Examination of Witnesses (Questions 320-339)
TUESDAY 11 MARCH 2003
MR DAVID
REDFORD, MS
CATHERINE SMITH,
MS SUSAN
BRESLIN, MS
JULIE BALL,
MR JOHN
WATTS, MRS
TONI MARTIN
AND MRS
DAVIDICA MORRIS
Sandra Gidley
320. Did they make any different decisions when
they were given the responsibility from scratch, as it were?
(Ms Breslin) No, most of the women who want to make
the decisions, who want to be involved in the decision making
tend to prefer the lower risk side of things and the fact that
it is such a big county you are talking miles of travelling as
well. If they are going to be booked in Shrewsbury and live in
Ludlow they have been on the road an hour and a half before they
get to us. There is a big appeal in being delivered on your doorstep
because your family is there and you probably know the midwife
anyway because they are of that community. It is a very, very
pleasant way to have a baby and a lot of them do choose that when
you give them that option. Of course, they can have a home birth
if they wish or they can be delivered on the consultant unit,
if that is their wish. We have a lot of people who deliver on
the consultant unit but then transfer back to the low risk unit
for the post-natal care. Lots of women choose to do that.
Andy Burnham
321. Have either of you had discussion with
PCTs about how care should be delivered? You seem to have a good
record in delivering care closer to people's homes but the previous
group were talking about the difficulties in making changes and
breaking the cycle. Is that something that you have worked on?
(Mrs Martin) With one of the PCTs—Wyre Forest—we
are in greater discussion but they are a far more established
PCT. The ones in Worcester are very new and it is quite hard to
engage them in something that is not a waiting list initiative
or a money-based issue. In time I think they will become far more
involved and be much greater drivers.
322. From your point of view you are doing that
quite well ahead of the game.
(Ms Breslin) I think we have got a particularly good
set-up in Shropshire and we have worked hard to get it so. It
did not drop down from heaven. This started in 1974 and we have
been working to perfect what we have had since 1974.
323. Because of the geography?
(Ms Breslin) Because of the geography and what we
inherited and how we worked to change it and keep it so and Mr
Redford is absolutely right, we have recruited people who are
like minded. If you want to keep something going and you believe
in it you do not want to employ people who do not believe in what
you believe in. You tend to recruit like-minded people. When I
interview midwives who have not trained in Shropshire, although
most of mine have trained in Shropshire, some of them have never
seen a baby born in breech, they have never been with twins who
have delivered vaginally. I am employing them as midwives to work
on my unit; what am I to do with them? They almost need retraining
to be able to work in Shropshire. They have never seen a breech
and they cannot believe that women are delivering vaginally, and
their first thought is, "It must be a caesarian. Why are
we doing this?" We have to show them how we look after women
in labour and show them how it can be a perfectly straightforward
delivery and I think the consultants have a similar problem with
the middle grade who come to us who trained elsewhere whose first
recourse at the first blip is caesarian, get the baby out.
324. Is it not like Mr Watts was saying earlier,
that there has been this trend towards a litigation culture and
a pressure to take the safe option quicker?
(Ms Breslin) I am not even sure it is litigation,
it is just an unwillingness to persevere with a difficult labour.
325. Why is it an unfortunate system when it
costs the system so much more to do that?
(Ms Breslin) I do not know. If you are the person
who is on duty and you have got a girl whose labour is going to
last another eight hours and you do a caesarian now and you will
be home for your tea—
326. Do people really do that, make the decisions
on that basis?
(Mr Watts) I disagree with that, I am sure that does
not happen. To go back to a couple of points as regards training
issues and continuity of care and the Working Time Directive,
I think the previous group mentioned, and I am sure David will
agree with me, as regards the training of our juniors at the moment,
the number of hours that they work and the number of years that
they do now before they become qualified to become consultants
are reduced, so they do not see as much as we used to do in the
days when I was training and we get several of our juniors coming
to us who have never ever seen a normal vaginal breech delivery,
and the likelihood is they probably will not.
327. And the effect of that is because they
have not experienced that they are then more likely to opt for
a caesarian?
(Mrs Martin) They will opt for a caesarian section.
328. So it compounds the problem?
(Mrs Martin) It compounds the problem.
John Austin
329. Can I come on to the training issue as
well about common training and different perceptions from different
professions. How important is training and breaking down these
barriers between the different professions?
(Mr Watts) Between midwifery—
330.—And obstetricians. Is it being done?
Is it being done effectively?
(Mr Watts) There is no reason why some of the training
which the midwives get and some of the training doctors get should
specially be normal births.
331. Are they getting it?
(Mr Watts) No.
332. They should get it?
(Mr Watts) They should get it, yes.
333. For the majority of trainees the only time
they saw a normal delivery was when they were an under-graduate
and at that time they perhaps only saw a handful, let alone actually
performed a vaginal delivery.
(Mrs Martin) It is completely different training.
There is no point in a budding obstetrician looking after one
woman in labour and delivering one woman. That is not going to
influence his practice in any way other than he has seen it. I
would think that we do not have joint training other than CNST
requirements, the skill drills, and that is very good because
it is team working. If you are going to look at training midwives
and potential obstetricians together you need to completely re-look
at why you are training and who you are training because they
are very different skills, completely different skills at the
end, and a lot of it should be about respect for each other's
professions as well and each other's skills.
334. That is like informed consent. Is there
some role that training has to play in helping professionals to
enable women to make an informed choice?
(Mrs Martin) I think it is, first of all, the belief
of the person who is being trained that there is such a thing
as informed consent and the patient/the woman can make a decision
for herself. Unbiased information is rarely truly given. You increase
the time you spend with the woman significantly if you give true,
unbiased, wide-choice information.
335. Do you think the training that is available
for midwives enables them to do that better than the training
that is available to obstetricians?
(Mrs Martin) It is difficult because I have not been
trained as an obstetrician but I would imagine so because a midwife
spends three years—
336. That was not intended as an attack on the
medical profession.
(Mr Watts) I did not take it as such.
(Mrs Martin) It takes three years to train to become
a midwife. To become an obstretrician it is a different process,
a series of different roles ending up as an obstetrician rather
than very specific training.
Dr Taylor
337. Chairman, several of our witnesses last
week said that multi-disciplinary training was taking place. Was
that at the lower level? Were they talking about at student level?
(Mrs Martin) Perhaps Sue you might feel the same,
it is at the local unit level—the skill drills and team
working with trained people. You are probably talking about that
level rather than student midwives and medical students, We do
not have joint training for those but we have joint training for
medical colleagues and midwifery colleagues at local level.
(Mr Watts) At local level on the labour ward.
Andy Burnham
338. Can I ask both groups the question we asked
the others, which is do you have a shortage of training places
for midwives locally? Is that something that has cropped up?
(Mrs Martin) We have a shortage. I do not know if
you do, Sue.
(Ms Smith) One of the problems is the establishment
of midwives that we have in Shropshire. That is linked to the
number of midwifery places from the local university, so we feel
it would be wrong of us to ask for training places for midwives
if we know that we cannot employ them. We feel, particularly now
when they enter training as a midwife not a nurse then a midwife,
that if there is not a job within the county they have got to
move county once they have trained as a midwife, so the moral
obligation is not to ask for too many places that we know we are
not going to be able to recruit from. That is our biggest problem
in Shropshire—the low establishment of midwives. We have
not traditionally had a recruitment problem, we hit a blip 12
months ago which was the first time we had come across it. Up
to that time we had a waiting list for those who wanted to be
midwives.
339. Do you have a high a roll-out rate as Nottingham
told us about with people coming through who do not like the harshness
of job when they first come on to the ward? Do you notice a lot
of drop-outs?
(Ms Smith) No, we did worry about this problem when
we had direct entry into training if they had not been in the
NHS at all, whereas when nurses came to train as midwives knew
what the culture was like. The majority of training was worked
around trimesters and they did not have to work weekends and nights
and they then qualify and it is a huge shock so, yes, we have
an issue with that and with some of the training.
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