By now, everyone working in the NHS should have heard of QIPP – quality, innovation, productivity and prevention – the national strategy aimed at reducing real spend in the NHS by £20bn in four years. The context for this is that over the last 10 years, the NHS saw unprecedented growth in its budget. Even before the coalition government implemented its budget measures, the last government had recognised that while the growth in spending could not continue, the growth in demand meant that cuts would have to be made just to stand still.
Going forward, while other public services are experiencing real cuts, the NHS will get ‘flat cash’, which means the same amount of money going in year on year. The idea behind QIPP is that we need to do things differently if we are to save this money. This is where the quality, innovation and prevention bits come in. However, you would not be blamed for thinking it’s all about saving money because that is the key requirement. How does the NHS continue to do more with the same?
Maternity is not exempt from this debate. If the NHS is to challenge outmoded ways of providing services, and be sure it spends money prudently maximising clinical and cost efficiency, maternity must be included. But maternity is different, and clinicians, managers and commissioners need to be clear about where the scope for savings lies and where cuts threaten quality and safety.
So on one hand, we can point out that the birth rate in England has risen by around 20% in the last 10 years (RCM, 2011) and at the same time levels of acuity have increased dramatically (RCOG, 2011). The fact that resources have not increased at the same rate and that standards remain high is testament to how much productivity maternity services have already delivered. However, the consequence of this increased demand, which in maternity cannot be managed, and activity, which cannot be controlled, means that in many parts of the country we now do not have enough midwives, doctors or sonographers to keep our services at the quality we expect.
We can also point out that maternity is a high-profile service and excites political and public attention. The reputation of the NHS in any local area is closely linked to perceptions and experiences of its maternity services. There is little in the way of private provision, so for most commissioners their local acute trust is their only provider. Endeavouring to do things differently in maternity is also challenged by the paradox of an acute trust-based service delivered primarily in the community; and one where the pathways of antenatal, intrapartum and postnatal care must be joined up to provide a seamless service. All of this might suggest that there is no room for saving any money. While maternity will not release big cash savings, the variation around the country in staffing levels, activity, outcomes and performance is a good indication that some are doing things better than others.
In NHS South Central we benchmarked all of our providers and PCTs to open up a discussion about where the scope for savings might lie. We identified the following and, through engagement between clinicians, managers and commissioners, we have sought to support, encourage and perhaps even penalise where necessary, so that all reach the best standard. Our list is not one that will surprise:
► Reducing CS rates
Under the current payment system, reducing the CS rate saves money because PCTs only pay for activity. Our rates range from 19% to 29%. We estimated that if everyone achieved a rate of 20%, we would save £4.8m a year. A reduced CS rate also means shorter lengths of stay, reduced re-admissions, fewer postnatal contacts and improved breastfeeding – all of which save money. We have used contractual levers, adopted a standardised normal birth pathway and helped commissioners focus on midwifery-led services, while engaging clinicians around promoting and supporting VBAC and managing choice, so that women deliver in the environment appropriate to their clinical need. Last year seven of our 10 providers saw a reduction in their CS rate.
► Reducing unplanned antenatal care
Again, under current payment rules when a woman attends for antenatal care in a day unit or overnight as an admission, PCTs pay around £500 for each episode of care. In our SHA of 50,000 births a year, that equated to around £16.5m a year. We spent a long time working out whether the large variance in activity between providers was a coding problem or a care model problem by looking at the differences in reported activity, how trusts recorded activity and the pathways women followed. This information has provided the evidence required to support innovations, for example, in antenatal triage to avoid unnecessary admissions, as well as the opportunity to consider the impact on safety of developing a self-care tool for women to self-manage minor conditions. We have recommended organisations adopt standardised clinical pathways and protocols for dealing with the common reasons women present antenatally.
► Reducing re-admissions
We recognise that reduced length of stay saves no money if women are re-admitted, so we have encouraged providers to prioritise community postnatal support. Again, we have benchmarked re-admissions and admissions to special care baby unit giving commissioners the evidence to challenge existing models of care.
► Action to improve skill mix
We have adopted the principle of the right staff in the right place at the right time doing the right thing. This means supporting providers to be flexible and creative in the way they deploy staff, including: MSWs in the community providing routine postnatal care; obstetric sonography assistants undertaking simple bio-mechanical measurements and GPs managing women’s long-term medical conditions during pregnancy.
► Development of networks and leaders
The ability to foster good relationships between clinicians, midwives and commissioners has been instrumental in ensuring the rapid spread of innovation for improvements in quality and performance and in identifying opportunities for using resources productively. Alongside this, we have provided support to develop our local talent as clinical leaders and leaders for quality. The new world of the NHS will look very different and this will impact on the way we make the case for investment in maternity services. The focus on outcomes and not activity means a service success will not be measured by how many midwives it employs, but how women experience the service and whether they experience a safe, quality service. With the birth rate continuing to rise and complexity unlikely to decline, commissioners (and that will soon mean clinical commissioning groups) must be assured that they are spending wisely and that their providers are using this money to deliver evidence-based pathways and models of care that are proven to deliver the best outcomes. Despite the anxieties surrounding the NHS Bill, the new structures could create opportunities for strengthening services across England. Better integration of support to new families, combined with a clinical perspective to challenge existing behaviours where outcomes vary from benchmarked norms, offers the chance to eliminate fragmentation and duplication that so often undermines the effort and commitment of those who strive hard to deliver the very best. Dr Suzanne Tyler
Associate director for maternity and newborn programme for NHS South Central References
RCM. (2011) State of Maternity Services Report 2011. RCM: London.
RCOG. (2011) High quality women’s health care: a proposal for change. RCOG: London.