News / Review calls for rethink on maternity tariff system

A new pathway tariff payment system was introduced in 2013 for maternity services, replacing a system that paid providers for individual interactions. But the national maternity review report Better births: improving outcomes of maternity services in England calls for the payment system to be reformed ‘so that it is fair, incentivises efficiency and pays providers appropriately for the services they provide’.

The review said the system should take into account the cost structures of different services, particularly the high fixed costs in obstetric units. Currently providers receive one of two prices for deliveries (to reflect complexity) and one of three prices for ante and postnatal care. These prices are not setting dependent.

Cathy Warwick, chief executive of the Royal College of Midwives (RCM) and a member of the review panel (pictured), said the review had heard concerns about the total spent on maternity and how it is split between providers. ‘We had to separate concerns with the tariff from concerns about the money in general,’ she said. ‘Any changes need to be thought through quite carefully.’

The RCM has separately identified a need for 2,600 more midwives, but it believes some of this could be funded from reduced agency staffing.

As a first step in payment reform, the review team wants NHS Improvement and NHS England to undertake a ‘comprehensive review’ of cost structures to propose adjustments to the existing tariff. This is understood to be separate to a costing exercise Monitor has been undertaking to inform 2017/18 maternity prices. ‘This could include potentially introducing different prices for home births, freestanding midwifery units, “alongside” midwifery units and obstetric units,’ the report said.

The review also wants the two tariff bodies to ‘test more radical changes’ in the longer term.

It suggested a revised system similar to plans for urgent care tariffs. This might mean multi-part payment, recognising the higher fixed costs of some units, including an element of volume-based payment, while also incentivising quality and efficiency improvements, the report said.

It also hints at a system that takes account of provider rurality. And it suggests a strong local element to payment with localities deciding the best payment structure and choosing the most appropriate outcome measures. Proposals should be worked up in 2016/17, piloted in 2017/18 and implemented from 2018/19, the report said.

The review team has also proposed new personal maternity care budgets, although a reported figure of ‘at least £3,000’ appears to have been more illustrative than accurate. Choices would include where to give birth, the type of antenatal or postnatal care, preference for home visits, choice of breastfeeding support services and services offering greater continuity of care.

Although the approach has parallels with existing personal health and care budgets, it is not clear how this might work for maternity. The choices available under personal maternity budgets in most cases already exist – women can choose different providers for their antenatal and delivery phase – and much of the care delivered is a formal part of the pathway.

Other recommendations include: providers and commissioners joining up in local maternity systems covering populations of 500,000 to 1.5 million; every woman being assigned a midwife who would be part of a small community-based team with links to a named obstetrician; and community hubs giving access to care and electronic maternity records by 2020.