Oral evidence: Maternity services, HC 276Tuesday 28 June 2016
Oral evidence, 28 June 2016.
Witnesses
Baroness Julia Cumberlege CBE DL, Independent Chair, National Maternity Review, Professor Sir Cyril Chantler FRCP FRCPCH FMedSci, Vice Chair, National Maternity Review, and Sarah-Jane Marsh, Chair, NHS England Maternity Transformation Programme Board, and Chief Executive of Birmingham Children’s Hospital and Birmingham Women’s Hospital, gave evidence.
Chair
Welcome and thank you very much for coming. I am sorry that the second panel has been delayed by the Division earlier. Could we start this session by you introducing yourselves to those who are following from outside the room?
Sarah-Jane Marsh
My name is Sarah-Jane Marsh. I am the chair of the NHS England Maternity Transformation Board. I am also the chief executive of Birmingham children’s hospital and the chief executive of Birmingham women’s hospital.
Baroness Cumberlege
I am Julia Cumberlege. I am the Independent Chair of the Maternity Review.
Professor Chantler
I am Cyril Chantler. I am the Independent Vice Chair.
Chair
Thank you all for coming this afternoon. I want to start off by trying to explore further the workforce issues and how far that will create barriers to what you are trying to achieve within the National Maternity Review. Perhaps I could start with you, Baroness Cumberlege.
Baroness Cumberlege
We did do some modelling. One of the things that has come out of the first session, and it is something we feel very strongly about, is this continuity of carer: the person looking after the woman throughout the antenatal, the birth and post-natal care. We did some modelling on that. It did not come out that in fact we would need a lot more midwives. However, I think it is fair to say that there is a shortage and there is pressure on midwifery services. One of the things that really interests me is that on the NMC register there are 2,500 midwives who are not working in the service at the moment on the frontline. Clearly, some of those are not working for very good reasons; they are taking a break because of family or whatever,[1] and they may be doing other things that are essential in terms of running the services. Nevertheless, we know that there are quite a lot of midwives who feel that they are disadvantaged in the way that they are being treated and managed. Too often I hear the phrase, “I love the work but I hate the job.” Something has to be done about reorganising and looking at new ways of care[2] to ensure that women have a safer service, have choice but also that the workforce is happy in the way that it is working.
Chair
As you envisage it, there would be groups of midwives working together and women being able to use their personal budgets to access a continuity of care. Surely one of the issues is that, if we are going to provide choice and that level of continuity to everybody, it is surprising, reading the report, that you did not feel that would need an increase in the current workforce.
Baroness Cumberlege
That was the modelling that we received. Throughout this review we have been very careful not to be top-down. We have tried very hard to be bottom-up because we think that people in the service know the service extremely well and will know how best to work. We were anxious not to say, “This is the way you have to do it.” We have looked across the country. If you go over the river to St Thomas’s, they have six maternity teams working, where they are providing continuity of care. St George’s medical school[3] is the same. In fact, we went to Birmingham and we saw a very interesting project there where they managed to get continuity in antenatal and post-natal care but not throughout the birth. We visited a huge number of places round the country and met thousands of women, midwives and others, who could just drop into our centres and tell us what they thought. Many of them were saying that they wanted continuity; that was very important to them. They also wanted choice. We see safe care and choice as two sides of the same coin. We believe that both are very important. Sometimes people talk about safe[4] versus choice. No; the two are very closely linked. It is quite disappointing that the NPU based in Oxford, which did the research for us, found that 33% of women had no choice at all and they were told where they had to go in order to give birth. I just do not think that is acceptable. Most of us decide how we are going to live our lives and what we are going to eat. Our children get some choice of school, in terms of having parents who can exercise a preference, and we know that most parents get that. If you can afford it, you buy the car and the holiday you want.
Chair
I do understand that, but I am trying to get to whether that lack of choice is because of the shortage of the workforce or just poor planning. What is causing that to happen?
Baroness Cumberlege
We start with the woman. Throughout this report, the woman, her family and the baby are the most important thing to us.
Chair
I get that, but where you are seeing that there is poor choice—in some areas you are saying there is good choice but there is huge variation on this—where there is lack of choice, is it fundamentally because there is not the workforce, or is it just because people are not planning properly and thinking about it?
Baroness Cumberlege
Very often it is because they are not given the choice. They are not told that there is a choice. In Hampshire, they have an app from which women can see locally what the choices are. It seems to me that that technology should be spread throughout so that people can actually see what the choices are. We think that that is really important.
Chair
To press you further on this, if people could see where the choices were, you think that that would happen. Is that what you are saying? It is just that women are not aware of it, rather than it is just not available to them.
Baroness Cumberlege
I think that at the moment they do not know what the choices are. In the future, they are more likely to have some different choices from what they have now, but I know that some women are going to say, “I have listened to all the evidence. Midwife, obstetrician, what do you think?” and that is a choice, if they go with exactly the information they are given. My postbag, emails and all the information I am getting is from women who do not get a choice, who want a choice, who have made a decision.
Chair
Just to be clear, what you are saying today is that it is because they are not being given a choice or supported to make those choices. It is not that they are not there.
Baroness Cumberlege
Yes, absolutely. I think that they need unbiased information and it is up to them to make a decision. Then it is up to the NHS to wrap the services around them.
Chair
Earlier you used the phrase that you are hearing that people love the work but hate the job. How much of that is because they are not able to deliver care in the way they want, for example, through providing continuity and job satisfaction in that regard, and how much of it is just because of overload of all the other things that the NHS staff get burdened with, such as bureaucracy and other issues that sometimes get in the way?
Baroness Cumberlege
If I may say so, that is a very good point. One of the things that midwives have told us is that 50% of their time is spent form filling. When we went to see an electronic system at St Thomas’s on Friday, we were told that we could cut that time spent by 50%. We have seen a very good example in Holland, Buurtzorg, which is community nursing. We hope you will visit that, if you have not seen it already. You can see small teams of district nursing, in our terms, how they work together and how the satisfaction rate has gone up hugely from the people they are looking after. There is a very high retention rate of the staff involved. There are different ways of doing things. I also think that the hospitals have such pressure put on them. You will have seen and heard, as I have, of hospitals that close their labour wards, and some of them quite frequently—as much as four times a year. Women have told me that in labour they have had to go 50 miles to another place to give birth. That is unacceptable. We have to take the pressure off the hospitals so that they can operate not at 100%, but, as we saw in Holland and Sweden, at 80%. It is totally different.
Chair
You will have heard from our first panel that there is a shortfall of 2,600 midwives. You are saying yourself that there are a lot of midwives out there who are qualified but not working. Am I right in thinking that your view is that, if we could make people love the work and love the job, they would be attracted back in, and you see this as being a way forward?
Baroness Cumberlege
Absolutely. We know that there are many midwifery practices. These are groups of independent midwives who would like to come in. We have set out very clearly what that means in terms of their contribution and the way that they have to be accredited so that we can make sure it is a very safe service. We would like to see other people coming into the service.
Chair
In the series of reviews that we would like to do, we are going to focus on implementation. Perhaps I could ask Sarah-Jane Marsh to come in here. How should we be holding you to account? What is a realistic timescale for moving forward along these lines? Do you agree with what Baroness Cumberlege has said?
Sarah-Jane Marsh
Absolutely. We have only had one implementation board so far, but from the outset we have recognised that the workforce is both the biggest risk to implementation and the biggest opportunity, because that is where all the energy and enthusiasm is. It is going to happen on the ground because this is the change that people have said they want to see. Workforce is one of the main work streams of the implementation board and it is the one where we are going to spend the most time initially. We know that if we do not get that right, we will not get anything right. We fully accept the gap that has been described at the moment. It is obviously a gap around our ability to deliver current models of care. As part of the implementation, we now want to look at whether there is an opportunity in the new model to not only make more attractive roles, ensuring that people can work in teams together and feel more supported so that people may want to stay in role and we can retain more people, but whether there are other new emerging roles that we have seen as best practice as part of the review that we could look to implement across the country. In some places we have seen the midwifery support worker. They are able to take on real roles. We have some examples of where they have been the second attendant at a home birth and the evaluation of that has gone well. There is still more work to do, but there is every sign that that could be a role we could develop more into the future. There is also the midwifery assistant role. We have heard about the role of doulas and how they are valued by women.
Chair
Sorry, you said—
Sarah-Jane Marsh
The doula. It is a support worker who can come along the journey with the woman and support them during labour. It is really important that we do not sidestep the fact that there is a gap and there are issues, and we do need to do more to be able to retain the midwives that we have. We need to do workforce planning to ensure that we have the right number for the future. These new models of care do not just rely on obstetricians and midwives. There are other really key important parts of the maternity team as well. That is one of the things that we are going to be exploring very early on as part of the implementation. We need to take the best practice. We have seen so often that, if we can take a little bit of the good in the NHS that is everywhere, and put that all together, you could see the emergence of quite a different sort of maternity workforce.
Chair
You will have heard the concern expressed from the first panel about the impact of NHS bursaries. Is that something you are actively looking at and what impact that could have on your future workforce?
Sarah-Jane Marsh
The workforce work stream in the implementation is being led by Health Education England. They are ensuring that that ties to all the broader work that is being done around the impact that bursaries might have. We recognise that, unless we have the right number of people coming through the profession and training into the roles, not only will we have a problem now but we will have a problem into the future. Whatever lessons are taken from across nursing would apply equally in midwifery.
Chair
We heard earlier too about trying to expand clinical placements for nursing students. Do you have any comment that you want to make on that at all?
Sarah-Jane Marsh
The more people that we can get trained to fill the workforce gaps we have, the better. We know that, when we do not, we rely on bank and agency, and that is when the costs go up.
Chair
But do you agree with the previous panel that there could be complications in expanding the number of clinical placements?
Sarah-Jane Marsh
I am not sure. In relation to—
Chair
Trainees; that even if there were increased numbers there would be pressure on placements.
Sarah-Jane Marsh
Of course. I think it would be very difficult to do immediately, but, in my experience, if you work very carefully with universities and other providers, it is something that you are able to do over time. People can be very responsive around that, so I cannot see why it would be a problem in the medium to long term. I am sure it would be a problem to do immediately.
Chair
Professor Chantler or Sarah-Jane Marsh, are there are any other specific areas in terms of implementation of the workforce work stream that you would like to draw to our attention as a Committee?
Professor Chantler
Only a general comment about the whole report. Implementation is going to be crucial to it. There have been other reports, not least the King’s Fund report of 2008, which is excellent. It is the implementation. There is more to the doing than bidding it be done, as has been said. We have 28 recommendations grouped into seven areas, and they all matter. The notion that you could cherry-pick and have a good outcome is to be resisted. They are all justified in relation to each other. I can expand on that later, if you like.
Chair
I am particularly interested to hear which ones you feel are at the greatest risk of being dropped or you feel concerned might be downgraded.
Professor Chantler
Some are potentially more difficult than others because they have to do with how the NHS itself is developing. I will give you one. It is not about units but about local commission maternity footprints—so 1.5 million people. It only works if you take into account the main hospital provider or providers, the alongside unit, the midwife unit and the home births all working together. If you work together, you train together. That is particularly about service training, which is PROMPT or MOREOB, the Canadian model. It has to be within that network. You talked about maternity practices. Think of them like general practices. They are part of the national health service, and they have to comply with the governance of the national health service. If they provide a service within the network, they train together and work together. Then you have to have proper ways of reimbursing them. One of our areas of concern is about the so-called tariff. Tariff is a bad word. Basically, you want payment that promotes good practice and does not obstruct it. At the moment it obstructs it. The Royal Liverpool maternity hospital, where David Richmond comes from, is not part of a big hospital; its fixed costs really matter to it. Therefore, we propose that the fixed costs and the variable costs have to be dealt with separately. I could go on forever, which you do not want me to do.
Chair
It would be helpful if you could perhaps write to the Committee setting out your concerns so that we know what areas we should be looking at.
Professor Chantler
I do not think they are concerns. It is all in here; we just want it implemented.
Chair
It is just implementing what is in the report; thank you. Unfortunately, there is a Division in the House; so apologies. We will be back as soon as we can; thank you. Sitting suspended for a Division in the House. On resuming—
Chair
We are actually quorate. A couple of other Members will join us in a minute but I am conscious that we have kept you rather a long time, so we will crack on and go to Maggie next.
Maggie Throup
This question is particularly for Sarah-Jane. I am aware that you have had only one meeting of the implementation board, but how do you see the separate Neonatal Review being integrated into the implementation of the Maternity Review?
Sarah-Jane Marsh
One of the agenda items at our first meeting was to make sure that it is, because we know it is absolutely critical that we do not look at those two things in isolation, particularly when we think about the new maternity systems that will sit at the STP level that David described earlier. Neonatal absolutely has to sit alongside and inform that because the two things are critical. We are very sighted on the need to bring those two things together.
Maggie Throup
Have you any more thoughts as to how you will do that?
Sarah-Jane Marsh
At the board level we have the representation, the intelligence, the learning and the outcomes of both of those. The place on the ground where they meet is in the strategic clinical networks, where we have maternity and neonatal sitting side by side. The people who have led on those reviews are very clear about the links between the two. They will have some oversight of the implementation. As we said earlier, we are very keen that it is bottom-up, but we need to make sure that we are setting the standards and we are very clear about that. There will be oversight there. Maternity and neonatal will sit very closely side by side within those strategic clinical networks anyway, because you cannot disaggregate the two.
Julie Cooper
We were talking about choice in provision in pregnancy, but what about the variation in service? I am concerned about that. What recommendations in the report best tackle variation in quality of provision available?
Baroness Cumberlege
I am going to ask Sir Cyril if he would answer that because it does fit very much into the way that we are thinking about not only preventing problems from arising in terms of continuity of care, which you have heard a lot about this afternoon, but about investigations when things go wrong. It is certainly about ensuring that we have a proper information system held by the woman to which everybody has access. We are very anxious that she should be in the centre of care. This should be electronic. We want an electronic maternity record, but also the woman’s birth plan should be on that so that people can share that information.
Professor Chantler
Safety goes all through the report. That is where we started from. Part of what stimulated this report were the events in Morecambe Bay. We were very conscious of the fact, putting it clearly, that, if you had a baby in Sweden, five years ago there were 20 damaged babies for every 100,000 live births. There are now five. In our country there are 35. So it can be done because there are units in our country—David Richmond mentioned North Bristol—that are as good as anywhere in the world. There are other units like that, but it is not generalised; that is the variability. There is no simple solution. There is a whole series of things. I mentioned learning and working together. It is crucial that, after every poor outcome, there is a proper investigation that involves the families and that it is done on the basis of full disclosure. What they did in Sweden was to develop an insurance-based system, based on the concept of avoidable harm but not immediate blame, which inhibits full co-operation. I know about the importance of justice when things go wrong, but we are talking about justice for the baby. We need to improve the outcomes. Part of this is saying, “Let’s have a proper investigation,” and this links into the new Healthcare Safety Investigation Branch, which you will know about. It is organised on a regional basis with outside assessment; the colleges and so forth are involved. When you know what went wrong, you can feed back to the clinical unit immediately because that seems to be what has worked in Sweden. You also support the family through that process. You do not wait 10 years through the litigation process to get the learning back, by which time it is too late. If you do all those things together—you work together, learn together, investigate and get the learning back with proper support through information systems and continuity of care—putting all that together, there is no reason to suppose that we cannot get the stepwise improvement in this country that they have seen in Sweden, and, I understand, in Canada, although I am not familiar with that. We are proposing a rapid redress system as an insurance-based system to aid that just as they have in Sweden. If we are successful, that will not only improve the outcome for babies but will save this country an enormous sum of money. Last year, NHS litigation for 137 or 139 babies was a pay-out of £574 million. It is estimated to be going up to £1 billion a year by 2020. If we could get the same amount of success as they have had in Sweden, that sum of money will be much less. Then we should have the capacity not only to support the families where clinical negligence has been proved but the other 70 families, who have just as many problems in looking after their disabled children but do not actually get that support. You put together the whole thing: the rapid investigation; the learning together; the working together; the insurance system to get the support to the families; and the learning back. You will then have a system that will promote safety. Within that are such things as co-ordination of care and the digital record. That is why I say it all has to be done together.
Julie Cooper
That is very encouraging to hear. It is obviously what we are aiming for and we all want to see these numbers as low as they possibly can be. Even in pregnancies where something does not obviously go wrong or there is not an obvious problem, how will the implementation of the report ensure that more vulnerable women or women who have barriers to the choice that you talked about overcome the inequalities in maternal care—for example, women who have language barriers, or, as the other panel mentioned, women in prison or those suffering with substance abuse issues?
Baroness Cumberlege
We looked very carefully at that when we were doing the review. We particularly looked at disadvantaged women. I think of the day I spent in Brighton with the Gypsy community, which was very interesting. We also talked to women from black and ethnic minority groups, and many others. One of the things that really struck me about that was that they were the women who would probably most benefit from continuity of carer—somebody looking after them.[5] When I went to Bristol and said to them, “You are looking after women who have really severe mental health problems; that must be such a challenge,” they said, “No. Actually, it is the first time somebody has really cared about these women and listened to them. They are very grateful for some help and some guidance.” I think this is all very possible, and I also think, as do others, that they do want some choice but not always.
Julie Cooper
Following up on that, I think Janet Scott in the first panel said that she hoped this would lead to an improvement for all women during pregnancy, but a significant improvement for these more vulnerable women. Would that be your view as well?
Baroness Cumberlege
Absolutely.
Julie Cooper
We are looking to achieve a differential improvement.
Baroness Cumberlege
Yes, and in our report we have quite a lot on that, especially on women who have mental health problems. I was staggered that 20% of women during pregnancy and the first year after the birth of their baby suffer severe mental health problems. These women need a lot of help, especially after the baby has been born. Bringing up a child is very challenging. Where we have families today who are not as integrated as they used to be, you have to rely on professionals and others to fill that gap.
Sarah-Jane Marsh
I would add that we have several pioneering sites that we are working with at the moment; they are early implementers of the choice and personalisation budgets. Again, we are in the very early stages, but part of the work we will be doing with them is to see the outcomes of the introduction for all women, but especially that they are able to demonstrate that it is universally applied and that it is going to make a significant impact for some women in the harder-to-reach areas. We do not have outcome measures yet, but that is something we discussed at the board. The outcome cannot be that the woman was given choice; it has to be that as a result of that choice we have a safer outcome and a better experience, otherwise we have not achieved anything. We are in the very early stages but that is built in. We recognise that we are taking a step here into something that we have not done before. Before we do it on a mass scale across the whole NHS, we need to understand the best ways to do it, as well as some of the potential pitfalls. We are working closely with those pioneers and getting reports back at every board to see what the progress is.
Julie Cooper
In terms of the personal care budget, that might well be something that the more articulate, educated or advantaged women are able to access. They will see an improvement but I would worry that it is at the expense of other less able women.
Sarah-Jane Marsh
Again, I totally accept the challenge. We are asking the pioneers to demonstrate to us how they are going to support all women who want to exercise a choice to be able to do that. I do not think anybody has a plan to say, “Does anybody want choice and here’s a leaflet. Fill it in,” or whatever. We are asking people to build in that there will be workers there who can support people through that choice—and help and guide. It is how we get that information to be independent. Very clearly, we need to make sure that that does not happen, otherwise we are not setting out to meet the vision in Better Births.
Baroness Cumberlege
I would like to add to that. Originally, we thought that we would perhaps have three or six different CCGs who would want to do this. We put it out to invitation, and a third of the CCGs in the country applied to do this. We said that one of the criteria was that you had to come together in order to form a bigger footprint than just one CCG. In some of the pioneers we have seven CCGs, for instance. In one, which is a very rural area, we only have two CCGs coming together. All together, we have seven pioneers whom we have chosen and they do cross the spectrum. We have some very challenging areas in terms of disadvantaged women. As Sarah-Jane has been saying, we have been looking very carefully at that as well as the other areas.
Julie Cooper
Presumably you will be monitoring this carefully to measure the impact across the spectrum.
Baroness Cumberlege
Absolutely.
Sarah-Jane Marsh
Yes.
Dr Whitford
What will be the process of actually working out the nuts and bolts of the new payment system? There is no detail in it. Will it be a consultation or how will you decide it?
Baroness Cumberlege
We have the seven pioneers now to do the personal budgets. We have put some resources into each one of those, so we are expecting them to do things differently in different areas. After all, this is a pilot and we need to learn from each of them how they are doing and how different they are from another one and so on.[6] Again, I did not really want to choose people and say to them, “This is the way you have to do it.” We have said to them, “It is up to you. You decide how you are going to do it.” We will have seven areas that will probably do things differently in each area. That is fine by me.
Dr Whitford
How will you evaluate them at the end?
Baroness Cumberlege
Yes, very much so.
Dr Philippa Whitford
But how—so that you can then say, “It is model six that seemed to have the biggest impact, and that is what we would suggest the rest of the country follows”?
Baroness Cumberlege
We are bringing in evaluation. We have to work through that, as Sarah-Jane has said. It is not just the choice; it is what that has done in terms of outcomes, satisfaction and safety—all the important issues.
Dr Whitford
At what level has the personal budget been set?
Baroness Cumberlege
It has not. Again, it is up to the individual pioneers. At the moment they have to work with the tariff that they have, which is in three different sections. We do not like the words low risk, medium risk and high risk, because women have told us that they hate it. They feel that once they are high risk they are going to be in deep trouble. We are talking about standard care, intermediate care and complex care. The difference between those tariffs is quite considerable. If you look at standard care, it is just over £3,000 for each one.[7] If you look at complex care, it is over £6,000. The intermediate comes, as one would expect, intermediately. Then it is up to the women and the pioneers to choose how they want to implement this. Some may say, “We want to go just for the standard care.” Others may say, “We want women to choose everything.” Again, we are going to see how that pans out.
Dr Whitford
So it will be down to the woman to choose whether she was complex.
Baroness Cumberlege
On the advice that she is given. She must have unbiased information. If she is assessed to have standard care, that will be the tariff. If they say to her, “Look, you have had real troubles in the past,” and there is talk about whether she needs an obstetric service or not, it is up to her to choose. The choice is hers but she must have the unbiased information.
Dr Whitford
She is choosing which budget she is as opposed to choosing how to spend the budget she gets given.
Baroness Cumberlege
Yes; she is choosing which type of care she wants. She is choosing where she wants to have the baby. Some will obviously choose to have an obstetrics birth; others will have a freestanding maternity unit or a home birth.
Dr Whitford
I understand that. I am just trying to understand how the woman has the choice of which budget she gets. Surely, everyone would choose to be the £6,000, no matter what they choose to spend it on.
Baroness Cumberlege
No, they don’t. We know they do not want obstetric care throughout.
Dr Whitford
It comes down to what they choose to do. If a woman chooses obstetric, then that automatically carries a £6,000 tariff.
Baroness Cumberlege
Yes. Of course the money does not go into her bank account and she can’t buy another buggy or whatever with the money. We have a very good example in terms of long-term conditions and the way that personal budgets work with those, but this is a different system.
Dr Whitford
Yes, I am aware of that. Obviously it is a different system because, as we talked about in the first panel, it is not trying to deal with a lifelong chronic illness. It is something that is going on for maybe one and a half years from pre-conception right through to support. I am just trying to understand how that choice will actually get you the outcome in the end. How will that improve the care that the woman gets, including safety?
Sarah-Jane Marsh
We are only a few weeks in but people are approaching it differently. Where everybody is starting from is getting together a list or guide of services that are available locally for women to choose. At the moment, as Julia has said, one of the issues is that not everybody is aware of all the choices available to them. Therefore, they just go to the local hospital or whatever because that is the thing that everybody in their family has done. The first thing is to get a guide of what some of those services are, and then to think through how the woman can sit down with somebody who has the expertise to guide them to say, “These are the different choices that you have at this stage.” One of the powers of our models, potentially, is that the right decision for you when you book your 10-week appointment might not be the right thing at 32 or 34 weeks. At the moment, you might not know how you are going to feel sometime down the line about what is right for you. You may initially choose a home birth or a midwifery-led unit or whatever and you may escalate later to needing obstetric care. Equally, we are not very good at de-escalation at the moment. People may originally have said, “I would like obstetric-led care,” but now feel quite confident because they have had a very good pregnancy and the baby is in a good position and so on, who now think, “I have changed my mind; so I will go for midwifery-led and home birth.” We need the flexibility built in so they can change along the way. It is not a one size fits all. We are not saying that it is this way or that way, but everybody is moving in the same direction to be clear about the menu and the fact that women are not locked into a choice once they have made it. They can move in and out of different packages.
Dr Whitford
Is there not an issue, though, about both managing and providing the capacity? Having one organisation that encompasses everything from home birth to very intensive obstetric is one thing, but I am concerned about fragmentation when you have them competing with each other to get hold of the budget from the patient. There is still that issue that, if you have A, B and C, what if everyone chooses A so that A cannot cope? Our problem at the moment is that everything is at capacity. How do you manage that when you have no idea what women will choose?
Sarah-Jane Marsh
One of the mechanisms for delivery is around the STP that we have talked about: the sustainability and transformation programme. This is true not just in maternity but in the rest of the NHS. We are moving towards delivering care in systems rather than in organisations. We almost want to make it impossible for organisations to say, “I can act in a silo here and just do what I need to do to compete and get the income I need to make the service sustainable.” We cannot afford to run a health service that way. The maternity plans that we are looking for people to provide via the STP will be a system-wide maternity plan that needs to address some of those issues. We are not looking for the Birmingham women’s hospital plan or the South Central CCG plan; we are looking for a joint plan for that area, which means that everybody is signed up to the consequences.
Dr Whitford
Does that not then lend itself back towards more area planning and area funding? You say, “We have X number of women so we expect this many deliveries; we know from our data, which hopefully will be good, that there will be that many home births, that many midwife and that many obstetric,” rather than turning the woman into a customer where you have created this complexity whereby you do not quite know in any financial year how that will go.
Professor Chantler
Yes. The thinking behind this recommendation is important. As Julia said, choice and safety are not alternatives. They are crucially linked together. We know that our obstetric units are overburdened. We also know from the surveys done by the National Federation of Women’s Institutes that 87% of births occur in an obstetric unit but only 25% of women say that is what they want. We also know that 10% say they want a birth at home but only 2% get it. In midwife-led units, there are 2% of births but 6% of women want them. If more women want births outside the hospital, and it can be done safely, then isn’t it a good idea to facilitate their choice?
Dr Whitford
But do you really need the personal budget to do that? Is that not training us to actually sit and have a decent conversation with the patient?
Professor Chantler
Indeed. That is the question that is being tested. They are not getting money into their hands, but will the budget encourage the system to listen to the mum so that she gets her choice? We will find out whether it does or it does not, but that is the thinking behind it. Also, how can we bring into the provision people who are specialised in home births and so forth? This is where these independent maternity practices, which will be part of the NHS if they are working for the NHS, come in. I was in a hospital in the north of England and I listened to two families tell me what a terrible time they had had with their first births, with instrumentation. There were terrible mental health issues after that. On the second occasion, the three community midwives in the hospital came along and said, “We will support you to have a home birth.” One had had a Caesarean section before. Both thought it was absolutely wonderful and it was all fine. Hospitals are not always the right place. I am a paediatrician. I have spent hours in neonatal units and they are not always the right place. This is part of a strategy. You are absolutely right that it is not about a hospital or a midwife-led unit. It is about the local commissioned maternity network, which will be required to improve its services, to report its annual report, to work and train together, and to facilitate choice for families in a safe way. It is all together.
Dr Whitford
If you actually create a network that has everything from home birth to high intensity and we work on training—as I said, being a cancer surgeon and learning to work to give women the choice, it was not a budget that changed that. I would be afraid that something like this could go the other way. With regard to Mid Staffs and Morecambe Bay, with people trying to be a foundation trust, what if they say, “We need to get her to go for that”?
Professor Chantler
That is why I mentioned that the payments system has to promote good practice and not obstruct it. We can give you an example, which I will not do now, of a unit where it is quite clear that the present payments system was obstructing this sort of co-operation. There is a saying in our profession now, and that is that the patient is the pilot and the doctor is the navigator. It is about giving people information and supporting their safe choices. It is only a little part of it. I do not think it will go the way you fear, but obviously we do not want that to happen either. The one thing I do know is that it is no longer the case that a good cancer surgeon, important though that is, will give you a good outcome. Medicine is no longer about individuals; it is about teamwork. What went wrong in Morecambe Bay was teamwork. What is going wrong across this country in some places, but not in others, is a failure of teamwork. Everything we are doing here is about how you promote that teamwork. You talked in the earlier session about multidisciplinary teamwork. This is training on the job. This is postgraduate. It is not about how you alter the undergraduate curriculum. I used to be the dean of a medical school and I could talk for hours on that, but this is much more important. It is about how you get teams to work together.
Dr Whitford
Is that not really where we should be putting our effort? Rather than having different systems competing for this personalised budget, should we not have a multidisciplinary team, educating them to listen and understand the woman, and put the money and the energy there?
Professor Chantler
They will not be competing.
Baroness Cumberlege
I did the report on Changing Childbirth all those years ago. Even then we were talking tremendously about choice and continuity of carer. We tried to instil that into the service. As we know from the surveys the NPEU surveys have done, 33% of women do not get a choice; they are not even told about it. The idea of a personal budget was to try to use a trigger, a mechanism, some way of trying to give women a bit more clout in order to get the choices that they wanted. We have been very careful to tie it into the NHS services so that the money will not seep out of the NHS; it will be contained within the NHS. We would love to hear from the Committee if you have other ideas that we can adapt or adopt in order to give women the choice that they are not getting now. This was just a mechanism, a trigger.
Dr Whitford
My concern is that it is the staff you have to change. I am just not sure that a funding mechanism changes the interaction of GPs, obstetricians or midwives with the women. That is who sits there, takes the time to listen and speak to the woman, explains things and accepts her choice. I just worry that this budget in the background could cause problems or at least not particularly get past this idea that the woman should be sitting there, understanding her options and making a choice.
Baroness Cumberlege
We will wait and see. We have seven pilots, so we will see what comes of them.
Chair
I want to ask about the pilots. We were hearing earlier from Sarah-Jane Marsh that you had not really decided on your outcome measures either. Therefore, how are you going to compare all these different systems if you are using different outcome measures?
Sarah-Jane Marsh
We have not decided on them because we literally only gave the pioneer status a couple of weeks ago.
Chair
So it is not that you are not going to do that.
Sarah-Jane Marsh
No.
Chair
I am just worried how you will compare whether it is a place-based system without personal budgets or—
Sarah-Jane Marsh
We have been clear that, while there is flexibility about the way you do the design, we have to be able to benchmark the outcomes to see which is having the greater impact. That is one of the pieces of choice and personalisation work that the board is doing. How do we get meaningful outcome measures that we can track over time and benchmark against each other to see which ones are working more effectively?
Chair
Will you also look at comparing that with models such as Philippa has described, where you are actually focusing on training the team to deliver choice rather than using a different method of delivering budget?
Sarah-Jane Marsh
There is no reason why not. That has outcome measures as well. That is another of the work streams of the board with outcome measures. There is no reason why we could not compare those too. I can talk about the Birmingham example because I know it better. Birmingham is a pioneer site, and almost the reverse has happened to what you have described there. There is widespread recognition now that unless we work together and have a common shared understanding of the services we provide—what sits on what part of the risk system—we will not be able to provide a single front door for choice for women; we will just completely confuse them. For the first time, certainly in my time in Birmingham, we have had a big event where we have got all the midwives together from all the different providers and said, “How could we do this?” There is a real sense of opportunity to work in a different way to the extent—and this is not a decision—that we have started to talk about the idea of maybe an accountable care organisation. Again, similar to cancer, can we be single organisations of care no matter where they might sit? Having single leadership teams potentially and single governance structures across patches could be a way to overcome this and for us to encourage women to move between the services. I think it has provided an opportunity to have a different sort of conversation. We have deliberately picked pioneers where they have been able to demonstrate that that leadership is there. A kind of “every man for himself” competition where “we are in this to attract the most women we can” model is not something that we have awarded the pioneer status to, and nor would we, because that is not what this is about.
Dr Whitford
Obviously, the system is so different, because in Scotland we have health boards. We simply have place-based planning. We do not have hospital or primary care trusts; we now have integration joint boards. That is how our services are put together. It is the complexity that I am anxious about.
Professor Chantler
We expect there to be 40-odd locally commissioned maternity networks. We expect them to produce an annual report of their outcomes, in terms of clinical and functional outcomes, and patient satisfaction. We expect the boards of the organisations within that network providing the service to look at those outcomes and to intervene if there are problems. We expect the colleges to help them achieve that. We expect them to look across regions, compare their results and to help each other. That is all in this report. This is why I am so intent on thinking of these 28 recommendations taken as a whole. If they are cherry-picked, it will not work.
Dr Whitford
Baroness, you talked about what you had seen in Holland, which was running at 80% capacity instead of 100% plus, which is what we run at here. Surely to turn our 100% plus into 80% would mean that we would need 25% more capacity. Surely we would require at least some increase in staff or else we are still going to be at capacity.
Baroness Cumberlege
The issue there is that, if we actually see women exercising their choices, we know that some of them are going to choose midwife-led units. We know that some of them are going to choose home births. That will take some of the pressure off the hospitals.
Dr Whitford
So it is really just getting them out of hospital and into those choices.
Baroness Cumberlege
It is not for us to get them out.
Dr Whitford
No, for sure.
Baroness Cumberlege
It is up to the women to choose whether they want to. I just think at the moment, where we are having labour wards closed, it really is unacceptable for this country at this time.
Dr Whitford
So your recognition is that the capacity issue is at the obstetric end where we are bringing perfectly healthy women to have their births, when in actual fact many of them could be in midwife units.
Baroness Cumberlege
If they choose to do so, yes; absolutely.
Dr Whitford
I am sorry for focusing on the budget, but that is my bit; that is the bit I am exploring. How do you see that working for the very complex patient? You helpfully described that it was from £3,000 up to £6,000, but what would happen for the very complex patient where in actual fact that individual’s budget goes way beyond £6,000?
Baroness Cumberlege
One of the things we are recommending in the report is that, first, we want to see this tariff system overhauled. As Sir Cyril was saying, we want to make sure that it does not act as a barrier to choice or other things. Certainly we want it to be fair. At the moment we do not think it is even fair. The budget at the moment is not sensitive enough to women’s needs. We also think that there should be a tariff for neonatal care because that is so intensive and so expensive. At the moment that does not seem to be recognised. We really want an overhaul, and that is going to take quite a lot of time to achieve. We are very anxious that this report should be implemented at a brisk pace. We want to see it happen quickly, as far as we possibly can, but we do recognise that some things are going to take a bit longer than others. One of them is the tariff and how we can reorder that to make it more sensitive and to make sure that the money follows the woman.
Dr Whitford
So you would not particularly want to go to place-based commissioning around birth. You would still want to keep a tariff that is reformed.
Baroness Cumberlege
Not necessarily, no; we are open to ideas. We were asked by Simon Stevens whether we would look at the future shape of maternity services, and so clearly we are open to ideas. We put down the ideas that in nine months we actually came to conclusions on. Someone had a sense of humour in saying nine months, I think, because that was the time we were given. There are so many ideas in the service. We tried to listen to as many as we could, but I am sure that as things evolve we will get better ideas.
Dr Whitford
You have touched on the idea of independent providers should the woman choose that, but then they have to accept certain standards.
Baroness Cumberlege
Absolutely.
Dr Whitford
What if, in actual fact, a patient chooses that service but it is only a handful of patients? That provider might say, “Well, I am not going to set up and order this, that and the other for two patients.” How will you enforce that they, in essence, come into the NHS, as you have described?
Baroness Cumberlege
It is up to them to choose if they want to come into it. We are not forcing them to come into it.
Dr Whitford
But would the patient be able to use them?
Baroness Cumberlege
Not individuals. We are saying that a maternity practice has to be a number of midwives working together within the NHS. As Sir Cyril said, it is like GP practices. They are in the service but they have more autonomy. In order to make sure that they enjoy the work and the job, we want to make sure that they have more autonomy over their work. We can see some midwifery practices coming together and wanting to provide that choice, but I am sure it will be patchy. We cannot expect an evenness across the country because, again, it depends on them.
Dr Whitford
Does that mean, in essence, that it would not include independent providers who are outwith the NHS, as in private providers?
Baroness Cumberlege
It would not include private providers.
Dr Whitford
Even if that was the woman’s choice, she cannot say, “I fancy the BUPA home; it looks nice.”
Baroness Cumberlege
No. She would then have to pay for it privately out of her own income. It would not be part of the NHS.
Dr Whitford
Okay; thank you very much.
Maggie Throup
What does the review have to say about the difficulties of delivering maternity services in remote and rural locations?
Baroness Cumberlege
It is very difficult. Catherine Calderwood, who is your CMO in Scotland, was on our review team. We did keep her to the end because we saw this as a really difficult area. I rang up Tony Faulkner, who is the person who has been doing the work in Cumbria. Tony was very interesting. He was a previous president of the Royal College of Obstetricians and Gynaecologists. When he looked at the plan, he said, “It’s easy. You have to put this unit with that unit, and then that unit…” and all the rest of it. The thing about Cumbria is that it is beautiful—we saw it in the sunshine and it was just sensational—but there is an awful lot of it. That is the problem. In the middle there is a mountain, so you have a real difficulty with the coastal areas and so on. They have worked so hard in Cumbria and they are beginning to get the solutions through now. We will watch what they are doing. As I understand it from Catherine, what they are trying to do in Scotland is upskill some of the workers. They are sharing obstetricians across different sites. Sometimes it means that they have to go and stay in an area for six weeks or something like that. They are looking at other, very innovative ways of working, but I have to say that it does cost more. Some of these small units are providing a really good service and we would not want them closed, but it does cost more. In Cumbria, they have found that and they have flexed the budget so that they can support some of these more isolated units. Then I went to Lincoln, and I have been to Devon and Norfolk and seen other areas as well. It really is a challenge.
Professor Chantler
We have learned that there really is not a universal solution. That is why we talk about networks. You have heard this before but the local networks are part of regional networks. It is at that level that they have to work out how they can support people in diverse communities. The solution, for example, in Bournemouth and Eastbourne is not the same as it is in Barrow-in-Furness or Whitehaven.
Sarah-Jane Marsh
The important thing is for there to be a sense of shared governance, because what we cannot have is people delivering different standards of care and that not being exposed and fully understood. Going forward, it is not about saying the system needs to look like whatever it needs to look like, but everybody needs to take part in those networks and governance systems and share the outcomes. If things are not working, then they need to put different solutions in place, but everybody has to be part of that overall system.
Maggie Throup
You said you have a pioneer covering a rural area. Is there anything else that needs to be done differently during the implementation stage, or are there specific challenges that you feel should be addressed?
Sarah-Jane Marsh
Yes. We were really clear, in selecting the pioneers, that we had to have a range and it was really important that we had a pioneer from a rural area. Likewise, we are about to move into the next phase of early adopters. The early adopters will be looking at the whole implementation of the report. Again, it is really important to us that we have a variety of areas with different sorts of provision included in that because we know that solutions look different in different places. Predominantly, again, it is the workforce challenge that we talked about at the beginning and sorts of rotas and numbers of staff that are required. There are fixed costs almost irrespective of how many women access the units, but we know they are absolutely crucial, and the small to medium-sized district general hospitals and delivery units are the backbone of maternity. Through these systems, we have to look at how we can support them.
Maggie Throup
I want to move on now to another subject and pull everything together. Do you agree with the suggestion that has been made to us in written evidence that bereavement care should be specifically covered in the recommendations in relation to better post-natal care, as well as being part of the multiprofessional training?
Sarah-Jane Marsh
Yes, absolutely. Bereavement care is such a crucial thing that we provide in maternity and in paediatric services. Sometimes that needs to be up front; sometimes people do not realise that they want it until later down the track, and we need to be there for them whenever that is. It is crucial. We know the impact that not providing it can have. It is also related to the fact that we should be completely open and transparent about all our investigations if something has gone wrong. We know it can be very difficult to move into the bereavement phase if families do not yet have the answers to the questions they need the answers to. It is a crucial part of the review and the implementation that that bereavement care is there for everybody who needs to use it.
Baroness Cumberlege
Can I say that we have the transformation board, which Sarah-Jane is going to chair? Under that, we have a stakeholder group and Sands—
Sarah-Jane Marsh
Side by side, Julia, not underneath.
Baroness Cumberlege
We are going to challenge you, because the stakeholder is there; so we have the NCT, with Elizabeth Duff and Janet Scott from Sands. We have all these people; Sir Cyril is the vice chairman of this board and I am going to chair it. We are not going to stop working with them. We are going to continue, and I am sure that we will be challenging you if people like Sands say that you have not made enough effort on bereavement counselling or the service generally.
Sarah-Jane Marsh
We have thought really carefully about all the stakeholders that have been involved in Better Births. We are in an implementation phase. It is a different sort of skill to do implementation, but what I just said to Julia was not a joke. We have said that we really want the council and the board to sit side by side and for there to be accountability. If there is anything that any stakeholder feels is not being implemented true to the review, or if there is any issue, they can come back to the board through Julia and say, “We want a discussion; we want a paper; we want a joint meeting,” or whatever it is. They are the people who have put their heart and soul into this and it is our responsibility now, as the implementation board, to make sure that we do not lose sight of any of that.
Maggie Throup
An organisation like Sands is a great stakeholder, but will there be any mechanism for parents to input directly?
Baroness Cumberlege
Yes. Even on the stakeholder board we have somebody who has suffered a really tragic personal situation. We wanted people who had suffered the traumas to be on the board as well. It is not just organisations; it is for individuals as well to have an input.
Sarah-Jane Marsh
To come back to the pioneers and the early adopters, because there are so many differences nationally, it is really important that we continue to engage with women and families in the local systems. There is good evidence that that is happening. We need to make sure via the board that it is universal and that women are involved in the implementation as well as the design.
Maggie Throup
You will be pleased to know that we are moving to the last phase of questions. We have received evidence that an implementation body should be established to drive through the changes. Is that the role that you see for the implementation board?
Sarah-Jane Marsh
Yes. The implementation board is a cross-system partnership board to ensure that Better Births is implemented. We also have under us other maternity transformation work streams. There are things around safety and midwifery supervision and so on, so that we do not act in isolation on our own evidence of maternity transformation. I am chairing that on behalf of NHS England, but we have stakeholders round the table from NHS Improvement, Health Education England, Public Health England, the Royal Colleges, the CQC and so on. We have our nine work streams. Each of the members round the table is either involved, leading or participating in one of those work streams, but our joint absolute commitment is to move now into the delivery phase. So, yes, we are that board and our accountability then sits through to NHS England.
Maggie Throup
You might have answered my next question. Do you think that the board has the necessary levers to establish sustainable change?
Sarah-Jane Marsh
Yes.
Maggie Throup
With all those different bodies involved, it sounds like it.
Sarah-Jane Marsh
I think it is fair to say that, in the NHS as it is currently organised, implementing large-scale change is perhaps more complex than it might have been previously. I am sure that is something that you have explored at another time. It can perhaps be more difficult than it was previously. Nevertheless, we have all the right people round the table to be able to do that. We have made sure that they are the people who would naturally lead that work stream, so I think we have the right people around the table. They understand the accountabilities in the organisation. We have also signed up all the chief exec leaders, so they are really clear that they are signed up to it as well. We have the STPs, which we have talked about. They are the local delivery mechanism. For the first time, we also have maternity indicators in the CCG assurance plans. The CCGs will be held to account for improvements across a range of indicators in maternity. That will be part of CCG ratings, which is something we lobbied quite hard to have in order to make sure that CCGs have that at the forefront of their minds. I think we have all the technical levers. The other thing I would say, to go back to where I started, is that the real lever is the workforce. In my day job and in this role, I meet so many people who say that it feels like it is the time for maternity. Almost every service has its day and everybody seems to be listening to us now. We have a whole series of opportunities and we want to do this. The majority of it does not need a lever at all; it just needs really dedicated clinical teams to go out there and make the changes that they want to make for women. I sense that energy coming. I feel that the levers are there and I feel we have everything we need to make progress, but it is a very significant challenge. Of course, we are making it in the current financial climate, which makes everything challenging because it is.
Maggie Throup
You have just painted a very positive picture, but what do you see as the barriers?
Sarah-Jane Marsh
We have a very thorough risk register; so we have identified some of those barriers ourselves. There are some issues about making sure that all the business plans of the individual organisations join up in terms of timescales so that we do not end up in a situation where one part of the system sees something as a priority and another one does not. That is why we have a work plan. We are asking everybody to sign off almost before we get going on that. The vice chair of the implementation board is Keith Willett, who you are probably aware has led on the trauma and urgent care implementations. He said that in all the large-scale changes in which he has been involved the problems are workforce, finance and information sharing, in that order. He has no reason to believe that the maternity transformation will be any different. I think we are very sighted on those as our three big risks, but we are doing everything that we can to make sure we mitigate them through the board.
Maggie Throup
What plans do you have to involve the public in the work of the board and the implementation of the review?
Sarah-Jane Marsh
We have said that the really important part of that is the stakeholder council; we sit side by side. The stakeholder council has core members but it can also go back out to the big group of people involved in the review at any time it needs to, if it needs to source more information. We also have some key implementation events over the next month. We have an official launch to make sure that everybody is fully aware of what we are doing, and we have a series of set piece events. We have also been doing more work on communication. Some of our implementation board documentation is quite wordy, “management-y” and potentially a bit bureaucratic. One of the challenges we have given ourselves is how we keep meaningful communication coming. A woman who has found out she is pregnant today will know that on the back of the implementation board she will get a better service in six or seven months’ time. We are very clear that we need to keep that communication and that dialogue there. We see this as a blueprint for the future, but we also know that if other things come up as we go along—if there are challenges, a new idea or if we spot something—then we can be flexible and make sure that is also embraced in the programme.
Maggie Throup
Obviously you are aware that as a Committee we like to do follow-up sessions. My last question is this. How will the work of the implementation board, including costs of delivering the recommendations, be reported?
Sarah-Jane Marsh
We have our work plan and our nine work streams. Each of those has key milestones in them. Month by month we will know where we will be and what progress we expect to have made. Some of them can be implemented sooner than others for some of the reasons that we have just described. In the run-up to a future session we could provide you with the progress that had been made but also what our next challenges would be, the cost envelopes of those and any financial gaps or opportunities that might have arisen. That would seem like a sensible way to proceed, because then you can hold us to account for achieving what we said we would achieve at that date but also provide challenge around what the next phase is.
Maggie Throup
It might seem a bit of an unfair question, but you obviously have some ideas.
Sarah-Jane Marsh
Absolutely. The agenda is so huge that we recognise that we need to take a risk-based approach, particularly at board level, and to ensure that we dive on to the subjects that are potentially those of greatest risk. Hence we are going to spend a significant proportion of the September meeting talking about workforce. I am very happy to be open and transparent about what we see as the risks and the milestones as we go through, so that you can see where you would expect us to be and whether we are on track. I am sure it will not happen, but if, for whatever reason, we have gone off track we will have a very clear understanding of why that has happened and how we might turn it back round.
Baroness Cumberlege
In relation to the 28 recommendations, we have set out the owner—the person responsible for the recommendation—the timeframe and how we will know whether it has worked or not. I hope that will be helpful to the Committee.
Chair
That will be very helpful. As we go through, don’t wait for it to be another year. If you feel that things are slipping and you would like to communicate with the Committee any concerns you have, then please do.
Baroness Cumberlege
That is very kind. Can I just say to you, as Members of Parliament, that I am so conscious that you are all tied into your own communities and constituencies? I think it would be very helpful if members of this Committee were also to ask locally, “Have you been doing this? Has this happened? Do you know?” That would be really helpful to us because we want to implement this at a brisk pace. We just know that, if you let things slide, you lose momentum and then nothing happens. I do not want another Changing Childbirth; I want Better Births.
Chair
Yes; there are far too many reports sitting on the shelf.
Professor Chantler
I do think that NHS England has made a really good start on this. The enthusiasm of Sarah-Jane and other people in taking it forward is encouraging. There are some things that I thought were probably going to be really difficult. Indeed, the rapid resolution and redress scheme is very new, but the Department of Health has been really helpful in that. Where it will end up I do not know, but they have done a lot of work on it and it is a very important part of the recommendation. Continuity of care absolutely requires a digital record; it cannot be done any other way. With regard to both the care plan, which usually the midwife discusses at booking, and the mother, the woman, owning that plan—not the NHS—right through the process but linking into the GP record, which is crucially important, and the obstetric unit, we did not know how to do that 10 years ago. I was involved in it then. We now do know how to do it and we know it can be done because we are doing it. It is not just in births but in the practice I chair now in north- east London for people with chronic illnesses. We are doing it, so that is going to happen. That is the one area where I understand that there is some money. It is just a question of getting our share of it.
Dr Whitford
In the first panel we heard concerns about the multidisciplinary team having time to review cases of stillbirth or disability. The report showed that more than a quarter had insufficient information. Is this something through MBRRACE that you see improving? I assume that that would be one of the outcome measures. At the end of the day, we want fewer bereavements.
Professor Chantler
It is crucial. It is the core of the report and there is money to get it going.
Chair
We have now finished our questioning. Thank you very much indeed for coming this afternoon. Oral evidence: Maternity services, HC 276 34 [1] Baroness Cumberlege correction: replace “whatever” with “or for other personal reasons”. [2] Baroness Cumberlege correction: replace “new ways of care” with “new ways of working”. [3] Baroness Cumberlege correction: replace “St George’s medical school” with “St George’s University Hospitals NHS Foundation Trust”. [4] Baroness Cumberlege correction: replace “safe” with “safety”. [5] Baroness Cumberlege correction: add “throughout antenatal, the birth and postnatal care.” [6] Baroness Cumberlege correction: replace “another one and so on” with “each other.” [7] Baroness Cumberlege correction: replace “one” with “woman”.