Putting Better Births’ Personalised Care into Practice: Comments on Progress and Recent Guidance of the Better Births Recommendation

AIMS Journal, 2021, Vol 33, No 3

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By Georgia Clancy

It’s been five years since Better Births (2016) was published and over the last few years ‘early adopter’ sites across England have been trialling different aspects of the policy ahead of national rollout. In March 2021, NHS England published guidance on the implementation of Better Births’ first recommendation, personalised care, in the form of their Personalised Care and Support Planning Guidance document^[1]. Drawing on my PhD research exploring women’s childbirth preferences, decisions and outcomes in England today^[2], in this article I will comment on the recent guidance on personalised care and consider whether it was worth the wait.

In recent years, the goal of delivering personalised care has not been exclusive to the maternity services, but is representative of wider shifts across the NHS put forward in the Five Year Forward View (2014)^[3] and Long Term Plan (2019)^[4]. The latter of these two documents sets out the NHS’s ambition to roll out a ‘Comprehensive Model of Personalised Care’ across England by 2023/24, including personal health budgets. However, Better Births’ concept of Personal Maternity Care Budgets was absent from the recent Better Births Four Years On review (2020)^[5], and appears to have been quietly dropped from the Maternity Transformation Programme.

The widespread change towards more personalised care in NHS policy and practice should help to normalise this approach in maternity care for all women, and not just those considered ‘high-risk’ or with complex needs. Indeed, it is fundamental that management as well as obstetricians and midwives get on board with personalised approaches to care since workplace cultures and differing ideologies of birth and best practice can pose a significant barrier to effecting change.

In Better Births^[6], personalised care was defined as being

centred on the woman, her baby and her family, based around their needs and their decisions, where they have genuine choice, informed by unbiased information

Central to this is the development of personalised care plans for women, which the Personalised Care and Support Planning Guidance document^[7] seeks to provide in the form of personalised care and support plans (PCSPs) whereby

people [have] proactive, personalised conversations which focus on what matters to them...and [pay] attention to their clinical needs as well as their wider health and wellbeing

However, it is unclear how PCSPs fit alongside the types of birth plans which women might make of their own initiative, or whether PCSPs are a formalisation of the birth plan process. Indeed, it is important that any plan for birth is considered a living plan that can evolve during pregnancy and includes preferences for different situations that might arise during labour and birth. Furthermore, women must be adequately informed about their choices and birth options so that they can take on a proactive role in their care and make informed decisions.

PCSPs must meet five criteria as set out in the NHS’s Universal Personalised Care Model:

1. People are central in developing and agreeing their PCSP, including deciding who is involved in the process.
2. People have proactive personalised conversations that focus on what matters to them, paying attention to their needs and wider health and wellbeing.
3. People agree the health and wellbeing outcomes they want to achieve in partnerships with the relevant professionals.
4. Each person has a sharable PCSP that records what matters to them, their outcomes and how they will be achieved.
5. People are able to formally and informally review their PCSP.

Applied to maternity care, PCSPs are reminiscent of the approach set out in Better Births, with greater discussion around women’s choices during pregnancy and birth and plans continually reviewed and risks assessed at each contact. In addition, and in light of the Montgomery ruling^{[8] [9]}, providers are encouraged to respect and seek a better understanding of women’s reasoning, values, expectations, previous experiences/trauma and fears. Personalised care is highlighted as being particularly beneficial to people from lower socio-economic groups and presented as a positive step towards reducing health inequalities by tracking the implementation of PCSPs according to age, ethnicity and “complex social factors”^[10]. Of course, this is highly topical in light of public pressure for the NHS to tackle inequalities in maternal mortality and AIMS has long called for the improvement of services and experiences for historically under-served communities at risk of poorer-outcomes^[11].

Continuity of carer is identified as key to facilitating personalised care through the development of effective and trusting woman-midwife/doctor relationships. Women will also be given responsibility over their personalised care and support plans, with unbiased information to inform these decisions. However, it is important to bear in mind that not all women may want to assume or feel capable of assuming this additional responsibility for their care and appropriate support will need to be provided. Furthermore, the provision of unbiased information often sounds more straightforward than it is in reality and masks the socio-economic, cultural and political factors which influence the information produced, how providers deliver it and in turn how women receive and process information, choosing to act with or against the recommendations of their providers. Indeed, the issue of providing personalised care to women who engage in informed dissent against the recommendations of their clinician is not tackled in Personalised Care and Support Planning Guidance, but rather is delegated to Trusts to develop their own strategies. This is a serious shortcoming in a document which has taken five years to produce.

Elements of Better Births have been trialed across England by the early adopter sites since 2017, but the findings of these trials, with regard to the implementation of personalised care, are absent from the Personalised Care and Support Planning Guidance document. For example, the 2018 ‘Personal care plans for Mums and Families’^[12] information booklet developed by NHS North West London as part of the maternity early adopters project.

The main means by which the Maternity Transformation Programme intends to achieve personalised care now appears to be with the implementation of personalised care and support plans (PCSPs) as part of the NHS’s Universal Personalised Care Model. However, the recommendations are vague and without clear targets or measures of success. Indeed, the recommended ‘Audit tool’ in the guidance document focuses on assessing the use of PCSPs rather than the actual implementation of personalised care as set out in Better Births. It is also unclear how these plans will link in with the 2020 Interim Ockenden Report’s^[13] Immediate and Essential Actions, in particular with regard to listening to women and families, managing complex pregnancy, risk assessment throughout pregnancy and informed decision-making.

What is clear from reading this new document is the interrelatedness of Better Births’ recommendations. The plan for implementing personalised care is interwoven with the need for progress in improving choices, Continuity of Carer, unbiased information and safer care. As such, it will be interesting to see what guidance is issued next to continue moving forward with Better Births’ implementation.

Actions for birth activists:

• Ask your LMS (Local Maternity System) how they are implementing personalised care in your area, and if it is in line with the recommendations in Better Births.
• Encourage women to learn about their birth choices and rights to support informed decision-making (AIMS has lots of helpful information here^[14]).
• Share resources and talk to your maternity care colleagues about what it means to provide personalised care.
• Get involved with your local Maternity Voices Partnership^[15].
• Let’s talk! Join in the conversation around NHS maternity care online with AIMS on Twitter^[16] and other groups such as National Maternity Voices^[17] and the Midwifery Unit Network^[18] on Facebook.

Author Bio: Georgia Clancy is a research fellow at the University of Warwick. Her ESRC-funded PhD research explored women’s childbirth preferences, decisions and outcomes in light of the Better Births policy in England today. Georgia is also a member of the AIMS Campaigns Team.