On the 4th November 2016, Liverpool Women’s Hospital board heard a report on how the Maternity Review is to be implemented in Liverpool and Merseyside. It was not a pretty picture. Little reference to the background reality, of shortages, cuts and  privatization, but the proposals open up a real risk to the hospital services.

Senior staff at the meeting indicated real concerns, the first time we have seen this.

Maternity care needs more resources from central government. There is nothing more important than the safe birth of babies, nothing at all.

First, the Reality Check. before we look at the detail of the Maternity Review.

The government itself said “NHS England has estimated that the total NHS cost for delivering maternity services in 2013/14 was £4.7bn. This does not capture some costs, such as expenditure on perinatal mental health, which was taken into account as part of the work by the Mental Health Taskforce. It also does not include costs incurred by the private and voluntary sectors.

Save Liverpool women’s Hospital Campaign says

• We are short of 3,500 midwives; there are not enough midwives to support women when  giving birth
• The Maternity Tariff, the money that is given by the government to hospitals and midwife units, to provide care in pregnancy and birth. The money is insufficient to employ the midwives we need.
• Many women report being alone in labour, and receiving inadequate care after birth.
• The figures for safety in giving birth in this country are not amongst the best. Our stillbirth rate is poor.
• Many women, who would like to breast feed for longer, give up, for lack of support
• Many women want more help after the birth.
• Midwife recruitment has been damaged by the removal of the Bursary for training midwives
• Midwives work long hours under difficult conditions.
• The National Health service is massively underfunded
• The market model of the NHS has caused administration costs in the NHS to soar. Once the NHS had the lowest admin costs globally and now admin eats into the money available because of the internal market and commissioning
• Cathy Warwick from the Royal College of Midwives voiced concerns about the ability of maternity services to fully implement the plans and achieve the ambitious targets in the current climate.“With a shortage of 3500 midwives in England, a historically high birthrate and increasingly complex births, she said there is a lot of strain on services.

  ‘It is essential that staffing numbers are optimal if safety is not to be compromised,’ Cathy said.

  ‘If we are truly to become a country with world class maternity services, the government has to ensure that the longer term resourcing of maternity services is addressed”

The Maternity Review was not intended to point out the need for more resources. In all the 90 plus pages it does not discuss the crisis in funding.  Accompanying documents talk about the cost of ceasarian sections, the cost of women going into hsopital and the need to cut these costs.

Its a bit like bringing in a posh interior designer to address the problem of a house with structural problems. The house would look lovely with those changes but  it would still fall down.

That is the background for  the Maternity Review. On first reading, virtually every woman (and man) would  support it. The document is written in sugary prose, which  with a repeated mantra of choice.

However  a second look shows very real problems.

First amongst these problems is the idea of a giving  women a personal budget to spend on maternity care. It sounds harmless, but is it?

It suggests giving women a £3000 persoanal budget to spend on maternity care.

The danger of the personal budget is best shown in the example of personal payments given to some parents of children with disabilities. The idea was sold to parents on the promise that it  could  be used it to buy in the services they wanted. But because the money that went to the parents was cut from providers like the local authorities and voluntary organisations, those services had to close  from lack of money, So there were very few quality services left for the parents to buy. Any quality independent services were often too expensive.

The model given at the Liverpool Women’s hospital  was that there would be no more resources but what we have, would be divided between NHS hospitals, local hubs, “pop up” midwife led units (don’t ask!), and the private provider. Each would create a menu of services.

The money each woman had to spend could be used on  pre natal support, support in labour, post natal, breast-feeding support, each in the proportion the woman choses.

Over  this, there would be an “independent” organisation ensuring the women’s choices were independent and fair to all providers. This organisation would have to be “fair” to the private providers too. Note fair to the providers, not fair to the woman.

“The need to ensure that the money follows the woman and her baby as far as possible, so as to ensure women’s choices drive the flow of money, whilst supporting organisations to work together.

“The woman will enter into a commitment to her chosen provider through an agreed process which will also trigger the necessary payments for the provider.” Report to theboard on November 4th 2016

The Maternity Review uses the same phrase

• Nevertheless, there is a need to ensure that the money follows the woman as far as possible, so as to ensure women’s choices drive the flow of money. used to buy her care. Maternity review

This would create yet another layer of expensive bureaucracy and the hospital and other services would be reduced to pay the extra bureaucracy. The hospital would lose still more, because each time a woman chose an out of hospital service the hospital income would fall. Yet the hospital would still need to provide top quality specialist and emergency services.

(There are many examples of damage done in this way since commissioning began. Specialist high quality care was subsidised by lower cost routine care. Then the lower cost routine care was farmed out to a private provider, and the specialist care was left with much higher unit costs and its future is put at risk).

Now if we were dealing with shops or restaurants, it would not matter  n the same way. That is the way the market works. If one shop goes out of business, it’s not a catastrophe. But the market system is  not a safe way to treat our maternity services.

Liverpool Women’s Hospital, the largest Maternity Hospital in Europe, represents many tens of millions of pounds of investment in the buildings and grounds, in the fabric and in technology. Very many more millions have been and are being invested in the skills, education and research of the hospital and university staff. Our taxes have paid for this over the twenty years of its existence and in the earlier Women’s hospitals in Liverpool and Merseyside. It is part of the common wealth of Merseyside and beyond. The impact of this hospital is world wide. Changes to this huge asset must be resourced, planned and monitored with full risk and equality assessments in place well ahead of changes, not what is happenning now.

Liverpool Women’s hospital was not created by the market, it was created by public service and by  charities in the 18th and 19th centuries.

So without huge additional investment, distributing funds to individual mothers risks the existence of the hospital.

Giving ADDITIONAL money to mothers to support choice is a different matter. That would be really good, so long as the hospital and community funding were adequate. Women need to feel that they are respected and that their choices matter, in childbirth and in life as a whole.

What will happen to the mother who makes a budget that runs out? This is the second major objection to the Maternity Review Personal Budget concept.

A woman might sensibly decide to pay for prenatal checks and scans, support in delivering the baby, support with establishing feeding and perhaps extended support in the weeks after birth.

But the pregnancy gets complicated; she needs extra scans, and blood tests. Then she needs bed rest, then specialist advice over unexplained issues with the scans or blood results , then she needs a  cesarean section and the baby needs intensive care. By then £3000 is spent many times over.

Who is supposed to pick up the extra? The hospital has been made even more short of money and many services will have been cut. Will the help be there? Or will it be a hundred miles away?

Then perhaps someone in the excitement of pregnancy spends a lot on the elaborate scans to send pictures to friends and family, and then has no money to pay for post natal support?

“This report envisages more births taking place in the community, i.e. in midwifery care and at home. Commissioners will need to ensure there are services available to support this additional community-based demand. As a result, there may be lower demand for obstetric services, which must nevertheless remain easily accessible to those who need them. Obstetric units will require appropriate local configuration to satisfy demands for safety as well as access.” Maternity Review

Save Liverpool Women’s Hospital view on this is widely shared. Read more here.

There are other objections to the maternity review and to the implementation plans in Liverpool, whichwe will cover in subsequent posts.First amongst these is that another provider, possibly a private one, will bid to run these devolved services. More in alater post.