Why was the decision made to give commissioning responsibility for maternity services to CCGs?
Indeed, when the white paper was published in 2010 it put maternity services in the list of services to be commissioned by the NHS Commissioning Board. But a U-turn followed with an announcement that it would go to CCGs.
Dr Suzanne Tyler, strategic maternity lead at NHS South of England and author of a new NHS Commissioning Board maternity resource pack, suggests the decision to move maternity services to CCGs came from the clinical commissioners themselves.
‘When the reforms were first announced and maternity services was originally in the list of services the NHS Commissioning Board was going to commission nationally, with national expectations and contracts, a lot of people involved in maternity thought that was absolutely right and were quite pleased it wouldn’t be CCGs. And I think it was the CCG community themselves who said if we’re commissioning early-years services and children’s services, it doesn’t make sense to exclude maternity services.’
So what are CCGs letting themselves in for? Maternity is very much a ‘shop window’ of the NHS, with the childbirth experience playing a fundamental role in the public’s perception of the service. This sensitivity is illustrated by the furore of headlines that were generated by a recent joint report from the NCT, the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists – a report that suggested GPs have a strong influence over their patients’ choices and that many women eligible to deliver in midwife-led units are still in the main going to more expensive obstetric units. The RCOG has now taken the report off its website pending a review by senior college members.
The significant midwife shortage poses the biggest challenge for commissioners, according to Elizabeth Duff, senior policy adviser at the National Childbirth Trust. The birth rate has increased by 22% in the last decade but the number of midwives has increased by just 16%. And pregnancy has become more complicated now with older women having babies, higher rates of obesity, patients from overseas accessing services and, of course, increasing patient expectations.
Almost all maternity care is provided by NHS trusts and with around 100 private midwives in the country and just one example of a private provider offering services to NHS patients (see case study page 18), the alternative provider is not a serious option for many CCGs.
On the plus side, maternity is an area where the commissioning tools are ready and able to demonstrate what is happening in terms of outcomes and patient experience.
Involving primary care
The role of primary care has also become much more limited in the past decade and some suggest GP commissioners will have to work to close this knowledge gap when commissioning maternity services.
But it is this potential role of primary care, rather than opening up the market, that perhaps appeals most to the policy makers.
Dr Tyler says: ‘Commissioners who have worked hard on maternity have tended to see it as part of the whole early-years agenda, and to see that a good investment in maternity care can pay dividends in those early-years services. For me that’s one of the key links about the re-engagement of primary care with maternity services because when I speak to GPs they really get that. They see those families after maternity and appreciate that maternity is not a bubble on its own but part of the early-years agenda. I think we’ve got a real opportunity to do something different here.’
Dr Tyler says when she speaks to GPs, many are hopeful the reforms will mean their practice will have its own midwife again. In reality, the shortage of midwives means that won’t be possible. ‘But that doesn’t mean there shouldn’t be a strong connection,’ says Dr Tyler.
‘CCG leads will have much better relations with maternity services and I’m already seeing that. CCGs have identified a maternity lead and that person is already meeting the head of midwifery and the lead obstetrician and meeting the community midwife managers and discussing local services to find solutions that work best for women.
‘When I talk to midwives, I hear about GPs who don’t share information, won’t let them use practice facilities and don’t communicate. If I talk to GPs I hear about midwives who don’t share information, and patients who never see the same midwife from one week to the next. A divide has developed between midwifery and primary care in the last 15 years or so and this is an opportunity to bring them back together.’ Dr Tyler cites the Luton preconception diabetes service as an example of how primary care can connect with maternity services to improve care (see box, page 20).
Until now, the inability to demand-manage maternity services has meant PCTs have not given much attention to maternity contracts, with many rolled over from one year to the next. Where there has been a focus, it has tended to be on supporting ‘normal’ births rather than interventions such as caesarian sections.
The NHS Institute believes the proportion of births that were caesarians can be reduced from 24% to 20%, producing a significant saving for the NHS.
The funding of maternity services has been a combination of tariffs for deliveries, outpatient activity and unscheduled attendances. There are also block payments for community midwifery – including GP surgeries and children’s centres and there is wide variation in these block payments, which accounts for the variation across the country in spend per birth.
The joint report mentioned earlier highlights that half of all spending on maternity care is unscheduled antenatal care – women attending hospital day assessment units, foetal assessment units or antenatal wards with reduced foetal movement, vaginal bleeding and abdominal pain. The report argues that if such women – as well as those who make contact out of hours with maternity services for travel advice, swollen ankles and failure to detect baby before 20 weeks – could be better supported in primary care this would ease the pressure on busy maternity units.
A new tariff system has been introduced in shadow form in some areas which grades a woman at her first booking-in interview with the midwife as requiring standard, intermediate or intensive resource usage. The pathway tariff is made up of three chronological parts:
•birth spell to discharge
The level of payment for the pregnancy is determined at the outset, creating much more
control over maternity expenditure for commissioners.
Sean O’Sullivan, head of policy at the Royal College of Midwives, is hopeful the new funding model will lead to more preventive care: ‘We like the new system because it’s simpler and we think it ought to give both commissioners and providers more certainty about what the costs will be. The thinking is by loading up payments based on the information at booking, it’s basically giving providers an incentive to say “if we got X number of women we regard as at relatively low risk we know we will be paid X amount for them. And if that number of women receive more medicalised care, that will cost us more so it’s in our interest to try and provide care consistent with their risk category”.’
Elizabeth Duff of the NCT thinks the revised model offers an opportunity for more equitable funding, though worries the new system could create an incentive to rate the pregnancy risk level upwards. ‘The previous system seemed to leave some acute trusts feeling that they benefited more financially the more interventions they carried out. That was never the intention and is not good for our economy overall. The danger is when health professionals are being asked to classify women, I can see the temptation to classify a woman as perhaps potentially needing more complex intervention because of the worry that there won’t be enough money to pay for it later if an emergency arises. It’s always difficult to know how things are going to progress in a pregnancy.’
Dr Tyler says informal feedback about the new system from trusts has been about the capacity of IT systems to cope with the new coding and finance systems.
Sue McNulty is editor of Practical Commissioning
Making sense of commissioning maternity services in England –
some issues for CCGs to consider. nct, Royal College of Midwives, RCOG 2012 rcm.org.uk/college/policy-practice/government-policy/commissioning
Commissioning maternity services – a resource pack to support CCGs.
Dr Suzanne Tyler, NHS Commissioning Board, July 2012
Commissioning maternity services under AWP
Wirral PCT made national headlines at the end of last year when it commissioned a private company to provide maternity care under the then Any Willing Provider model.
The company, One to One Midwifery, was founded by a midwife and the AWP announcement followed a pilot scheme in the area involving 167 women.
Under the model, the company provides the entire pathway of antenatal, intrapartum and postnatal care and can offer one named midwife throughout the pregnancy to enhance continuity of care.
One to One midwives go into hospital with mothers for the birth or can offer a home birth.
Women can self-refer or be referred via their GP. The company employs 28 people, of which 18 are midwives.
A landmark moment for the company was in August this year, when the Royal College of Midwives signed its first formal trade union recognition agreement outside the NHS.
Wirral CCG accountable officer Dr Abhi Mantgani, a GP in the area, said: ‘The service was initially set up as a response to an external review of maternity services that indicated the need for a focused and personalised service, especially for young mothers and people with complex social circumstances in areas of socio-economic deprivation. We are now starting to see women from other areas of Wirral choose this service. Increasingly women are learning about the service – via Facebook, social networking and the media, so women are coming to the GP practices and initiating the choice themselves.
‘Women seem to like that it’s a personal service. Telephone contact is made with the midwife within 48 hours and first appointments are arranged within one week.
‘The women are given a named midwife they can contact, who will come to their house and midwives are available on the phone 24 hours a day, seven days a week. The women feel they have a lot more personal contact with the midwife. And after the pregnancy is over the midwife continues to be involved. The outcomes for breastfeeding and home births are very good, as are their rates for normal births compared to the national average.
‘Essentially, this is a service targeted at women considered low risk especially for intra-partum care. The service has had a positive impact on reducing frequent drop-in attendances at the delivery suite for routine and minor issues during the pregnancy. The service has provided care to 357 women in the past year compared to over 3,000 deliveries in Wirral.
‘All organisations providing a service to Wirral women are now more sensitive to their needs and are designing services in a manner that meets the women’s requirements rather than the clinician’s. For me, that has been the fundamental shift in what’s happened. It is an attitudinal shift. Maternity services should be designed around the needs of the women and children rather than around organisational need. The choice of providers has meant they are reaching out to see what is wanted and how they can meet that aspiration. This is great news for women in Wirral, as it means improved services for all.’
Case study: Luton Diabetes Preconception Care Project
For women with diabetes who do not plan their pregnancy, the risk of serious complication is about one in 10, compared with one in 50 for women without diabetes. Most of the damage is done in the first six weeks, making pre-conception advice and care vital.
The project in NHS Luton involving six practices aimed to establish how best to implement effective pre-conception counselling and care for women with pre-existing diabetes.
The funding and timetable for the pilot meant it was not possible to demonstrate sufficient final outcomes for mother or infant but it does provide key insights for other commissioners.
The model agreed used computer prompts and templates, so a discussion about pre-conception care could be initiated with potentially fertile diabetes women in primary care.
Secondary care clinicians in obstetrics and diabetology were consulted to agree the specifics of advice at each point in the pathway and contact details for referral.
Contact was also made with maternity services so GPs could be advised if one of their patients suffered a miscarriage so they could introduce pre-conception advice for the next pregnancy. Read codes were agreed and it was left to practices to decide how to contact women aged 15-49 whose contraception or conception intentions were not known.
As part of the model of care, women who currently had no intention of getting pregnant were offered a leaflet developed by the East Anglia Study Group Improving Pregnancy Outcomes in Diabetes (EASIPOD). This highlighted additional risks to diabetic women during pregnancy and outlined steps to take prior to trying to conceive. The leaflet, developed as part of a project funded by Diabetes UK, was already familiar to secondary care clinicians in the locality (tinyurl.com/easipod).
The limitation of existing pre-conception Read codes meant codes had to be manipulated – potentially causing problems if the code was then used for another purpose. The time-consuming part of the template proved to be deciding which code to use. The template sat in the diabetes template, so it would be introduced during a diabetes consultation, but patients seen outside diabetes consultations would not trigger the template use. A template adaptable to each of the four practice IT systems had to be built.
Over a six-month period, some 192 women were seen, and 149 had no intention of becoming pregnant. But four were found to be already pregnant at the time of pre-conception counselling, 14 were trying to conceive and a further 11 planned to conceive. Results for the remaining 13 could not be established. The pilot also found 20% of women had ineffective contraception.
Source: The diabetes pre-conception care pilot project Final Report, October 2011, NHS Luton.