Examination of Witnesses (Questions 40-59)
THURSDAY 6 MARCH 2003
PROFESSOR LESLEY
REGAN, MS
LYNNE PACANOWSKI,
MS CATHERINE
ECCLES, MS
BETTY LARKIN,
MS KAY
BARBER, MS
SELENE DALY
AND MS
CATHY ROGERS
40. Do your staff rotate? Would you at some
points work on the consultant unit and sometimes in the birth
centre?
(Ms Barber) Only from a refreshing point of view if
we were working in a consultant unit. Working at a birth centre
utilises the full range of midwifery skills. You are using everything
that you have been trained to do. The core staff stay as the core
staff at the birth centre and we do not rotate, although there
are some rotational posts from the three Trusts that we are working
with so that midwives who are not working within the birth centre
can have the experience of working at the birth centre. That helps
to integrate it into the services.
41. Is it the other way round? The ones working
in the major centres would get de-skilled with the ordinary births.
(Ms Rogers) This is what has been shown by the evidence.
We know that we have a shortage of midwives nationally. One of
the problems has been—in terms of attracting midwives and
midwives staying in the profession—is around not being able
to practice what they considered midwifery to be. What we have
is a lot of demand in our units from midwives wanting to go to
the birth centre to practice midwifery. We need to create more
environments where midwives can practise the full range of their
skills as they do at the birth centre. That is what we are finding.
42. Should one of our recommendations be rotations
between the two sorts of unit.
(Ms Barber) Absolutely.
(Ms Pacanowski) Going on from what Catherine was saying
about setting up these new guidelines about not doing the admission
trace, we are just implementing that at the moment. Because of
the way that midwives are used to working, actually that is not
the way they are used to working, in a high-tech obstetric led
unit. They have almost had to have a refresher course in using
those skills and it has been wonderful. They have really enjoyed
going back to practising basic normal midwifery. I do not think
you need to rotate from one unit to another. We have quite an
antiquated labour ward that has recently been refurbished and
we have tried to create an area which is like a low-risk area
with a birthing pool. If you turn left you go to that bit and
if you turn right you go into the more high-tech part. The midwives
work across the labour ward and so they actually get experience
in both which I think is pretty beneficial.
Sandra Gidley
43. I am not very familiar with staffing numbers,
but I have just been passed a note from one of our advisers which
says that Edgware has seven whole-time equivalent core staff on
the labour ward for 500 deliveries. Comment, that seems quite
high. I know it is difficult to compare the two, but how does
that compare with staffing levels at St Mary's, bearing in mind
the comments you made earlier about this being one of your problems?
(Ms Pacanowski) This comes up in staffing structure
as well. We have been part of a London-wide project looking at
assessing midwifery establishments in all 27 units in London and
they compared the ratio of midwives to births. They took the birth
rate of a Trust—ours is around 3,000—fed in the establishment
of midwives and then worked out the ratio. We have one of the
worst ratios, I have to say. It is something like 38:1, 38 births
to one midwife. There is a huge variation across London from 28:1
to 41:1.
(Professor Regan) I think we need to add here that
the advantage of this new audit system called Birth Rate Plus
is that in addition to counting numbers of baby's bottoms that
hit beds and the number of midwives who delivered them, it was
also factored in the dependency of the case mix in that hospital.
For example, if you can imagine in Paddington we have a large
number of intravenous drug abusers, we have a large number of
HIV-positive patients, and those patients—proportionately—take
up a lot more midwifery time and medical time as well. These figures
were the first time there had been any attempt to analyse what
these midwives were doing and to factoring what was necessary
to look after some under-privileged groups and some ethnic minorities.
(Ms Barber) Can I just add that we do not have access
to the monitoring that you have been talking about at St Mary's
which means that the way we monitor the baby is by listening to
the baby's heart rate every 15 minutes. That alone—with
all the other things that a midwife is doing when she is caring
for a mother in labour—is another reason that you need the
one to one care in labour. Within 15 minutes the midwife is going
to be present, you need to be present to monitor the mother's
labour and hence the statistics with the low Caesarean sections.
(Ms Rogers) I think if our ultimate aim is to reduce
the Caesarean section rate and reduce intervention and to truly
get evidence based midwifery practice off the ground we are going
to have to re-invest in midwifery. Women who come to the birth
centre require as much input as women who are perhaps drug addicts
in terms of really giving them the level of support, encouragement
and facilitation that is required to get the positive outcomes
we have.
44. I fully take on board all those comments
about facilitating and empowerment, but do women actually have
enough information about Caesarean sections to actually actively
participate in that decision?
(Ms Eccles) Only if they look for it. If they go on
to the Dr Foster website or something like that. I think at the
moment where women decide to give birth, some of them might decide
to go on to Dr Foster and look at Caesarean section rates across
the country, but I think that is about the only statistic they
can get easily. There are other things like instrumental delivery
and epidurals. How women make their choices at the moment is they
go to look at the birth unit and just at the general environment,
and by word of mouth. I think perhaps it would be beneficial for
women to have more automatic access to the statistics in order
to make informed decisions rather than ad hoc decisions about
where and how they are going to give birth.
(Ms Rogers) People who have had previous sections
are very late when it comes to making decisions about subsequent
mode of delivery and if we want to reduce Caesarean section rates,
reduce second Caesarean we really have to start after the woman
has had her first section and meet with her, debrief her, really
give her information very early in pregnancy in relation to supporting
and being more positive about the whole thing. I think we leave
it far too late sometimes.
(Ms Eccles) What women do not realise is that the
admission trace or an epidural or induction are all very positive
steps towards having a Caesarean section. That information really
needs to be put across more forcibly than it is at the moment.
I think at the moment women seeing having an epidural as having
pain relief and therefore having an easier time. What they do
not understand is that they have a far higher chance of an instrumental
delivery or a Caesarean and I think that information needs to
be given.
45. So you are making the case for more information
generally.
(Ms Daly) Absolutely. From my point of view I went
to a major hospital first before I found the birth centre and
I felt I was coached in how to use pain relief. When I went to
the birth centre I was advised about pain relief in far greater
detail. I was also given the option of none and that actually
might be far more positive for my birth. If I do not have pain
relief then I am probably slightly more corpus mentis and therefore
I can probably get through my labour more quickly and deliver
more quickly. In fact, you will find in statistics that women
do, on average, have shorter labours in birth centres than they
do in conventional hospitals. If you look from the cost point
of view of a birth centre ethos, reduction in drug use, reduction
in intervention, shorter labours, reduction of equipment to use,
you do not need the monitoring equipment. Postnatally the GPs
have said that the women from the birth centre do not go back;
there is a potential reduction of costs of postnatal care. Even
rooms management in a birth centre: woman X is in room 1 and that
is it. You will never have to look in the loo for her because
she has one in the bedroom. That is from a business point of vies.
Also midwives: you have staff retention, you can get staff back
in, there is high morale. I would say for not containing costs
you can actually get far better birth experiences, far better
outcomes, raised morale of midwives and women as well and, I think,
very much PR for the NHS in this particular area. For me it is
a compelling business argument to look at this in greater detail.
46. But you cannot provide some of things unless
you have the staff to support the women, so it actually comes
back to the same point.
(Professor Regan) Can I make a point there about the
electronic fetal monitoring. I am a great supporter of having
this midwifery-led unit within our labour ward and we are not
actually performing electronic fetal monitoring. One of the problems
is that if you have a particularly bad day and you have staff
shortages, you could find one midwife looking after three labouring
women in three different rooms. In that situation one of the only
things that that poor midwife will be able to do to facilitate
safety of both mother and baby is to leave these monitors on and
when she is in room two just hope that her right ear will here
the pip, pip, pip in room three and vice versa. I am exaggerating
a little bit, but that is an issue. I think that all of the aspirations
that I have heard I entirely agree with and want to support going
into practice are just going to be pie in the sky until we completely
review our midwifery staffing structure. It is not a question
of upping it a little big; it is dramatically increasing it if
we are wanting to achieve what has been voiced here.
(Ms Barber) I would never have been able to deliver
the care that I can give at the birth centre when I worked in
the consultant unit.
(Professor Regan) It is extraordinarily difficult
to retain good experienced midwives who find themselves regularly
in a situation where they are caring for three women and feel
that the situation is unsafe. They are going to leave the service
and then you have lost this extraordinary resource. However many
people you put back into that one job you may never replace the
experience.
47. Since you have had the midwifery-led care
unit, has that actually made St Mary's a bit more attractive to
midwives?
(Ms Pacanowski) We have been fortunate in that our
vacancy rate has been quite low, which I think is due to a lot
of other initiatives. I think being able to practise in those
different ways is attractive to midwives and Lesley was saying
about how stressful it can be, you can only take so much and in
the end you think, "I am not practising what I am supposed
to be doing".
(Ms Daly) The model of care here that is being demonstrated
here attracts midwives and helps to retain them and increases
morale. From a business point of view I am screaming out here:
"Why aren't we looking at it?" I have been saying that
for the past three or four years as a supporter of the birth centre.
As a support group we do not support women; the women are supporting
the birth centre because we think it is so important.
Andy Burnham
48. From a constituency point of view I have
picked up that it is a very difficult challenge getting a midwifery
training place in the north west. There is a great shortage and
great competition to get a training place.
(Ms Pacanowski) We were having a conversation before
we came in about that. The staffing situation is very different
around the country. We recruit people from the north, from the
midlands, because they train and then there are actually no jobs
for them to go to. It is certainly an issue for London.
49. A constituent of mine had applied something
like six times and was about to give up just because they could
not get a training place. Desperately keen to get into the profession—change
profession from something else—and has finally just got
on.
(Ms Pacanowski) Whereabouts was that?
50. Manchester. Living in the north west, applying
to train in Manchester.
(Ms Pacanowski) I think they are training to replace
and they do not have big vacancies. Certainly we have recruited
midwives who have undergone their training and then cannot get
a job because there are not any vacancies.
51. So the problems differ markedly across the
country. Some places it is the lack of training places, other
places the jobs cannot be filled.
(Professor Regan) In central London it is retention.
It is very difficult to live on a midwife's salary in central
London.
52. There is no chronic shortage of training
places in London.
(Ms Rogers) There is an issue round the number of
midwives who are training , the number of midwives who are getting
on courses and then leaving, as well as retraining them when they
are qualified. I have been in midwifery education for 10 years
and student midwives are leaving because they are frustrated with
what the profession has to offer. They come into the profession
and aspire to give the model of care that we have talked about
but the reality is that it is very difficult because they work
on labour wards where midwives are looking after two or three
women, where they are not getting to know the women like they
hoped they would or provide the support they want. I think in
London—certainly at the university where I was attached
to—we were having difficulties at times in getting enough
recruits to the programme in addition to students leaving, having
worked for a while and being frustrated by what they saw. Then
they are coming to placements like the community or the birth
centres or the midwifery led units we have talked about, they
are inspired and it has given them hope for the future . They
might have left had they not had that opportunity to see that
midwifery does not have to be like it is in some of the large
units.
Dr Taylor
53. In your unit at St Mary's at what level
is the decision to perform a Caesarean section carried out? And
at what level should it be carried out? Is it consultant level?
SpR level?
(Professor Regan) No Caesarean section is performed
without the agreement of the consultant on call.
54. Does that go throughout the country, do
you think?
(Professor Regan) I think you need to ask you advisers
that. I do not know. I do not have a snapshot of every unit.
55. Is that what you think should happen? Should
it be a consultant decision?
(Professor Regan) I think it should be yes. I think
induction of labour should be a consultant decision as well.
Chairman
56. Who makes the decision on induction?
(Professor Regan) Frequently our midwifery staff will
assess the patient and then we will discuss it. But since the
responsibility of the failed induction/Caesarean section becomes
mine we obviously have a good understanding that—
Dr Taylor
57. Obviously it is a team working together,
but the responsibility is the consultant's.
(Professor Regan) Yes.
(Ms Rogers) I think nowadays with the expertise of
registrars being very different because of training, it is very
important that decisions with respect to Caesarean section are
made in direct consultation with the consultant rather than being
just seen by somebody who talks to the consultant on call in terms
of confirming the decision or not. I think that for the future
maybe we need to be strengthening that process so that consultants
are directly involved . I think there should be direct consultation
with the woman—given that having a Caesarean section is
such an important decision—with the expert, who is the consultant
obstetrician, before they make that decision.
Chairman
58. We have covered quite a lot of issues on
staffing. Could you just pull out for us what the major issues
are for you on staffing. We are perhaps particularly interested
with St Mary's. You have the midwifery-led area. Would you say
that genuinely was midwifery-led care there? I would be interested
in your views on that and what are the major challenges. Professor
Regan, you were saying that although you have had a relatively
low vacancy rate of midwives you have had the experience of one
midwife having to run through three rooms which obviously does
not sound good. Is there an issue that there are just not enough
in the structure?
(Ms Pacanowski) It is the establishment. The number
of midwives that we are allowed to employ, when we had this Birth
Rate Plus workforce planning tool—which was Department of
Health funded and supported—the outcome from that showed
a shortage of 40 midwives in our establishment.
59. Will you be saving some money if you are
reducing your Caesarean rate?
(Ms Pacanowski) We would do, yes. If I could go back
to the case load teams, I looked at the statistics for the last
eight months for the Caesarean section rate for the maternity
unit as a whole, which was 27%. I looked at their outcomes and
their Caesarean section rate was 15%. The remarkable thing is
that they are not looking after women who are low-risk, who would
go to the birth centre. They are actually based in an area of
the highest social deprivation around Paddington; that is seriously
deprived. They have all the usual challenges in terms of perinatal
outcomes, and yet because they were able to provide this continuity
of carer and were with the women all the way through their labour,
I am sure that had a direct impact on the outcome of those women's
births.
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