Vision of Better Births – Baroness Julia Cumberlege and Sir Cyril Chantler

Vision of Better Births – Baroness Julia Cumberlege and Sir Cyril Chantler


>>Baroness Julia Cumberlege: Wow, what a wonderful
gathering; Sarah Jane, thank you so much. I want to say, I do not think we could have
a better person to chair the transformation board, and that is really good; your commitment
shines through. Your experience recently, I think, is hugely valuable; and I love your
phrase, and I so believe it, that we at last have a chance to influence the next generation,
and that is what we are about. I want to start by saying that our ambition
for Better Births, while we were thinking about the report, what we wanted to do: we
wanted to ensure that our services in England are among the safest in the world. And we
do start well, because we know that the services in this country have never been safer. Still
births, neonatal deaths have fallen by 20% in the last ten years. Maternal deaths have
never been fewer, and we just know that the vast majority of women and their families
experience birth as a very joyous occasion, a time for celebration.
However, of course, we do know that things can go wrong, and when they do it is simply
devastating for those families who are concerned; obviously for the parents, but wider, the
friends as well as the families. It is a tragedy, and we know that for many it is a scar for
life, so we have got to do better. We must make giving birth safer compared with the
other countries in Europe. If we were doing as well as Sweden, which is the safest place
in Europe to give birth, we would be saving a thousand babies every year. So, we know
that it is good at the moment but it has got to be better. In the Five Year Forward View,
Simon Stevens promised that there would be a review of maternity services and he invited
me to chair it, and it has been a great privilege. So the first thing we did was get together
our team and we set out the values that we wanted to ensure; values that we felt as a
team were important. We wanted our services to be personalised, we wanted them to be family
friendly, safe, kind and professional. So these were our thoughts, but that is nowhere
good enough; it is very easy to make assumptions. I have a label; I am called a Baroness, and
people assume things about me: I am rich; I wish I was! They think I live in some great
country pile; I live in a modest Tudor cottage. They think I have a flashy car; gosh, I wish
I had. So these assumptions are made, and it is very easy to make assumptions, but if
you look at other areas, other organisations, they do a lot on market research.
So we said, ‘Right, we are going to find out exactly what women in this country want;
what they think is important to them, what they feel is important to them.’ And so
as Sarah Jane said, we went round the country and we had the drop‑in events that were
very, very informal; they were not in NHS premises, they were women felt comfortable.
But we not only had the women, not only their partners, but we also had a lot of midwives,
obstetricians, GPs, anaesthetists: all sorts of people came to these events. And in the
middle of this picture you will see a very smart woman in a black suit, and she was the
local MP. So we did involve a huge number of people. We also did online surveys; we
had two birth tank events, which some of you I know were there for that.
So, in addition to that we also had service visits, and we were looking for the best;
we were trying to find out in this country where the really good things are, so we could
learn from those. And I do want to thank all of you who hosted us; we could not have been
more welcomed, and we could not have met more inspiring people, it really was just wonderful.
So, we were doing all that, going round the country, talking to people; what did we hear?
Well, from the women, the women told us that they wanted choice, they wanted their decisions
respected, they wanted continuity of the people looking after them, the professionals. They
wanted a safer service. They told us to wake up to technology, and they told us that we
should embrace it and that their lives were in their iPhones. And where were we? We were
in the Dark Ages. They told us that they wanted the labour wards to be open, and I have to
say I have been quite shocked: quite recently we had something in the House of Lords, a
member of the House of Lords asking a question about the number of times in his local hospital
the labour ward was closed. They also wanted competent, kind, skilled staff, and they wanted
services nearer to home, and when things go wrong they want prompt action. And they also
talked a lot about after the birth, and they wanted post-natal care. Dads told us very
often that they were ignored, and they wanted to feel much more part of the event, and they
felt it was a life‑affirming event and they wanted that to be recognised.
Health professionals told us that they valued great leadership, that they valued respectful
team working; they wanted more autonomy over their work and they wanted more professional
training and education that was multidisciplinary. They told us there was too much form filling,
and we did sense on our visits that there was a thirst for change. Commissioners told
us that the payment systems were not working; they were totally inadequate and very often
a barrier to really progressive new types of maternity care. The tariffs needed to be
sensitive. They felt that categorising women as we do in high, medium and low risk was
really unhelpful, and they really wanted to ensure that the rural areas were also looked
after. So we heard all that and we then said, ‘Right,
well things that we are going to bring into our report are certainly personalised care;
personalised care centred on the woman, the babies, and the families, and that requires
a care plan. And the woman drawing up her care plan needs to ensure that there is unbiased
information, so that she can make a choice that is suitable to her but also is well informed.’
We also felt it was important to have a digital maternity tool, so that she could have access
to her record and even put in her record, and she should own her record. Sir Cyril will
be saying something about that later on. They wanted to choose their provider, and for that
we have introduced this idea that Sarah Jane talked about, about the pioneers: the system
whereby women can hold their own budgets. We have a table here today where we can explain
how that is going to work, because at the moment we have seven different groups of CCGs
around the country who want to explore this area and really try and see how we can give
women greater choice. We found that choice was actually very much wanting, and that 87%
of births are in obstetric care, and actually 25% of women told us that was what they wanted.
Now, there are reasons obviously why some women have to give birth where they have not
planned, but what was really staggering was the NPEU told us that 33% of women got no
choice at all. Now, we choose all sorts of things in our lives: how we live, where we
live, what we eat, etc., and yet this very seminal, very important event, there is little
choice. So it is not just about place of birth, but it is also about the choice of the provider
and also the choice of the type of care that women want. Relationships we feel are terribly
important. Continuity of care: difficult, we know it is difficult to introduce; that
does not mean to say we should shy away from it. We are looking at teams of four to six
midwives. And listening to women: I remember one who told me she had had 43 different health
professionals during the antenatal, birth and postnatal care. 24% of women who get continuity
are less likely to have a premature birth; 24%. If you can get this relationship working,
what a difference that would make. In the heart of our report, we have not only
got choice but we have also got safety, safer care, and Sir Cyril is going to be talking
about that in a minute. We also heard a lot about the need for better perinatal care,
and the Mental Health Taskforce has got serious money and they are taking on this issue, but
we will be involved with that to make sure the right decisions are made, and also of
course very important to have postnatal care. I just think, you know, your first baby, it
really is a struggle; you do not know what this creature is going to be like, really:
always crying, always needing feeding, all this stuff. And that is just so important,
and we have to address that issue. So, multi‑professional working I am going
to leave to Cathy Warwick and David Richmond, who are going to talk about that. Working
across boundaries we think is hugely important; we are talking about setting up maternity
hubs, and we see these as really vibrant places where you can bring all sorts of other activities
in there. And sometimes perhaps sited, as we have seen, in a GP practice or a children’s
centre or community centre or wherever, so it is to bring all these different helpers,
in a way, together. We see, in addition to that, bringing the hubs together. We really
want, and we are very lucky about this, the local maternity systems – we set out a population
of between 0.5 million and 1.5 million, and it pretty well exactly matches the STP
footprints, which is really lucky and good news. And in addition to bringing all those
services together, the local maternity services into these clinical networks, where we see
these as regional about 12 and we think that is going to improve services. So everybody
knows what everybody else is doing. So, I am going to pass on now to Sir Cyril,
but before I do, I will just say on the payment system: this is something that really needs
addressing and we are working on that at the moment. So Sir Cyril, this is over to you.
>>Sir Cyril Chantler: There are 28 recommendations in the report, and they all fit together.
So, it is not going to work unless all 28 are paid attention to and implemented; it
cannot be cherry-picked because so much of what produces safety is systems that work,
and our recommendations are related to systems; that is my first point.
My second point deals with choice and continuity and the record. Now, I am a paediatrician;
I know how important the red book was in my practice and I know how important the paper
maternity record is too. So when we talk about a digital record, one has to be conscious
of the failed attempts to digitise the National Health Service record system over the last
generation. So, I am not saying that we should ditch the paper record now; it is usually
best to make sure the new works before you take the old out.
Nor am I saying that we need to have some national scheme that is imposed on everybody,
because we know that does not work. What we are talking about here is putting the mum
and the family in charge; the record should be the mum’s and the professionals should
interact with that record, the GP record, the hospital record, and that is now possible.
It was not possible five or ten years ago, but it is possible now through something through
interoperability software. So on this slide you see on the left‑hand side, to you, the
old system; on the right‑hand, side the new system. The new system enables the mum,
the maternity record, to interact with all the other records that exist and are necessary
to co‑ordinate and integrate care. It is beginning to happen in certain places; we
mention examples in the report. I chair a general practice in outer Northeast London;
we have set up such a system for dealing with people with chronic illness over the last
year, and it works. This can be done, but it will be done by you; it will be done locally,
but there are national initiatives going on to facilitate that. That is my second point.
Next: this is the experience of Sweden over the last five years. In Sweden five years
ago they introduced a system whereby they made sure that after every poor outcome a
proper investigation took place, the learning was fed back to the clinical team and a system
for recompensing and supporting the families through an insurance system was available
immediately to support them. So, it all happens systematically: a poor outcome, a proper investigation,
a rapid resolution and redress system to the family and the learning fed back to the clinical
team. If you work together, you train together. Now, the outcome of that has been, as shown
on this slide, that over those years the number of bad outcomes, damaged babies, has fallen
from 20 per 100,000 live births to five; 20 per 100,000 to five, and that is what this
slide shows. The current figure in England is 35.
So, we think that we ought to pay attention to this, and we should see whether we cannot
do what they have done, and part of that will be talked about through the morning and today
about the working together, training together, learning and so forth. But the government
has accepted the need for a proper investigation on a no‑blame basis, and they are looking
very seriously at a rapid resolution system similar to the Swedish system, and that is
set out on this slide. What it would mean is that we would get support to families immediately,
not five to ten years later, and we get the learning back to the teams immediately, not
later. So, three things: 28 recommendations need
to be taken together; the need to introduce a digital system for dealing with the maternity
care plan and the record; and a rapid resolution and redress system which will compensate or
support the families and allow the learning to get back to the teams. Thank you.
>>Baroness Julia Cumberlege: Just finally to say, Cyril is absolutely right: we know
a lot of reports are written, we see them on shelves gathering dust. This one is not
going to be, because NHS England, with Sarah Jane leading it, we have now built around
Better Births an implementation report; not only a report but a doing, so we are determined
this is going to work. But it will not work, nothing will happen, unless you people in
the service really want it to happen, and think about some of the complex issues that
are here and how you are going to do it locally. Because you can only do so much from the top,
too much from the top; it has to come from the bottom up. And I will just leave you with
this thought: chains of habit are too light to be felt until they are too heavy to be
broken. So we have to discard our chains of habit, we have to embrace creative disruption.
Uncomfortable, difficult, but we simply cannot go on adding and subtracting; we actually
need a fundamental change, and it is up to you to see how we can achieve that. Thank
you very much.

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