Better Births: improving outcomes of maternity services in England — the report of the National Maternity Review — was published on February 23rd (NHS England 2016). It has a lot in its 125 pages and its style was described by blogger Roy Lilley thus: ‘If Waitrose wrote reports they would probably be like this… an elegant production, beautifully reasoned, full of supporting facts and an easy read’ (Lilley 2016). But what does it offer that’s new?
Recommendation 1 is for ‘Personalised care, centred on the woman… [who] should be able to choose the provider of… care and be in control of exercising those choices’.
Recommendation 2 is for ‘Continuity of carer, to ensure safe care based on a relationship of mutual trust and respect in line with the woman’s decisions’.
This all sounds distinctly familiar to those who recall the legendary ‘three Cs’ — choice, continuity and control — of Baroness Cumberlege’s Changing Childbirth report (Department of Health 1993). And there is absolutely nothing wrong with that: it was revolutionary, and correct, in 1993 to identify these attributes of a safe, effective and woman-centred service; it is evolutionary, and correct, in 2016 to emphasise them again with the reinforcement of a mass of up to date evidence, for example the 2015 Cochrane review on continuity models of care (Sandall et al 2016).
The five other headline recommendations focus on safer care, better postnatal and perinatal mental health care, more effective multi-professional working, commissioning and provision across boundaries, and a reformed, fair and adequate payment system for providers. All of these are well-known areas highlighted repeatedly in the past — by National Childbirth Trust (NCT) and others — as key to improving both outcomes and quality of care. So the problems that need addressing have not much changed; the principles of how to move forward are familiar; but the practice of what to do needs to be updated and innovated, and that is what Better Births has aimed to do.
There are new terms and phrases in Better Births’ recommendations, which will need to be clearly understood as the impact of the report is felt and implementation work goes forward.
The ‘community hub’ is a new player on the maternity stage and looks like one who will engage well with the audience. Duff & Dodds (2012) found, after a series of focus groups with new parents organised through NCT, that the services they preferred have the attributes of ‘continuity, communication, a community base and coordination’. NCT stopped short of launching a ‘4Cs’ campaign but have maintained a stance of supporting models of service that tick these boxes.
This is what Better Births says about them:
‘Community hubs should be established, where maternity services, particularly ante- and postnatally, are provided alongside other family-orientated health and social services provided by statutory and voluntary agencies. … to help every woman access the services she needs… These might be ultrasound services, smoking cessation services or voluntary services providing peer support. Women may also be able to meet professionals who will be involved with them after childbirth, for example, their health visitor. [Hubs] could be located in a children’s centre, or in a freestanding midwifery unit. They could be embedded in new at-scale models of primary care, including multi-specialty community provider models being adopted by many GPs as part of the NHS Five Year Forward View.’
If these excellent proposals are implemented, the ‘4Cs for services’ will be demands-fulfilled.
Please note, there is a distinction between the ‘community hub’ concept and the ‘hub-and-spoke’ model of service where the hub would be an obstetric unit, and therefore seen as the dominant maternity setting. As described by McCourt et al (2011), while this can work well, it can also lead to one or more of the community ‘spokes’ being seen as an optional extra and vulnerable to closure if there is shortage of funds or staff.
Duff E. MIDIRS Midwifery Digest, vol 26, no 3, September 2016, pp 290-294
© MIDIRS 2016
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