Examination of Witnesses (Questions 620-639)
TUESDAY 1 APRIL 2003
MRS DONNA
OCKENDEN, MR
CHRISTOPHER GUYER,
MS SUE
CREEGAN, MS
PEGGY HAND,
MS MARGARET
WHEATCROFT AND
MRS MANDY
GRANT
620. And for you that feels comfortable?
(Mrs Ockenden) No, that is too small. We are currently
working in partnership with the Department of Health to look at
the messages women receive about choices in pregnancy, particularly
around birth in peripheral units. The Department of Health fortunately
has funded a two-year study for us to look at increasing the use
of our peripheral units.
621. So where are you sure you are comfortable
with?
(Mrs Ockenden) We have one peripheral unit, a midwifery
led unit on the ground floor of our maternity unit, with 120 births
a year. There is no obstetric involvement at all. Probably around
250-300 is where we would aim for those units in the community,
and so there is room for improvement.
622. Would you share that view?
(Ms Wheatcroft) Yes. We feel that we could improve
the number of deliveries. Our lowest number was just above 600
but we have been up to 900 so there is quite a variance, but we
think it probably reaches a plateau at around about 750-800 which
we feel is quite a good number. It gives plenty of experience.
623. Would you share the concern about the level
of 85, particularly because when somebody is having a home birth
there is only one happening in that place?
(Ms Wheatcroft) Yes.
624. But you would still say that in a hospital
you need to have more than 85, in any sort of community unit?
(Ms Wheatcroft) Yes, I think so.
625. Moving on to training, are training needs
adequately met? Do you need more national direction on what training
there should be? Is multi disciplinary training done? Are users
involved?
(Mrs Ockenden) In Portsmouth we have two education
providers for student midwifery training and, from the time I
took over, we work in really good partnership with our universities
in that the lecturers are involved in providing post-qualification
training for midwives; as members of staff we are regularly involved
in training opportunities for students. There is a really good
partnership working. Also, we have a good multi disciplinary training
set-up with midwives, obstetricians and student midwives working
together on skills and emergency drills for labour ward care,
so I would say we have made pretty good progress.
(Mr Guyer) From an obstetric perspective the programme
that we have via the RCOG is very good for training both in obstetrics
and gynaecology. I would support the College's view that there
is very little in the way of community-based obstetric training
both at undergraduate and post-graduate level and that is something
that needs to be looked at, particularly if we are trying to promote
this idea of normality and allowing our trainees to get some perspective
as to what normality is, which they do not currently have. The
one issue I do have with training, which is a concern, really,
is that with the new PMETB there is potential for obstetric training—in
fact training across the board of medical specialties—to
be reduced in years and, given that we are currently having junior
doctors working less hours, if they have reduced training years-wise
as well, I wonder about the amount of training they can get before
reaching consultant status and what sort of quality they will
be.
(Ms Wheatcroft) We have very close links with our
local university, Bournemouth University. We have a lecturer practitioner
and there is a set rolling programme of both in-house training
for midwives and for the junior medical staff. Equally through
appraisal systems there is the opportunity for other external
training, so it is crucially important particularly in a unit
like ours to ensure that midwives keep their skills up to date,
and we have certainly not found that a problem.
(Ms Grant) Particularly in my specialty which is breast
feeding, in the three groups where we train, our peer supporters
have 12 hours' training in breast feeding and I would like to
see the midwives doing their breast feeding training together
because that is really important. With all the pressures we have
on resources in the NHS the women who are the peer supporters
can take on such a big burden, and have the time to do it. Sometimes
a midwife has not got two hours to sit with a mum while she does
her breast feed but a peer supporter would, so that would be a
way forward.
626. How much presence in the unit do you have
of these peer supporters?
(Ms Grant) At the moment none but we are evolving,
and we would like to start having some mechanism whereby our peer
supporters would go into the maternity units. At the moment we
do home visits, mums come to our drop-in groups and we give support
in the community, but we would like to take it further.
(Ms Hand) On training, we also include the health
care workers and invite medical staff to attend as well, especially
in skills and drills, because even working in a low risk unit
it is very important that all the staff are up to date with skills
so we can deal with an emergency.
627. Do you think there is a bigger role for
health care assistants?
(Ms Hand) Yes.
628. Is enough being done on that nationally
to pursue that, or is it a local issue?
(Ms Hand) It is done nationally to pursue that.
(Ms Wheatcroft) Certainly we are developing in line
with the NVQ 203 programmes, but just as other professional groups
are expanding their boundaries, be they qualified or unqualified,
we are doing the same with the support workers and that is also
being reflected within maternity services. There is still enormous
scope to be able to develop that and certainly, when one looks
at examples in Holland and other places where they have this support,
it works very effectively and there is a lot of scope.
629. Would you share that, Portsmouth?
(Mrs Ockenden) Yes. We have an excellent peer support
network in breast feeding. We are about to start these supporters
coming into the maternity unit. Historically they have just been
involved in community care. We are looking at the roles of health
care support workers in Portsmouth, and have recently secured
funding for them to be paid a B grade. We are also mindful, however,
of the very special roles midwives play, and one of the roles
we are not planning to go down is replacing midwives and health
care support workers in our peripheral unit. We are very adamant
that midwifery led care does mean midwifery led care, and the
midwives will have a constant presence in our periphery units.
Sandra Gidley
630. On the question of peer support, which
I think is excellent, is there ever a problem concerning lack
of consistency of message between what the midwives are doing
and what the peer supporters are doing? I know from personal experience
that you sometimes do get mixed messages, and obviously training
together would facilitate that.
(Ms Grant) Yes, because everybody would then be singing
from the same hymn sheet, and women would love it.
631. Is there a problem?
(Ms Grant) As far as Bournemouth is concerned they
are very good on breast feeding so there is not, but with other
maternity units in the area there sometimes is because midwives
are not so well informed about breast feeding.
(Mrs Ockenden) We do not have a problem. Our peer
supporters work in close partnership with our infant feeding advisers
and with midwives, and we have not encountered a problem today.
They are a really important part of our team.
Dr Taylor
632. Are GPs involved in the peripheral units
you have? Are they interested? Are they helpful, or do they want
to leave the midwives to get on with it?
(Mr Guyer) There is very much a mixed bag in Portsmouth.
By and large the GPs are not involved in the peripheral units.
There are a small number who are keen to be involved but have
worries about being involved, mainly surrounding medico legal
issues, and that has on occasion led to some conflict between
midwifery staff and the general practice staff. Certainly it is
one of the areas that we will need to target if we are going to
increase the number of births that we have in peripheral units,
to try and get the GPs more on-side with that particular way of
managing maternity health care.
(Ms Wheatcroft) Like Portsmouth, we are a mixed bag
in that some GPs are very keen and some are less keen. It is important
if they are going to be involved that they have up-to-date skills
and do not just dip in and out as they feel appropriate. It is
something that we have had discussions with our local PCT about
when discussing maternity services generally in the locality,
and there are some GPs who will practise, when there will be suppositions
made.
633. Looking to our two user representatives,
what were your experiences with your GPs when you were expecting?
(Ms Creegan) On one occasion I was confused as to
why I was asked to sign a form because I did not want care from
my GP but from my midwife, but he said I needed to sign the form
so he would get paid for my ante natal care.
(Ms Grant) Because I have so much contact with women
using the service I will tend to give you a broad view of what
their impressions of the service are rather than my own, and I
would say that most women tell me that their GPs can often be
quite off-putting about going to the low risk unit, so I agree
that first contact needs to be with the midwife who can give them
an informed choice about where they would like to go. Some GPs
are a bit frightened; they think women should go where the technology
is in case something goes wrong.
Chairman
634. Is there nationally anything that needs
to be done particularly on medico legal worries? We have heard
from other units about how they would end up recommending transferring
GPs while somebody is pregnant and giving birth so they can go
to a GP who is more friendly.
(Mr Guyer) From a national perspective there needs
to be some sort of national guidance for GPs and for community
midwives on who is appropriate to be managed at a peripheral centre
and who should be referred to the central unit where there is
obstetric, anaesthetic and paediatric support. On education, we
have a group of GPs at the moment who have gone through a system
whereby all they have seen from an obstetric perspective is the
abnormal, and it must be very difficult for them to perceive what
normality is like and, as a consequence, being able to support
women delivering in areas where there is not obstetric, anaesthetic
and paediatric support. So we come back again to offering some
insight probably at undergraduate level into community-based maternity
care so they have a perception as to what that is.
Dr Taylor
635. Do students not go to peripheral units
to be taught by midwives on normal births?
(Mr Guyer) Not at the moment, no.
Dr Taylor: We used to, but that is a long time
ago!
Chairman
636. On home births, you have a few at Portsmouth-150.
Is that something else you are trying to increase as a further
choice for women, and do you have the same issue of problems with
GPs?
(Mrs Ockenden) Twenty three per cent of our births
happen outside the main maternity unit and it may well be that,
because we have peripheral units, women choose those rather than
home but it is something we are looking at. One of the issues
we have is that women in Portsmouth do receive mixed messages
about places of birth. GPs are one of the issues we have touched
upon but we are hopeful that the Department of Health funded study
is going to help us take forward our desire to increase the choice
of women on the place of birth.
637. Do you support home births?
(Ms Wheatcroft) Yes. Quite a lot of our midwives are
particularly interested in home births, but it is very much the
GP who gives the first impression.
638. Is it the same midwives that work in your
unit who also support home births?
(Ms Wheatcroft) Yes.
639. Is there a bit of tension I am picking
up here, because you want to keep the numbers up in your unit
yet you want to support giving women the choice?
(Ms Wheatcroft) They are included in our numbers because
they are our midwives that deliver them, so it does not create
a tension.
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