Published: 15/12/2005 Volume 115 No. 5986 Page 18 19
What better time of year than Christmas for junior health minister Liam Byrne to focus on the vagaries of maternity services? But to improve satisfaction and safety, better data is needed
With demand outstripping capacity at the inn, the biblical Mary was forced to accept a community-based birth, with very little in the way of continuity of care. But thanks to Labour's manifesto commitment, 2009 years later she would have been able to get full choice of birth provider and the right to access the same midwife throughout her pregnancy. Hallelujah, indeed.
Maternity services are a neglected area - held back by poor information, high variations in outcomes and lack of flexibility.
Department of Health research published last week showed one in five women are unhappy about their birth experience. The main sources of dissatisfaction are lack of information and choice.
Next year that will begin to change, according to the junior minister in charge, Liam Byrne. Last week he announced the appointment of Dr Gwyneth Lewis as the DoH's clinical lead on maternity, backed by advisory groups, networks and a series of best-practice workshops.
The main problem with improving services in this area is the poor level of information available. Dr Lewis's 'much stronger national leadership' is intended to focus on 'precisely where different services have got to, ' says Mr Byrne. 'We need to make sure people are clear about what good local service needs to look like.
'It will mean trust boards and senior managers listening to maternity in a way that I do not think they have traditionally. When you talk to frontline staff in maternity on how loudly they think their voice is heard at board level you typically get the same answer - It is not.' A big part of the improvement drive will be setting up what Mr Byrne describes as a 'much more robust dataset' next year on individual trusts' patterns of service delivery. The DoH is working with Durham University on the system.
Mr Byrne says by the second half of 2006 this should set the stage for 'targeted performance improvement to make sure everywhere is up to the level of the best'.
Meanwhile, there are strong concerns about patient safety in maternity services and the rising number of incidents. One senior clinical governance figure says privately it is the one area that 'keeps me awake at night'.
Mr Byrne is more circumspect on safety issues, but he does say one of the lessons of the Healthcare Commission inquiry into maternity services at Northwick Park Hospital was the danger of poor data. '[The new dataset] will allow us to track far more effectively where we think things may not be going in the right direction and see patterns of activity more clearly.
'We want to get [to problems] sooner and I do not think we have the tools to be able to target interventions early enough. We are very reliant on local management teams - That is as it should be, but if they have got a lot on their plate we need to satisfy ourselves we can take action.
'It is not easy to track different patterns of outcomes but we know there is much too much variation. It is very clearly an issue of leadership - when you look at the best, they all have one thing in common and that is outstanding local leadership.' The Royal College of Midwives has called for targets to drive improvement, but Mr Byrne is not keen for the moment. 'It would be dangerous to talk about targets, though we'll have to see how people progress in the next four years.' He predicts that next month's white paper on healthcare outside hospitals will encourage health and social care to work together to increase flexibility on home and community-based deliveries. 'We will be asking trusts and commissioners to work in a different way - some areas of the country will find that challenging - with community resources such as children's centres.' One of his first actions as minister was to announce the merger of the green paper on social care with the white paper. The resulting white paper is delayed, but promised by the end of January. The opportunity for social care is clearly huge, based on a landscape of largely coterminous primary care trusts and councils, growing numbers of local area agreements in place and the merger of the regulatory bodies. Mr Byrne says the 'appetite for local alignment' is ravenous.
'Unless you understand the chemistry of local change, how those frontline managers make decisions and negotiate with each other, the policy that will be delivered will be faulty.' He is less keen on imposing a duty on health and social care to work together, a duty that applies to children's trusts and one that some would like to see extended into older people's services. 'The mistake would be to write a duty and think That is going to be the answer - systems do not change in that way.
We need to look at a multiplicity of forces to push people together and That is what the white paper will explore. You have to be careful a duty is not a figleaf.' Consultation on the regulatory framework for adult social care ends next month, although the wider review of health and social care regulation is working to a different timetable. It seems likely that the white paper will be light on regulation as a result. My Byrne says: 'In the new year whether It is in the white paper or not we will need to look at what we can do to strengthen measures to increase quality in social care.
'The proposals to give the Commission for Social Care Inspection much greater latitude to concentrate on providers that cause them concern are important but we also need to signal that care regulation is based more around the outcomes rather than how big a room is or how wide the door is. At the moment a lot of the regulation is written based on input and prescription rather than being linked to outcomes.' Joint inspections of PCTs and social services are being considered, according to documents seen by HSJ (news, page 5, 27 October) and Mr Byrne does not deny it. 'The ambition may be signalled in the white paper, but the practicalities may have to wait for the review to report.' Some go further and say local government should take on commissioning for health and social care. Mr Byrne says NHS 'commissioning has not been strong enough which is why the reorganisation is so crucial'.
'We need to go further now and say there is room to expand joint commissioning between PCTs and local authorities. It is only local government that can bring together a well-being package of transport, housing, education, welfare to work, regeneration and all other factors necessary to strong social care. Health is part of that package. How joint commissioning will survive devolvement to practices remains to be seen.' That said, local government has disappointed many in its implementation of direct payments in the limited areas it currently applies - low take-up has been blamed on a lack of information for the people who would benefit most.
The white paper will greatly expand the scope of individualised budgets and Mr Byrne says 'we are looking at the kind of support individuals need to take on these opportunities'.
'We know what people with learning and physical disabilities need - we do not know what older people need.' The appetite for personalised care outside hospital may be keen but the activity report published by NHS chief executive Sir Nigel Crisp last week shows relatively weak growth in homecare and case management.
Mr Byrne points towards next year's report from Sir Derek Wanless on adult long-term care 'that will force us to ask questions about future funding needs for social care'.
He also points to coming funding for telecare and the Partnerships for Older People pilots on reducing admissions. 'I do not think it will be until towards the end of next year that we will have enough answers.
But the timing is crucial - we need to draw those things together to put in as strong a spending review bid as possible.'
The Liam Byrne CV
2005 Appointed minister for care services
2004 Wins Birmingham Hodge Hill in by-election Member of Amicus, Christian Socialist Movement and Fabian Society
2000 Starts venture-backed technology company
1996-97 Adviser to Labour Party on general election organisation; manages Labour's national business campaign