One to One – Choice for women?

13-Dec-2014

Winter 2014 ISSUE 143 Midwifery Matters 23

Jo Parkington is passionate about keeping One to One (North West) going, both for the benefit of women and to give midwives the opportunity of working as autonomous practitioners, working in partnership with parents rather than working as a cog in a system which regards them as obstetric nurses and sees doctors and hospitals as responsible for the birth of the next generation. One to One gives women the option of true continuity of care from their very own midwife – and on the NHS – this private company does not cater for private patients.

When the NHS opened up to competition from the private sector, Jo went down the limited company route because, back in 2011, it was the only way to obtain insurance, although now the service is insured via the NHSLA. Three years after One to One negotiated its first contract with Wirral PCT, Jo is still delighted to have broken the mould. This contract established One to One as an NHS provider, thus opening the door to providing services to other NHS commissioners. Whatever you think about the role of the private sector in the NHS, for maternity care this does seem to be one of the few ways of delivering the type of care that women really want.

Feelings run high in Greater Manchester. A few years ago the number of obstetric units was reduced from thirteen to eight and now there are moves afoot to reduce that number even further, while the hard fought for Salford midwife led unit is under threat. Maternity care provision is getting further and further away from the communities where women live. Some women in Greater Manchester have received ‘non-contract’ care with One to One but someone in the NHS hierarchy appears to be spreading alarm: the Manchester Evening News was leaked a story stating that One to One had cared for two mothers whose babies had died; the paper talked of stillbirths (not so) and that the private company was facing investigation. Facebook was awash with links to this story, spread around the Internet with no attempt to discover the truth behind the headlines. My heart sank. Was One to One going to go the way of the Albany, another gold standard midwifery service killed off five years ago by NHS doctors and managers, terrified of relinquishing control of birth to women and their midwives? I contacted Jo, could she cast some light on the situation?

One to One had put a statement on their Facebook page giving a little more of the background – these deaths were not stillbirths. Jo confirmed that both babies had been born in hospital, one case was an early neonatal death and the other an infant death but the families didn’t want any more information in the public domain and she respected their wishes. The quality of midwifery care was not implicated in the deaths, she added, the families and the midwives were devastated. What about the investigation, I asked? Jo said that investigations into infant deaths were routine for all providers, any infant death in Greater Manchester was investigated, no matter who provided the care.

One to One is probably the best investigated midwifery service provider in the country. They have had five CQC investigations, three of which were unannounced, and two LSA audits. I looked at the CQC website. The results of the last two investigations are there for all to see, one coming through with flying colours, the other passing all but outcome 16, “quality checking systems to manage risks and to assure the health, welfare and safety of people who receive care”. The concerns of the CQC have since been addressed.

According to the CQC website, "Before the inspection we had received information of concern about the provider. The concerns were that people who used the service were not receiving appropriate care and treatment during their pregnancy." "Before the inspection we had been made aware of three complaints about the service. The complaints were from a local NHS hospital..." The service was 'quality assessed' by the Greater Manchester CCGs, led by Trafford CCG, at the same time as a CQC inspection. One to One was passed by the CQC but failed by the CCG. It is difficult to understand quite how the two inspection teams could have arrived at such different results. Was there an underlying political agenda? Quite apart from political arguments against privatisation, another argument is that the hospitals want every penny of available funding for maternity.

However, One to One plugs a gap in NHS maternity provision, showing that continuity of carer can be achieved, and within the constraints of Payment by Results. It has excellent results, with homebirth rates of 32%, a normal birth rate of 74%, CS rate of 16% with 80% of mother’s breastfeeding at 10-14 days. All these outcomes take pressure off NHS services and achieve long-term health gains.

Bradford

Meanwhile, over in Bradford women were asking for care from a named midwife in pregnancy and childbirth but local commissioners were reluctant to reconfigure their NHS services. With ‘patients’ having the option of choosing ‘any qualified provider’ under the new Health and Social Care Act, One to One stepped into the breach. It seemed an ideal moment to put the concept of ‘Any Qualified Provider’ to the test. There was a financial mechanism in place for payment of noncontract activity and a pro choice agenda in maternity care according to Maternity Matters. One to One ventured over to Bradford and women self-referred, booking directly with the midwives. Bradford CCGs objected and would not pay One to One’s invoices; a large amount of money is still outstanding. One to One went through the official channels to gain clarification of their right to be paid for their services and, eventually, in April this year a statement was issued by NHS England (Gateway 01110) stating that any provider approached to deliver care had first to obtain authority from the local CCG before agreeing to provide care. However, even if CCGs refused, GPs were still at liberty to refer their patients to non-contract providers, so, theoretically, there was still a route for women to take to access caseload midwifery on the NHS, albeit breaching the principle that women should be able to book directly with midwives. However, the cluster of CCGs in Bradford and surrounding areas circulated a letter to GPs briefing against One to One, citing safety concerns and lack of equity of access.

NHS Constitution – No choice of provider for pregnant women

Despite the rhetoric of choice in childbirth and the fact that Maternity Matters is still official Government policy, the one area where women have no legal right to choose who provides their care is maternity. The NHS Constitution allows patients to choose any qualified provider for nearly everything else but the paternalistic NHS has ruled that women cannot choose who provides their maternity care. Dan Poulter states repeatedly in Parliament that the NHS is working towards providing women with a named midwife (though he fails to mention that this does not include care in labour). Midwives are ready and willing to offer this service, One to One as a limited company and Neighbourhood Midwives as a social enterprise, but until more CCGs award contracts it remains a pipe dream for all but women in the most enlightened CCGs.

CCGs which continue to perpetuate the factory model of birth are throwing away a golden opportunity to show that community based care is the way ahead not just for maternity but for the NHS.

One to One is now facing yet another quality review by NHSE. Jo says, "I will NOT give up. There has to be a way through."

Margaret Jowitt