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As well as distance, we must consider the cost not only for the mother, who might be reimbursed but who does not necessarily have the money available at the time, but for the father and the immediate family. Just one return bus journey from Blairhall to Kirkcaldy costs £5.70. Many of my constituents do not have one £5.70 to spare, let alone several such amounts. The bus journey from Blairhall, just one west Fife village, to Kirkcaldy takes one and a half hours each way. There is no evidence that many people have access to a car. In fact, in High Valleyfield, another village, more than 50 per cent. of households have neither a car nor access to one. The Minister and the Government tend to forget that there are people who still do not possess or can afford to possess private motor cars. On safety grounds, there is no reason at all why the service should not be provided in Dunfermline.

I have no doubt that the Minister is preparing to assure me and my constituents that a full evaluation of a midwife-led service is being conducted in Kirkcaldy, and that, if successful, that service will be brought to Dunfermline. Frankly, that would not be good enough, because, for the reasons that I have outlined, there is no reason why a midwife-led service should not be established in Dunfermline now. It would not be good enough because there is no real commitment from the Government, there is just a woolly statement--"If the Kirkcaldy scheme is successful, we might consider placing such a service in Dunfermline."

That answer would not be good enough because, frankly, Dunfermline would have been a far better place to pilot such a service. We have had a midwife -led service in essence for years. It would not be good enough because, bluntly, some people in influential places do not wish that midwife-led service to work, because they want things run their way, not according to the wishes of the mothers.

That answer would also not be good enough because I have yet to be convinced that a fair and objective evaluation of the Kirkcaldy midwife-led pilot is being carried out. To my knowledge, the Scottish Office refused to fund a statistician to help to conduct the survey, and the position is only now being advertised by the health board. In conclusion, I can do no better than once again quoting the Health Select Committee's second report:

"We conclude that there is a widespread demand among women for greater choice in the type of maternity care they receive, and that the present structure of the maternity services frustrates, rather than facilitates, those who wish to exercise this choice." That is a good description of how my constituents feel about the maternity service at the moment.

It has often been said, but it is worth repeating, that giving birth is a normal part of life, not an illness which requires the constant presence of consultants. I now call upon the Minister to demonstrate his and the Government's commitment to providing a maternity service in Dunfermline by doing several things. First, I ask the Minister to name the people who have strongly advised centralisation in Kirkcaldy. I challenge them to come to public meetings that I will happily arrange in my constituency and debate the issue with the public whom their decision has affected.

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Secondly, I ask the Minister urgently to intervene in the dampness problem at the new Queen Margaret hospital and deal with the muddle and incompetence that has led to elderly people being moved out of the rehabilitation assessment wards that were built for them and being put in the obstetrics unit, leaving the obstetrics unit unavailable for the purpose for which it was designed.

Thirdly, will the Minister let me know exactly how an objective evaluation of the Kirkcaldy service will be conducted? Lastly, will he accept an invitation to come to Dunfermline next year and join me in opening the maternity service in the Queen Margaret hospital, which I hope he is about to announce this evening?

10.14 pm

The Parliamentary Under-Secretary of State for Scotland (Lord James Douglas-Hamilton): I congratulate the hon. Member for Dunfermline, West (Ms Squire) on her success in the ballot, and on initiating the debate tonight. I am aware of her deep interest in the subject over a considerable time. I should also mention that my right hon. and noble Friend the Minister of State approved the decision to centralise Fife's obstetric delivery services at Forth Park hospital in Kirkcaldy, and he has continued to take a close interest in the development of maternity services there. Last June, he met members of the Fife Maternity Action Group.

The hon. Member raised some relevant and important matters. One was accessibility. Fife health board recognised the increased inconvenience that was caused to women in Dunfermline when the delivery services were centralised, but that had to be weighed against the importance of ensuring safety. A full range of ante-natal and post-natal services is available in Dunfermline. For the delivery itself, the journey to Kirkcaldy is about a 15-minute drive. Families without cars and on income support can claim assistance for public transport fares.

The hon. Lady will be aware of the Domino scheme. It is a form of midwifery care in which the community midwife who has cared for the woman ante- natally escorts her to hospital at the appropriate stage of labour, attends her at delivery and escorts her back home, usually within six hours. Usually, the same midwife continues the post-natal care for 10 days. Any woman who wants Domino care and is assessed as appropriate for such care will receive it.

The hon. Lady also raised the pressing matter of babies who are born before arrival at hospital. Happily, this does not occur very often, but in the year to October 1994, 12 babies were born in such a way to women living in Dunfermline and west Fife. The figure for other parts of Fife was 14.

If a woman is in transit when the baby is born, she is taken to the nearest hospital, where the help of midwives or GPs can quickly be called upon. In an emergency, the Forth Park flying squad will be called out. The squad exists to provide back-up where mothers cannot get to Forth Park. It responds to requests from midwives, GPs, relatives and the ambulance service. The Kirkcaldy acute

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trust is seeking to improve the information given to mothers to ensure that they do not leave it too late to get to hospital.

Mr. Michael Connarty (Falkirk, East): Will the Minister give way?

Lord James Douglas-Hamilton: May I respond to another question which the hon. Member for Dunfermline, West asked, about the existing services for women in Dunfermline?

There is well-developed ante-natal and post-natal care for women in Dunfermline. Out-patient clinic and day care facilities are provided at Queen Margaret hospital. Ante-natal clinics are also available in the community. They have expanded since delivery services moved to Kirkcaldy.

The health board is also piloting a new project to allow mothers to return to the care of community midwives shortly after giving birth. The board is committed to offering real choice to mothers. Its maternity liaison forum is currently developing an information leaflet to inform women of their choices for delivery. They include home delivery, Domino, and midwife-led and consultant-led delivery.

Mr. Connarty: Will the Minister give way?

Lord James Douglas-Hamilton: I have a lot to reply to. If the hon. Member for Dunfermline, West, who initiated the debate, wishes to ask me a question, I shall be happy to give way.

I should explain the background to the development of maternity services in Dunfermline and the decision to centralise delivery services. Scotland enjoys an excellent level of maternity services, and has seen considerable improvements in maternal and infant health in recent years.

All the indicators of safety have improved dramatically. Scotland in general, and Fife in particular, now enjoy outcomes in childbirth comparing favourably with levels anywhere in the developed world. In parallel with those improvements in the quality and safety of medical care has come a growing realisation of the importance of giving mothers a service that is responsive and sensitive to their needs, which ensures continuity of care, which avoids unnecessary medicalisation, and which gives greater scope for midwives to exercise their skills. It is a fact that most babies are delivered by midwives in the course of uncomplicated births.

Increasingly over recent years, health boards have been trying to move towards more sensitive maternity services. I have mentioned the Domino schemes, which will be of considerable assistance to an enormous number of mothers. There are also a number of midwife-led units at early stages of development throughout Scotland, including one that has just been evaluated in Aberdeen, and the new midwife unit at Forth Park hospital itself.

All these changes came in to improve women's satisfaction and enhance the quality of care. The hon. Lady is, of course, aware of the 1993 Scottish Office policy review on the provision of maternity services in Scotland. This has set the policy framework, and health boards have been asked to review their maternity services in the light of this policy review and to move towards improving choice, encouraging the greater provision and

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uptake of Domino and community-based modes of maternity care and bringing about a shift from specialised to less- specialised care. We have also set up a CRAG/SCOTMEG working group on maternity services, which has been taking forward detailed work on such issues as neonatal flying squads and the role of professionals in maternity services.

The policy review did emphasise the primacy of safety. The benefits of access have to be weighed against the need for the sufficient concentration of resources and expertise, so that obstetric units can offer the best in medical care and take advantage of the latest technology.

Ms Rachel Squire: I have been listening carefully to what the Minister has said. Is there any evidence that, since the closure of the maternity services in Dunfermline, the service has improved? Is it not the case that a very good service was provided beforehand, and that there was no reason why that service should have been removed from the Dunfermline area?

Lord James Douglas-Hamilton: The specialists would take the view that the service would now be regarded as safer, and the improvements have been steady over a period of time.

Fife health board is committed to developing maternity services along the lines that I have described. In its draft local health strategy issued for public consultation, the board committed itself to securing a range of community and hospital services from home births to low-tech and high-tech hospital services, which will offer women real choice.

The overall direction will be to promote continuity of care through a greater role for midwives and the development of team midwifery. I have mentioned the services which are currently provided, and current trends are for women to stay in hospital for less and less time after the delivery of a baby. Although short, this is of course the critically important time for delivery itself, and that must be set in the context of a period of care spreading over several months. During this period, a full range of care is, and will be, available in Dunfermline. It is worth remembering that, of the whole range of maternity services, it is only delivery services that have been centralised in Kirkcaldy. Obstetric services, in the form of midwife- led ante-natal clinics in the community, have always been well developed in Fife and have been extended, especially in the Dunfermline area, since centralisation of delivery services. As the hon. Lady mentioned, there is now a pilot project to enable mothers to return home to the care of community midwives shortly after birth, and two additional midwives are providing a community-based service, which also enables a midwife service to be attached to a further two general practices in the area.

Like the hon. Member for Dunfermline, West, I much regret the fact that it proved necessary to close the Dunfermline delivery unit last year. She will know that the decision to approve that closure was one that my right hon. and noble Friend the Minister of State took only after the closest examination of all the facts.

The key issue was ensuring that specialist care was available 24 hours a day for babies needing immediate medical treatment. As I said, the vast majority of births are uncomplicated and require no medical intervention, but in a minority of cases a newborn baby and sometimes the mother need specialist help.

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The number of difficult cases has declined a lot over the years because of improvements in ante-natal care, which can prevent unpredicted problems arising in labour. When problems arise, however, specialist help is sometimes needed urgently and unpredictably in cases that had seemed straightforward.

The problem in Dunfermline was that there were too few paediatricians to guarantee the right level of such emergency cover. An increase in paediatricians could not be justified in terms of the total number of births in Fife. Furthermore, if more doctors had been taken on, there would not have been enough training experience for them, because of the unit's small caseload. The royal colleges would not have recognised the training posts.

Taking on extra trained doctors would not have worked either, because the unit at Dunfermline did not see enough of the rarer difficult cases to ensure that they could maintain and develop sufficient skills and experience in dealing with such cases and emergencies. That is because the unit was small, and simply did not generate enough difficult cases.

The independent task force, which Fife health board appointed in 1991, was clear that the only solution was centralisation of the specialist in- patient maternity services in Kirkcaldy. It concluded that it was not possible simply to increase the number of doctors there, as that would only have diluted the level of experience. The rotation of staff between Dunfermline and Kirkcaldy was also rejected as unworkable. It was clear that the centralisation would have to take place on the Forth Park hospital site, where paediatricians and neonatal intensive care were already available, and not at Dunfermline. The conditions that held then are still valid now and were not materially affected by the advent of the new Queen Margaret hospital. The issue was one of staffing and clinical safety--not physical space.

Other small obstetric units remain in Scotland. The continued survival of each of those depends on a locally specific configuration of skills, experience, specialties, emergency arrangements and the viability of training posts. Maintaining those conditions can be difficult, and the challenge is one that health boards generally will have to grapple with in the context of their broader review of maternity services.

My right hon and learned Friend the Minister of State was, and remains, committed to the establishment of the midwife-led unit in Dunfermline if that can be safely done. He was not satisfied that the board's proposals

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sufficiently overcame the two main concerns- -the need for midwives to gain confidence in running such a unit, and the need to ensure proper paediatric and obstetric cover. The board's public consultation also revealed mixed feelings about the proposals, including doubts among some midwives about their preparedness. The Minister of State was aware that, at the time, there were a few other midwife-led units in the country, but all were at a very early stage of development and only one --the stand-alone unit at Bournemouth--was directly comparable with what was being proposed for Dunfermline. He therefore actively encouraged the board to work towards developing a midwife-led service in Dunfermline by asking it to develop a midwife-led unit in Forth Park hospital on a pilot basis. That would enable the essential experience in running such a unit to be acquired, while minimising the risks to mothers and their babies.

The health board is committed to developing that model, to commissioning a full evaluation of the Forth Park pilot unit and to identifying the potential to set up a similar service at Queen Margaret hospital.

The board collected detailed information from the outset, and a full-time researcher is about to be appointed. The board hopes that the evaluation will be completed by the end of 1995. It has already opened up discussions with the division of obstetrics, gynaecology and paediatrics about the way forward.

For the time being, it remains too early to be able to set up a midwife-led unit in Dunfermline now. I acknowledge that there are other midwife-led units in the country from which lessons can be drawn. As I said, only one is directly comparable--the stand-alone unit at Bournemouth--and they are all at early stages of development. In time, there will be important lessons to be learnt from those initiatives, including the Aberdeen unit, but it should be remembered that solutions must be directly tailored to local circumstances and needs, and that the essential issues here are local --the importance of developing skills and confidence in local midwives, and ensuring the adequacy of arrangements for medical cover.

I must congratulate the hon. Member on raising this matter. I will draw to the attention of the Minister of State the issues that she mentioned. I have given her, to the best of my ability, the up-to-date position. The matters will be borne closely in mind, especially in light of the assessment made of the pilot unit. I again thank her for raising the subject tonight.

Question put and agreed to.

Adjourned accordingly at half-past Ten o'clock.

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