AIMS response to the Change NHS Consultation

AIMS has submitted an organisational response to the Government's Change NHS consultation. This sets out the key improvements to the maternity services that we want included in the new 10-year Health Plan.

The consultation is still open for responses from individual members of the public. Please look at our points, and if you agree, include them in a response of your own. Change NHSProject: Start here | Change NHS

Q1. What does your organisation want to see included in the 10-Year Health Plan and why?

Our area of focus is the maternity services and we would like to see a renewed commitment to the recommendations from the Better Births report. This was the result of a wide-ranging National Maternity Review and the recommendations are as valid and even more urgent than when it was first published. We would like to remind you of that vision:

“Our vision for maternity services across England is for them to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances.

And for all staff to be supported to deliver care which is women centred, working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and break down organisational and professional boundaries.”

Although some progress has been made this has been patchy and much remains to be done. AIMS is concerned that since the launch of NHS-England's Three Year Maternity and Neonatal Delivery Plan there is no longer an NHS-England team with the phrase 'maternity transformation' in its title. The focus on the essential longer term transformation vision seems to have been replaced by a series of disjointed initiatives and targets.

Rather than embarking on a further review of the maternity services, as some have suggested, we would like to see the Government commit to implementing the changes that we already know are needed. We highlight the key ones below.

Continuity of Carer (see our position paper Continuity of Carer)

The move to a relational model of care (Continuity of Carer) was a key element of the Better Births recommendations. In this model “Every woman should have a midwife, who is part of a small team of 4 to 6 midwives, based in the community who knows the women and family, and can provide continuity throughout the pregnancy, birth and postnatally” As we explained in our letter of 14th August to the Secretary of State the case for this model as essential for the delivery of safe, respectful, high quality and human rights respecting maternity services was already strong. Further support comes from the recently-published analysis of the CQC maternity survey 2023, which demonstrates that ‘full pathway continuity of carer’ (from first to final contact with the maternity services) is associated with improvements across multiple aspects of high quality maternity care. In the light of this new real-world evidence AIMS urges the Government to recommit to a rollout strategy that prioritises those at most risk of poorer outcomes. (See our article AIMS urges action as newly released analysis demonstrates better care when ‘full pathway continuity of carer’ is in place for details.)

Choice of birthplace including community-based birth (see our position paper Choice of Birthplace)

AIMS would like to see a commitment to ensuring that all four options for place of birth listed in the NHS Choice Framework are available to women in all parts of the country and at all times. The options of both a freestanding and an alongside birth centre, and support for homebirths, need to be offered and fully resourced, in addition to hospital obstetric wards (labour wards). In practice, this may include ensuring that midwives are ‘ring-fenced’ to cover birth at birth centres or at home and are not diverted to cover staff shortages in the labour ward, as well as having robust contingency plans in place.

Enabling more births to take place in community settings would promote women’s health and autonomy. It would reduce the number of unplanned caesareans, births assisted with forceps or ventouse, severe tears and excessive blood loss (as shown by the Birthplace in England study and recognised in the NICE Guideline on Intrapartum care .) This would have the added benefit of saving the cost and drain on staff resources resulting directly from these interventions and from the additional aftercare required.

In practice, as the NMPA organisational report 2019 found, as many as one in five Trusts has no birth centre, and only 25% offer both freestanding and alongside options.

Enquirers to our Helpline tell us that in many areas support for homebirths is being restricted or women are being told that support cannot be guaranteed due to staff shortages. Similarly, birth centres are often closed at short notice due to staff being called in to cover the labour ward, and some have been closed completely. Not only is this a denial of mothers’ human rights, but it also causes great distress to mothers who are left with the choice of either birthing in hospital against their wishes or freebirthing (birthing without a midwife or doctor present).

Community hubs

The Better Births report recommended the establishment of community hubs “where maternity services, particularly ante- and postnatally, are provided alongside other family-orientated health and social services provided by statutory and voluntary agencies.”

We would like to see these go further and be integrated with support for community-based births – both homebirths and births in freestanding birth centres.

Ideally these hubs would be not only for maternity care but ‘women’s health hubs’ providing services for women’s whole life course, covering sexual and reproductive health as well as all aspects of perinatal care. Services should include pre-conception care, antenatal and parenting education, breastfeeding support, post-natal contraception and perinatal mental health services. We would like these to be not only places where women would go for medical care but also resource centres, providing information in accessible formats, and social centres along the lines of existing breastfeeding cafes, but available to all mothers.

Physiology-informed maternity services and Salutogenesis (see our position paper Physiology-informed maternity services)

Salutogenesis is the concept of focusing on factors that promote health and wellbeing, in contrast to the pathogenic approach of focusing on detecting or avoiding problems. For safe care, both are needed, but currently the maternity services tend to emphasise pathology and efforts to minimise short-term risks. This can lead to the inappropriate use of medical tests, interventions and treatments without consideration of the physical and emotional (iatrogenic) harm these can cause.

AIMS wants to see physiology-informed maternity services that are designed and act with an understanding of physiology in order to BOTH maximise the chances of pregnancy, labour, birth and the postnatal period remaining problem-free, without any requirement for medical treatment AND support the delivery of timely, safe and effective medical treatment when this is beneficial and wanted. AIMS believes that this approach is key to underpinning a holistic approach to maternity safety. This means having a focus on avoiding causing harm to the long-term well-being of the whole family, including their mental health, as well as on reducing the risk of mortality and short-term physical harm.

This will require changes in the culture and organisation of the maternity services, the initial training and continuing professional development of all staff and the physical environment, to promote the physiology of labour and birth, postnatal recovery and breastfeeding initiation.

Equity of access

The NHS has a legal responsibility to make sure that its services are accessible to everyone. However, there are many groups that in practice face barriers in accessing care and especially the information that they need in order to make informed decisions. This includes those whose first language is not English, the Deaf community, the blind or partially-sighted, and those with limited literacy skills.

AIMS would like to see a commitment to ensuring that the needs of these groups are met through the provision of all relevant information in formats accessible to them, and the availability of qualified translators/BSL signers for all maternity appointments and during labour and birth.

Q2. What does your organisation see as the biggest challenges and enablers to move more care from hospitals to communities?

This would be a major change to the organisation of maternity care and would require genuine buy-in from both management and staff at all levels. A major barrier to the implementation of the Continuity of Carer model, identified in this recent independent evaluation report from City University was that boards and senior managers in many Trusts lacked the change management skills and/or the will to make such major changes. This could be mitigated by ensuring that there is clear accountability for the delivery of new initiatives, and that progress is tracked and reported transparently.

The City University report also identified as barriers insufficient planning time and funding to undertake a major service change and concerns amongst staff about the impact. These are all likely to be issues with any initiatives, such as a transition to community-based care, that require radical re-organisation of existing services.

Staff will need to be engaged in the planning and development, so that they have ownership and confidence that their own needs will be met.

For community hubs and community-based birth options to succeed it is essential that they are staffed by adequate numbers of suitably skilled midwives and support staff. It is also essential that these midwives be ring-fenced and not called in to cover staff shortages in the hospital. It is therefore critical that the current shortage of midwives is addressed as a priority.

Q3. What does your organisation see as the biggest challenges and enablers to making better use of technology in health and care?

We feel that it is important to recognise that technology does not improve accessibility for everyone. Not everyone has internet access, a smart phone or the digital literacy to use such services. There must be alternatives to meet the needs of those that are unable or reluctant to use digital services.

It will also be important to have adequate user testing of any digital technology, including testing by those who are inexperienced in its use. It should also be made available in at least all the major language groups spoken in the UK.

Q4. What does your organisation see as the biggest challenges and enablers to spotting illnesses earlier and tackling the causes of ill health?

We feel that the women’s health hubs that we described above would encourage women to engage both with maternity care and other women’s health care at an earlier stage. This would make it easier for pre-existing health issues to be identified, and also to provide timely information about promoting mental and physical health and wellbeing.

Information both on promoting health and identifying potential issues needs to be made available in a wide range of languages and formats. It should be engaging, clear and factual, and written in non-specialist language. Too often, well-intentioned patient information leaflets written by doctors and midwives use technical terms or acronyms, making them difficult for lay readers to understand.

Continuity of Carer, by enabling the development of a relationship of trust between a mother and her midwife, should make it easier for a midwife to spot concerns, raise issues and provide health information in a way that meets the needs of the woman. It should also help the mother to feel confident about sharing any worries, and avoid the current problems where fragmented care can result in failure by carers to pass on important information.

Q5. Please use this box to share specific policy ideas for change. Please include how you would prioritise these and what timeframe you would expect to see this delivered in, for example:

• Quick to do, that is in the next year or so

Government to develop a strategy to address the chronic shortage of midwifery staff. This needs to include plans for retention of experienced midwives as well as training and recruitment.

All Trusts to implement Continuity of Carer models for all those at most risk of poorer outcomes.

All Trusts to have plans in place to ensure adequate staffing to meet local demand for homebirths and birth centres.

• In the middle, that is in the next 2 to 5 years

Expand Continuity of Carer models to become the default option for all.

Community-based women’s health hubs to be available in all areas.

All four birthplace options to be available in all areas, with freestanding birth centres and homebirth teams linked to community hubs.

• Long term change, that will take more than 5 years

Transition to physiology-informed models of care where:

  • an understanding of physiology is recognised as a core competency for all working in, and responsible for, the maternity services.

  • there is a focus on salutogenesis (promoting wellbeing and the operation of physiological processes) and a holistic view of safety

  • policy and practice are informed by consideration of the potential impact of any test, treatment or intervention on the physical, mental and emotional wellbeing of mothers, babies and their families


We hope that this page is of interest, especially to our colleagues in the maternity services improvement community.

The AIMS Campaigns Team relies on Volunteers to carry out its work. If you would like to collaborate with us, are looking for further information about our work, or would like to join our team, please email campaigns@aims.org.uk.

Please consider supporting us by becoming an AIMS member or making a donation. We are a small charity that accepts no commercial sponsorship, in order to preserve our reputation for providing impartial, evidence-based information.

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