Health Bill [HL]

I have coupled my name with the amendment tabled by my noble friend Lord Howe, and I declare an interest as executive director of Cumberlege Connections and patron of Independent Midwives UK. I thank the noble Lord, Lord Darzi, and the noble Baroness, Lady Thornton, for the briefing meeting that they held last week, which I found very helpful indeed. I have also found very helpful the document—Personal Health Budgets: First Steps—to which my noble friend referred. At that meeting, I told noble Lords that I am strongly in favour of personally held budgets, and particularly direct payments. At Second Reading, the Minister told your Lordships that he believed that, ""the potential for personal health budgets … is significant. The opportunities they present are exciting".—[Official Report, 4/2/09; col. 673.]" I so agree. I was interested to hear the history of the policy, which the noble Baroness, Lady Barker, outlined. I took through the Community Care (Direct Payments) Act 1996. I remember that there was very little opposition to it, and it went through quite easily. In the intervening time, we have seen evidence of a very successful social care policy. I appreciate that it is not all wonderful, and that there are people who have found it quite challenging, but that is no reason not to go ahead with this legislation. I have been particularly impressed by Kent County Council, whose inspirational director has introduced the Kent card. It is very similar to a credit card and has a monthly allowance that is based on the user’s needs for the service or services of their choice. The strength of the Kent scheme appears to be the minimum bureaucracy, and I understand that the county council is now having detailed discussions with Eastern and Coastal Kent Primary Care Trust to see how the card can be used as a vehicle for the implementation of personalised health budgets. I have also read the evaluation report which the noble Baroness, Lady Barker, mentioned. She is quite right that it highlights things that have proved to be a challenge, but it also says that individual budgets were generally welcomed by users because they gave them more control over their lives and produced better outcomes for the costs incurred compared with the standard care. I am very tempted to get into a Second Reading debate, but I am not going to do that. I take the lead from my noble friend, who was trying to explore the range of people who could benefit from direct payments. That brings me to the amendment in my name, Amendment 58A, which would enable the Secretary of State to make regulations, ""as to circumstances in which a direct payment may be used to secure the services of an independent midwife"." In the foreword to Changing Childbirth, which was a policy document for maternity services that I wrote when I was a Minister, I wrote: ""Pregnancy is a long and very special journey for a woman. It is a journey of dramatic physical, psychological and social change—of becoming a mother, redefining family relationships and taking on the long-term responsibility for caring and cherishing a newborn child. Generations of women have travelled the same route, but each journey is unique"." I suspect that there is not one person in the Palace of Westminster and beyond who has not been touched by a midwife. There is an understanding that every mother and every newborn baby needs a midwife and, of course, some need a doctor as well. At such a time, the relationship between mother and midwife is critical. Choice of midwife, choice of clinical care and choice of place of birth make for a more confident mother, a more successful pregnancy and birth and better postnatal care. Giving birth is not only a unique experience: it is a team effort involving mother, midwife and sometimes a doctor. If I were to write that foreword again today, I would include the father. I witnessed our son bathing his newborn baby from the day that he was born. I wondered at this tall, handsome fellow, tenderly holding in his huge hands this tiny mite, who was hardly bigger than a packet of flour, and tending him with huge confidence. Every night it is he who reads the bedtime story and he, like many other fathers, is totally involved in bringing up his son. Compared with past generations, that is a huge social change. Fifteen years ago, Changing Childbirth did make a difference. Its three tenets of choice, continuity of health professional, and control by the woman over her care were adopted and implemented in most maternity services around the country. Its philosophy was embraced, putting the mother at the centre of care. In recent years, although that philosophy has not been eroded, its implementation has. We hear too many stories of mothers being left alone in labour and their partners traumatised by what should be a joyful experience. The problem is principally due to the shortage of midwives. Again, it is not recruitment; the service is under such pressure that midwives leave. The impact on parents and their families of a traumatic experience is simply devastating. There is strong evidence that the emotional turmoil and distress that follows is profound and long lasting. The last official inquiry into unexplained stillbirths—the Confidential Enquiry into Stillbirths and Deaths in Infancy—found that nearly half of all unexplained stillbirths might have been avoided with better antenatal care. At Second Reading, the noble Lord, Lord Darzi, stated that his aim was for, ""an NHS that gives people more information and choice, works effectively in partnership and has quality of care at its heart".—[Official Report, 4/2/09; cols. 671-72.]" With regard to maternity services, we have a long way to go to recover the quality that was apparent in the mid-1990s. Where we do see outstanding quality, it is in the care given by independent midwives. The underlying core principle of independent midwifery is that the woman chooses her midwife at the beginning of her pregnancy. She is not simply allocated one. That enables a true partnership between a woman and her midwife to develop, with all the benefits that that brings. Our modern acceptance that women should give birth with total strangers just because our system of provision has evolved into an industrial model needs to be challenged. We need a more humane, supportive and essentially safer model based on the genuine continuity of care offered by independent midwifery. Some women are able to choose an independent midwife and do so because these midwives are able to give the time and information to enable women to make their own informed choices. They choose independent midwives because they want the continuity of care, because they want to know who will be with them when they give birth to their babies, because independent midwives know about and support their intentions, and because they are with them throughout their postnatal period. They choose them, especially, if there may be complications and the woman may need extra support during her labour and giving birth. The results are self-evident. There is a much higher home birth rate—64 per cent, whereas the national average is around 2 per cent. There is a much higher normal birth rate—77.9 per cent. There are fewer interventions, high breast-feeding rates and fewer admissions to special care baby units. In contrast to the NHS services, independent midwives can give the care that meets all a woman’s needs, including her emotional ones. Women who have had a traumatic first birth make up approximately a third of an independent midwife’s caseload, including vaginal births after a caesarean section. Women frequently comment on the importance of having time to talk through their fears and their previous traumatic birth experience, resulting in a normal, positive experience for their second and subsequent births. In the Minister’s next-stage review, he embraced the concept of social enterprise and the opportunities for clinical leaders to deliver innovation for the benefit of users. Independent Midwives UK is now a social enterprise in the form of an industrial provident society. It stands ready to deliver services to the NHS within the tariff that a PCT invests in each birth, meeting the national choice guarantees. We know that many midwives who are frustrated and disheartened with the current structures are keen to work in this way. Until now, there have not been the mechanisms to make this happen, but I am aware that this is changing. Commissioning by PCTs will, in future, embrace a plurality of providers to extend choice and drive up quality. This choice and quality of service should be available to as many women as possible via the NHS, so that maternity choice is not only for those with the means to pay. The Royal College of Midwives is hesitant about direct payments, but if they were linked to the maternity care pathway—that is, normal births—a component could be added based on payment by results if and when complications arose. I have no doubt that direct payments, with women voting with their feet and choosing independent midwives, is the quickest way to improve services. In response to my amendment, I suspect that the Minister will reply that it is up to the PCTs to decide which services they will offer to individuals. I understand that. However, believing that we are at one on the need to improve maternity services, I seek that the regulations may provide for direct payments to be made for the services of an independent midwife. The circumstances need not be controversial. If the Care Quality Commission found that specific maternity services did not meet the necessary registration requirements, the Minister could then make a direction. It would at least open the door, although, I confess, not as far as I would like. I ask the Minister and his officials seriously to consider the suggestion, and to think through the means to encourage PCTs to include maternity services as part of their plans in piloting direct payments.