistakes without fear of being blamed and to come up with suggestions for improvements. But there has long been a culture of blame and cover-up in the NHS – time and again I’ve heard stories from women of trusts that failed to acknowledge their mistakes and sought to put the blame elsewhere. A remarkable number of trusts manage to “lose” a woman’s maternity notes as soon as a complaint is made. So a move towards acknowledging mistakes and putting steps in place to rectify them is long overdue.
On the other hand…
There are other elements of the maternity review I’m less sure of.
The recommended change to payment systems needs to be treated with caution. The review wants to “shape the payment system to reflect the different cost structures of different models of providing care” and also to “incentivise community deliveries where clinically appropriate”.
It suggests “working with providers to undertake a bottom-up costing exercise and proposing adjustments to the existing tariff in light of this so as to more accurately reflect relative costs. This could include potentially introducing different prices for home births, freestanding midwifery units, alongside midwifery units and obstetric units.”
Obviously it’s important that women have the choice to give birth at home or in a midwife-led unit if they prefer. But there is a danger that trusts will try to save money by encouraging women towards those options when they’re not clinically appropriate. As soon as you offer financial incentives, you also offer an incentive to cast clinical judgement aside in favour of saving money.
Personal budgets – too many unanswered questions
Finally, we’ll have to wait and see what happens with personal budgets, but it’s difficult to see how they will work in practice. Personal budgets have been used successfully for people with long-term conditions, but giving birth is unpredictable: if you use your budget up on antenatal classes and hypnotherapy, what happens if you suddenly need an expensive emergency caesarean? Or if you want to sue your private provider, paid for by a personal budget, who pays – the provider, or the NHS?
More fundamentally, women need good quality care, and the opportunity to choose between a number of poor options is not really a choice at all. So, while I’m not totally against personal budgets, I’d really need to see a lot more detail before I’m convinced they’re the route to delivering the best outcomes for women and their babies.