Intelligent Commissioning of
Maternity Services
How do we make it happen
Suzanne Tyler
The key maternity messages
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Birth rate has gone up 22% in last decade
Complexity and risk factors for women (BMI, age, LTC) have increased considerably)
Staffing levels in midwifery, obstetrics and sonography vary considerably around the
country and in many areas fail to meet national recommendations
Outcomes are generally good, with considerable local variation and many
opportunities for improving clinical outcomes and experience exist
Safety is the highest concern, but women’s experience of maternity services impacts
longitudinally on health and wellbeing
It’s a high profile service which excites public and political attention especially around
configuration
Focus tends to be on the birth event rather than the contribution of
antenatal/postnatal care to long term health and wellbeing
Implementing policy around choice, continuity, 1:1 care in labour etc has been patchy
and there is till much to do
There is a good track record of involving users but the voice of GPs has declined
over time
Links to neonatal services and seamless transitions are essential and much excellent
work has been done around the country – but it is not uniform
The Commissioning Challenge:
Dame Barbara Hakin: October 2011
“ The system we are developing gives us a real
opportunity to do things differently. I would encourage
everyone who is involved with or has an interest in
commissioning to really think about how we can be
different, how can we use commissioning to give patients
much more voice and choice”
Liberating the NHS: Legislative
Framework and Next Steps December
2010
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While responsibility for commissioning maternity services should sit with GP
consortia, we will expect the Board to give particular focus to promoting
quality improvement and extending choice for pregnant women. The Board
will support consortia to work together collaboratively to commission
services: consortia will be able to group together, or pool resources with the
Board, where this makes most sense. The Board will also directly
commission specialist neonatal services*
* i.e. the 10% of babies requiring SCBU
Developing the NHS Commissioning
Board: July 2011
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In addition, the NHS Commissioning Board will host clinical networks, which
will advise on distinct areas of care, such as cancer or maternity services.
The Board will also host new clinical senates which will provide multidisciplinary input to strategic clinical decision making to support
commissioners, and embed clinical expertise at the heart of the Board. The
purpose of these groups is to ensure that clinical commissioning groups and
the Board itself have access to a broad range of expert clinical input to
support and inform their commissioning decisions. The relationship between
the Board and clinical networks and senates is likely to change as the new
commissioning system matures.
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Clear arrangements for key service areas, which would gain particular
benefit from dedicated professional and clinical leadership. These might
include children’s services, mental health, older people’s services,
dementia, learning disabilities, maternity and primary care.
Clinical Commissioning Groups: what
we know
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c260 pathfinders
– 11 CCGs in every neonatal network?
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Size range from pop 18,900 to 755,906
– Pop 100,000 equates to approx 1400 births
– Pop 200,00 equates to approx 2800 births
– Pop 300,000 equates to approx 4000 births
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Average maternity unit delivers around 3-4,000 babies a year
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Around a quarter of units deliver over 6,000 babies a year
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Low level of GP engagement with maternity services to date
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Direct maternity spend accounts for about 3% of existing PCT budgets
What CCGs are likely to see
CCG
Population
Est
births/Year
Est births
women
>35
100,000
1400
200,000
Est
perinatal
mortality
Est LBW
Est LSCS
Est
maternity
spend
250-300 9
90-120
336
£3m
2800
550-600 18
180-240 672
£6m
300,000
4000
800-900 25
260-340 960
£9m
500,000
7000
14001500
44
455-600 1680
£15.5m
700,000
9800
19502000
62
635-835 2352
£21.5m
CCGs holding the ring in the new
‘architecture’ for maternity commissioning
NHS
Outcomes
Framework
Quality Standards
E.g. NICE
NHS
Commissioning
Board
Commissioning
Outcomes
Framework
Fit with
primary care
Maternity
Networks
Fit with
Child health
PbR
Tariff
Reform
Commissioning
Support
Units
CCG
Records,
data and IT
Evidence
Base
E.g. Birthplace
Study
Public Health
Outcomes
Framework
Public
Health
England
Smoking
Breastfeeding
Screening
Teenage pregnancy
AQP
Health &
Wellbeing
Boards
Maternity
Data
Set
Health
Education
England
Workforce
Health Watch
This project
• Identify CCGs who would like support to develop maternity
commissioning skills and expertise
• Work with them and other stakeholders to identify skills, tools and
learning required
• Share that learning amongst the CCG network and Commissioning
Support Organisations
• Inform the NHS Commissioning Board in developing its assurance
role
Messages so far
• Confusion about who commissions what
– NHS CB: neonatal services and health visiting
• What about transitional care
– LAs: public health (smoking, obesity, teenage
pregnancy)
– CCGs: maternity – routine and specialist
• Strong desire for locally provided services
• Opportunity for shared commissioning arrangements
• Links with Health & Wellbeing Boards emerging
• It’s all about relationships
Scope for doing things
differently
• Pathway redesign of whole -9 months to 5 years
services
• Better integration of primary, acute based, community
based and social care that supports new families
• A clinical perspective to challenge existing provider
behaviour where outcomes vary from neighbouring,
regional or benchmarked norms
• A clinical perspective into provider network discussions
about configuration that ensures patients’ needs are at
the heart of decision making
? What about neonatal care?
Likely ‘product’
• Key messages/principles about what is important in
commissioning maternity services
– Operating & Outcomes Framework
– Policy
• Links to resources, guides and templates that will help
– Standard service specs
– Benchmarking data
– Professional guidance etc
• Case studies from CCGs already engaged
Example: Aligning local and national
priorities
90% of women to have a completed medical and
social booking by the end of their 12week 6 day of
pregnancy
National requirement: links to Operating framework
Evidence of 1:1 care in labour
Local requirement: links to Operating & Outcomes Frameworks
Increase in normal birth rate and reduction in
caesarean section rate
Local requirement: links to Operating Framework, Outcomes
Framework and QIPP
Prioritisation of care for women with BMI >35
Local requirement: links to Public Health Outcomes Framework
Promotion of choice of place of birth
National requirement: links to Operating Framework and
Outcomes Framework
Maintaining low rates of perinatal mortality
National requirement: links to Outcomes Framework
Maintaining low rates of Low Birth weight babies
National requirement: links to Public Health Outcomes
Framework
Focus on reducing admission of term babies to
neonatal intense care
National requirement: links to Outcomes Framework
Reporting of PROMS
National requirement: links to Outcomes Framework
Reducing unscheduled antenatal activity
Local requirement: links to QIPP
Implementing SHA Workforce Framework
Local requirement: links to Operating Framework & QIPP
A focus on preparation for parenthood that aligns to
national best practice
Local requirement: links to Public Health Outcomes Framework
What do CCGs need so they become
informed commissioners of maternity
services?
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What do CCGs need to know about the needs of their local
population, as well as local and national requirements and where
will they get this information from?
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How will they know whether the services they commission are
safe and of high quality as well as meeting the specific needs of
their local population?
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How will CCGs make arrangements with their local providers to
negotiate activity, service models investment decisions and
outcome expectations?
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What do GPs see as the priorities for improving maternity
services?
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How can maternity networks support CCGs in delivering their
commitments?
Contacts:
suzanne.tyler@dh.gsi.gov.uk