British maternity services now at breaking point

Your article detailed the Healthcare Commission's first review of mothers' experiences of maternity services, "the most comprehensive assessment of maternity services to be conducted in England" (Mothers-to-be get guide to the best and worst NHS care, January 25). Thirty-one hospital trusts were categorised as "least well-performing", which has become a euphemism for a lack of resources.

You reported "inadequate checks on whether staff intervene effectively to prevent unnecessary caesareans", and that "too many trusts do not adequately support mothers in breastfeeding and too few offer comfortable delivery rooms to encourage natural birth".

I was quoted in response to the prime minister's acknowledgment that "an extra 1,000 midwives were needed". But this number needs putting into a wider context. Ambitious guarantees were made last April in the government's new strategy, Maternity Matters, which aims for England to have a first-class maternity service by the end of 2009. However, the review highlights a shrinking maternity service and an overworked midwifery workforce - without pointing a finger at the maternity funding crisis.

The Royal College of Midwives has calculated that England needs 5,000 more full-time midwives to deliver the government's maternity strategy in the light of the current birth rate, the highest since 1993. In 1997 there were the equivalent of 18,053 full-time midwives in the NHS. The most recent figures, however, saw only a 4.5% rise by 2006. Meanwhile, between 2001 and 2006 the number of births rose by 12.7% - in short, midwives in 2006 coped with 71,935 more babies than five years earlier. The furore this week over the pressures that immigration poses for maternity services rams our point home - not that we are against immigration, but the government has to ensure there are enough midwives to cope.

Your article is correct in pointing out that "hospitals in the north scored particularly well and those in London did badly, with 19 of the capital's 27 trusts relegated to the bottom division". But in the capital the number of births increased by 16.1% over five years.

Moreover, there has been a drop of 16% in student midwife places over the past two years. Health secretary Alan Johnson did acknowledge that "more had to be done to modernise the service". But he needs to do his maths. Our members tell us that the gaps in service are basic. There aren't enough midwives or beds, and they hate that they don't have time to give the care and reassurance they want to provide for expectant mothers. They are reinforcing the review's findings of a "failure to recruit enough midwives for one-to-one care during labour".

We feel that maternity services are now at breaking point. Given the staffing shortfalls, we need real figures underpinned by the demographic changes facing this country - rising birth rates and the retirement of baby-boomer midwives - if the government is to honour its guarantees for maternity care. Otherwise we will be failing mothers, babies and their families.

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The failure of RomneyCare may have killed HillaryCare

On Monday, California Gov. Arnold Schwarzenegger's "universal" health-care plan was shot down by a committee in the state's Senate, 7-1. The most vociferous opponents were not fiscal conservatives, but labor unions that launched a last-minute revolt against its most crucial feature: an individual mandate that would have forced everyone to buy coverage.

This defeat has national political implications. Hillary Clinton, for example, has denounced Barack Obama for refusing to include an individual mandate in his health-care plan. Yet many California unions argued that a mandate would force uninsured, middle-income working families to divert money from more pressing needs toward coverage whose price and quality they cannot control.

The unions are correct: This is exactly what is happening in Massachusetts, where Mitt Romney enacted a similar plan two years ago as governor. (And Mr. Romney's plan is the inspiration for both the Schwarzenegger and Clinton plans.) The experience in the Bay State deserves a lot more scrutiny than it has been getting.

Massachusetts uses a sliding income scale to subsidize coverage for everyone up to 300% of the poverty level -- or a family of four making around $60,000. Everyone over that limit is required to pay for their own coverage if their employers don't provide it. All this has inflated demand, which, combined with onerous regulations on insurance suppliers, has triggered premium increases of 12% for this year -- double last year's national average.

No one is escaping the financial sting. The state health-care bill for fiscal 2008-2009 is expected to touch $400 million -- 85% more than originally projected. Still the state won't be able to fully shield those it subsidizes from the premium increases. But uninsured folks who don't qualify for government help really get pounded. Before the hike, the cheapest plan for uninsured couples in their 50s cost $8,200 annually. Now, unless government bureaucrats hand them an exemption, they might well find it cheaper to pay the penalty -- up to half the price of a standard policy -- than purchase insurance. That is, pay to remain uninsured. This is legalized extortion: TonySopranoCare.

The government response to rising premiums is, unsurprisingly, price controls. The Commonwealth Health Insurance Connector Authority -- the bureaucracy created to oversee RomneyCare -- is considering prohibiting underwriters from raising premiums more than 5% for unsubsidized plans, meanwhile requiring them to cover 40-odd benefits from hair prostheses to chiropractic services. If companies can't scale back coverage, they'll have to compromise care; and the Connector is perfectly willing to assist.

As reported in the Boston Globe, the Connector is encouraging insurance companies to include only a limited network of cheaper physicians and facilities in some plans to hold down premiums. Patients who wish to see more expensive providers will have to dig into their own pockets. Dr. Steffie Wollhandler, a professor of medicine at Harvard University, worries that the Connector will revive Gov. Romney's original idea of enrolling poor people in plans that only offer access to neighborhood health centers ill-equipped to treat anything beyond routine ailments. Forcing people to buy substandard care they cannot afford is not universal care, she says. "It is a hoax." And so Massachusetts is marching toward a system of two-tiered medicine -- the alleged market inequity that universal care is supposed to cure.

How about enforcing the mandate? In Massachusetts, non-compliers lose their personal tax exemption -- about $220 -- the first year, followed by fines in subsequent years. California was planning to garnish the wages or impose liens on the mortgages of the uninsured to pay for coverage. "This bill was like telling someone who is in need of help, 'I'm going to give you food, but I'm going to take away your clothes," Leland Yee, a Democratic senator from San Francisco, told the California Chronicle.

The problems with RomneyCare have prompted Mr. Romney himself to abandon it. And Mr. Obama is surely correct that part of the reason 45 million Americans are uninsured is not that no one is forcing them to buy it, but that they can't afford it. It may be too much to hope that Mr. Obama would embrace market-oriented measures -- such as deregulating insurance markets, giving patients more control over their health care dollars, and fixing the federal tax code to let individuals, like employers, buy health coverage with pre-tax dollars -- to bring down insurance costs. But unlike Mrs. Clinton, he at least seems to understand the perverse side effects of an individual mandate.

Should Hillary Clinton ever be in a position to bully people into buying coverage, a coalition of labor and fiscal conservatives might well do to HillaryCare what it just did to GovernatorCare.

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