Free to choose

By Sarah Campbell on 24 November 2017 Midwives Magazine Maternity Transformation

Sarah Campbell reviews the first year of Maternity Transformation Programme pilot schemes for spreading knowledge and expanding choice among mothers.

December 2017 marks one year since the first Maternity Choice and Personalisation Pioneers started to run pilot programmes for widening choice initiatives in their areas.

It started with Cheshire and Merseyside. Within a few months, six other areas – Birmingham; Manchester, Salford, Wigan and Bolton; Hampshire, Gosport, Portsmouth and Isle of Wight; south-west London; north-east London; and west Kent, Newhaven, Maidstone and Tunbridge Wells – had also got with the programme. These seven areas encompass 36 clinical commissioning groups, with the pilots in each area headed by a Pioneer supported by NHS England. This work forms part of the Maternity Transformation Programme (MTP) triggered by Better births (NHS England, 2016), which called for maternity services across England to become more personalised, professional and family-friendly.

So what exactly are these pilot programmes, and how do they affect midwives’ daily interactions with women in their care?

Bolstering better outcomes

First of all, the big picture. Tim Straughan, head of patient choice in the Personalisation and Choice Group at NHS England who is helping to support the seven Pioneers, says: ‘Essentially we want to have a better conversation with women about their choices. We’re trying to get women to be more informed, through their midwife, and to know that, depending on their clinical circumstances, there are potential choices that will give them a better experience and better outcomes.’

More choice could have a positive effect not only on women and their babies, but on the health service as a whole. Tim says: ‘The general ambition a lot of the time is to increase the percentage of births happening outside of hospital – in the community or at home. That’s not appropriate for everybody but for many it’s better for women, plus it takes pressure off hospitals... Potentially that could be more cost effective because we’re using hospitals differently.’ 

Pilots in practice

In practice, then, what do the pilot programmes look like? Midwife Mel Hudson is the Maternity Pioneer lead in Cheshire and Merseyside, where the first personal maternity care budgets (PMCBs) were piloted. She describes the experience of women in her pilot area – to start with, this included around 200 women in Liverpool – at the beginning of their maternity care journey. ‘At booking with their midwife they’re offered the opportunity to be on the pilot,’ she says. ‘With that, they get choices around their care and where they have it. We had to structure the choices carefully so that women couldn’t say: “Rather than having the 20-week scan, I’ll have hypnobirthing.” So we have a suite of options on top of the standard package of care, and that suite includes additional breastfeeding support, hypnobirthing, and so on. The women’s choices are reviewed at every antenatal visit. We’re getting positive feedback: women say they loved having a personalised care plan; they could see what choices they actually had.’

Another helpful outcome of the pilot has been a better understanding of the services that women value most. ‘Women very much chose hypnobirthing,’ says Mel. ‘Postnatally, women are choosing additional breastfeeding support and more midwife visits. So as we move forward and plan services, we are able to say: “This is how we are going to use our resources because this is what they’re telling us they want.” It allows us to influence where we should be directing our precious resources. Too often in the past we’ve configured our resources in the way we thought was right. Now women are telling us what’s right – that is really empowering.’

Although this pilot programme is called PMCB, the budgets are notional. At this stage it’s really about laying the groundwork for how to offer choice to women. A separate workstream in the MTP is looking at tariffs and payment structures, according to Tim Straughan.

‘We’re working closely with [that other workstream] on how the tariff is constructed and how money flows around locally to help support choice,’ he says. ‘In parallel with this, there are huge amounts of work going on [...] around service configuration. Where do we need the big hospitals? Where do we need the community hubs?’

Echoing Mel’s point about directing resources, he says: ‘The PMCB pilot will give us hard evidence and numbers around how people are using services, so we can start to let the money go where women are choosing. That’s quite a powerful change agent.’

Data crunching

The next big push for Tim’s team and the Pioneers is data collection. ‘As of the end of September, we had about 1200 PMCBs in place and our goal is to have 10,000 by the end of March. So our real focus for the next few months is ramping up those numbers. Then it’s about turning those numbers into evidence and working out whether the PMCBs have made a difference to women and outcomes.’

The information is still being captured locally but, at the beginning of November, Tim’s team was in the final stages of agreeing a partnership with an academic institution to analyse the data. ‘It’s important that it’s independently verified centrally,’ he says. ‘But what I hope is that we can show the difference the PMCBs have made. The central part of the PMCBs is the personalised care plan – and that’s a fundamental theme of Better births. For me, that is absolutely core to delivering safe, effective, personalised care.’

Transformation in Scotland

Scotland is pressing ahead with its own change agenda. Following the publication of the Best start review in January, which made 76 recommendations for improving maternity services, an implementation board chaired by Jane Grant, chief executive at NHS Greater Glasgow and Clyde, has been busy working out how to put those recommendations into action.

Mary Ross-Davie, RCM director for Scotland, says: ‘The board has agreed that 23 of the recommendations can be implemented at local level. For example, ensuring partners are able to stay with women during induction needs local policy change.’

The board has also established four working groups: continuity of carer and local delivery of care, workforce and education, perinatal services, and information and data. The remaining recommendations have been divided between these groups.

‘The next stage is really about identifying five Early Adopter sites,’ Mary says. ‘They will be supported by the implementation board and charged with setting out to meet the key recommendations around continuity of carer, creating community hubs to provide care nearer to women’s homes, and ensuring that women have options for birthplace.’

The board has been working with RCM workplace reps across Scotland to make sure that they are aware of the recommendations and to help them feel ready to support members around implementation, says Mary. ‘It is a big shift for members in terms of how they will work, so we want to make sure local reps are able to help, to work with management, and to make sure the changes work for midwives.’