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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. Drawing on my PhD research exploring women’s childbirth preferences, decisions and outcomes in England today, 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) and Long Term Plan (2019). 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), 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.
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 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:
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 , 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”. 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.
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’ 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 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.
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.
 Clancy, G. (2021) Better Births? An Exploration of Women’s Childbirth Preferences, Decisions, and Outcomes in England. Unpublished PhD thesis. Coventry: University of Warwick
 NHS. (2014) Five Year Forward View, available online at https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
 NHS. (2019) The Long Term Plan, available online at https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
 NHS England and NHS Improvement. (2020) Better Births Four Years On: A review of progress, available online at https://www.england.nhs.uk/wp-content/uploads/2020/03/better-births-four-years-on-progress-report.pdf
 NHS England. (2016) National Maternity Review: Better Births Improving outcomes of maternity services in England A Five Year Forward View for maternity care (page 8), available online at https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf?PDFPATHWAY=PDF
 NHS. (2021) Personalised care and support planning guidance - Guidance for local maternity systems, (page 2) available online at https://www.england.nhs.uk/wp-content/uploads/2021/03/B0423-personalised-care-and-support-planning-guidance-for-lms.pdf
 The Montgomery ruling and your birth rights https://www.aims.org.uk/journal/item/montgomery-consent-law
 NHS, 2021: 9; NICE 2010 https://www.nice.org.uk/guidance/cg110/chapter/1-Guidance#ftn.footnote_6
 NHS North West London. (2018) Personal care plans for Mums and Families, available online at https://www.chelwest.nhs.uk/services/maternity/ccg-booklets/personal-care-plans-en.pdf
 Ockenden, D. (2020) Ockenden Report, available online at https://www.donnaockenden.com/downloads/news/2020/12/ockenden-report.pdf
 National Maternity Voices: https://www.facebook.com/groups/MaternityServiceUserReps/
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
The AIMS Journal spearheads discussions about change and development in the maternity services. From the beginning of 2018, the journal has been published online and is freely available to anyone with an interest in pregnancy and birth issues. Membership of AIMS continues to support and fund our ability to create the online journal, as well as supporting our other work, including campaigning and our Helpline. To contact the editors, please email: email@example.com
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