Examination of Witnesses (Questions 120-139)
THURSDAY 6 MARCH 2003
MRS JENNIFER
FAKE, MS
MARIE PEARCE,
MS KATY
WATERS, MR
CHRISTOPH LEES,
MS JANE
HURLEY MRS
JEN FERRY
AND MS
LIVIA MITSON
120. I think we have talked about the decision-making
process in relation to when the decision is made and who makes
it, but it is quite complicated. There is quite a difficult set
of discussions going on and sometimes the patient may see things
quite differently to what the professional story would have been
of that birth. I do not know whether you would agree with that.
(Mrs Fake) I think the one thing we are absolutely
consistent on is giving conflicting advice and I think that is
the trouble. I think you will get a different view point from
whoever you speak to.
(Ms Pearce) I actively encourage women—unless
there is proven reason for Caesarean—to try to try for a
vaginal delivery after Caesarean section because it ruins their
obstetric career as far as I am concerned. More and more people
are having three or four children and to have repeated Caesarean
sections is not a good idea. We will actively encourage them.
I spend a lot of time in my clinics going through what happened
the first time with women and then empowering them to go to the
consultants and getting what they want. I know the doctors are
doing it and they have to do it, they have to give the negative
side, the risks of having a vaginal delivery after a Caesarean
section, but they also do give a balanced view by telling them
of the risks of having another Caesarean section as well. We have
to get away from the elective sections which are putting the rate
up more. People in the press make it sound so easy, you can have
your section at nine o'clock on a Tuesday morning and have your
visitors at three. You have your champagne afterwards and it looks
so nice. Some women see it in the press and think that if they
can do it and get their figures back in three days then why shouldn't
they. I have to say that is not impossible, but it is very difficult.
The popular press is making it worse.
(Ms Mitson) I think we also have an issue that if
someone is pregnant for the first time and they are not aware
of childbirth and children, childbirth can actually be really
quite scary, whereas a Caesarean section is seen as an operation
and it is planned and is under control. You do read about Caesarean
section in the media and you are aware of them whereas you are
not so aware of encouragement for home births and that kind of
thing. You do have some level of pressure from the women themselves
and I think that is partially due to the lack of information.
121. I do not know what the proportion of people
who go to the NHS antenatal classes or people who do NCT, but
are you saying that they are not good enough? They are not telling
people enough about what to expect?
(Ms Mitson) I think in a sense the antenatal classes
are almost too late. I went to antenatal classes when I was about
six months pregnant and by that stage I was already really quite
worried about giving birth. I have friends who are also very worried
about giving birth and it affects their decision as to whether
to get pregnant or not. In a sense the antenatal classes are too
late.
(Mr Lees) I think this is a fascinating choice of
information and I would just like the Committee to perhaps pick
up on a reference from about two years ago. I think it was a British
obstetric journal that surveyed female obstetricians. Most of
them decided that if they were going to have a baby they would
want to have a Caesarean section rather than a vaginal delivery.
I am not saying that in defence of Caesarean sections but these
are people who are extremely knowledgeable.[5]
Chairman
122. It is a bit worrying if they are obstetricians.
(Mr Lees) That is absolutely true, but I think it
underlines two things. Firstly that information does not necessarily
push you towards normal delivery and secondly that this is an
issue about choice as well. If we are going to give choice in
pregnancy care then we have to allow people choice.
Andy Burnham
123. When you are doing your audit, do you look
carefully at how patients are communicated with when the advice
is given? A recommendation or a "We think you should"
are very, very important when the process is under way and people
may not be in a position to counteract a recommendation. I think
that communication is absolutely crucial.
(Mr Lees) We cannot actually audit exactly how the
information is given. We can certainly look at the seniority of
the person giving it which may not give you the same answer.
124. Can you see what I am getting at?
(Mr Lees) I know exactly what you are getting at.
Chairman: We will pick up some of these issues
perhaps when we go on to staffing a bit later, but just on that
paper on obstetricians' attitudes, 70% of women obstetricians
decided they would have a vaginal delivery, but 92% of men, if
they were in a position, would. It is culturally interesting as
well because apparently in Holland 99% of obstetricians would
go for a vaginal delivery, so clearly there are other things that
can influence this, but we need to move on now to data.
Dr Taylor
125. Data and its collection. In our written
evidence we have really had very severe worries expressed about
the quality of the collection system for the data. I would really
like the comments from West Hertfordshire and from Cambridge about
how you collect data at the moment, the quality of your computer
systems, or, if you are still on paper, your records. Can we start
with West Hertfordshire. What are your comments about the way
you collect data?
(Mrs Fake) This is not my forte, I will be honest.
We have just gone from SMIS—the St Mary's system—to
another system called SEEMIS which is much more sophisticated.
However, it is very much in its early stages and data retrieval
is proving a little difficult. It is being audited; we are coming
up with what we are finding are problems. I would just make one
comment that as a unit which is running on a huge vacancy rate,
we are trying desperately to look after women, we are trying to
give one to one care. If, at the end of looking after that women,
you then have to spend a considerable amount of time inputting
that information—of course it is vital information and it
is where we get all our information from—it is very, very
time consuming. I do not know any way round it. We have to have
the information, but I do not know if it should be midwives putting
the information in.
126. Our previous witnesses mentioned the Scottish
system which seemed to be much simpler and yet adequate. Do you
know anything about that?
(Mrs Fake) No, I do not at all. I think the trouble
is that because you want so much information, you want to audit
everything that you do, you have to put the information in and
I think it is probably midwives that have to put it in.
127. So your main worry is not really the equipment
so much as the time to actually record the information.
(Mrs Fake) I think the data retrieval is quite complicated
at times.
128. But the time is not there to do it. How
about at the other end of the table?
(Mrs Ferry) We have a system which we have had in
place since 1998 and is called PROTOS. That is our maternity system
and we also collect information, as other units do, through the
HISS system.
129. PROTOS is one of the three commonly used
ones, we gather.
(Mrs Ferry) Yes. PROTOS as a software package has
not been without its problems. It is moderately difficult when
we have upgrades to do and you are dependent on a system that
does not go down, and when it does go down then you are back into
paper trails. I can only support and echo what West Hertfordshire
were saying about the time it takes for midwives to input to these
systems, but I also have to say that midwives have always had
to make records whatever. I think there is an expectation that
the computer makes things a lot faster. I also think that certainly
we have an improved and enhanced performance with our systems
upgrades, cabling upgrades, computer upgrades and everything else
but people still perceive it as a problem because they still have
to do it. It is something that perhaps we need to quantify. I
do think we have to look very carefully at what we are using midwives'
time for. We share with West Hertfordshire the difficulty of London
and the M4 and M11 corridors and the staffing difficulties. It
is difficult to have a midwife out being a project midwife all
the time to run these computer systems. It is difficult to have
midwives inputting to these systems all the time, but if you do
not have that clinical overview and that clinical responsibility
then your validation becomes very poor.
130. Is there a fear that you are trying to
keep paper records and computer records?
(Mrs Ferry) I think certainly we are doing that at
the moment. Our system is installed in the Delivery Unit which
is a strange place to start a patient journey that starts out
in the community. We currently have a bid in to extend that system
out into the community but it is then very difficult when you
have a bespoke system to build it forward. I think we all have
different systems around the country. We do have PROTOS. A lot
of people have PROTOS. But we have a bespoke system so upgrades
are very difficult for us.
131. Will PROTOS link into your PAS system?
(Mrs Ferry) Yes, it will. We have built a neo-natal
module to go with it and we are in the process of building with
them a fetal module that can link into it. It is expandable. Our
problem is finding the project staff and the funding for them
to be able to run the computer system rather than using midwives
to do that. Midwives, whilst they have the clinical expertise,
do not necessarily have either the project or the IT expertise
and it is poor use of valuable clinician time.
132. Can you interface with GPs?
(Mrs Ferry) At the moment no, but we have a bid in
with the region at the moment to do that. We would like to be
able to do that.
133. Turning to the new unit at Hemel, what
system will that have?
(Ms Pearce) It will have the Ciconia Maternity Information
System (CMIS), I believe.
134. Which is relatively new, as you say.
(Ms Pearce) Yes.
135. Do you about the current national data
set? Do you know what they are? No? A complete blank. We are getting
the same message as before.
(Ms Waters) May I say that in April West Hertfordshire
is beginning an audit on normal births and what the users will
be asking for is a comparison of normal births between the ADC—which
is a midwife led unit within Watford—and normal births within
consultant units.
136. That leads on to rather major issue that
has been hinted at. Is there possibly a danger—and this
is to everybody—that one is getting excellent care in the
midwife led units but because of the stresses on the consultant
units, because of the more complicated problems, the loss of junior
doctors with the European Working Time Directive, that the standard
of care in a way could be more difficult to maintain. We have
had pictures from the first birthing centre of really one to one
care, one midwife looking after the lady for the whole time which
is probably completely impossible in a consultant unit. Is there
any feeling that this is right? Better quality in the birthing
centres and because of the stresses on the consultant unit the
quality is suffering.
(Mrs Ferry) We have had to do things to maintain our
quality. Our staffing numbers are considerably on from where they
should be. We have had to look very carefully at the skill mixes
and we have introduced a new role of maternity care assistant
to back-fill where we do not have midwives. We have had to look
very critically at how long we keep people in hospital. I think
we are fairly committed to the fact that normal healthy women
and babies should not be in hospital anyway. We did actually have
an abnormally long length of stay; we had the space, we had the
staff and we were keeping people in. We have now reversed that
because it is not appropriate and also we could not staff it.
Your question was directly about delivery units. I think we have
to put in contingency plans and strategic measures to ensure that
we keep the risk at a minimum whilst the staffing is so difficult.
The staffing is compounded on two fronts. We have the difficulty
of lack of medical staff coming through into senior posts and
for all the discussion about the lack of midwives our region will
be training across Norfolk, Suffolk and Cambridgeshire 30 extra
nurses and midwives by the next three years. Our staffing at the
moment sits at 105 and Birth Rate Plus which is the acknowledged
workforce planning tool said that we need 168.8.
137. You are training 30?
(Ms Ferry) No, that is the whole of Norfolk, Suffolk
and Cambridgeshire are training 30 extra nurses and midwives.
The training complement for Cambridge at the moment, that is three
units—ourselves, Huntingdon and Peterborough—is 24
midwives per annum. That gives me a training complement of 12
per annum which, as you can see, is less than 10% of my workforce.
I obviously want junior midwives coming in but I also need seniors.
But by the time we have had attrition—as you would get at
any training school—that is not sufficient to hold our numbers
never mind increase them. The difficulty that we are now facing
is that our staffing is so low, although I have now got some tacit
agreement to increase those numbers and we should now be starting
three year direct entry training in September. I am going to have
difficulty supporting and mentoring those midwives as they come
through training.
Dr Naysmith
138. I want to pick up on that information we
have just had from Mrs Ferry. What was the number of midwives
you have?
(Mrs Ferry) My funded establishment is 135.
139. That is what you should have?
(Mrs Ferry) That is what I am funded for. I have 105
in post and Birth Rate Plus—a national workforce planning
tool—has calculated that we need 168.8.
5 Note by witness: I should like to add that
the correct reference for the study of female Obstetricians is,
in fact, European Journal of Obstetrics and Gynaecological Reproductive
Biology 1997; 73; 1-4. I have been guilty of reading the figures
the wrong way round, in that 31% of female Obstetricans would
elect for caesarean section if there were no medical indication.
This leaves 69% that would not and it is incorrect to say that
most would opt for a caesarean section. Back
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