Will Darzi bring about a renaissance in maternity services?

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A number of regional Darzi plans have promised midwife-led units and better information. Daloni Carlisle asks if this vision will become a reality

Midwives and mothers view the Darzi review process as it applies to maternity services with mixed feelings. We have been here before - and the gap between the ambition and the reality is as wide as ever. Can it really be different this time?

The National Childbirth Trust and the Conservatives say midwifery-led units are still under threat, despite this being what women say they want and what many of the strategic health authority Darzi plans have pledged to provide.

But Royal College of Obstetricians and Gynaecologists president Sabaratnam Arulkumaran says he is encouraged by much in the regional plans, which were published in May and June. The SHAs appear to have built their maternity work on existing policy, he says. "The responses are built on evidence and they were worked up locally," he explains.

And although they differ in detail, they all identify some common themes. Public health, with a focus on obesity, smoking, teenage conception and alcohol, figures prominently with SHAs looking at how to reach women early in pregnancy or even pre-conception. The second theme is information and advice that helps choice, says Professor Arulkumaran.

"Some SHAs have some interesting ideas such as a maternity call service like NHS Direct, Maternity Direct." All SHAs acknowledge that there is a shortage of midwives, he adds, and have looked at addressing this through a variety of means including using more maternity support workers.

They have also all taken on the looming European working time directive, which will restrict doctors' working hours, and begun to explore whether to implement a consultant-led or a consultant-delivered service. Several have committed themselves to having 98 hours of consultant cover per week; others to 60 hours.

Professor Arulkumaran is optimistic. "Lots of funding is going into this and the question is how best local areas can utilise it," he says. "They now have a good road map."

No change

The regional Darzi reports are just the latest in a long line of maternity policies under the Labour government. The trajectory in modern health service policy started with Changing Childbirth in 1993. This articulated a vision of midwifery-led, woman-centred care in which women could choose where to give birth. The verdict, broadly speaking, was this: plenty of lovely pilots, no systematic change.

In April 2007 came Maternity Matters, which set out the wider choice framework for maternity services, including a guarantee (within safety limits) of choice over where to give birth, how to give birth and what pain relief to use.

Since then, there are pockets of excellence, but little cause to believe that much is fundamentally changing, according to the Royal College of Midwives and the National Childbirth Trust.

Midwives are in short supply in many areas, even after a government promise in February to recruit 4,000 of them. The college says plans for return to practice are faltering on the ability of an overstretched workforce to provide clinical cover.

Meanwhile, news of extra resources has been met with equal scepticism. In January health secretary Alan Johnson announced an extra £330m for maternity services, partly to help services meet a new public service agreement to book all pregnant women with the service of their choice by 12 weeks.

But RCM deputy general secretary Louise Silverton says the funding was subsumed into primary care trusts' general budgets and, so far at least, is not feeding through to maternity. "We saw the Darzi review as a chance for SHAs to plan their Maternity Matters implementation," says Ms Silverton. "It was a huge opportunity for macro-level thinking about what you are going to do to make these promises come alive."

But she is disappointed. "I'm sorry to be a dog in the manger, but what seems to have happened is that the existing proposals about reconfiguration, which were based on medical workforce, seem to have gone ahead."

That's a shame, she says. "Maternity services are such a good framework for the public health agenda, getting young parents to understand how you use the health service and what your responsibilities are as a user. It's such a good point to empower people."

Not everyone shares this view. The midwives who led the maternity work streams at SHA level are upbeat, although realistic too.

Cathy Warwick, director of midwifery at King's College Hospital foundation trust in London and a member of the clinical advisory group for NHS London, agrees there is a gap between the ambition and the reality.

One factor is anxiety about the cost-effectiveness of midwifery-led models of care. She says that in some places midwifery-led units have been set up but not used. Women say they want them, but then choose to go elsewhere when it comes to delivering their baby.

Professor Warwick believes they can be cost-effective but need to be marketed to women. "That gap will only be closed if we really work with women to describe the benefits and risks of each model," she says.

"Women need real assurance based on reality that if they are in a midwifery-led unit and then suddenly want an epidural, they will be able to transfer quickly. Women need to be able to trust the system more."

Likewise, home birth services need pump-priming until they attract enough women to become viable. Until they do, it is not safe to withdraw funds from hospital-based services.

"I really do think the gap is bridgeable," she says. "If we work within networks and through a commissioning process that sets out what we want as a group of maternity units and accept it may take a few years, I do not see it as impossible."

Impaired vision

Similar themes emerge from the South West, where North Bristol trust clinical director of midwifery Ann Rimmers chaired the Darzi maternity group.

She says: "I think there is a gap between the vision and the reality. We know that because we have not got consistency across the region. We have inequities here in the South West that are reflected nationally."

For example, Torbay has achieved a 12 per cent home birth rate and is delivering on a range of health benefits and associated savings in hospital care as a result. But overall the rate is stuck at 3-4 per cent - some way off the South West's target of 10 per cent.

"I do not see the gaps as insurmountable," says Ms Rimmers. "We need to make the case for more midwives and begin to understand how we can use and negotiate on payment by results to make the business case. We need to look at different models such as team midwifery and bring GPs back into maternity services."

In the West Midlands the argument is taking on slightly different dimensions. Fay Bailie, who chaired the region's Darzi maternity and newborn group, says: "Our vision is centred on the needs of women and babies and the fact that we need to provide an equitable service that is high quality and community based."

A large part of the vision involves not maternity services per se but access to the support services that some disadvantaged women need: dietetics for obese women; mental health services or rehab for others.

"We recognise that some women will have huge complexities of care and will have chaotic lifestyles," she says. "One of the key things for us was that a lot of our systems and processes are not accessible to women. We have to enable women to be signposted to the places they need."

That is not necessarily a midwife's job but could fall to an outreach worker or critical friend.

This links into the region's overall approach, which is based not on midwifery or consultant-led care but teams with the right competencies that are "local, safe and accessible". For that, the West Midlands will need sophisticated workforce planning.

In the South East Coast region, meanwhile, the vision is for a model of care in which pregnant women have a clear pathway where they engage early, with those most at risk engaging earliest.

Regional director of public health Yvonne Doyle acknowledges that there are gaps in the service that mean women do not always get a choice and are not supervised one to one during labour.

That is going to change, she says. "We have a reasonable resource base and we are starting to see some assertive commissioning. We need our community and primary care services to have a sense that they are the most important part of the pathway because if everything outside hospital goes well, then it minimises the risk of childbirth."

Yes, some midwives will end up working in different situations from those at present and there will be additional training needs. Some new services will start and others will close. That will not be comfortable.

But Dr Doyle's starting point - and that of others - is simple. "I want to see commissioners with attitude," she says.

HSJ's forum on maternity is on 11 September in London