The National Health Service (NHS) in England is set to trial a scheme of personal maternity budgets. Expectant mothers will be able to choose from accredited providers in order to build a tailored care plan, which could include a home birth, a water birth or even hypnotherapy.
The budgets are one of the recommendations of the National Maternity Review, which was set up to investigate standards of care following a series of tragedies at a hospital in Cumbria. The report (pdf) identifies two particular concerns common among mothers – lack of choice and lack of continuity.
But given the diagnosis, are personal budgets the correct prescription?
Midwife Sue Austin wrote in 2012 about the introduction of multiple providers to NHS maternity services. Even then, she could see that in a climate of limited funding, the apparent choice given by a diverse range of companies and organisations might rapidly be rationalised into very little real choice at all. After all, market forces have tended to give us more generic supermarkets than specialist local stores. She also suggests that a fractured marketplace will lead to less integration between different branches of the profession, as providers have a vested interest in non-cooperation. So, less choice and less continuity.
The personal budget introduces the need to consider cost as a factor in deciding what care to choose. Although it’s not the mother’s own money, she still has to make sure the funds stretch to cover everything required. The traditional NHS model very deliberately removes this pressure from the patient. It puts the responsibility onto the trained medical professional to base decisions on obtaining the best medical outcome. Of course it would be naïve to think that doctors, especially at more senior levels, aren’t aware of financial constraints, but they still have to be able to justify their choices medically. It is very welcome that mothers are being put at the heart of the decision-making process, rather than being dictated to. But less welcome that the process will now be influenced by a patient’s ability to set budgets.
The personal budget is expected to be around £3,000, roughly the cost to the NHS of a routine birth. Extra costs due to complications would be covered by the NHS, as they are now. The details of how the budgets might work (on page 117-121 of the report) are still quite vague. They offer only optimistic platitudes as to how the system will serve less capable and less proactive patients. The report says nothing about accidental overspends. Will there, for example, be an option to combine care received under the personal budget with care obtained privately?
In the United States, where healthcare has been financialised to the extreme, the cost of a standard birth is upwards of $9,000 (nearly £7,000), excluding antenatal and postnatal care. Caesarean section deliveries push the cost past $14,000 (around £10,000) and in some cases can be significantly more expensive (see this bill for $42,347.36). It’s precisely the fear of being landed with £30,000 bills such as that which makes most UK citizens heartily grateful for the NHS, and keen to see it protected in its established form. The spiralling costs in the US are said by some to be the consequence of a profit-driven urge to use increasingly high-tech procedures, regardless of clinical need.
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Our NHS is the best healthcare system in the world (see the table in this article) because, until relatively recently, the forces of commerce and profit have been largely excluded in favour of a simple focus on meeting medical needs. This focus has been maintained by keeping all talk of money firmly in the back office. With personal budgets, the NHS is in danger of getting its priorities upside down. Yes, mothers should have greater choice in the care they receive, but forcing them to become healthcare administrators is not the answer.
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