An important reason why small groups of midwives have not already contracted
into PCT or Trusts (other than the very successful Albany Practice which has now done so for many years) is that the expertise, time and resources in
drawing up a fair contract is onerous for both commissioners and the midwives themselves. This is why a standard national contract template, as
proposed in the NHS Community Midwifery Model (NHSCMM) done once would overcome this hurdle and enable PCTs to offer choice of providers without
the burden of writing and negotiating contracts. Any PCT could commission the service for any women in their area. The PCT would use the standard
contract and simply administer it.
It would be essential that the contract included a detailed level of service agreement and standards based on the statutory Midwives Rules and Standards
(NMC 2004) and The NMC Code of Professional Conduct, Performance and Ethics (NMC 2004) (which are there to protect the public and put the woman at the
centre of the care). Midwives signing up to the scheme would have to work to the contract and be accountable for their own practice. All midwives in the
UK are already currently responsible for their own continuing professional development which is reviewed annually at the statutory supervisory meeting
and their registration with the Nursing and Midwifery Council is dependent on this.
Under the current structure of maternity services women have no option at all in choosing their midwife. The vast majority of women receive care from
many different midwives throughout their pregnancy, labour and after their baby is born, most of whom they have never met before. Women would therefore
be empowered by having choice over their midwife.
Under the proposed NHSCMM the midwife would be self employed, as are their GP colleagues.
It is proposed that the NHSCMM would have its own funding stream and as seen in
our diagram (click here), a set sum per women would be paid to the NHSLA
to provide indemnity as there is no commercial professional indemnity insurance available to self employed midwives in this country. This would
mean that neither PCT's nor hospital trusts would be responsible for midwives indemnity cover. The remainder of the funding allocated for each
woman would then go to the PCT who would pay the midwife.
The move towards 'Payment by Results' in its present form of breaking down payment per contact/treatment has yet to be found appropriate for the
maternity services. Government recommendations for over a decade now have recommended that maternity care should be focused on having a baby as a
normal life event as opposed to an illness and that care should be woman centred and individualized throughout pregnancy, birth and the postnatal
period. Payment per episode (pregnancy, birth and the postnatal period) sits comfortably with the proposed NHSCMM.
The standard contract would also ensure women had access to all appropriate screening, (laboratory and ultrasound facilities) and access to birth
centres and maternity units and obstetric and peadiatric services with their chosen midwife. The NHSCMM is about the 'midwifery aspect' of their
'maternity care' and in choosing this model of care, women would not give up any entitlement to access other NHS services if necessary.
For many women with uncomplicated pregnancies midwifery care will be all they require. For
others with more complex needs, the midwife will be a part of the interdisciplinary team and provide the ongoing continuity and support that
helps improve outcomes for the woman and her baby.
This model has the potential to improve care for all women as the mounting evidence from research for one to one midwifery care shows. It would have a
particular relevance for vulnerable women who often find the current system does not meet their needs as it is based on an industrial model with
geographical boundaries rather than the needs of the individual woman despite the often hard work of the midwives in the system. The NHSCMM puts
the woman at the centre of the care with the midwife and the woman working in partnership.
Building on the good work of Sure Start and Children's Centres, women could be referred to midwives working in the NHSCMM. An awareness campaign about
the NHSCMM with such groups as asylum support organizations, probation officers, social workers, women's refuges, health visitors, ethnic community
groups, disability support groups would spread the word that this is an important option for pregnant women to consider. Word of mouth within
communities is also powerful. The work done by Jo Hindley (Having a Baby in Balsall Heath - Women's Experiences and Views of Continuity and
Discontinuity of Midwifery Care in the Mother-Midwife Relationship. 2005) clearly demonstrates that women know what they need for the best outcome for
themselves and their babies and it comes down to an expert they know and trust who will be there for them on the night.
Implementation of the NHS Community Midwifery Model would be a means of:
* Meeting the governments agenda of choice for users, diversity of providers of NHS services and putting resources directly into 'patient' care
* Implementing Standard 11 of the National Service Framework for children, young people and maternity services
* Providing equitable access to maternity services for all women which is particularly important for vulnerable groups
* Helping solve the midwife recruitment and retention crisis
* Improving public health outcomes such as breast feeding rates and mental health of new mothers
* Reducing litigation costs by providing one-to-one midwifery care
The NHS Community Midwifery Model provides the structure for this to happen and all that it now requires is the political decision to implement
it.
