Spin out lessons from Independent Midwives UK

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Next year Independent Midwives UK (IMUK) hopes to start delivering youngsters who could become known as the first 'big society' babies in the UK.

The business plan seems sound; a social enterprise employing and run by top-level midwives delivering gold standard one-to-one care. That brings very low complication rates – for example the number of caesarean sections are almost halved.

But it has been, and remains, a complicated eight-year gestation according to board member Annie Francis. She feels that the government must introduce smarter, faster and more effective business support for social enterprise and encourage public services into more collaborations.

It's not as if the midwives business model doesn't tick all the boxes of any government desperate to save money, retain happy midwives and improve the long-term wellbeing of mothers and babies. Given the patchy state of NHS midwifery, IMUK even promises a return to domiciliary midwifery – each area having a dedicated local team of midwives.

It's even got a letter of support from England's chief nursing officer and the Department of Health.

IMUK already works one-to-one with expectant mothers, offering them the choice of where and how their baby is delivered, under what is agreed by all as the gold standard of midwifery care from 12 weeks to birth.

They arrange their work programme so that they are only paid for the jobs they do. "That's unlike the NHS where there are periods of frenzy but also times when midwives are paid for inactivity," Francis says.

They have a caesarean ratio of 15% compared with NHS caesarean ratio of 24% ... if the NHS could match that it would save £93m a year.

"And in terms of long-term public health, babies delivered by an IMUK member are usually breastfed which helps defend against obesity and diabetes in adulthood. For mothers breastfeeding offers protection against osteoporosis."

IMUK's long term goal is to deliver 14,000 (2%) of the 700,000 babies born in the UK every year giving an annual turnover of £42m.

It may be that it actually fulfils its dream and can start work in a pilot scheme with two primary care trusts next year. One of them is particularly hopeful of the IMUK tie-up as it may prevent many of its disaffected midwives quitting the NHS.

Francis says the continuing sticking point is insurance, or rather lack of it. When something goes wrong in obstetrics apart from the tragedy and trauma of a baby with brain damage, the costs in terms of damages and long-term care, perhaps for decades, can amount to £6m a case.

It was assumed the insurance problem was solved when the Health and Social Care Act 2008 opened the doors for non-NHS organisations to provide NHS care; and at the same time the Clinical Negligence Scheme for Trusts (CNST) was extended so that non-NHS bodies working under contract to NHS organisations are covered when treating NHS patients.

But problems have arisen that aren't of the midwives making. The current system stipulates that insurance is provided so long as organisations providing a service stay within the NHS.

But in the brave new world organisations might only have an NHS contract for three years.

In this situation the CNST would be null and void and worse still would not provide retrospective cover for any work done under the NHS ... this is not acceptable when it comes to delivering babies as claims can arise many years after a birth.

... Scott has recommended that organisations like IMUK that are "of value" be covered by CNST. The Department of Health ... will make a decision in due course.

Indemnity aside IMUK were also burdened by the thorny issue of deciding on an appropriate social enterprise business model ...

Francis says that what followed was "tortuous" not least because it took time for the midwives – "quite stroppy and independent minded individuals" – to agree a constitution and organisational structure.

... IMUK applied for £200,000 start-up funding ... They ended up with £20,000.

... "To begin with, the problem is you don't know what you don't know and I can't imagine how many great and innovative ideas never see the light of day because it is too exhausting and dispiriting to keep going when you feel you just aren't getting anywhere and you are not being heard, or listened to, often because it feels like there are deliberate blocks being put in your path."

Melissa Maimann, Essential Birth Consulting 0400 418 448