Maternity services are an important part of the NHS, but how can CCGs help improve service so standards are higher?
Maternity services are an important part of the NHS, but how can CCGs help improve service so standards are higher?
Maternity services in England attract a high level of public and political interest. This is understandable: having a baby is the single most common reason for hospital admission in England. Maternity services cover care for women from when they become pregnant through to sign off by their midwife: this is usually around 10 days after the birth but can be up to six weeks postnatally1. The components of maternity services are typically divided into the three stages of pregnancy: antenatal, intrapartum (birth), and postnatal care. In addition, neonatal care can be seen as an extension of maternity care as the baby has not yet been discharged home.
According to the 2016 National Maternity Review2, in 2014 there were 664,543 births in England, compared to 566,735 in 2001. Statistical forecasts foresee that by 2020 the number of births will increase overall by 3% to 691,038.
For mothers and the wider family, pregnancy may be the first time they have sustained contact with health services and so presents the ideal opportunity to influence their lifestyle and to maximize their life chances. As noted in the 2016 National Maternity Review,2 it is therefore vital that families are supported by high quality maternity services which cater for their needs and support them to begin their new lives together.
At the moment, there is evidence of a need for improvement in several aspects of maternity services. During the period December 2013 to May 2015 almost half of maternity services safety assessments in inspections by the Care Quality Commission were either ‘inadequate’ (7%) or ‘requiring improvement’ (41%)3.
The NHS Maternity Survey 2015 showed these trends persisting to some extent: for example, only 57% of women said their midwife definitely asked them how they were feeling emotionally during antenatal visits. Similarly, just 54% of women giving birth for the first time felt they were definitely given enough information about emotional changes which may be experienced after the birth.
Experiences of care
The latest available evidence on women’s experience of maternity services has been provided by the 2015 NHS Maternity Services Survey, published in January this year.4 The survey provides the biggest and most systematic insight into the experiences of women in maternity services in England. The 2015 survey was completed by 20,631 people and found variation in the quality of communication, involvement and information provision for mothers using maternity services. According to the survey’s findings, more attention needs to be paid on good information provision, support around physical and emotional wellbeing, and involvement in decision making, as well as practical issues such as feeding. The survey shows evidence of particular challenges around postnatal care. For instance, once mothers returned home, they reported poorer continuity of care and there were some gaps in information and support. In 2015:
- Only 51% of women giving birth for the first time were definitely given enough information about their own physical recovery after the birth;
- Only 28% of mothers saw the same midwife for each of their postnatal appointments and check-ups, despite the majority (78%) seeing a midwife no more than four times after returning home;
- One in four (24%) of women who saw a midwife at home after birth wanted to see the same midwife on all visits but did not. In terms of continuity of care, this figure has important implications: when looking at the results for being listened to alongside whether women had seen the same midwife for each postnatal appointment, there were more positive responses from women who saw the same midwife for each postnatal appointment (88% said that they always felt listened to). Of the women who did not see the same midwife but would have preferred to, only 56% said they felt the midwives listened to them. This shows a similar pattern to the antenatal findings, again showing how good communication is an important part of continuity of care.
The survey also showed that women who saw the same midwife for each appointment tended to report better experiences of care. This demonstrates the value of having an ongoing relationship with a single practitioner as a means of ensuring continuity of care. Whilst there will be occasions where people need to see different midwives due to changes in staffing, personal circumstances, or preferences, it is important for as many women as possible to be given the opportunity to see the same midwife throughout their maternity care if they want to.
The role of CCGs
The 2012 Health and Social Care Act set out special arrangements for the commissioning of maternity services; whilst responsibility sits with clinical commissioning groups (CCGs), NHS England is in charge of setting a national framework for quality and choice and is expected to work collaboratively with CCGs to ensure this is delivered.
In March 2015, Simon Stevens, chief executive of NHS England announced a major review of maternity services as part of the NHS Five-Year Forward View. Baroness Julia Cumberlege was asked to lead the independent review working with a panel of experts and representative bodies.
The scope of the review was to assess current maternity care provision and consider how services should be developed to meet the changing needs of women and babies.
The National Maternity Review, published in February 2016, set out wide-ranging proposals designed to make care safer and give women greater control and more choices.
Among its findings, the review acknowledges that despite the increases in the number of births and the increasing complexity of cases, the quality and outcomes of maternity services have improved significantly over the last decade. However, the review also found meaningful differences across the country, and further opportunities to improve the safety of care and reduce the incidence of stillbirths.
Since every woman, every pregnancy, every baby and every family are different, quality services – safe, effective and providing good experience – must be personalised, argues the review. Therefore, care during antenatal, intrapartum and postnatal stages should be personalised and centred around the woman, her baby and her family; based around their needs and their decisions, offering them choice and unbiased information. In the Review, the concept of personalisation of care develops around four principal items:
- Personalised care plan: this plan sets out women’s decisions about care, and so it should reflect their wider health needs and is kept up to date as the pregnancy progresses. The plan should be developed by women with their midwife and other health professionals.
- Information provision: the report recommends that unbiased information should be made available to all women to help them make their decisions and develop their care plan. This should be through their own digital maternity tool, which enables them to access their own health records and information that is appropriate to them, including the latest evidence and what services are available locally.
- Choice: women should be able to choose the provider of their antenatal, intrapartum and postnatal care and be in control of exercising those choices through their own NHS Personal Maternity Care Budget. Women who choose to use the NHS Personal Maternity Care Budget could use it to select their chosen provider which is accredited and incorporated within the local governance arrangements.
- Involvement in care: women should be able to make decisions about the support they need during birth and where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit, after full discussion of the benefits and risks associated with each option. In order to drive improvement on the four areas above, CCGs will be responsible for the introduction of personal maternity care budgets – sometimes referred to informally as ‘birth budgets’. More specifically, the Review suggests a core set of principles to which CCGs implementing NHS personal maternity care budgets would be expected to adhere:
- The personal budget can be used with accredited local providers for each of antenatal, intrapartum and postnatal care. The process of accreditation of potential providers will reflect those providers approved by CQC.
- Information regarding locally available providers will be made available on the appropriate online platform e.g. NHS Choices or equivalent.
- In the medium term, accredited providers will be required to participate in interoperable care records, complete national maternity data set returns to NHS Digital if requested and provide data to the CCG on a set of locally determined outcome measures.
- Clear local routes of access by women to facilitate choice are agreed and publicised.
The implementation of these policy measures will be monitored and reviewed systematically by NHS England – which expects outcomes to be delivered by 2021 – through its CCG Assessment Framework, and annual Ofsted-style rating of each CCG on its commissioning of maternity services. According to this new scheme, CCGs will be rated by independent panels on 57 indicators in 29 other areas, including quality of their maternity services provided, their models of care, efficiency and their management of conflicts of interest.
The role of patient experience
At present, there are a number of initiatives underway with the specific aim of using people’s feedback about their experiences, which can then feed into improving maternity services:
- The Maternity Experience Challenge Fund was created by NHS England at the request of Ben Gummer, the then Parliamentary Under-Secretary of State for Health. The fund aims to explore innovative ways to make better use of patient insight to deliver improved services. The initiative is about finding new ways to use the feedback that trusts are already collecting to generate change and add value for patients.
- #MatExp is a grassroots social campaign run by a team of volunteers whose main task is to identify and share best practice in maternity services all over the country so every woman gets the care that is right for her needs, every time. The #MatExp community, comprised of women and families, midwives and doctors, promotes its work by using the Whose Shoes?® approach, which has triggered interesting discussions on the aspects of maternity experience that need improvement.
- Always Events – this is an improvement strategy now being trialled in England – and has an organising principle defined as “those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the delivery system”. As such, an Always EventTM is a clear, action-oriented, and pervasive practice or set of behaviours that provides: a foundation for partnering with patients and their families; actions that will ensure optimal patient experience and improved outcomes; and a unifying force for all that demonstrates an ongoing commitment to person and family centred care.
- Finally, users of maternity services have a long tradition of being involved in the design and delivery of maternity care, from giving feedback to running support groups and antenatal education. The Maternity Services Liaison Committees have been established as a forum in which commissioners, providers and service users (women and families) work together to explore what is known about particular groups of pregnant women and families, service users’ experiences, services and the profile of service users locally; covering what needs to be researched further locally and what needs to change.
As locally-based groups of all those involved in planning, providing and receiving maternity care, MSLCs are well placed to advise on developments in local maternity services and monitor progress towards agreed standards.
Improving people’s experiences of maternity care requires providers to hear and respond to user feedback, and to ensure that staff feel supported to provide the best quality care. Results from the national maternity survey and the NHS staff survey should be powerful tools to help services in this task, but they should be complemented by other evidence – including the feedback volunteered by families through compliments and complaints, as well as through targeted efforts to understand and explore people’s experiences.
This is particularly important for those kinds of maternity experiences less well served by national datasets at present, and the challenge for services and researchers alike is to ensure the broadest possible range of voices are heard. If this can be achieved, then there is a good chance of addressing the areas – such as involvement – where improvement is most needed.
Therefore, CCGs need to focus on ensuring the best experiences of care for people in their local communities.
In order to do this they need to be aware of existing maternity experience evidence, and use this to identify areas where there is a need for further information assurance from providers.
For example, drawing on insights from the National Maternity Survey, we suggest CCGs should make a better use of the data available to them and actively seek patients’ feedback in order to improve services and comply with the indicators of the scheme.
In addition to that, improving services requires collaboration, and the ability to work together to assure that the care delivered is truly person-centred. A good way to approach this would be to seek input from mothers and expectant mothers about the quality of their experiences, and networks like #MatExp would be very useful. CCGs should be aware of these and other similar initiatives, such as the Maternity Challenge Fund, and build on their networks. Finally, CCGs should get more involved in workshops organised by groups like #MatExp, and use them to build on best practice and understand what matters most to and the needs and preferences of those using maternity services.
1. Office for National Statistics. Birth characteristics in England and Wales: 2014. October 2015. Available from http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebir ths/bulletins/birthcharacteristicsinenglandandwales/2015-10-08
2. NHS England. National Review of Maternity Services: Assessment of Quality in Maternity Services, 2015. Available from https://www.england.nhs.uk/wp-content/uploads/2015/07/Assessment-of-Quality-in-Maternity-Services.pdf
3. Care Quality Commission. Maternity services survey 2015. Available from http://www.cqc.org.uk/content/maternity-services-survey-2015
4. 2015 NHS Maternity Services Survey