Examination of Witnesses (Questions 60-79)
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
60. Do you feel, particularly in the midwifery
led end of the unit, that your midwives are really skilled in
supporting normal births?
(Ms Pacanowski) The midwives work all round the unit.
They work in clinics; they work on the postnatal ward and they
work in the labour ward as well, which I think is very good for
them. They get experience of everything all the time. When this
workforce planning tool showed that we had such a shortage, our
strategy is to create more of these case load teams which are
community based, have a case load of women which are already showing
very good outcomes, reduce Caesarean section rate which will actually
save us a lot of money. They also have far fewer epidurals.
Chairman
61. From a user perspective, would you say it
was genuinely midwifery-led care?
(Ms Eccles) I think it is probably half way between
the two. In some hospitals—like the new Charlotte's unit—they
have actually got the midwifery led unit on a different floor
to the obstetric bit. I think that more physical sort of barrier
probably makes it more of a self-contained unit. I think what
St Mary's has done is within the huge constraints of the area
that they have to have the labour ward in, they have done a really
good job in trying to have a low-risk end and a high-risk end.
62. What do users want?
(Ms Eccles) I think users want the choice. I think
that the Charlotte's set up is more attractive to users than the
St Mary's set up.
(Ms Daly) If you think about it, I can understand—again
from a business point of view—a hospital is on a very macro
level. You have a lot of resources to manage and it is managed
as a business. Then out at the end pops a woman and a baby, which
is wonderful. But if you turn that on its head and start from
what the woman and the baby wants, from what women have told me
they want, when you logically work back you would never get to
a huge unit. Even in St Mary's which is a huge unit, even there
they are saying: "We want some other different unit which
is away from the white coats where midwives can get back to doing
what midwives have been trained to do." That kind of a model
gives women a lot more safety and security and a far better birth
experience.
(Ms Larkin) I worked two years as a manager for the
community midwives and they all work in teams and they got such
great job satisfaction. Some midwives have worked there for 20
years. They would not change because they get so much job satisfaction.
They are not just looking at one set of clients, they are looking
at the whole range of clients. In the delivery suite they are
doing both and they are getting such good job satisfaction that
they just do not leave.
(Ms Rogers) Because we are here representing the birth
centre and as you know the birth centre is some distance from
the main unit, I would be concerned if the way forward was just,
in terms of the future provision of maternity integrated birth
units in large hospitals.[4]
Most of the women at our birth centre are local women and are
delivered there. You have to provide a range of models for women.
(Professor Regan) I think it is important
that your Committee also takes on board that we are talking on
staffing structures there has been an enormous change in the staffing
structure from the obstetric side. For example, the European Union
Working Time Directives—the need for much reduced hours,
the limited number of trainees, et cetera—has had a big
effect on the way the staffing structure runs in the maternity
unit. It has also had a big effect on the amount of supportive
care which the midwives can provide.
63. I did want to pick that up about what cover
you have. Do you have the 40-hour consultant cover on delivery
suites and 24 anaesthetic cover?
(Professor Regan) We have 40 hours of consultant cover
on our labour ward?
64. Does it feel right?
(Professor Regan) Yes, in the sense that I am sure
it is better for patient care and it is better for staff training,
but it has come at a cost to other facets of a busy department
of obstetrics and gynaecology. In order to meet that demand or
necessity other things have had to be put down the priorities
list. The demands on consultant time and on SpR on issues such
as clinical governance and audit, appraisal, et cetera, they all
have to be fitted in in addition to the clinical work.
Andy Burnham
65. We talked a moment ago about training places.
I want to talk to Professor Regan, Ms Pacanowski and Ms Larkin
about the kind of courses available for staff to up skill once
they are in post and what kind of training you offer. I have in
mind things like neo-natal resuscitation courses or management
of obstetric emergency. Those kind of things. Is there a continuous
programme that you take?
(Professor Regan) There is a rolling programme for
both SHOs who are taught separately to the SpRs and in some of
the training programmes like neo-natal resuscitation and interpretation
of CTG electronic fetal monitoring we have explored a joint model
of training and upgrading with the midwives which we found very
productive.
66. Midwives and consultants together, you mean?
(Professor Regan) SpRs and midwives together, being
led by a senior midwife and a consultant. There is some in-course
training which is a rolling programme which are delivered individually
to specialist groups and some of which we get every team member
in the unit together and they undergo the training programmes
or the updates together.
67. Is that a change? Was there more demarcation
or has it always been that way?
(Professor Regan) That is just our unit which, I think,
has a good reputation for working together as opposed to: "This
is a midwife's case" or "This is a doctor's case".
(Ms Pacanowski) I think in terms of training as well,
that is one of the reasons we have been quite successful in recruiting
and retaining staff because we have a generous sort of approach
to people who want to do different types of study.
68. Is it that at a certain stage of their career
they can do a certain course, or can they do a course if they
have a particularly interest?
(Ms Pacanowski) If they are interested, yes. We have
midwives who trained in Shiatsu for instance, as well as midwives
who are doing coping with obstetric emergencies. There is a big
range of professional development for them.
(Ms Rogers) Midwives have a named supervisor and that
supervisor meets with the midwives on at least a yearly basis
but much more frequently than that in most cases, and part of
that meeting is about identifying learning needs and practice
development requirements. As a result of that meeting recommendations
would be made in terms of training and provision and access to
courses. In terms of training at the birth centre we have the
same philosophy as our colleagues that it is inter-disciplinary
multi professional education and the midwives at the birth centre
attend educational programmes with their colleagues both obstetricians
and midwifery colleagues on the host site, which is Barnet. Again,
multi-disciplinary education is important not just because of
the cost effectiveness, but it is also about developing the necessary
collaboration and trust and respect for each other's contribution
to maternity services. It is an excellent forum for that.
69. Is the trend towards giving midwives more
responsibility, doing things now that they perhaps did not do
in the past? Is that the way it is developing?
(Ms Rogers) Yes.
(Ms Barber) One example of that is the N96 course
which is the examination of the new born which, until relatively
recently, was undertaken by a paediatrician. Obviously at the
birth centre we do not have paediatricians.
70. It still is in some places, is it not?
(Ms Barber) In the majority of places, yes. But this
course is now available to midwives so that they are actually
able to undertake the examination of the new born.
(Ms Rogers) You mentioned about SpRs and reduction
in doctors' hours and more pressure on the consultants. The backlog
effect is that there is more pressure on the midwives. First we
have a shortage of midwives and in order to provide services to
women and their babies midwives are taking on new responsibilities
and although that is something we would wholeheartedly embrace
as a profession we have to be aware of the extra pressure it places
om midwives.
71. Is the hearing test one of those?
(Ms Rogers) The hearing test in our unit is done by
specialist people, not by midwives.
72. Is there more way to travel along that road
then, that midwives can carry on taking more and more responsibility?
Where is the boundary?
(Ms Pacanowski) I think you can come to a point when
they are overloaded.
Chairman
73. Are we getting near that point?
(Ms Rogers) I was very fortunate to be part of the
national study looking at midwives extending their practice to
include the newborn examination and as part of that study we conducted
interviews with midwives. We found they were very positive about
extending in what they perceive are the core values of midwifery,
such as the new born examination . This was seen as a natural
extension of midwifery responsibilities. Midwives had more concerns
about extending into areas which they considered were outside
the parameters of what they considered normal midwifery practice.
(Professor Regan) I would like to make a point about
retaining experience staff, and I think nationally we are rather
poor at utilising our midwifery workforce after they have gone
off to have their own children. Coming back to work, particularly
in an inner city, can be almost cost-negative not even cost-neutral.
The current head midwife at St Mary's has adopted the policy:
"Okay, what would you like to do?" and, as a result,
a couple of our very experienced midwives have come back to work
for one or two long days and nothing else. This would not have
been possible if the answer had been: "You can't do that".
Her answer was: "Yes, do whatever you would like to do."
Flexibility in employment, especially when they have small children,
is really important otherwise you lose that resource completely
and you lose their capacity to teach as well.
Dr Taylor
74. Professor Regan, you mentioned the European
Working Time Directive. How does that actually impact on your
unit with loss of junior doctor time? Can you keep the unit safe?
(Professor Regan) I am sure it is good for those junior
doctors in terms of their quality of life. It has had a massive,
devastating impact on the sort of standards of care we have been
able to provide and how we have been able to maintain minimum
standards. For example, because we do not have enough SpR training
numbers it is not a question of being able to go out there and
recruit more people even if we had limitless resources. Those
people are not out there. As a result of reorganisation they just
do not exist at this moment in time. In our particular unit, we
have had to beg, borrow and steal from our chief executive to
get a pot of money and then advertise for what we call "clinical
fellows". We were advertising for individuals who would come
and be part of a team structure. The quid pro quo was that they
would help us with the hours issue in covering the labour ward
safely and also the emergency gynaecology theatre at the same
time since they are dual trained, and what we would give them
would be a specialist skill, for example a year or 18 months doing
specialist fetal maternal scanning or working in the reproductive
medicine unit, doing a research project, supervising an MD thesis
which might help them in the future. It has been very difficult
to appoint to those posts because there are not the people out
there. There is a timing problem here. There is going to be an
interval until it is possible to redress that even with limitless
resource.
75. How does it actually impact on the training
the SpRs receive?
(Professor Regan) They, I think, feel disenfranchised
and often very isolated because the hours that they have to work
mean it is not longer possible for them to be in the old team
structure. For example, the SpR I did a ward round with on Monday
morning will be different from the person who goes to theatre
with me in the afternoon and will be different from the person
who does the post-operative ward round the next day. That may
be frustrating for me, it is not very good for the patient, but
if we are talking about the trainees—which was your question—it
cannot be the happiest way to be trained. I used to know the trainees
that were with me very, very well and now I sometimes find it
quite difficult to remember who I am trying to bleep.
76. It is a huge disaster across the whole field
of medicine, is it not?
(Professor Regan) Yes, and you will recall that historically
what happened was that obstetrics and gynaecology, surgery and
anaesthetics were picked off first. I think we are at the front
of that vanguard and now general medicine is experiencing similar
sorts of problems. There just are not enough people in the system.
Chairman
77. We have not talked at all about breastfeeding
rates. We know that breastfeeding rates are very different across
the country. Do your staff have any training and do you know anything
about your own breastfeeding rates?
(Ms Larkin) Some months we have 100% of mothers who
deliver at the birth centre. I do the figures every month and
I know it is usually 96 to 100%. That is going home breast feeding,
but one of our midwives follows that up and they are usually feeding
for at least three to four months.
78. At St Mary's?
(Ms Pacanowski) We have quite a good breastfeeding
rate, about 70%. This goes right back to collection data at the
beginning. I was trying to collect data that was comparable with
10 days or two weeks post-delivery and it is just not available,
so it is very difficult to compare units.
79. What would you need to do to get closer
to a hundred?
(Professor Regan) Massive infusion of midwives onto
the postnatal ward. The postnatal ward is always the poor relation.
Whenever there is a shortage of staff that is where they are lost.
(Ms Rogers) I work across the Trust and one of the
issues that has come up in one of the other hospital units is
this very issue. Eighty per cent of the women come to the unit
wanting to breastfeed and in one group we looked at it was less
than half who were actually breastfeeding One of the reasons for
this was because of the lack of support that was available.
(Ms Daly) In the birth centre if you do have problems
you know you can go back and call a midwife up, whatever midwife,
it does not have to be the same midwife, and you know you will
get support. You cannot always do it yourself; you do not know
how to do it. The first time I had to breastfeed I just got some
quick techniques and the next day it worked.
4 Note by witness: This is for two reasons.
Firstly, there is no evidence that this is the most cost effective
or safety approach. Secondly, it would reduce choice for local
women given the centralisation of most maternity units that is
now happening. Back
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