COMMONS

NHS midwives shortage remains despite increasing numbers

31 January 2014

The Public Accounts Committee publishes its report into maternity services in England

The Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts, today said:

"The vast majority of women who use NHS services to have their babies have good experiences, but outcomes and performance could still be much better. Despite an overall increase in the number of midwives there is still a shortage of 2,300 that are required to meet current birth rates – a truly worrying figure.

What’s more, the Department of Health and NHS England struggled to tell my committee who is accountable for ensuring something as fundamental as whether the NHS has enough midwives.

We know that many women do not want to give birth in hospital, with care led by consultants, and this is also more expensive. However, 87% of women still gave birth in this setting in 2012. Women who have a low risk pregnancy should be able to choose where to give birth, such as in a midwife-led unit. More could be delivered for less money with better results if there were more midwife-led birth centres available.

As things stand there is evidence that many maternity services are running at a loss, or at best breaking even, and that the available funding may be insufficient for trusts to employ enough midwives and consultants to provide high quality, safe care.
Pressure on staff leads to low morale, and nearly one third of midwives with less than 10 years’ work experience are intending to leave the profession within a year, an appalling waste of talent.

However, this current shortage is compounded by the fact that more than half the obstetric units cannot ensure appropriate consultant cover at all times.  All those who use the NHS will be alarmed to hear that evidence suggests the quality of care is worse at weekends.

We know that when NHS maternity care goes wrong, the impact can be devastating for those concerned and costly for the taxpayer. Some £480 million is spent on clinical negligence cover – equivalent to £700 per birth. This is money that is sorely needed for frontline care. Maternity claims have risen by 80 per cent over the last five years. The Department of Health and NHS England should address the main causes of maternity clinical negligence claims so that fewer tragic mistakes occur.

The rate of babies who are stillborn or who die within seven days of birth compares poorly with the other UK nations and some European countries – and this is just not good enough.

Furthermore, black and minority ethnic mothers were less positive about the care they received during labour and birth, and the NHS has failed to address persistent inequalities in maternity care. NHS England must set out as a matter of urgency how it intends to reduce inequalities, and report annually on progress."


Margaret Hodge was speaking as the Committee published its 40th Report of this Session which, on the basis of evidence from the Department of Health, NHS England, the National Childbirth Trust, the Royal College of Midwives and a consultant obstetrician, examined maternity services in England.

Having a baby is the most common reason for admission to hospital in England. In 2012, there were nearly 700,000 live births, a number that has risen by almost a quarter in the last decade. There has also been an increase in the proportion of ‘complex’ births, such as multiple births or those involving women over 40. Maternity care cost the NHS around £2.6 billion in 2012-13. The Department is ultimately responsible for securing value for money for this spending. Since April 2013, maternity services have been commissioned by clinical commissioning groups, which are overseen by NHS England. Maternity care is provided by NHS trusts and NHS foundation trusts.

There is confusion around the Department’s policy for maternity services, what it wants to achieve and who is accountable for delivery. Having clear objectives and accountabilities is crucial in a devolved delivery chain like the NHS. Stakeholders told us they were confused as to the current policy objectives and whether Maternity Matters removed the policy framework. In addition, some of the Department’s main objectives for maternity services, such as continuity of care for women by midwives, are described only as aspirations not objectives. The Department and NHS England struggled to articulate to us who is accountable for even the most fundamental areas of maternity care, such as ensuring the NHS has enough midwives. At local level, it is unclear how commissioners are ensuring maternity services meet the Department’s policy objectives, or how they are holding trusts to account. Over a quarter of trusts lacked a simple written service specification with their commissioner last year.

Recommendation: The Department should set out clearly its objectives for maternity care, explicitly stating who is accountable for their implementation and how success against its objectives will be measured.
 
The Department has not demonstrated whether its policy objectives for maternity services are affordable. There is evidence from stakeholders that many maternity services are running at a loss, or at best breaking even, and that the available funding may be insufficient for trusts to employ enough midwives and consultants to provide high quality, safe care. The Department has recently introduced a new payment framework for maternity care. However, the evidence we received suggests that the Department had only limited assurance that the new tariff payments would provide sufficient income to providers to deliver the Department’s objectives. Stakeholders believed more could be delivered for less money with better outcomes if there were more midwife-led birth centres available. The payment framework was one factor inhibiting the increase in such birth centres. Although there has been a welcome increase in midwives there is still a national shortage of some 2,300 midwives required to meet current birth rates. Pressure on staff leads to low morale and nearly one third of midwives with less than 10 years’ work experience are intending to leave the profession within a year. Over half of obstetric units do not employ enough consultants to ensure appropriate cover at all times. Evidence suggests quality of care is less good at weekends.

Recommendation: The Department should assess, through a detailed costing exercise, the affordability of meeting its policy objectives, and work with NHS England and Monitor to review whether the current tariffs for maternity care are set at the right level. The department should ensure the financial incentives enable the best and most appropriate services to be developed at the lowest cost.

The clinical negligence bill for maternity services is too high. Clearly victims of poor care need to be properly compensated, but clinical negligence costs have spiralled and reduce the money available for frontline care. Maternity cases account for a third of total clinical negligence payments and the number of maternity claims has risen by 80% over the last five years. The rate of babies who are stillborn or die within seven days of birth in England compares poorly with the other UK nations and some European countries. Some £480 million, nearly a fifth of trusts’ spending on maternity services, is for clinical negligence cover, equivalent to £700 per birth. The NHS Litigation Authority has recently produced helpful research on the causes of maternity claims, such as mistakes in the management of labour.

Recommendation: The Department and NHS England should build on recent research to address the main causes of maternity clinical negligence claims and to stop so many claims coming forward. They should also investigate the variations in performance between trusts to see how services can be improved so that fewer tragic mistakes occur.
 
Women want more choice about where to give birth. The number of midwifery-led units, where midwives take primary responsibility for care, increased from 87 in 2007 to 152 in 2013, but only 11% of women gave birth in these units in 2012. Research by the National Federation of Women’s Institutes and the NCT suggests that only a quarter of women want to give birth in a hospital obstetric unit, with care led by consultants. However, 87% of women still gave birth in this setting in 2012. Women who have a low risk pregnancy should be able to choose where to give birth and such a large disparity between what women want and what women receive in terms of choice of place of birth is unlikely to be driven by clinical need alone. Over a quarter of maternity units had to close to admissions for half a day or more between April and September 2012. While such short-term closures of maternity units can safeguard the quality and safety of care when demand might outstrip capacity, they further restrict the level of choice available to women.

Recommendation: 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.

The NHS has failed to address persistent inequalities in maternity care. The NHS has had a specific objective to promote public health with a focus on reducing inequalities in maternity care since 2007. However, the latest available data (from 2010) on women’s experiences showed black and minority ethnic mothers were less positive about the care they received during labour and birth than white mothers. They were also significantly more likely to report shortfalls in choice and continuity of care. The Department intended to address inequalities through improved early access to maternity care, but data also show regional and demographic inequalities in the proportion of women receiving an antenatal appointment within 12 weeks of conception.

Recommendation: NHS England should set out what it intends to do to reduce inequalities, take the appropriate action as a matter of urgency, and report annually on progress.

Local maternity networks are an important way of sharing good practice and reducing variation, but they are not obligatory and those that do exist tend to be less well developed than other NHS networks. Maternity networks bring together commissioners, providers and other stakeholders (including users of maternity services) in a local area with the aim of achieving the best possible outcomes for women and babies and tackling variations in outcomes. Despite recommending the creation of maternity networks in its 2007 maternity strategy, the Department has not made it compulsory for commissioners and providers to create them and a quarter of trusts are still not part of a network. In addition, less than 40% of trusts are part of a maternity network with a paid coordinator, compared with 90% for neonatal networks.

Recommendation: NHS England should actively manage the development of maternity networks across the NHS, and set out what arrangements it will put in place to ensure the sharing of good practice between, as well as within, networks to improve quality and eradicate unacceptable variations across the country.

The Department lacks the data needed to oversee and inform policy decisions on maternity services. The Department’s main source of data for assessing performance against its strategy is the Care Quality Commission’s survey of women’s experiences carried out once every three years. The Department seemed to be unaware of other relevant research, for example from the National Federation of Women’s Institutes and the National Childbirth Trust, that it could be using to supplement its understanding of the performance of maternity services. The NHS is in the process of implementing a new ‘dataset’, comprising over 100 data items covering all the maternity care received by every woman. But collection of this data will only be mandated from 1 April 2014, almost five years later than planned and there are no minimum requirements for the IT systems that will support collection of the data.

Recommendation: The Department and NHS England should make better use of existing and emerging data, and of research, to monitor progress against its policy objectives and to inform decisions.

Further information

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