Friday, 21 February 2014

Delivering a patient centred approach

Putting patients at the centre of the NHS is a challenge facing every single commissioner and provider for our National Health Service. A big part of that is designing services around patients, and the key for that process to even begin is listening to those patients.

Maternity Policy is a good place to start, in so far that unlike other kinds of health care, it has various established longitudinal surveys of women’s experiences. It should be easier to put women at the heart of maternity services, because thousands of women tell the NHS how it was for them every day. Having said this, the research we published last year found that too often, women’s experiences were not being taken into account. How can we ensure the NHS uses the data it has to improve care?

One thing that might help is that just like any other area of policy, in the NHS, money matters. With the UK facing a deficit (and the Nicholson Challenge in relation to the NHS in particular), spending is under greater scrutiny than ever before. It’s up to the Commons’ Public Accounts Committee to hold the government to account for its spending. The Committee builds on the work of the government’s auditor, the National Audit Office. In November this year, the NAO turned its attention to maternity services, which cost the NHS around £2.6 billion in 2012-13.

We published our report Support Overdue on the experiences of women using maternity services a few months before the NAO published theirs. Despite the different approaches of both studies, both accounts of women’s experiences and their hard financial performance data tell a very similar story; there is room for improvement, and this improvement will improve both the quality, consistency and cost effectiveness of services. Alongside the data it has about patient experience, the NHS can learn financial lessons from the NAO’s work, and that is a real opportunity to raise standards of care in a responsible way.

After the NAO’s report, the Public Accounts Committee took evidence from clinicians and NHS leaders in November. They used our report to highlight the inequalities in care, and the gap between the Department of Health’s aspirations and the reality of women’s experiences. The NFWI was heartened to see women’s experiences held up beside financial information to present a fuller picture of what was going on in maternity. MPs on the committee took direct quotes from women published in our report and put them to Department of Health Permanent Secretary, Una O’Brien, and Sir David Nicholson, NHS Chief Executive. Now that’s putting patients at the heart of the NHS!

The Public Accounts Committee has now published its own report into maternity services. Using the NAO’s analysis, the evidence MPs took from clinicians and NHS leaders and the NFWI’s Support Overdue, they found:

- There is confusion around the Department’s policy for maternity services, what it wants to achieve, and who is accountable for delivery.

- The Department has not demonstrated whether its policy objectives for maternity services are affordable.

- The Department lacks the data needed to oversee and inform policy decisions on maternity services.

MPs highlighted the paucity of research into women’s choices around birth. Surprisingly, considering choice has been a cornerstone of maternity policy for seven years, there is little understanding about why women choose particular locations or clinicians for birth. This has a massive impact on the financial viability of new or refurbished maternity units or the provision of home birth. Our study showed that women’s ‘ideal’ birth location was heavily influenced by what her reality was: it was much less likely to even occur to a woman that a freestanding midwifery unit or a home birth was a hypothetical ‘choice’ when it wasn’t actually a real one. The Committee has echoed our findings and recommended that “NHS England should build on recent research to investigate the factors that affect women’s choice of place of birth, including closures of maternity units, and what inhibits women from exercising choice in practice.”

Why does choice matter? Different birth locations provide different types of care for different women, and they allow flexibility and individuality. For the NAO and the Public Accounts Committee especially, they allow the NHS to provide lower-cost options (with no reduction in clinical outcomes, and sometimes, even better outcomes for some women in particular). Choices also have repercussions for the midwifery workforce.

When we made recommendations at the end of our report, we encountered a problem: who should we make them to? Reorganisation of the NHS, in England in particular, has fragmented decision-making. The Public Accounts Committee has encountered the same problem and has chastised the government for making it very unclear who, in fact, is responsible for maternity care, even its very basic requirement like having enough midwives.

We know England in particular is short of thousands of midwives, and we know the ones we have are overworked and many want to leave. We hope the Department of Health and the NHS work constructively with CCGs and Welsh Health Boards to get clear lines of accountability for hiring enough staff and making sure women get the quality care they need. The voices of women are loud, and now the money is talking too.

All photos in this post feature WI members campaigning for More Midwives.

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