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Budget Consultation: is it asking the right questions?

29th January 2014

Here is an extract from the Budget Consultation for Adult Social Care. This is the proposal relating to Gateway’s Pregnancy Outreach Worker Service (POWS):

Proposal 15: Public Health – decommissioning pregnancy outreach

This proposal is to stop funding initiatives around pregnancy support. These services have been running as a pilot for some time and are awaiting evaluation. These services could be supported through the Health Visitor expansion, a responsibility of NHS England. Pregnancy outreach is not a traditional responsibility of the local authority. The cessation of these services will affect the most disadvantaged communities.

Question: Unless the evaluation shows good outcomes, should we decommission these services?

There are two important points I’d like to make about this consultation.

The first is that it refers to POWS as a pilot. The Pregnancy Outreach Worker Service is a contracted service that is performance-managed against a clear set out outcomes. It has been running for seven years and has consistently achieved its contract outcomes.

The second point – my main concern – is about the question you are asked to answer:

Unless the evaluation shows good outcomes, should we decommission these services?

It’s natural to read this and think, “of course a service should be decommissioned if it’s not shown to achieve good outcomes”. I certainly would. But is the public getting the full picture?

The outcomes in our contract cover things like safeguarding, housing, domestic violence, substance misuse, alcohol use and debt management. And we prove, every month, that we deliver on these.

In fact, we place so much importance on measuring our outcomes and impact that we devised a management information system for POWs, based on multiple national outcome frameworks for pregnancy and birth. This includes an Impact Assessment App that gathers direct feedback from the women we help.

But what is “the evaluation” the consultation refers to?

The evaluation that the question refers to – the evaluation upon which the future of POWS will depend – is a Randomised Control Trial (RCT) that took place in 2010-11, the results of which are not yet available.

An RCT, by its very nature, is a clinical trial. Generally, RCTs are set up to assess the effectiveness of medical interventions: drugs, or medical procedures. This one tested the impact of POWS on clinical, more than social, outcomes; things like postnatal depression, whether a mother had suffered an episiotomy tear during the birth, method of delivery (C-section or forceps) and length of stay in hospital.

But POWS is not a clinical service. The RCT couldn’t, and didn’t, cover social interventions … so it doesn’t measure the vast majority of the outcomes the POWs are contracted to achieve.

Why is Birmingham Public Health using an RCT to evaluate the Pregnancy Outreach Workers? Well, it’s the only type of trial they have – it’s the only evaluation method that has the required “academic rigour”.

I understand that RCTs are the gold standard for clinical research, and that the results will have academic rigour. My concern is that other evaluation methods, particularly those that assess social outcomes that are known to increase the risk of infant mortality, should be taken into account. At the moment this is not being considered.

It’s also worth mentioning that we had to change the service to fit the requirements of the trial; it was restricted to first time mothers and we could only work with women already booked with a midwife. After the trial we were able to work with women who had had other children (many in care) and referrals from other agencies, such as hostels, refugee and asylum support services – but we were unable to do this during the evaluation period.

We’re still fulfilling our original aims

The Pregnancy Outreach Service was originally set up as part of Birmingham’s efforts to reduce infant mortality. Of course, no-one can directly reduce infant mortality; all you can do is to try and reduce the risks associated with a poor pregnancy. Some of the risk factors are things that we can’t do anything about, like the age of the mother – but some, like nutrition, or smoking, are factors we can address, so we concentrate on those.

We soon realised that there are social barriers many of our clients need to overcome before we can address their health issues – domestic violence, debt, or homelessness, for example – so we tackle those first and achieve our original outcomes via a slightly longer route.

risks Over the years the service has been running, we have worked collaboratively with commissioners to take these social issues into account and design our outcomes. The screenshot on the left shows just some of the current risks that our POWS are working with.

Reducing these risk factors is what helps to reduce infant mortality. And so, of course, we believe these are the outcomes we should be tested on when the future of the service is being decided.

All services commissioned by the council should be constantly evaluated and we are constantly evaluating ourselves. But it’s frustrating that the future of the service is dependent on one evaluation, which assesses us on a very small area of our work.

We WANT to be evaluated. We want to prove our worth. We deliver on our outcomes every month and we’re proud to show that. I’m not dismissing the RCT – it is important as part of a fair evaluation of the worth of the service. But we are so much more than this.

If you would like to give your views on POWS being decommissioned, you can take part in the Budget Consultation for Adult Social Care by filling in the online consultation questionnaire.

The Proposal relating to POWS is Proposal 15, on page 21 of the Budget Consultation 2014 pdf.

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1 Comment

  1. Sarah Sameresinghe

    As a POW I feel the need to comment on the service being decommissioned. I think it is shortsighted and indicative of how knee jerk reactions see a way to save money but don’t fully consider the consequences.
    The fact that the council has seconded POWs to work with the homeless team “to replicate the support they give to clients” suggests that they understand the impact of our work but are not mirroring that with their response, which is not consistent.
    It seems that it is simply an easy answer to save a percentage of the budget because you won’t necessarily see a cause and effect as a result. The work we do is too intricate for such an obvious outcome.
    Which leads me on to my next point; Health Visitors pick up on what we do? Would a Health Visitor take a client to a hospital appointment that may last for three hours and stay with her to ensure she attended? Would a Health Visitor take a client to the neighbourhood office to declare herself homeless due to domestic abuse? Would a Health Visitor attend a drugs clinic with a client? Would a Health Visitor be a birthing partner to a vulnerable teenager? Obviously the examples are endless as we never know what we are going into. The roles are to compliment each other not act a replacement.
    I have a bizarre, but topical comparison to liken this situation to. Before the Water Authority was privatised, rivers were dredged. This hasn’t happened for years and now there is ceaseless flooding. My worry is that it won’t take so long for the demise of the POW service to have a devastating effect.