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The noble Baroness said: My Lords, in introducing this debate, I start by declaring an interest. I am a patron of the National Childbirth Trust and, I hope, a friend to the Royal Colleges involved in maternity services.
The expert committee which I chaired found that women and their partners wanted three things: choice, continuity of professional carer--"all I wanted was a familiar face" was a phrase which haunted us wherever we went--and control over their care. Those are such very simple aspirations and are so possible to achieve.
I know that it can be done because I have witnessed it. I have spoken to countless parents, midwives and obstetricians and there is no doubt that where there is continuity of carer, the satisfaction rates are high and the waiting list is long--long for midwives wishing to work in those units. But more importantly, as research into the pioneering one-to-one scheme introduced by Professor Lesley Page shows, the intervention rates are lower and, as a result, the schemes are cost effective. We know that they are cost effective because they have been evaluated very thoroughly by York University.
Where those schemes have closed, the disillusionment has been enormous. Midwives have left because they could not bear to go back to a poorer quality service which satisfied no one. The shortage of midwives does not require rocket science. It is quite simple. We need to stop the closure of one-to-one maternity-led schemes, introduce others, trust midwives, and ensure that they have autonomy over their work.
I know that my noble friend Lord Howe will deal with some issues relating to the midwife crisis and I look forward to hearing the Minister's reply on that. I believe that my noble friend Lord Chadlington will deal with some issues relating to autonomy of midwives.
But I am aware that the Government view Changing Childbirth as yesterday's policy. Although it has been reaffirmed by each successive health Minister, there really is no sense of ownership. I am not proprietorial; I am not proud; I understand government; I also understand the needs of childbearing women.
Along with those working in the field, I want the principles in Changing Childbirth to be adhered to. But I really do not mind if the Government tinker with it at the edges. The Government could call it "New Labour", or in deference to the Minister, who I know feels strongly about this issue--he is the father of five children--we could call it "Hunt the baby". However, I really believe that all of us should recognise the common principles, the common sense, the proven value, the NICE qualities inherent in this policy--and invest some political will.
In her new year press release, Yvette Cooper, a Minister in another place, stated that maternity services are at the heart of government. I am delighted, but what does that mean? Can the Minister tell us where maternity services stand in the list of government priorities? Are they third or fourth or 44th? Can the Minister be specific on this issue because we need to know?
The Government are determined to reduce inequalities, and rightly determined to reduce the number of low-weight babies. The Sure Start programme is a brave attempt to do that, with its target of a 5 per cent reduction by 2002. I believe that it is disgraceful that in this country we have a higher percentage of low-weight babies than even Albania and Latvia.
Research shows that intensive support during pregnancy reduces the chance of a low-weight baby, and improves the physical and psychological health of the mother. Joined-up government should target resources and introduce schemes that offer continuity of care by a midwife, caseload midwifery, one-to-one midwifery, or whatever one wants to call it, in areas of poverty and deprivation. Will the Minister take that modern suggestion of mine to his colleagues and ensure that babies born to the most vulnerable parents have a sure start to life?
Your Lordships recently debated, with grave concern, the rising caesarean section rate. Mr Nigel Perks, an obstetrician in Greenwich, spoke for many when in Monday's press he highlighted the dangers of a caesarean section and the fact that several women in London have ended up in intensive care.
I strongly support women-centred care and the right for women and their partners to choose the place and type of birth that they would like, but the choice should be informed. How many women choose to have what is a major abdominal operation without being given all the facts? Are they told about the risks of both mortality and morbidity; the pain; the discomfort; the delays in returning home; the separation from their baby; secondary infertility and the increased risk of complications including deep-venous thrombosis and infection? Do they really appreciate the effects that that type of birth will have on their baby, including the greater risk of respiratory disorders?
Does the Minister realise the cost to the NHS? With every 1 per cent increase in the caesarean section rate, we add £5 million to the maternity bill--the equivalent of 167 midwives. If the caesarean section rate reached 50 per cent, it would consume a third of the total budget. People may feel that that is a ridiculous statement to make, but the figure has already reached 29 per cent in some places and it is still rising. Does the Minister agree that action is essential?
I know that an audit is being undertaken by the Royal Colleges but that, of course, is a one-off exercise which will take months, if not longer, to complete. We need systems in place that will produce annual audits, close monitoring and consistency, and information UK-wide in the same format so that comparisons can be made on an annual basis. Those systems need to be put into place now. Just as with winter pressures, where exact information is not available when planning starts months ahead, so the Government should start to think about this serious and costly issue now.
Lastly, can the Minister tell us the Government's policy on home births? I know that he will be aware of the huge concern felt by many that the United Kingdom central council has sought legal clarification regarding the obligation of health authorities to provide a domiciliary service for women planning a
Lord Patel: My Lords, I thank the noble Baroness, Lady Cumberlege, for initiating this debate, and in particular for all that she has done to improve maternity services in this country for the benefit of mothers and babies.
Having worked for over 30 years as an obstetrician--I mean as an obstetrician rather than a gynaecologist--I believe that there is no other branch of medicine that is more rewarding, exciting and at times frightening as obstetrics. Of course, I am not biased in any way!
I also assure your Lordships that pregnant women and their partners value above all the safety of their baby. Today childbirth in Britain is very safe, but it could still be safer. We have the skills in our midwives, nurses, doctors and scientists to deliver the best care to the mother and the baby, and to create a healthier population with only a little more effort and commitment, and with not a great deal more resources.
How does one judge the quality of maternity services? The key indicators of a good service are, first and foremost, client or patient satisfaction with the service. Others are hard indicators such as maternal and perinatal mortality; morbidity such as reduction in birth handicap, early childhood illnesses and infections. A good service that meets the needs of the consumer will be successful in recruiting and retaining high quality staff.
So where are the shortfalls in the service? As recently as 1935, one in every 200 pregnancies ended with the death of the mother; that is, one death every two weeks in my city of Dundee. Today the risk is less than one in 10,000 pregnancies--one death every three years in my city. That improvement was not the result of better social conditions--although that too has improved--but of better care from midwives and doctors, and with antibiotics, safe blood transfusion, safer abortion and better treatment of medical diseases such as diabetes and high blood pressure.
How do we compare with the rest of the world? The lowest maternal mortality in Great Britain was in 1985. Some of our European partners--Scandinavia, the Netherlands, Germany, France and so forth--report lower figures. We need to match and better those figures.
All deaths of babies and infants are now analysed by the Confidential Enquiry into Stillbirths and Deaths in Infancy--CESDI for short--which recently produced its sixth annual report and with which I have been involved from the outset. It monitors the causes of death. Two years ago it carried out a detailed analysis of 873 babies who died as a result of labour--so-called "intrapartum" deaths. Those were babies who were normally formed and were not premature; at the start of labour the baby was healthy and then something went wrong.
For the past 50 years, the medical care in Britain's labour wards has been provided by trainees--something I have never accepted and not considered to be correct. In the 1990s, 40 per cent of forceps deliveries were carried out by young doctors who had done fewer than 20 such deliveries before. Those young trainees have done remarkably well, but women now deserve better care from fully trained midwives and specialists.
Last year, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives together produced a guidance document called Towards Safer Childbirth--minimum standards for the organisation of labour wards. One of its recommendations was for a consultant to be present in the labour ward for at least 40 hours a week--at least; there ought to be more--in all large maternity hospitals. The function of the consultant would be to educate and train younger doctors as well as to look after women with complications in labour; to work with midwives as a member of a team; and to formulate policy in co-operation with the clinical midwife manager.
There is some evidence that in units such as Portsmouth, where those recommendations have been implemented, there has been a reduction in mortality in intrapartum deaths. The question will be asked: can Britain afford a safe service, properly staffed by fully trained midwives? If not from a humanitarian point of view, then from a financial one, the answer is that the NHS cannot afford an unsafe service. Litigation costs
What about other areas of maternity services, such as pre-pregnancy care and advice, prenatal care, diagnosis of foetal abnormalities, and antenatal tests? Currently, the expertise to deliver care in all these areas varies from region to region and from hospital to hospital, with a lack of national guidance.
I shall now speak briefly about the rising rate of caesarean sections. Of course the noble Baroness is right, the caesarean section rate has risen in the past decade and in some hospitals--mainly tertiary referral hospitals--it is nearly 18 to 20 per cent. I agree that any decision to undertake major surgery such as a caesarean section, which carries a risk of mortality and morbidity, should be taken seriously.
Advances such as the ability of paediatricians to care for smaller and smaller babies; increasing numbers of pregnancies as a result of assisted conception and multiple pregnancies; increasing numbers of older mothers; successful pregnancies in women with medical conditions; and an increasing number of women wishing to have a caesarean section by choice, particularly if they have had a caesarean section previously--I agree that that choice should be based on informed consent and should be clearly understood--have also contributed to this increase. Because of the complexity of factors involved in human birth, and both the changing circumstances and outcomes that are desired, defining the optimal caesarean section rate is difficult.
I believe that a proper audit needs to be carried out, particularly to find the reasons for inter-hospital variations in rates of caesarean sections for the same cause. There are three major causes: Cephalo-pelvic disproportion (failure to progress), foetal distress, and repeat caesarean section. This matter needs to be explored. There is also a need for guidance and monitoring of the rates of caesarean section. I hope that the audit that is being carried out by the two Royal Colleges will provide some answers in this matter.
I believe that the time has come when all the good recommendations in the variety of reports on maternity services compiled by professional organisations, government and other bodies should be brought together in a national service framework for maternity services. Standards should be subject to audit. I believe that this would help to improve maternity services and make childbirth in this country even safer and a happy time--which I believe that it ought to be--for parents. I have no doubt that we can make maternity services in this country consumer friendly and safer and that we can match the best outcomes that exist anywhere in the world. Will the Minister's department consider the proposal to develop a national service framework?
Lord Chadlington: My Lords, I also am grateful to my noble friend Lady Cumberlege for introducing this important debate. I speak this evening very much as a layman although I am also the father of four young children and have taken a keen interest in the National Health Service all my life. I served on the policy board of the National Health Service between 1991 and 1995.
The health of mothers and babies is clearly of paramount importance in this country. The midwifery profession, despite increased pressures both in terms of changes in society and the resources available to it, has continued to provide a service to mothers and babies which is a shining example to other countries. We have a midwifery profession of which we can justifiably be proud and we must make all efforts to preserve those aspects which make this profession so exceptional.
Since 1983 midwives have shared their legislative framework with nurses but the profession has been recognised as quite distinct. It benefits from a mechanism which is held up as an example of responsible nursing to the rest of the world--the statutory supervision of midwives. That mechanism must be preserved. It provides both the midwives and the mothers whom they serve with a unique support structure which in turn gives the babies in their care the best possible start in life.
The first point that I wish to raise concerns the recognition of midwifery as a profession distinct from nursing. Indeed I should like to see this distinction strengthened and reinforced by further empowerment of midwives, allowing them to practise autonomously. It seems to me that the most effective way to do this is to take midwifery out of consultant hospitals and put the emphasis on midwife-led birth centres.
In accordance with this view I therefore wholeheartedly support the Changing Childbirth policy which my noble friend Lady Cumberlege has both championed and spoken of already in this debate. I believe that my noble friend is absolutely right and that it is a first-class policy which should be reaffirmed. There can be no doubt that the role of the midwife in our society is a highly valued service. We need the health service to support pilot schemes for midwifery-led care, which have been run in parts of the country already, and to show a determination to implement that policy on a nationwide basis.
What stronger signal can we give women that the Government take this issue seriously than a network of midwife-led birth centres devoted to the health of mother and child? After all, midwives are not just there to assist with the practicalities of the birth itself. The responsibilities now taken on by midwives are wide ranging, dealing not only with the dissemination of information to the expectant mother but often providing much needed emotional support.
To pick up the point made by my noble friend Lady Cumberlege about the regular monitoring of services, I suggest that the Commission for Health Improvement should review all of the Changing Childbirth pilot
Secondly, I should like to see every woman in this country guaranteed that a midwife will be present at the birth of her child. The current situation allows for one-to-one care solely in the case of a home birth or where an epidural is required. Provided that there are enough midwives available to provide such a service, perhaps with the comfort and support of midwives at every birth the need for obstetric intervention may be lessened.
The resources are there in human terms--although admittedly thin on the ground--but we need, in addition, a way of mobilising and motivating midwives, especially when, for some reason or other, the number of women in labour at any given time is particularly high.
Having access to a midwife before, during and after a birth has proved to be of real benefit for both mother and child. A 1998 national survey by the Audit Commission, which researched women's views of maternity care, clearly highlighted this. One of the findings of the survey was that when participants were asked the question,
Maternity services can and must be improved. The Changing Childbirth model ensures that improvements are executed. I understand that midwifery-led care would certainly be popular with those in the profession and that large numbers of midwives would be keen to be part of teams in midwife-led units.
Baroness Emerton: My Lords, I, too, wish to thank the noble Baroness, Lady Cumberlege, for introducing the debate. I declare an interest as chairman of Brighton Health Care NHS Trust, where, for the past five years, I have been very involved in developing maternity services to improve the quality of care to pregnant women during their pregnancy--from the antenatal period, through the intrapartum stage, the delivery and postnatal care. We aim to incorporate the Changing Childbirth aims of choice, continuity and control.
Within the five years we have actively evaluated any changes that we have made. Indeed, after four years of introducing a pilot scheme of midwifery with three teams of midwives, changes were made to ensure that instead of three geographical areas having team midwifery, midwives were reorganised into five groups to ensure an equity of care, although this meant that a smaller package of care was given because we needed to cover a larger geographical area.
Fundamental to the development of team midwifery was the philosophy of integrated patient care which during this time involved a total capital expenditure of £2.3 million to develop the unit. That included bringing together the ante-natal facilities and all the facilities concerned in the maternity department, including foetal assessments and diagnostic procedures as well as a modern delivery suite and a birthing pool, a post-natal ward and an intensive baby care unit, as well as developing role descriptions to allow multi-skilling among the staff within the unit.
The first evaluation showed that, where appropriate, care was given in women's homes. The numbers of bookings rose by more than 120 per cent between 1993 and 1997. Home-based ante-natal visits increased by 37 per cent and home assessments rose from nil to 68 per cent. Continuity of care was assured, with two midwives being present at all home deliveries. That illustrated that there was an increase in women's choice for home deliveries. The current home birth rate in my trust is 8 per cent.
However, the evaluation demonstrated that there was a need to give parity of care which could not be afforded by developing and maintaining team midwifery across the geographic area while at the same time ensuring that an optimum number of midwives was available in the hospital unit.
The reorganisation for midwives has resulted in continuity of care during the intrapartum period but allows less flexibility to ensure continuity of ante-natal and post-natal care. Even to achieve that the addition of six whole-time midwives is required. In the period between 1995 and 1999 the number of hospital midwives increased by 12. Those in the community rose by four and then the number was reduced by four. The total number of midwives is now 88, with a vacancy factor of five. Funding is currently required for an additional six midwives. That has been discussed by the primary care group and the health authority. We know that if this funding is not forthcoming a further reorganisation will have to be undertaken. That will inevitably reduce the continuity of care which is our aim.
It will be impossible to sustain the home birth rate of 8 per cent. Therefore, women who wish to have a home birth will be asked to deliver in hospital. Should those women refuse to transfer into hospital, that will present a grave clinical risk as midwives will be unable to attend. The number of midwives on call will be reduced; therefore flexibility will be reduced. Ante-natal clinic continuity will be reduced, resulting in women not knowing their named midwife. Post-natal continuity will be compromised, resulting in inconsistent advice and a reduction in effective care.
Midwife availability to provide breast feeding support at home will be greatly reduced. Intrapartum continuity of care for any women will be impossible. Outreach work for non-attenders at risk will cease. Ante-natal clinics, which are currently provided at small GP surgeries, will have to be withdrawn, thereby necessitating those women to attend hospital for ante-natal care. Such care currently delivered in the home will cease.
That is a grim picture when women have been promised a safe standard of care to which they have become accustomed over the past five years. The neo-natal intensive care unit responded to an increased demand of ITU cots, and a further £258,000 was invested by the health authority to pay for the extra activity. That resulted in the appointment of a second neonatologist and a part-time specialist registrar, together with 4.5 whole time equivalent nursing staff.
Activity has continued to rise. The occupancy of the 20 cots has risen from 93 per cent to 119 per cent during the period 1999-2000. Special care occupancy peaked in September to November at 136 per cent, which caused a bottleneck in our ability to accept intensive care admissions.
Quality of care is costly. Evidence-based practice, taking into account the best practice and consumer views, has to be gauged within available resources. Maternity services urgently need to know what actions Her Majesty's Government propose in order to improve those services and maintain standards that have already been established in these pilot schemes in the interests of providing a quality service, resulting in a healthy mother and a healthy baby.
Lord Mancroft: My Lords, we are indebted to my noble friend Lady Cumberlege for bringing this important issue to our notice this evening. It is, as other noble Lords have stated, appropriate to acknowledge my noble friend's expertise in this subject and the enormous contribution she has made through the work she did in producing the excellent report Changing Childbirth in 1993.
There is, I suppose, a temptation to cut the debate short by asking the Minister why the Government did not continue the implementation of my noble friend's recommendations: if that had been done, the need for the debate would neither be so great nor so pressing. However, it has not been done, and today we face a situation which, rather than having improved, has obviously deteriorated since 1993 or 1994.
I am no great expert in maternity care, but, like many men, I developed a degree of interest when I first became a father over six years ago. Although I am no greater expert now than I was then, I consider myself to be a reasonable amateur mid-husband, in part due to my wife's decision to give birth at home and in part as a result of my increasing interest in midwifery, following the absolutely outstanding level of care that
My noble friend's report clearly made the point that there are not enough midwives, and every noble Lord has emphasised that point. The figures that I have seen show that at present only 36 per cent of registered midwives are practising today, and the increase in midwives nationally is only 3.3 per cent. Although new admissions to the UKCC Register have increased by 1.7 per cent, I am told that this increase is entirely due to the number of registrants from overseas. One reason for this situation appears to be that the career and pay structures for midwives act as active disincentives to them to continue in practice. Can the Minister explain what the Government are doing to address the situation?
One of the consequences is that the choices open to women as to the way they give birth, which we all consider to be so important, are more limited. It is interesting to note that, while midwife numbers have been in decline, during the same period the number of obstetricians has remained stable. That is a good thing, but it means that women are bound to be pushed in the direction of a hospital-based medical birth as opposed to a midwife-led home or hospital birth, regardless of their individual wishes. I suspect that this may be compounded by the post-natal fees that general practitioners can claim, which are bound to encourage them to steer their patients in the direction that suits them rather than that which suits the patient, thus further limiting choice.
These two factors must contribute to the alarming increase in birth by Caesarean section, which every speaker this evening has mentioned. The figures that I have seen indicate an increase of 27 per cent in recent years. While Caesarean births will always be an important feature of childbirth, they cannot be ideal or desirable in cases where they are not absolutely necessary; nor can any other medical intervention unless necessary.
I shall take a lot of persuading not to conclude that too many of these operations are performed to suit the consultant rather than the patient. Clearly, all women are vulnerable at the time they give birth, and they need to be able to trust the professionals who care for them. It is therefore all to easy for the consultant to steer the woman in the direction that is most convenient for him, at the expense of the patient and also at the expense of the taxpayer. Clearly it is more costly to provide medical intervention in a hospital than a home birth or a midwife-led birth in a hospital.
I believe that some of these problems, if not all of them, occur because of our attitude to childbirth. The health service exists to help people who are ill or injured, or at least who are not well. But pregnancy and childbirth are not illnesses; they are part of the natural healthy process of life. Only in the minority of cases where something goes wrong with the mother or child do they become issues of ill health. The problem with hospital and doctor centred maternity care, wonderful though it is, is that it is naturally focused on
But maternity care is not primarily a health issue. It is a women's issue. Eighty per cent of the women in this country give birth at some time in their life. For many of them it is one of the most significant experiences of their whole lives and it is not being given the attention it needs or deserves. In that respect I have to say that I am sadly disappointed not to see the Minister for Women in her place this evening. In a recent newspaper interview, the noble Baroness said that, now that the House of Lords Act was on the statute book, she could turn her attention to her more important role as the Minister for Women. Indeed, in the Guardian newspaper on Wednesday, 8th December, she wrote saying that she had,
The final point I want to make is this. This debate is, quite properly, focused on the narrow area of maternity care because, as we know, it needs careful attention. But there are other factors to be taken into account. In particular, the report entitled Poor Expectations, published in 1995 by the Maternity Alliance, draws attention to the problems of poverty and nourishment in pregnancy--as my noble friend Lady Cumberlege mentioned, the problem of low weight babies. However carefully we look after women during childbirth and immediately afterwards, it will always be an uphill struggle if, in the months between conception and birth the mother and child do not receive the food and warmth they need. It is clear from that report that the benefits paid to pregnant women at present are not sufficient to provide for an adequate diet. It is also clear that, for those on income support, this problem is compounded if, for example, they are compelled to service a fuel debt during pregnancy.
In answering the Question, I have no doubt that the Minister will seek to lay at least part of the blame for the failure to implement my noble friend's report on the previous administration; but not too much, I hope. The previous government did implement a great deal of it. However, this Government appear to have stopped or prevented many of those initiatives from moving forward. I should like to hear what the Minister has to say about that.
Lord Chalfont: My Lords, I hope that I may have the indulgence of the House to say a few words before the noble Lord, Lord Clement-Jones, addresses noble Lords from the Liberal Democrat Benches. I have much appreciated the opportunity to be present at this debate this evening. I had not expected to attend. I confess that I am here only in the wake of the debate on the international situation that took place earlier. Knowing the noble Baroness's interest in and commitment to this issue, I believed that it would be a debate worth listening to, and it has been. The debate has been most instructive, informative and, in some cases, even moving, and I am most grateful to the noble Baroness for her presence.
The noble Baroness might have felt some discouragement at the sight of all the empty Benches around her when she initiated a debate of this importance. I hope that she will not be too discouraged. Not only will everything that has been said appear in Hansard, which I hope those interested in this matter will read and find informative, but I am also aware that the noble Lord, Lord Hunt of Kings Heath, who has a deep interest in and commitment to these problems, will take these matters back to his colleagues. I hope it is not inappropriate to say that the noble Baroness can be assured that all that she has said will have the impact that it should have on the Government's thinking.
Like many other noble Lords I am not knowledgeable about this subject. Although my wife is a doctor and I have had some second-hand experience of these problems, certainly I am not an expert. However, I believe that at the end of this debate I know a little more about it than I did at the beginning. The only reason for rising to my feet in the gap is to express heartfelt thanks to the noble Baroness, Lady Cumberlege, for introducing a debate of this kind which is in the very best traditions of your Lordships' House.
Lord Clement-Jones: My Lords, with all other noble Lords I join in thanking the noble Baroness, Lady Cumberlege, for initiating this debate. I pay particular tribute to her long involvement and expertise in this field. I wholeheartedly agree with the noble Lord, Lord Chalfont. Having listened with enormous
I declare an interest as a patron of the National Childbirth Trust. I pay tribute to that body, the Royal College of Midwives and other organisations in this field in their campaign for better maternity services. My own recent experience of maternity services occurred when my son was born across the river at St Thomas' on the first day of spring 1998. My motives in supporting the NCT arise particularly from the desire to see other mothers have the same quality of care as my wife and I experienced at the hands of the community-based Alpha Team at that hospital.
With great deference to the noble Lord, Lord Patel, like the noble Lord, Lord Mancroft, perhaps I have the rather unreasonable prejudice that the best births are those without doctors, if possible, despite the fact that both my nephew and his wife are obstetricians. It appears that my nephew's wife shares this prejudice since recently she gave birth to a healthy eight-pound girl at home.
There are many issues with which the maternity services currently have to grapple, and they have been graphically described by your Lordships during the course of this debate. Many of them stem from shortages. The most recent report of the English National Board for Nursing, Midwifery and Health Visiting shows that numbers entering the profession each year have fallen since 1994. Based on those figures there are about 2,500 fewer midwives than two years ago. Many senior people have left the profession and, as a result, there is a shortage of experienced staff.
In a reply before Christmas to a supplementary question that I put to him, the Minister seemed to imply that with the recent recruitment campaign the problem was now solved. Is that indeed the case? Has the shortage of midwives now been fully made up? After all, London hospitals such as the Chelsea and Westminster were turning away women in labour as recently as November because of lack of staff. Are we still recruiting midwives from abroad as we were last year?
I believe that our shortages will not be made up until we improve radically the pay of midwives and have much more flexible patterns of working. Without adequate midwives I fear that the grave picture painted by the noble Baroness, Lady Emerton, is only too accurate. By contrast there is an alleged oversupply of obstetrician and gynaecological doctors in training. What an argument for a massively improved workforce planning system.
There appears to be a strong link between shortages and the rising rate of caesareans outlined by the noble Baroness, Lady Cumberlege, and the noble Lord, Lord Mancroft. We shall have to wait for the Royal College's audit referred to by the noble Lord, Lord Patel, to see whether that is indeed the case. Be that as it may, the shortages have militated against what should have been the very essence of maternity care as
As regards choice, the NCT survey carried out last year and published in August, showed that there was a lack of awareness among expectant mothers about the full range of options, and then a lack of choice about the lead professional. There was also felt to be a lack of unbiased information. There were of course as well wide variations in frequency of seeing a consultant obstetrician. Very importantly, there was a lack of choice as regards home births. The majority of GPs seem actively to discourage home births, as that survey showed. I share the desire of the noble Baroness, Lady Cumberlege, to see the matter clarified.
There has been a long gap, as the noble Baroness illustrated, between the end of the period of the original 1993 five-year strategy, Changing Childbirth, of which she was the author. That has clearly not been implemented in full because of lack of resources, as the Audit Commission clearly showed in 1997. Do the Government now plan a national service framework, mentioned by the noble Lord, Lord Patel, which can set a truly high standard for maternity services? Are the Government planning a replacement strategy for Changing Childbirth? What guidance are they giving to primary care groups which are now thrust into the commissioning of those services? When the Health Act was going through this House, we were assured that user groups would be involved closely with PCG commissioning. Is that happening with maternity services?
What emphasis is being given to particular aspects of training? Is this being adequately resourced? I am sure that the House is aware that there are worrying issues about standards and some alarming cases pointing to a lack of training. Indeed, the joint report of the Royal College of Midwives and the Royal College of Obstetricians showed that a lack of adequate training, for example in the use of heart monitors, is at the root of a great many problems in delivery.
I hope that the Minister can at least respond to some of these questions. The NCT's 10-point plan published in 1998 seems to me to provide an excellent basis for the way forward. There are many aspects of the 10-point plan and the objectives of the Association for Improvements in the Maternity Services, which I could highlight. The aspects which strike the greatest chord with me, however, are the need, first, for user involvement in PCGs and in maternity service liaison committees; much improved recruitment and retention of midwives, in particular senior midwives; the importance that the NCT and others attach to integrated services, so well described by the noble Baroness, Lady Emerton, and, above all, the need for a national strategy to tackle inconsistencies and anomalies in maternity care.
Earl Howe: My Lords, I thank my noble friend Lady Cumberlege for the characteristically capable and heartfelt way in which she introduced her Unstarred Question tonight. I hope that the Government will pay close heed to what she said. My noble friend has a deep understanding of maternity services, based on many years' experience in the NHS and in government.
However, there was one matter on which she did not dwell but which ought to cause us particular concern. It is the current fragile state of morale among midwives. Midwifery is a special discipline and one that is quite distinct from mainstream nursing. Like nursing, it is a vocation and not just a profession. That means that midwives will always work longer hours and shoulder additional burdens, rather than compromise the professional standards of care given to the patient. I have no doubt that the commitment of midwives to their work has protected maternity services from the full effects of resource shortages over the past few years. I believe that but for that, the situation on the ground--by which I mean the situation as felt by the patients--would be far worse than it is.
If we believe that midwifery is a vocation--and I venture to suggest that we all do--it must be a cause of special worry that so many midwives are choosing to leave the service. That is not a sustainable position for the NHS if, as is now the case, more midwives are leaving the service than are joining it. This year's RCM survey shows that three out of four midwifery units are currently carrying vacancies and that the number of long-term vacancies has increased to 55 per cent of all vacant posts. Up to one-third of trusts are unable to provide one-to-one care for women. Pilot schemes promoting continuity of care have been discontinued. I have heard of some hospitals having to shut their labour wards and send women down the road to other hospitals.
When just before Christmas we debated the issue of the rising number of caesarean sections, the Minister said that the shortage of midwives in England as a whole was 2 per cent, based on those midwifery posts that had been vacant for more than three months. I do not dispute that figure but, like all averages, we should treat it with caution. In North Thames, the long-term vacancy rate is 5.9 per cent; in South Thames it is 6.1 per cent; and in Anglia and Oxford it is 4 per cent. Some units in London are operating with as many as 20, sometimes 30, vacant posts. In other words, there are particular parts of the country where the shortages, both long and short term, combine to create acute
No one is saying, not even the midwives, that the answer is simply more pay. It is about much more than that. It is about the status accorded to midwives as a profession distinct from that of general nursing. It is about the ability of midwives to exercise real autonomy and to contribute to improvements in the quality of care on the ward and outside it. Midwives need to feel that there is a proper career structure open to them that offers real opportunities for advancement. Many midwives feel that these things are being denied them and, as my noble friend Lord Mancroft said, that the grading structure within the profession offers inadequate reward for the level of responsibility and commitment that midwives undertake.
I have no doubt that until these issues are addressed, the recruitment, but more particularly the retention, of midwives will continue to pose a problem. Indeed, with the forthcoming reduction in the hours of junior doctors, the pressure on midwives is likely to worsen. In turn, that will lead to a diminishing ability to develop the standard of care to expectant and new mothers. That can only run counter to the Government's declared and worthy aim of providing women with greater continuity of care and with choice and control over their experience of childbirth.
Lest the Minister accuse me of setting out a stall full of problems rather than solution, let me offer one thought. One of the difficulties facing hospital managers--and, I suspect, Ministers--is that relatively few maternity units can claim to have coherent systems in place for defining and reviewing staff levels. The estimates made of staff shortages are, therefore, bound to be subjective to a greater or lesser extent. Yet, if the quality agenda is to mean anything and is to be delivered, proper planning is essential. As variations in care outcomes begin to attract more intensive scrutiny, it is certain that maternity units will have to justify both the quality of service provided and the number of staff employed to provide it. What is needed is a robust planning system such as Birthrate Plus that matches staffing and workloads to ensure that if more midwives are needed, the case for them is convincingly made to trust boards, health authorities and government.
However, we cannot examine the current state of maternity services without taking a hard look at what has happened in obstetrics. Some five years ago it was recognised that the number of consultant obstetricians and gynaecologists was too few in relation to the total number of senior house officers, registrars and non-consultant doctors. What the NHS had was a service that was consultant led, at least nominally, but which, in practice, depended far too heavily on non-specialist medical staff. What it needed was a service that benefited more directly from the professional input of the consultants themselves; in other words, more consultants actually on the labour wards.
The introduction of the Calman training programmes was intended to remedy this by ushering in a more structured, less disjointed and foreshortened training scheme for obstetricians and gynaecologists. The hurdle of progressing from registrar to senior registrar was removed and a new grade of specialist registrar was created. Because the training programme was to be condensed, more trainees would be completing their training in a shorter period of time than they would otherwise have done. It was therefore agreed that the numbers of specialist registrars should increase at a rate of 6 per cent year on year until the planned total of approximately 2,000 consultants had been reached. The process of gradual expansion was programmed to take place over a period of about 15 years.
In the event, the increase in consultant posts over the past five years has fallen considerably short of the planned rate of 6 per cent. The result is that we can now look forward to large numbers of trainees completing their training in 2000 to 2003 with no consultant jobs to which to go. For some, this is already a reality. At the moment, there are some 128 individuals who have completed their specialist training and who are not employed as consultants. Most of these, if they are unable to find work abroad, face imminent unemployment. However, over the next four years the position will become even worse with three times the current number likely to find no consultant posts available to them.
That is serious enough for the individuals involved, but it is even more serious for the NHS. The direct consequence of the failure to create enough consultant posts is that the number of trainee obstetric posts is now being dramatically cut back in step with this. Simultaneously, the money which would have funded the planned number of trainees is being siphoned off into other specialties. We are fast being drawn into a vicious spiral in which standards will be compromised and the individual who will suffer most is the patient. If both consultants and trainees are being cut back, who will there be to provide the necessary service? The answer is that midwives and gynaecological nursing staff will have to bear the brunt of it--the very thing that in their current depleted state we should not be asking them to do. The case for expansion in consultant numbers and for increasing labour ward cover for consultants is as strong as it ever was. But where is that expansion to come from if the Government refuse to facilitate it?
I must urge the Government to address these issues as a priority. The Minister ought now to say whether the Government and the NHS executive are committed to a long-term expansion of consultants in obstetrics and gynaecology. If they are, a useful start would be to introduce an element of central direction to NHS trusts to ensure that something approaching the planned rate of consultant expansion can be
If we needed any convincing as to the importance of maintaining standards in obstetrics and gynaecology, we need only look, as the noble Lord, Lord Patel, emphasised, at the two most recent annual reports of CESDI--the Confidential Enquiry into Stillbirths and Deaths in Infancy. In 1995, 453 babies died as a result of asphyxia or trauma suffered during labour or delivery where care was suboptimal and where different care would reasonably be expected to have made a difference to the outcome. That number represents, as the noble Lord said, just over half of infant deaths occurring during childbirth. I do not draw any inferences whatever from that statistic in terms of the total numbers of consultants or midwives practising nationally. What it does raise is a number of far-reaching issues related to the training, supervision and practice of skills of professionals--in all grades--looking after women in labour and newly born babies. That is not just my conclusion; it was a key part of the recommendations made by CESDI itself. Painful as it is, we need to remember that more than 40 per cent of all litigation costs incurred by the NHS relate to obstetrics and gynaecology. In terms of patient safety and all that flows from it, we simply cannot afford to short-change those who rely on this vital area of our health service.
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, this has been an important and instructive debate and I certainly intend to reflect on the points raised by noble Lords. I congratulate the noble Baroness, Lady Cumberlege, on securing the debate. It is a particular pleasure for me to respond to her Unstarred Question. I worked happily with her when she was chair of the National Association of Health Authorities. She went on to greater things as a regional chair and then a Minister. As other noble Lords have said, her leadership and commitment have led the way, along with many other people, to bringing about real and lasting change to maternity services over the past decade. All Members of the House will be indebted to her for her contribution. I know that she intends to continue championing this area in the new millennium and certainly intends to keep me on my toes.
Although the noble Baroness expressed concern about where maternity services stand at the moment, it is my contention that as a result of her work and the work of many other dedicated people huge advances have been made over the past decade. I believe that the experience of women during pregnancy and childbirth has radically improved. As the noble Lord, Lord Chadlington, suggested, the Audit Commission report, which reflected the views of many women,
The noble Baroness went on to ask what priority the Government give to maternity services. I want to assure her that we are fully committed to the principle of high quality, women-centred maternity care that offers greater choice, continuity of care and control to women. The ethos of putting women at the centre of maternity service planning is now firmly embedded in mainstream practice. I also believe that further improvements in maternity services can be made and are being made from the wider government initiatives that we are taking to modernise the National Health Service, improve public health and strengthen family life.
The noble Baroness asked me to say where I would place maternity services in the list of priorities. She asked whether they are number three or number 44. I shall not fall into that trap. The noble Baroness knows as well as I do the dangers of priority setting in the National Health Service; one may veer from picking two or three particular issues and focusing on those to setting 59 different priorities. In that case the messages to the service are mixed and the conclusion is that nothing is a priority.
I would look at the situation in the following way: maternity services, as I have stated, are a clear priority. The NHS is not in any doubt as to the philosophy and framework in which those services need to be developed. In the light of the commitment that I have given on our underscoring and supporting the principles of high quality, women-centred maternity care, I hope that the noble Baroness will take from this debate an understanding that we remain firmly committed to high quality maternity care services.
The noble Lord, Lord Patel, asked about the national service framework. There are of course many claims on the national service framework process. It would be wrong for us to hold out hope that there could be an NSF in relation to maternity services. Those matters must be considered from time to time against many bids and pressures put forward. If one looks at the areas where we have started to develop NSFs, the priority must be in those areas where there is a lack of policy and consistency within the health service. The position in regard to maternity services is much better in terms of the philosophy, based on Changing Childbirth, and actually in practice, than many other services. While I understand why the noble Lord, Lord Patel, would wish to see a national service framework, and while we shall consider that suggestion along with many others, I cannot hold out much hope to him.
I turn to the issue of caesarean section rates which we debated in this House only a few weeks ago. We are determined to tackle areas of practice where there is a lack of clarity about appropriate standards, as is the case with caesarean section rates. We are aware of the concern expressed over the variation in rates between different maternity units. I assure the House that we have an active programme of work in hand to address
Noble Lords are probably aware that the World Health Organisation does not make specific recommendations about the rates of caesarean delivery, which it has concluded will inevitably vary from place to place. They will reflect the health and nutritional status of pregnant women and the level of maternity care provision. However, the Department of Health has an active programme of action in hand in line with WHO's view that countries with caesarean section rates over 15 per cent and under 5 per cent should consider the possibility of whether the intervention is either over-used or under-used. That is why--as the noble Lord, Lord Patel, suggested--we have commissioned a national audit study of caesarean section rates from both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, which will then set standards in an area where they are badly needed. We shall be looking carefully to see what lessons can be learned from the audit and to ensure that the results can be used in best clinical practice in the future. I understand the noble Baroness's impatience regarding when the results of that audit study will come to hand. The audit will start in May this year. We expect that it will cover every NHS trust and that the results will be available early next year.
In the meantime, we have taken steps to strengthen local audit processes by publishing for the first time figures for caesarean section rates by individual NHS trusts. I understand that the publication of those rates has at the very least started the process of trusts considering how they stand in comparison with other trusts, and has led them to start to question whether they have in operation the correct policy and clinical practices. As I believe the noble Earl, Lord Howe, suggested, that will, of course, be underpinned by the whole process of clinical governance which, in itself, should be leading to the process of evaluating those figures and the caesarean rates in operation in individual NHS trusts.
The noble Lord, Lord Clement-Jones, asked about the position of electronic foetal monitoring. The department has commissioned the Royal College of Obstetricians and Gynaecologists to produce evidence-based clinical guidelines on the use and interpretation of electronic foetal monitoring. The main aims of the guidelines will be to ensure that technology is used appropriately in clinical practice and that those using it are competent in their
As the structure of the NHS changes, we must consider the impact of those changes. A number of noble Lords raised the question of primary care groups and the impact of primary care groups on the commissioning of maternity services. Of course, primary care groups have the ability to shape and commission the services that they consider appropriate for their patients and for the community they serve. However, commissioning decisions by those primary care groups should be made in agreement with all the local partners involved, based upon a shared vision contained in the local health improvement programme. I regard the role of the local health authority, in partnership with the primary care group, as being extremely important in ensuring that those commissioning decisions are consistent with the overall policies which we wish to see developed in the National Health Service. In addition, I understand that there are 16 midwives who are serving on the boards of primary care groups. On those groups where a midwife is not a member of the board, there are arrangements for the midwifery voice to be heard. Again, that is something which I very much wish to support.
The noble Lord, Lord Chadlington, asked a number of questions in relation to the position of midwives. First, he asked about the continuation of the statutory supervision of midwives. We are committed to the continuation of that position. We believe that it is a valued and valuable system and one which we see as being an integral part of clinical governance in the future.
The noble Lord asked also about the recognition of midwives as distinct from nurses. We expect that the new regulatory arrangements in relation to nurses and midwives will make it possible to take a mature and collaborative approach to that issue in ensuring that midwives play a full and active role in the new arrangements for self-regulation.
I turn to the matter of midwives. A number of noble Lords raised questions in relation to morale, shortages and the overall position and contribution which midwives make. We are all agreed that we owe much to the midwives in this country and to the enormous contribution which they make and the hard work that they do in so many settings.
In relation to recruitment issues, the noble Earl, Lord Howe, quoted back to me the statistics which I gave in December. I confirm that the position is that 2 per cent of midwifery posts have been vacant for three months or more. But we are not complacent about that. I take the point that 2 per cent can hide greater shortages in some trusts. Our aim is to work closely with trusts facing particular issues and pressures.
There are some positive signs. The noble Earl, Lord Howe, chided me about the morale of midwives. I say to him gently that nothing was more damaging to that morale than the staging of pay awards introduced by the government of whom he was a member. One of the most important decisions which this Government made when the pay review body recommendations were put forward last year was not to stage the awards.
There are other positive signs. Applications for midwifery training have risen by 50 per cent, so there are far more midwifery students now coming out of training as a result of the expansion which this Government have funded over the past two years. Again, I should say to the noble Earl, Lord Howe, that between 1992 and 1995 the number of nursing and midwifery training places was cut back by as much as 28 per cent. That has had a fundamental effect on some of the issues we have been facing in relation to nurses and midwives.
The future looks brighter. This year there are almost 19,000 nursing and midwifery training places available--4,000 more than three years ago. The noble Earl will know that more than 5,000 nurses and midwives are either returning or planning to return to work in the future.
I shall not respond in detail to the issues raised in relation to consultants in obstetrics and gynaecology. Of course we are aware of the problems. I listened carefully to the points raised. We have the benefit of a working group set up with the Royal Colleges, the BMA and others which made recommendations some time ago. We have held a series of regional workshops involving NHS managers and the relevant professions to explore how we can improve the staffing position in that specialty area.
I should say to the noble Earl, Lord Howe, that co-operation rather than direction is the key to good workforce planning. One of the great problems in workforce planning over many years in the health service has been that far too often in the past decisions were made by great and good committees at the centre without being relevant to needs in the field.
The new workforce planning arrangements, parts of which were put in place by the noble Earl's government, are starting to pull together the interests of local managers and those concerned at a national level in medical workforce planning. I believe that we are moving to much more sensible arrangements. But it takes time.
I was extremely interested in the remarks of the noble Baroness, Lady Emerton, who gave us an interesting insight into the experiences of her trust. I was really impressed by the figure of 8 per cent for home confinements. Her trust is to be congratulated.
She gave us a flavour of some of the challenges which NHS trusts face. I do not run away from the fact that they do face challenges and pressures in deciding where to spend their money and where their priorities should be. But such decisions must be taken in the context of the overall increase in resources which this Government have and will continue to put in to the National Health Service.
I turn to the issue of home births. The noble Lord, Lord Mancroft, made some helpful remarks. As I understand it, although the NHS has a legal duty to provide a maternity service, there is not a similar legal duty to provide a home birth service to every woman who requests one. However, I certainly hope that when a woman wants a home birth, and it is clinically appropriate, the NHS will do all it can to support that woman in her choice of a home birth.
On the point that the noble Baroness, Lady Cumberlege, raised about the Sure Start programme, which I believe is an important aspect of any maternity service, it is to provide £452 million over three years to give support to the children of families most in need. From a maternity service perspective Sure Start will integrate and build on existing antenatal and postnatal
In the short time available--I realise I have overshot my time quite considerably--I hope I have assured noble Lords that we are anxious to ensure that we continue to improve and develop good quality women-centred maternity services in this country.
I have listened to all the contributions tonight in this extremely interesting and informed debate and I assure noble Lords that I shall reflect seriously on many of the constructive points put forward.
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