‘We are all trapped in a marvellously pure ideology, the ideal socialist dream.’ So said Tory peer Baroness Cumberlege in 2000 of the NHS, as she advocated for an injection of private companies, competition and profit-making to improve ‘freedom of choice’. Cumberlege is the ‘independent’ chair of the 2016 NHS Maternity Review ‘Better Births’, and it seems her interests remain the same. The review recognises some maternity service problems, but offers a solution which would pave the way to further undermining of free, accessible, universal care.
Maternity Review
In 2000, Cumberlege argued against the NHS remaining free at the point of use for all, calling for an NHS insurance premium and private insurance. In 2001 she set up Cumberlege Connections, now Cumberlege Eden & Partners, to deliver training to NHS and private provider staff about health sector ‘development’, including a course on ‘politics, power and persuasion’. Whilst profiting from this venture, in 2012 she voted for the Health and Social Care Act, legislation which furthers private interests in the NHS. Her company’s partnership with the PricewaterhouseCooper Alliance, set up to bid for new contracts to develop Clinical Commissioning Groups (CGCs), put them in a position to profit directly from the law she voted for.1
Cumberlege has had a long relationship to maternity services, chairing ‘Changing Childbirth’ in 1993. The latest maternity review aims ostensibly to make care for women and babies safer and more personalised. It recognises that women generally want a familiar midwife to care for them, that women and health professionals should work in partnership and that longer appointments are needed for better care. None of this is new – the arguments for continuity of care have long existed with excellent evidence. The care already exists to a limited extent within the NHS, and has shown improvements to health outcomes and equity. However, rather than call for more resources to develop this care within the NHS, the report has its own proposal – a new system of funding incorporating personalised budgets. ‘NHS Personal Maternity Care Budgets’ would give women £3,000 to ‘spend’ on a provider of their choice, covering antenatal, labour and postnatal care. The details are still vague and funding for complex cases is yet to be worked out; a trial is proposed for 2016-17, with certain service providers to be approved by the Care Quality Commission (CQC).
Rights and choice, but not for all
Ultimately, this will mean socially organised care being gradually replaced with individual budgets to be spent by women as consumers. Competition between providers paves the way for privatisation – it should be noted that the CQC has already approved Virgin to provide other community health care services in contracts worth over £1bn. Personal budgets will shift any risk from collective care and responsibility to the woman herself. Will a provider, rewarded for meeting outcomes and racing to cut costs, aim to support a woman who is considered ‘risky’ or needs more complex care? Working class women, often considered ‘high-risk’ due to a toxic combination of inadequate housing, benefit and service cuts and poverty, will be expected to navigate such vested interests in the hope that a package will cover all their needs. This leaves personal budgets benefiting middle class women, who will be in a better material position to assert their needs and ‘top-up’ their care, however their risk is categorised. Any notion of equity of care is undermined. This has been long expected in maternity, with predictable outcomes: ‘these budgets too will be squeezed, creating a strong temptation for commissioners to redefine some items the budgets originally covered as extras that must be paid for’.2
The current crisis
Cumberlege ignores the current systemic problems. There are no proposals to increase overall funding, which looks set to be diverted and complicated. There is no proposal to hire the additional 2,600 full-time midwives the Royal College of Midwives say are needed to provide safe care. Staff provision is reaching crisis point, with a 75.7% increase in spending on agency midwives between 2012 and 2014; Trusts pay 2.7 times more than for a permanently employed midwife. The models of care that work within the NHS will continue to face underfunding and understaffing.
There are other serious problems that need addressing. The report cites the shocking statistics that babies whose mothers live in poverty have a 57% higher risk of perinatal mortality. Babies who are black, black British Asian or Asian British have a 50% higher risk of perinatal mortality. Recent research shows that three out of four pregnant women and new mothers face discrimination at work, and working class women face widespread financial difficulties during pregnancy and following birth.
Already in maternity services, care is not free for all women at the point of access – women without ‘correct’ migration documents are directly charged thousands of pounds for their care. Often not allowed to work, with no money and living in precarious situations, these women already face worse health outcomes, and understandable fear accessing services. Any debt accrued can be used against women’s claims to the Home Office, whilst healthcare professionals are expected to play the role of border police. Where is the talk of choice here?
Meanwhile, across the NHS, junior doctors are striking over unsafe changes to their contracts. Cleaners are striking for the living wage. Students have protested against the proposal to remove the NHS bursary that enables midwives, nurses and others to train, that will leave debts of up to £50,000 – a whole system reeling with tensions.
The greater importance placed on individual needs and choices being met, rather than access to collective care, is a persistent argument for private company involvement in healthcare. We need to be clear that this will mean the opposite of real choice for working class women, and is yet another threat to the NHS. Good quality and continuity of care that is sustainable needs more staff and funding and must be determined in the interests of working class women and the people who care for them – necessarily as part a commitment to free, universal access to healthcare.
Rachel Francis
1. http://socialinvestigations.blogspot.co.uk/2012/04/baroness-who-ran-private-business.html
2. Colin Leys and Stewart Player, The plot against the NHS, Merlin Press 2011.
Fight Racism! Fight Imperialism! 250 April/May 2016
