An independent review into the independent sector provider One to One Midwives: Published September 2022
North WestAn independent investigation into the dissolution of the independent midwifery provider One to One Midwives. One to One Final Report Appendices – August 2022 post One to One Midwives was an independent sector provider established in 2010 to provide maternity services to NHS-funded clients through a midwifery-led, community-based, ‘case loading’ model. One to One Midwives was one of a small number of similar businesses over the last ten years which aimed to bridge the gap between greater choice
Recommendations (81)
1
Commissioners/Policy Makers
No Response Published
Recommendation
Proposals for new maternity service models should be comprehensively tested before commitment to implementation through robust pilot evaluation and business case scrutiny, including consideration of procurement route.
1
Commissioners
No Response Published
Recommendation
As part of due diligence, commissioners should assess the governance arrangements in place with independent sector providers to ensure they will meet their expectations for delivery of NHS-funded services.
1
Policy Makers/Commissioners
No Response Published
Recommendation
Future proposals for new models to support the delivery of national maternity policy should be comprehensively tested from a clinical, operational, and financial perspective, with scrutiny of the business case and the implementation plan before commitment to and roll-out of …
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1
Commissioners/Service Developers
No Response Published
Recommendation
Proof of concept through pilot testing and consultation should be comprehensive and consider all pathway components that are intended to be commissioned before introduction into an established system.
1
Commissioners
No Response Published
Recommendation
Comprehensive due diligence should be undertaken with the appropriate commercial expertise before decisions to award and extend contracts.
1
Service Developers/Commissioners
No Response Published
Recommendation
Independent clinical review should be a standard component of service specification development. For new service models involving integrated care pathways and significant potential clinical risk, full engagement should be undertaken with relevant professionals to inform the specification.
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1
Commissioners
No Response Published
Recommendation
Commissioners should establish mechanisms for routine quality assurance on all contracts, to include reporting on incidents, complaints, claims and audit and periodic quality assurance visits. Commissioners should make use of a provider’s internal quality governance processes for this purpose.
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1
Commissioners
No Response Published
Recommendation
In the absence of national developments on tariffs for community-based models of care, local bespoke tariffs should be applied, based on a robust assessment of the cost base of providers.
1
Independent sector providers/Commissioners
No Response Published
Recommendation
Relatively small independent sector providers, particularly start-up businesses working exclusively in the NHS, should work transparently on their business plans with commissioners so that the commercial challenges are understood by all parties.
1
Commissioners/System Leaders
No Response Published
Recommendation
Potential cultural barriers to joint working in maternity care between acute and community providers should be tackled as part of engagement work before introducing a new model into an established NHS system.
1
Policy Leaders/NHS Teams/Commissioners
No Response Published
Recommendation
For further innovative developments in maternity services, testing should be undertaken at a design and feasibility stage before commitments are made to implementation. This would assist in building a common understanding, between policy leaders and local NHS teams tasked with …
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10
Commissioners
No Response Published
Recommendation
Commissioners should consider how they can be assured that they have oversight of low level incidents recorded by providers to allow the identification of trends and themes.
10
Commissioners
No Response Published
Recommendation
Data quality audits should be a core requirement of service specifications and the Data Quality Improvement Plan under the contract used to support this area of work.
2
Commissioners
No Response Published
Recommendation
Commissioners should consider whether maternity services can be improved through offering choice but should only contract with providers which can demonstrate the ability to meet local service specifications, quality standards and contractual terms required for the safe delivery of high …
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2
Commissioners and regulators
No Response Published
Recommendation
Proportionality should be exercised for small businesses in terms of how commissioners and regulators assess governance arrangements in the independent sector.
2
Local Maternity Systems
No Response Published
Recommendation
Local Maternity Systems should be tasked with direct responsibility for monitoring progress on such initiatives. These forums should provide a single point of oversight for service developments, pilots and evaluation. We note that the recommendations on governance from the Ockenden …
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2
Commissioners/Evaluators
No Response Published
Recommendation
A comprehensive pilot evaluation should be undertaken as a fundamental step in the commissioning process, at a pace which allows all stakeholders to contribute to feedback. This should set out the learning and challenges experienced, potential risks and implications for …
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2
Commissioners and independent sector providers
No Response Published
Recommendation
Commissioners and independent sector providers should work in an ‘open book’ way, particularly for start-up businesses offering new services, to ensure a full understanding of the cost base and allow scrutiny of the assumptions underpinning business plans.
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2
Commissioners
No Response Published
Recommendation
We recommend formal annual reviews of the delivery of the service specification and contract as good practice to highlight risks and emerging challenges.
2
Commissioners
No Response Published
Recommendation
For new, innovative services, experienced commissioning and quality leads should be involved in developing the quality assurance framework required and in signing off performance dashboards and ensuring they continue to reflect requirements and do not become onerous.
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2
Commissioners
No Response Published
Recommendation
Robust testing of tariff arrangements should be undertaken to understand the impact on commissioners and providers where joint working with the independent sector is proposed and different tariffs may need to be applied.
2
Providers/Commissioners
No Response Published
Recommendation
Business plans should be rigorously stress tested to ensure assumptions in areas of risk are appropriate and that the business plan has a buffer for contingencies and unexpected variations in key assumptions.
2
Commissioners/Service Developers
No Response Published
Recommendation
Service specifications should be agreed by all stakeholders involved in shared care pathways. Interfaces with other services should be defined and fully documented as part of an agreed shared service specification rather than being a development requirement of the specification.
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2
Quality Surveillance Groups/Risk Summit Processes
No Response Published
Recommendation
Where financial challenges are identified during the quality surveillance and Risk Summit processes, consideration should be given to appropriate financial representation in the meetings; this is important as safety and quality considerations are often inextricably linked to financial challenges.
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3
Commissioners/System Leaders
No Response Published
Recommendation
Engagement work with relevant stakeholders should be prioritised to assess the potential barriers to effective joint working before the introduction of a new maternity model into an established NHS system.
3
Commissioners
No Response Published
Recommendation
Commissioners should consider a contractual requirement for an independent clinical representative on the Board of small, family-run businesses providing NHS-funded services.
3
Policy Makers/Commissioners/Evaluators
No Response Published
Recommendation
Pilot evaluation should consider the impact on the wider system and include system-wide engagement and deliberation with all stakeholders involved. The potential risks of the cultural barriers involved in bringing the independent sector into an established NHS infrastructure should be …
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3
Commissioners
No Response Published
Recommendation
Commissioners should produce a business case for assurance and decision-making purposes for innovative and potentially high-risk service developments. This needs to be completely independent of proposals from providers offering their services and include a thorough evaluation of the market.
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3
Commissioners
No Response Published
Recommendation
Commissioners should consider direct award approaches for services where there is only one provider expressing serious interest, where this flexibility is permitted by procurement policies, to minimise procurement costs.
3
Commissioners
No Response Published
Recommendation
Amendments to service specifications should be fully documented and tracked to enable discussion at contract meetings.
3
Commissioners
No Response Published
Recommendation
For shared care arrangements, commissioners should obtain insight on performance from all providers involved through respective contractual quality performance meetings, to triangulate evidence from these multiple sources for greater insight and intelligence.
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3
Commissioners and NHSE/I (and their successor body)
No Response Published
Recommendation
Notwithstanding formal structural accountabilities and responsibilities, commissioners and NHSE/I (and their successor body) need to maintain oversight of material issues relating to tariff, which might impact on the stability of their local systems and create risk to the safety and …
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3
Commissioners
No Response Published
Recommendation
Commissioners should consider adding a section on non-contracted activity to their contract management policy and service specifications, so that the rules to be followed are clear to new providers.
3
Commissioners
No Response Published
Recommendation
Engagement should continue regularly with wider stakeholders to obtain comprehensive and honest feedback on implementation and to inform any changes to a service specification.
3
The Care Quality Commission
No Response Published
Recommendation
The Care Quality Commission should review its approach to consider the impact that financial instability might have on a small company’s ability to provide safe care.
4
System and Local Governance Bodies/Commissioners
No Response Published
Recommendation
Governance of maternity services including - due diligence, contract award and management, finance, quality and operational oversight - involving smaller providers, especially from the independent and voluntary sectors, must be improved at a system and local level. This must be …
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4
Commissioners (to require from independent sector providers)
No Response Published
Recommendation
A single governance forum for safety and quality with appropriate senior clinical representation and standardised performance reporting should be a core requirement for independent sector providers so that commissioners can link into this forum for more robust assurance.
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4
National Policy Makers/Funders
No Response Published
Recommendation
For new, innovative service models of significance to the delivery of national policy, specific funding should be considered to pilot and pump prime investment in a new service to stimulate greater market interest.
4
Commissioners
No Response Published
Recommendation
A tailored approach to due diligence should be applied to small private sector providers who have a limited track record of working within the NHS. This should be undertaken on an ‘open book’ basis and include review of policies and …
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4
Commissioners
No Response Published
Recommendation
Steps should be taken to ensure new providers to the NHS understand the technical requirements of contracts. Formal confirmation that they are set up to comply with requirements should be sought as part of pre-contract conditions.
4
Service Developers/Commissioners
No Response Published
Recommendation
Specifications should be explicit on the requirements of all stakeholders relating to the development of shared care protocols.
4
Commissioners/Providers
No Response Published
Recommendation
As part of the development of joint working protocols for shared care, responsibilities for performance reporting on key shared metrics should be documented.
4
Commissioners
No Response Published
Recommendation
Commissioners should use their audit powers under contracts with all providers to investigate any significant concerns about billing arrangements.
4
Commissioners
No Response Published
Recommendation
Commissioners should consider applying a tailored approach to oversight of small contracts to avoid a disproportionate bureaucratic burden and level of cost to providers of the resources and the systems required for performance reporting and quality assurance.
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4
Commissioners
No Response Published
Recommendation
Commissioner support should continue to broker shared care arrangements and maintain oversight of relationships across the system.
4
The Care Quality Commission
No Response Published
Recommendation
The Care Quality Commission should consider how they publicly share information about actions taken to address any issues from previous regulation activity, ensuring this is easy to understand, accessible and provides evidence of how they have held organisations to account …
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5
Commissioners/Service Developers
No Response Published
Recommendation
Service specifications for new service models for maternity services must be tested with all stakeholders involved in shared care arrangements; service specifications and annual reviews must include scrutiny by an external obstetrician and an external midwife.
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5
NHSE/I (and their successor body)
No Response Published
Recommendation
NHSE/I (and their successor body) should consider the guidance for commissioners regarding the overview, management, and assurance of incidents where there are complex care pathways with multiple providers, to ensure that there is clear accountability for oversight of all serious …
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5
Policy Makers/Commissioners
No Response Published
Recommendation
Mainstreaming of a new service should be at a prudent pace to allow full consideration of issues and risks raised as well as re-evaluation at milestone points.
5
Commissioners
No Response Published
Recommendation
As part of due diligence, commissioners should evaluate the extent of support that might be required by start-up businesses to understand the broad-ranging compliance requirements of the NHS regulatory and contractual infrastructure.
5
Commissioners
No Response Published
Recommendation
Commissioners should include a reference to their position on non-contracted activity in their procurement/contract management policies. This should be replicated in service specifications.
5
Commissioners
No Response Published
Recommendation
Terms of reference should be set out for contract meetings with defined responsibilities for areas of oversight, escalation protocols and delegated authority for decision-making. Issues logs and risk registers should be used routinely for escalation purposes.
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5
NHSE/I (and their successor body)
No Response Published
Recommendation
NHSE/I (and their successor body) should maintain oversight of its requirements relating to previous tariff guidance issued and provide clarity where previous national guidance might be inconsistent with current guidance or where tariff rules appear unfair.
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5
Commissioners
No Response Published
Recommendation
Increased commissioning flexibilities should be considered for small contracts, for example, local tariff arrangements between providers, block contracts and guaranteed activity levels.
5
Commissioners and professional bodies
No Response Published
Recommendation
Professional integrity issues need to be investigated as a priority by commissioners and professional bodies when concerns are raised either informally or formally.
5
The regional teams of NHSE/I (and their successor body)
No Response Published
Recommendation
The regional teams of NHSE/I (and their successor body) should ensure that a clear description of the Quality Surveillance Group and Risk Summit processes is shared with providers who are subject to them. This information should include the triggers for …
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6
The Care Quality Commission and NHS Resolution
No Response Published
Recommendation
The Care Quality Commission and NHS Resolution should consider the findings from this review to determine whether any changes are needed to their maternity inspection and assessment processes.
6
The regional teams of NHSE/I (and their successor body)
No Response Published
Recommendation
The regional teams of NHSE/I (and their successor body) should provide guidance to commissioners on the circumstances under which financial pressures on an organisation should be a reportable incident.
6
Commissioners
No Response Published
Recommendation
In line with national policy, commissioners should consider how to encourage innovative proposals for maternity care which are focused on plugging the gaps in provision which still exist, for example, access to continuity of care for women from vulnerable groups.
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6
Commissioners
No Response Published
Recommendation
Comprehensive audit, from both a financial and quality perspective, should be undertaken before all key contracting decisions and on a regular basis as part of formal annual reviews of contract performance.
6
Commissioners
No Response Published
Recommendation
Governance arrangements around material changes to service specification requirements should be clarified in commissioners’ relevant procurement/ contracting policies and the Scheme of Delegation.
6
Co-commissioners
No Response Published
Recommendation
Co-commissioners should work in a coordinated way to develop performance reporting frameworks and manage challenges arising under the contract which have the potential to destabilise local systems. The requirement for formal collaboration agreements should be set out in local contract …
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6
NHSE/I (and their successor body)
No Response Published
Recommendation
The maternity tariff guidance should be supplemented with more detailed guidelines on how to agree tariffs for provider to provider charges, as the current guidance leaves this open to interpretation.
6
NHS England/Commissioners
No Response Published
Recommendation
A prime provider model should be further investigated for services to be provided jointly between NHS and independent sector providers.
6
The regional teams of NHSE/I (and their successor body)
No Response Published
Recommendation
The regional teams of NHSE/I (and their successor body) should review processes and timescales for Quality Surveillance Group and Risk Summit processes, to ensure that they are transparent and that agendas are shared in advance so that providers are aware …
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6
Commissioners
No Response Published
Recommendation
Governance arrangements around material changes to service specification requirements should be clarified in commissioners’ relevant procurement/ contract management policies and the Scheme of Delegation.
7
The NHS National Maternity Team
No Response Published
Recommendation
The NHS National Maternity Team should consider the learning from the case study in terms of the future development and implementation of any new or prospective national maternity policy
7
Commissioners
No Response Published
Recommendation
Commissioners should review serious incident management processes to ensure these are robust in terms of identifying and managing incidents that involve care from more than one provider.
7
Commissioners
No Response Published
Recommendation
Due diligence should be undertaken with the appropriate clinical and commercial expertise, and this should be sourced externally if the skills are not available in-house or if independence is required.
7
Co-commissioners
No Response Published
Recommendation
Co-commissioners’ pre-meetings or other collaborative forums should be formalised so that common themes can be discussed, and queries raised at the formal contract meetings, without the need for attendance of multiple representatives from each commissioner.
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7
NHS England/Commissioners
No Response Published
Recommendation
The blended payment model introduced in 2019/20 should be tested for maternity services between an NHS acute and NHS community-based maternity provider as part of the system.
7
NHS Resolution
No Response Published
Recommendation
NHS Resolution should set out a transparent methodology for calculating premiums for community-based maternity care providers, this should be based on an appropriate risk assessment.
7
Commissioners
No Response Published
Recommendation
For new and/or high risk services, commissioners should consider the use of tools such as the Quality Risk Profile Tool, particularly for independent sector providers and start-up businesses whose arrangements do not mirror those of NHS providers. This should be …
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8
Maternity services’ commissioners, national policy makers, Local Maternity Systems, Integrated Care Boards and regulators
No Response Published
Recommendation
Maternity services’ commissioners, national policy makers, Local Maternity Systems, Integrated Care Boards and regulators should read the findings of this review to support future commissioning, policy and contract decisions.
8
Commissioners
No Response Published
Recommendation
Commissioners should consider implementing the serious incident Closure Checklist to support the review of investigations and reports, and to be assured that they meet the required standard. The Checklist can then be shared with providers to support their learning.
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8
Commissioners
No Response Published
Recommendation
A checklist should be developed to set out the areas of safety and quality which should be reviewed as part of routine annual due diligence of independent sector providers. This should include as a minimum: reviews of policies and procedures, …
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8
Commissioners
No Response Published
Recommendation
Commissioners’ contract management policies should be reviewed to consider tailoring the requirements for smaller, independent sector providers, for example, by strengthening requirements for annual service reviews and audit, as well as highlighting the commercial risks to consider on contracts with …
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8
Small companies
No Response Published
Recommendation
Small companies without any other sources of finance or a portfolio of services should ensure the sustainability of their business plans, particularly, that they should be prudent and be based on a realistic scenario.
8
NHS England/National Bodies
No Response Published
Recommendation
A robust methodology for determining the stillbirth rate by provider needs to be developed that takes into account shared care arrangements between providers of maternity care.
9
Commissioners
No Response Published
Recommendation
Commissioners should invite providers to attend the Serious Incident Review Groups when their serious incident reports are reviewed.
9
Commissioners
No Response Published
Recommendation
Performance management frameworks should be designed to reduce the burden of data collection and reporting while allowing a focus on risk. This should include highlights and exception reporting, a basket of critical performance metrics for routine monitoring purposes, and ‘deep …
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