of the pyramid were more important than those for whom the service was being provided. Patients were almost an inconvenience to the running of the hospital.
This development is not unique to the health service. The bus and train services still struggle to develop and run their services in order to meet the needs of their passengers; they are also noted for a belief that their services would run more efficiently and on time if passengers did not get in the way.
This contrasts significantly with the statement, written over 50 years ago by Mahatma Gandhi, proposing a different approach to patient care and found on a wall in a Bombay (now called Mumbai) hospital.
A patient is the most important person in our Hospital. He is not an interruption to our work, he is the purpose of it. He is not an outsider in our Hospital, he is part of it. We are not doing a favour by serving him, he is doing us a favour by giving us an opportunity to do so.
For maternity services, this led to births where women were drugged into semi-consciousness and were not allowed to have partners or close family with them at the birth and for days afterwards; where babies were separated from their mothers and where women were encouraged to spray their nipples with antiseptic before rigid 4-hourly feeding; a service where enemas were compulsory and episiotomy routine; where dignity was removed along with one’s pubic hair and yet, at the same time, one was expected to behave nicely, keep quiet and do as the doctor required, in passive grateful patient mode.
My baby was kept in the nursery and only brought to me every four hours for feeding.
When I went home ten days later, I didn’t have a clue what my baby did all day and breastfeeding was a nightmare. Because of concerns about ‘infection’, he was ten days old before his dad even got to hold him once. Two years later when his brother was born, Andrew, aged 2, was not allowed to visit me in the hospital for the eight days of my stay. Hardly the best start to family life!
(One of the author’s experiences [GF] – first baby born 1971.)
Many of the elements that drive this behaviour are still built into the service today. Those in senior positions are paid more, much more than those providing the services. A chief executive officer can expect to receive a salary six or seven times that of a midwife working with mothers. Traditionally many consultants received substantial merit payments that were based on their standing among their peers and their reputation in research, rather than on their effectiveness with those they treat or the views of those who use their services.
services they thought users ought to have, rather than what the user and ultimate bill payer actually wanted.
In the consumer world, commercial companies felt this pressure as customers showed their power by switching purchases from companies that did not meet their needs and listen to them to ones that did. As a result of this, the discipline known as marketing grew up, marked by a seminal text Principles of Marketing (Kotler and Armstrong 2006). It was Philip Kotler who understood and expressed clearly the principles of marketing and generated the acceptance that companies can only remain in business if they understand and meet the needs of the customers better than their competitors.
The NHS in the United Kingdom, however, was not subject to these pressures and is only now coming to the understanding that it must satisfy the needs of its users and the public. Although users do not have the power to withhold payment directly, the electorate can make their views known to their politicians at a local level. People are now more willing than ever to voice their concerns to those who run the service.
The development of organised bodies has been key in bringing those who manage the health service to this understanding. In the area of maternity, the National Childbirth Trust (NCT) was born in 1956. Users came together to change the way society dealt with the process of birth and of becoming a parent, and particularly the way maternity services were provided by the health service.
In 1956, the following were the original aims of the NCT:
• ’that women should be humanely treated during pregnancy and in labour, never hurried, bullied or ridiculed;
• ’that husbands should be present during labour if mutually desired;
• that analgesia should not be forced on women in childbirth (and) nor should labour be induced merely to save time;
• that more emphasis should be given to self-regulated breastfeeding and rooming-in allowed if the mother wants it, and for future maternity units to be designed with this in mind;
• that the mother trained for natural birth should be allowed and encouraged to carry out her training fully during labour;
• that all mothers should be encouraged to use natural childbirth for the benefit of themselves and their babies and that posters to this effect should be displayed in all antenatal clinics;
• that the idea fostered by many medical people today that natural childbirth includes routine examinations, routine administration of analgesia, routine episiotomy should be dispelled;
• as childbirth is not a disease it should take place in the home wherever possible.
If impossible, maternity units should be homely and unfrightening and in no way connected with ‘‘hospital’’ (Moorhead 1996).
The World Health Organization’s report on Appropriate Technology for Birth (1985) included 16 recommendations based on the principle that each woman has
a fundamental right to receive proper prenatal care; that the woman has a central role in all aspects of this care, including participation in the planning, carrying out and evaluation of the care; and that social, emotional and psychological factors are decisive in the understanding and implementation of proper prenatal care. These recommendations included easy accessibility to information about birth practices in hospitals (rates of caesarean section, etc.) and the suggestion that governments develop regulations to control the use of new birth technologies (World Health Organization 1985).
Although the NCT aims were written 50 years ago and the WHO document is now 21 years old, there is still not full acceptance of them. The Royal Col-lege of Midwives (RCM) recently created a Campaign for Normal Birth web site (www.rcmnormalbirth.org.uk) and published some tips for midwives to help them to use evidence based care to promote normal birth. These tips, which clearly reflect the aims listed above, include encouragement to watchful and sup-portive care based on intuitive knowledge, listening to the woman, encouraging mobility and intervening only when a rationale can be given.
In the early days of the NCT, it was as though battle lines had been drawn and the ‘David and Goliath’ contest had begun. From the late 1950s onwards, individuals who felt alone and unable to affect the sort of care they received flocked to become involved in an organisation that could give them the voice and the power they needed to influence a vital service.
Service users started to make their voices heard and, encouraged by the NCT, to complain about their treatment. For many years women had accepted the
‘doctor knows best’ approach, but by the late 1970s and early 1980s, the ideas of those who had long campaigned for change from within the NCT were becoming gradually more widespread. More women were starting to question the wisdom of blindly following the dictates of the medical profession. A couple of ground-breaking books published in the late 1970s empowered women and gave them more confidence to question decisions about their health care, especially in the childbirth field where women were being reminded that pregnancy is not an illness. One was called Our Bodies Ourselves written by a group of American feminists and launched in the United Kingdom in 1978 (Phillips and Rakusen 1989), the other was Sheila Kitzinger’s The Good Birth Guide (Kitzinger 1983).
This project was unique in that it gave maternity units a rating depending on women’s views of the treatment they had received. It was probably the first time women were encouraged to think like consumers and ‘shop around’ for the kind of care they wanted. This new wave of interest built on the campaigns of previous years, relating to the rising induction rates and challenging practices on the grounds of evidence and rates of some non-evidence based interventions, started to fall. Birth plans, a statement of women’s preferred choices, an idea originally conceived by Penny Simkin, a birth educator, and further developed in the United Kingdom by the Association of Radical Midwives, were beginning to become popular (Kitzinger 1983). Midwives too were joining the call for change, and Birthrights (Inch 1989), another book published at the time by midwife Sally Inch, demonstrated that many of the practices currently in use were not based on sound evidence.
Now user organisations involved in birth play an important role in lobbying and campaigning and working with the health service to make these aspirations part of everyday practice within the health service.