Niche Health and Social care Consulting, 2022

‘One to One Midwives was one of a small number of similar businesses over the last ten years which aimed to bridge the gap between greater choice and the NHS maternity offer; none of these businesses, to date, have survived. …..This report seeks to understand some of the many complicated barriers between strategy and implementation and how better design and planning, as well as full engagement between all stakeholders, was essential to ensure the ideals of Better Births were met’ (Foreword, p3).

This detailed report, commissioned by NHS England and carried out by an independent management consultancy, Niche Health and Social Care Consulting, provides a distressing account of how an inspirational, highly motivated effort to provide for women in the UK what they have long been asking for – namely, continuity of carer from pregnancy through to the early postnatal period – came to nothing. ‘Continuity of carer’ has been shown to result in better outcomes for mothers and babies, and greater satisfaction on the part of childbearing women and people than they report when they receive highly fragmented care.

The review acknowledges the good intentions of those who set up the One to One Midwives service in the north-west of England and those who tried – but ultimately failed – to support it. Its analysis on what went wrong is detailed and worth reading in full but might be summarised in the following statement: ‘There was a fundamental difference in maternity care philosophy between One to One and NHS obstetric-led maternity services’ (p3). One to One aimed to offer all women choice through a midwifery-led, community-based, case loading model. It was a strong supporter of home birth. If women needed to go to an obstetric unit for extra care, the intention was that shared care arrangements would be in place and that One to One named midwives would coordinate the women’s care and continue to provide support.

However, for this to work, ‘a safe and effective care pathway with supportive and flexible joint working relationships’ (p3) was needed and this was not realised. The report regrets that what it calls ‘the philosophical impediment’ to the integration of NHS and private sector maternity services could not be set aside to support and enable an initiative which, the report also notes, ‘offered significant benefits to many women and babies’ and which was not ‘any less safe than [services] provided by NHS providers’ (p6). One to One met with continuing resistance from an NHS ‘hidebound with restrictions and regulations’ (p7).

The report describes how One to One was not able to replicate NHS governance requirements and did not have ‘systematic, robust quality governance processes in place to ensure the safe care and treatment of all women’ (p12). The absence of shared care agreements and robust information sharing protocols between One to One and NHS trusts hampered safe care. The report notes a failure of ‘due diligence’ in that the safety, quality, operational and financial aspects of One to One’s service were inadequately scrutinised before contracts were awarded (p16). Similarly, the commercial challenges facing One to One and the associated risks to the quality and safety of services were not identified and addressed at contract meetings owing to a lack of senior finance representation (p20). The maternity pathway tariffs applied to One to One were based on an NHS hospital model and were not applicable to the activities undertaken by a community-based midwifery-led model. Financial issues were ‘inextricably linked’ to whether One to One was able to provide safe, high quality services (p27).

One to One faced difficulties in recruiting staff to implement a carer case loading model and many of its midwives were recently qualified, resulting in an overall lack of experience in the service. One to One was also unable to engage with GPs, and with health visiting, local authority safeguarding and perinatal mental health services and this impacted the activity levels that it was able to achieve.

Overall, the report paints a distressing picture of a highly-motivated drive to provide women with greater choice and a more personal, individually tailored, approach to care that was thwarted by numerous and ultimately insurmountable challenges to a new way of delivering services. It concludes:

‘For this (and other) independent maternity ventures to have longevity and provide real alternatives to women accessing services, there needs to be a radical rethink of how to operationalise such strategic plans’ with ‘motivation towards innovation and increasing collaboration’ (Foreword, p3).

For the sake of our broken maternity services, we can only hope that the motivation and collaboration which this report highlights as essential will materialise in order that the health and wellbeing of childbearing women and people, and their families, and the integrity and distinctiveness of midwifery services can be safeguarded.