The NHS would do well to adopt the one-to-one relationships between mother and midwife depicted in the BBC drama
Despite having a razor-sharp script and the sprightliest nuns this side of the Sound of Music, BBC period drama Call the Midwife might not be NHS commissioners' first port of call for best practice in service design.
Nevertheless, after a series of concerning revelations about NHS maternity services – which have led the Daily Mail to lament Britain's "Midwife Crisis" – commissioners would do well to watch closely as Call the Midwife returns to screens later this month. For despite its grimmer moments, the programme showcases a kind of relationship-based midwifery that is in serious danger of extinction; despite evidence it is cheaper and more effective than other delivery models.
In November the National Audit Office revealed that mistakes in maternity care account for a third of NHS negligence payouts, which have risen by an astonishing 80% in the last five years. There is a strong argument that one of the causes of this is the erosion of midwives' relationships with the women they treat. The fragmented way the system delivers care makes it harder to provide high quality midwifery services.
In the decades since responsibility for midwifery passed from local authorities to the NHS, the midwife's role has been pushed out of the community and into hospital wards. This has created a service that provides staff to fill buildings rather than care for women and treats childbirth as an illness, rather than a life experience.
For the majority of women in this country childbirth is very safe, but it is unpredictable. To respond effectively and proportionately to problems in pregnancy, and especially in labour, a midwife must make an informed clinical judgment about the mother's health and wellbeing. This kind of decision is better made by a midwife who knows and understands the woman she is caring for.
The characters in Call the Midwife practice along the lines of what is now known as caseload midwifery – one-to-one maternity care which sees a single midwife look after a woman throughout her pregnancy, during labour, and in the weeks directly after birth. The traditional argument against this approach has been that it is simply too expensive; that it is cheaper to encourage women to visit one central hospital staffed by a revolving cast than to pair them with a single, community-based midwife.
But recent research has challenged this received wisdom. A report from Sydney University published in The Lancet in September showed that using a single caseload midwife could actually reduce healthcare costs by more than £300 per birth. Reproducing this approach countrywide could help the health service find money for the 2,300 additional midwives the NAO concluded it needs; not to mention giving expectant mothers more consistent support throughout their pregnancy.
The study also proved that caseload midwifery is more clinically effective. The study's findings showed that women supported by a single, named midwife throughout their pregnancy were more likely to experience a spontaneous labour, suffered less blood loss and needed lower doses of painkillers.
These results expose the myth that midwifery care in the community – especially around birth, at home or in a midwife led unit – is somehow less safe. Alongside the excellent work of the Birthplace Research Programme at Oxford University's National Perinatal Epidemiology Unit, the findings undermine the assumption that care must be delivered through ever more restrictive guidelines and policies to ensure that it is safe.
There is a fear that if you allow midwives to be truly autonomous and take responsibility for their clinical decision-making, the risk is that they will deliver poorer care and make mistakes. In fact the opposite is true: a top-down, tick-box culture of quality assurance is no substitute for a genuine relationship between a midwife and expectant mother. The system must start to trust clinicians again.
An overly bureaucratic approach to midwifery is not just letting mothers down – it's putting the whole profession under strain. The Royal College of Midwives announced recently that nearly a quarter of all midwives in Britain have thought about leaving the occupation in the coming year; with many citing dissatisfaction with their NHS trust even as they restated their commitment to the women in their care. These are worrying figures for Britain's already short-staffed maternity services.
To resolve Britain's so-called midwife crisis, the government should remember the core principles of its healthcare policy: empowering clinicians; bringing care closer to communities; and freeing NHS staff of burdensome central control. Encouraging NHS commissioners to consider the benefits of caseload midwifery while supporting pilot programmes to build a strong UK evidence base would represent positive progress.
Effecting this kind of culture change is no mean feat; especially in the NHS. But community midwifery can point to a strong evidence base, a proud history, and a natural fit with government policy.
Looking for a solution for Britain's sputtering maternity services? Call the midwife, of course …
Annie Francis is chief executive of Neighbourhood Midwives
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It gives people a voice and saves money – so including patients in treatment decisions should not be an optional extra, says Richard Vize
With increasing numbers of NHS trusts destined to slide into the financial mire this year and next, there is one resource of which hard pushed hospitals enjoy a plentiful but underused supply – patients. They are the best hope for cutting demand and transforming services.
"Coproduction" is up there with "integration" and "transformation" in the NHS lexicon of abused words. It is intended to signify clinical staff involving patients in deciding the best course of treatment. As health secretary, Andrew Lansley pitched this as "no decision about me without me".
While this was certainly one of the more intelligible parts of his reform package, it conveys slightly the wrong idea about why patient involvement is so important. That slogan creates the impression that it is simply a right to be respected – but it is so much more powerful than that.
Patient involvement leads to better treatment, and often less of it. It is a simple way to save money and keep people out of hospital.
This week's announcement by the National Institute for Health and Care Excellence of new guidelines for treating prostate cancer is a powerful example of where helping patients understand the risks and benefits of treatment can avoid interventions that are unnecessary, distressing and costly.
The guidance is focused on giving men the information and support to decide whether living with prostate cancer and monitoring it is preferable to surgery. Choosing to live with cancer shows how patients are willing and able to make sophisticated, difficult decisions about their healthcare needs.
Involving people in care decisions means patients taking more responsibility for their own health. In many areas of of our lives, four years of austerity have opened up the debate about the balance between personal and state responsibility.
But while students are contributing to the cost of their university education and families and communities are increasingly being expected to take on more of the burden of social care, the NHS is still too diffident when it comes to pushing personal responsibility.
The shortage of cash means this will have to change. Patients will need to be supported in addressing the underlying causes of lifestyle-induced illnesses, while education and community support are now essential tools in reducing emergency admissions among patients with long-term conditions. There is convincing evidence that good self-management cuts A&E visits. At the other end of the scale, significant savings can be made simply by giving patients more flexibility over when to come back for a check-up.
The best hospitals are using patient insights to change their care pathways – coordinating services more effectively, giving patients better information with which to make choices, and encouraging clinicians to focus on the whole patient rather than the condition. Northumbria Healthcare NHS Foundation Trust is one that is embedding the patient voice into the way it thinks and acts. Yet despite the urgency of the need to save money and the proven effectiveness of patient involvement, it is still a minority sport in the NHS.
As the King's Fund has found, the institutional barriers to giving patients a voice are numerous and entrenched. Some doctors fear losing power, others lack the training, and too many have limited understanding of what it feels like to be a patient. I vividly remember a senior doctor admitting that it wasn't until he found himself in the position of a patient that he realised how astonishingly disempowering it was, even for him.
Amid the frantic activity of a typical NHS day there doesn't seem to be the time to involve patients in decisions about their care. In too many cases, patient involvement takes the form of projects and pilots rather than systemic change in the way care is provided. This needs to change.
It has to be seen not as a desirable extra, but the centrepiece of strategies to raise quality, improve the patient experience and cut costs. Listening to patients improves effectiveness and can save money – lots of it.
This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.Richard Vize
As a GP, curiosity about my patients often gets the better of me, but it helps build a rapport. However, there are some potential pitfalls
Like Dr Haider Warraich, I have to admit to occasionally Googling patients I have seen. When I ask colleagues and GP friends whether they do the same, there's a resounding "yes".
Someone is famous or has claimed notoriety of some sort during a consultation – who wouldn't be curious and seek to find out more? Over the years I've Googled the odd rock star, film-maker, writer, actor and others. GPs are sociable beings and interested in people.
The social side of people, who they are and what they do, can be important and relevant to the problem they bring to the consultation. It is unusual for me not to know what someone does as they leave my consulting room. Curiosity often gets the better of me but I feel it helps me build a rapport and a better understanding of the person.
I'm not presented with fame very often. Hackney, in east London, with its high rates of deprivation, isn't quite Hollywood. I also work for the NHS. I think the real celebs mostly see doctors privately. Seeing someone famous, however, does create a bit of excitement in an otherwise routine day.
Having said that I don't believe doctors in the UK Google their patients routinely. If I am puzzled about someone I've seen – it may be their behaviour or a life history that doesn't seem to add up – it is not Google I turn to, but their medical records. In the NHS we have access to records for the majority of the population from when they were born, and sometimes these can be quite revealing. Doctors working in a hospital or in some other context may not have this wealth of information to hand, so may turn to Google instead.
Googling and gaining further information about patients has its pitfalls. If it is used for medical purposes, can the information be relied upon? Most celebrity gossip probably couldn't. But if people have uploaded photos and personal information to a public space, then this is what they have chosen to say about themselves. Would they want their doctor to see it, though? In a world increasingly dominated by social media, I'm surprised how freely people share personal information that could backfire if others go searching.
What do doctors do if they find out on the web that one of their patients has a drug habit? If there were child protection concerns we would have a professional duty to act upon this information. But what about an adult on a drug binge, with no responsibility for others? If this is clinically relevant, how might a doctor introduce information gleamed from the public domain into a conversation that hasn't been initiated by the patient?
Maintaining trust in the doctor–patient relationship is very important. Can a patient trust a doctor who presents information that has not been offered within the confines of the consultation? Likewise, GP colleagues have been unnerved by patients who have Googled them. It seems to encroach on the personal when the doctor wishes to be in professional mode, and again may affect mutual trust.
The importance of maintaining professional boundaries is engrained in us from day one of medical school. No patient has ever told me that I have been Googled. I don't think I would mind but I might wonder why and feel it was irrelevant to the relationship that I have with them as their doctor.
Maybe there are power issues at play here. One party to the consultation knows more than the other. For some people, Googling and trying to find out about your doctor could be an attempt to redress this imbalance. However, patients are unlikely to find anything salacious. Our regulatory and professional bodies, the General Medical Council and British Medical Association, are very clear on this, which is good general advice for everyone. Simply, don't put anything out there that could come back to haunt you.Kate Adams
Until everyone in the NHS recognises that more female leaders means better services, culture will get in the way of good care
There seems to be a lot of discussion at the moment about women in leadership in the NHS.
This is good – however, it is nearly always being done by women. To some people it would seem odd to have a man speak or write about women in top jobs. How can they understand the issues and challenges that these women face? But this is an issue far greater than one of fairness or equality, and men do need to engage in the debate.
I was recently asked to give a speech on women in leadership and the opportunities and challenges this presents for men. I was surprised that there was only one male delegate, despite the efforts of the organisers. This was especially surprising given that we are trying to ensure a more visibly compassionate NHS – and this will take the leadership of both men and women.
Equality is important, which is why the debate about women leaders is often framed as one of fairness. And it's not just the NHS where this is an issue. In fact, the NHS does better than most. However, Michael West, professor of organisational psychology at Lancaster University, recently wrote that "leadership is the embodiment of culture" – and it is important to recognise that having more women in leadership roles is more than just an issue of equality, and will require organisational change.
A report from the Equality and Human Rights Commission measured the number of women in positions of power and influence, and calculated that at the current rate of change it would take around 70 years to reach an equal number of men and female directors of FTSE 100 companies.
Figures from the report reveal that, while women are graduating from university in increasing numbers and achieve better degree results than men, they only represent 13% of directors of FTSE 100 companies. In the public and voluntary sectors, women only account for 23% of local authority chief executives, 14% of university vice chancellors and 33% of health trust chief executives.
A well-known management theory called the Peter Principle suggests that people who perform well at their job get promoted into different roles until they reach a point where they are no longer good at what they do. But a conflicting theory called the Paula Principle argues that most women work below their level of competence.
It says they are held back by factors such as discrimination and the need to care for relatives. This theory also says that women are often averse to putting themselves forward for promotions; are less likely to have connections higher up the ladder; and sometimes even choose to stay where they are rather than move up to the next level.
It is largely accepted that men and women have different styles of leadership. For women these are often cited as collaboration, conviction, inclusiveness, creation and mentorship – and that is why having women in leadership is far more important than simple equality. We know that more women on boards leads to better services. It can be argued that this is not caused by having more women but rather a better gender balance, but whichever way you look at it the benefits include:
• Better governance; apparently linked to women's ability to better manage and control risk and initiate a different type of boardroom discussion
• Improved collaboration; linked to women's tendency to be more open and inclusive
• Values-led decision making; linked to women's tendency to operate on common agreed principles.
So the big opportunity for men is that if we have more women in leadership we get better services. Better for patients, better for our families and better for us. Of all the changes NHS culture needs, this one – on paper at least – should be easier to address.
The biggest challenge for men is that we do not fall victim to unconscious bias. We need to stop seeing the "problem" as one of women's leadership style or education. It is us, and the NHS culture, that needs to change.
It is really important that we as a sector continue to ensure increased participation of women in leadership programmes, training and development. And, for that matter, increased participation among the BME community where the gap is even starker. But more importantly we must look our predisposition and prejudice in the face and change our attitudes and understanding.
Without that, we have culture getting in the way of better patient care. This must change.
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Government policy and privatisation mean the NHS as we know it will be gone in as little as five years if no one speaks up
In school, I remember being part of a play called The Emperor's New Clothes.
The plot revolved around a king who was tricked into believing that he was wearing a special outfit when, in fact, he wore nothing at all. His sycophants complimented him for his wonderful choice of clothing, and on the street scared commoners praised the invisible suit until an innocent little kid screamed: "Look, the Emperor has no clothes!"
The one loud proclamation sent the entire town into shock. However, since it was the truth, nobody could deny it any more. And eventually, the Emperor came back to his senses.
The NHS desperately needs that kid. Someone who could stand up and shout: "Look! The NHS is at the brink of extinction. And David Cameron and Jeremy Hunt are facilitating its demise on the back of an unmandated NHS Act 2013!"
I've got 35 years experience of working in the NHS, from a junior doctor to a GP, and then chair of a Primary Care Trust and now deputy chair of the BMA council. This has taught me that most things can be made to work – even across organisational and local authority boundaries – if you have the right working relationships which develop over time through honesty, openness and trust.
The way this NHS is being managed by Hunt and the government is a stunning example of how not to do things. The roadmap of their policies is leading to the complete privatisation of the NHS, a process that has deep roots in Thatcherite ideology.
Aneurin Bevan once said: "No society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means." The new NHS Act has not just repealed society's contract with the health service, but it has made the NHS a repository of privateers with the mindset of venture capitalists.
For the entire length of 2013, the NHS came under relentless attack on grounds of "quality" by politicians and the right-wing press, driving the privatisation agenda.
I believe it will be a completely different healthcare system in five years time – one which will be much worse in terms of access, equity, health outcomes and cost.
We are inexorably moving toward a system ruled by bogus choice, competition, market forces and diversity of suppliers. By opening every NHS corner to "any qualified provider", the whole service can be taken over by private companies, with a few token charities and mutuals. NHS hospitals, faced with the consequences of cherry-picking by private consortia, risk bankruptcy when left to deal only with complex cases.
In the past two years, £11bn worth of our NHS has been put up for sale, while 35,000 staff have been axed, including 5,600 nurses. Half of our 600 ambulance stations are earmarked for closure. One-third of NHS walk-in centres have been closed and 10% of A&E units have been shut. Waiting lists for operations are at their longest in years as hospitals are consumed by the crisis in A&E.
The morale of the NHS family is at rock bottom. Their pay has been frozen for two years under the coalition, and they have been forced to accept a major downgrading of their pension benefits. Freezing and squeezing pay is heaping financial misery on more than one million NHS workers.
The NHS will just be a logo; a most cherished institution reduced from being the main provider of health services in England with one of the biggest workforces in the world, to a US-style insurance scheme, divorced from the delivery of care. Fewer treatments will be available to people as cuts start to bite, with wealthier people able to "top up" treatments. It's not just a postcode lottery – it's also a tax code lottery.
Patients are being denied prompt hip or cataract operations – and the list of hard-to-get services will grow and grow, reducing the NHS to a skeleton. Money that could be spent on patient care is being spent on unnecessary bureaucracy, debt interest and dividends. Meanwhile, Hunt blames individual cash-strapped trusts for making "bad choices".
Since 2012's Health and Social Care Act scrapped the government's duty to secure a comprehensive health service, Hunt is now legally – if not morally – able to wash his hands of the entire mess – a situation that must be reversed urgently, and democratic accountability restored.
We need to fight for universal healthcare as a basic human right, regardless of whether we live in flourishing suburbs or inner-city deprived areas. Passionate supporters of the NHS and ordinary people alike must speak out about their discontent with the government's reforms, just as the kid did to avoid further embarrassment to a narcissistic Emperor and a nation that would have suffered the consequences of self-indulgent behaviour.
The time has come to show that the NHS is not for sale.
Individual budgets will allow people to have control of their healthcare – and the NHS will have to adapt
Many of you will be familiar with personal budgets for social care, but from April, 56,000 people with highly complex, long-term health needs who are eligible for NHS continuing healthcare will have the right to ask for their care to be delivered as a personal health budget and the NHS will have to respond. And come 2015, commissioners are expected to be ready to offer a personal health budget to anyone with a long-term condition who could benefit from one.
This could transform the lives of people such as Stephen, who in 2008 sustained a spinal injury which left him paralysed from the shoulders down. After nearly a year in hospital, Stephen returned home to his partner and children but found that the care commissioned by his primary care trust was inflexible and not tailored to his needs.
It wasn't until Stephen participated in a personal health budget pilot in Nottinghamshire in 2010 that he was able to gain control of his care. He used his budget to hire his own team of carers, including two gardeners who can help him spend time outside with his young daughter. As well as allowing him to be a father again, being in the garden stops him getting ill. His personal health budget does not cost any more than the original care agency but offers far greater value for money.
Stephen is among several personal health budget holders who feature in Delivering Personal Health Budgets, a book that draws on my seven years of experience working to develop and deliver the concept in the UK and US. Personal health budgets present an opportunity for the NHS to broaden its focus from delivering healthcare to supporting people with health needs to live their lives to the fullest extent possible. This comes when the need for cost-effective approaches to the management of long-term conditions is pressing.
The biggest challenge for commissioners is to unlock money from existing contracts. NHS providers will have to change the way they do things or lose out to new entrants. Budget holders will demand greater flexibility and a broader, more preventive range of care services than the NHS currently buys. For clinicians, it will mean a willingness to explore new approaches to meeting long-term health needs.
I wrote Delivering Personal Health Budgets as a guide to implementation with the aim that many more people who depend on the NHS could experience the same life-changing impact from a personal health budget as Stephen and his family.Vidhya Alakeson
Dick Vinegar charts his highs and lows of the last year, including out of hours care and the backlash to Mid Staffs
For me, a noisy champion for patients' rights and a fierce critic of some doctors' attitudes to their patients, the high point of 2013 was when Dr Mark Porter, the chairman of the BMA, admitted that it might be a good thing that senior hospital consultants should be available out of hours and at weekends.
From the beginning of time, he and previous chairs of the BMA had robustly affirmed that consultants needed the weekends off to be able to perform effectively during the working week. What finally changed Porter's mind were several weighty reports over several years, which showed a weekend death rate for hospital inpatients that was 17% higher than during the week. I find his decision so momentous because I see it as the first time in my knowledge that a medical professional body has been forced to put the life-and-death interests of their patients above their own convenience.
Whether the consultants will play ball with this policy shift from the top is debatable. Already, I have heard of a group of neurologists at a nearby hospital who have stuck their heels in and are refusing to work weekends, because their contracts say otherwise. It is lucky for Michael Schumacher to have sustained his head injuries in France during a holiday period rather than South London.
Perhaps I should not be too harsh on doctors. Since Porter made his announcement, I have discovered that a lot of senior hospital doctors have always played their part at weekends. The same is true of GPs. Earlier in the year, when the official GP line was to denounce Jeremy Hunt or myself for wishing to return out-of-hours service to be overseen by GPs, a host of GPs crept out of the woodwork – perhaps up to 40% of them – who had happily been part of out of hours rotas since 2004.
I should perhaps divide doctors into "baddies", who wear black hats, and sit on the councils of the Royal Colleges and make a noise at BMA conferences, and in the columns of the medical journals, about how overworked and how badly paid they are. On the other side are the "goody" doctors, who wear white hats, and tend for their patients day and night. These are the real doctors. Fortunately, the doctors who care for my multiple comorbidities are among the latter group.
My low point of 2013 was the defiling of Julie Bailey's mother's grave and running her out of Stafford, after she had led a relatives' group of Mid Staffs patients to uncover the full horror of that hospital. I gather that the hate mail is continuing into 2014 with Facebook posts, which accuse her of wrecking health services in Stafford, and calling her newly awarded CBE an "insult to hospital staff". I worry about these reactions for various reasons.
It demonstrates what happens to whistleblowers in the NHS, and will continue to happen. Worse still, it shows that there are many NHS staff (and patients), who are still in denial about conditions at Mid Staffs. They demonstrate by their actions that they do not seem to have any concept of what are acceptable standards of care.
And I have a nasty feeling that there are many other parts of the NHS where staff do not realise what is acceptable. They mouth that "the NHS is the envy of the world", and resent it when people like me ask gently whether perhaps they are being a bit smug.
I had hoped that the barrage of reports that came out in 2013 might have alerted some people that there were things wrong with large chunks of the NHS. First, there was Mid Staffs.
Then there was Morecambe Bay. Then there was Basildon and Colchester. Then there were the 14 hospitals under investigation after Mid Staffs under the Keogh Review. At last, I thought, the time for being in denial is over.
More recently, there was the investigation into 590 GP surgeries, where a fifth failed various tests. Then, Hunt pointed out that poor access to GPs, and the failures of the 111 service, were putting an intolerable strain on A&E.
All demonstrably true, I would have thought, but all we get is the GPs and the College of Emergency Medicine attacking Hunt and each other. I feel they are, in a polite way, behaving rather like the Mid Staffs goons who vandalised Julie Bailey's mother grave. They do not look for a co-operative solution. They just concentrate on the ding-dong. And the patient, as ever, is in between. I don't see 2014 as being any different.