Examination of Witnesses (Questions 660-679)
TUESDAY 1 APRIL 2003
MR RICK
PORTER, MS
HELEN JONES
AND MS
JULIANNA BEARDSMORE
Chairman
660. Those are probably births that took place
at Poulton.
(Mr Porter) It was not a caesarean.
Mr Hinchliffe
661. You probably heard me ask the previous
group of witnesses about the steps you take to audit your sections.
Mr Porter, could you tell the Committee how you go about the audit.
Is it a similar arrangement to what we heard from previous witnesses
where a book is kept?
(Mr Porter) I did not hear them because I was late.
In fact, slightly embarrassingly, our ongoing running audit is
in abeyance at the moment largely because of junior staff issues.
Normally, what we have been doing is having is weekly run-through
of every single section that goes through the unit where we actually
critically analyse the decision-making process and I think it
has been fairly successful but, as you can see from our figures,
we are not among the lowest caesarean section rates in the country,
by any means. All I can say is that for Wessex we are the lowest
or the second lowest and, yes, I would like it to be lower than
it is at the moment and I do not think that 19.5% is the ideal
rate for us, but we are trying.
662. Can you explain in practical terms how
you carry out the audit. You mentioned a problem.
(Mr Porter) We have somebody as a co-ordinator in
the junior staff who co-ordinates all the information, brings
it to our weekly Friday departmental meeting and we sit down and
go through it. However, just over the last two or three months,
it has been hanging. I do not think we have noticed a massive
increase in numbers, but I think it is a very important part not
only of good housekeeping but actually also of training the junior
staff as well.
Chairman
663. Other witnesses seem to put so much of
this down to the individual personalities or thoughts of consultants,
which seems odd when it is such an important thing resulting from
those personalities. Would you share that?
(Mr Porter) I would say that has some input; there
is no question about that. I do not know how much input it has
but I can tell you that, within our own department, we have one
consultant who has a different view to the rest of us and certainly
has a much lower threshold for caesarean sections than the rest
of us. It seems to me that that is within clinical freedom. I
do not agree with the position that he takes but I respect the
fact that he believes deeply that he is correct.
664. How do users feel about the fact that there
are different views and it might depend on who you are with?
(Ms Beardsmore) I think that a lot of users are not
aware of that and, further away from Bath, quite a lot of the
care is that one consultant will visit each unit, so you do not
get a lot of knowledge about what different consultants have as
their thresholds. You do sometimes get somebody who, if they have
a query, may ask to see another consultant but it is unusual.
Dr Naysmith
665. You say that you have these regular departmental
meetings which are suspended at the moment for a couple of months.
Who participates in these meetings?
(Mr Porter) No, the meetings are not suspended.
666. This discussion and consideration of sections
are suspended. Who participates in these? Is it just medical staff
or are midwives included?
(Mr Porter) They are open to midwives.
667. Do they participate?
(Mr Porter) Yes and no, very few I have to say. One
o'clock on a Friday is not a good time for busy midwives to attend
as Helen would attest to.
(Ms Jones) I would agree that we have not been marvellous
in attending them.
668. Do you think it would be worthwhile to
attend?
(Ms Jones) Most definitely, but that used to be our
handover time and it was completely an organisational problem,
not lack of interest, as we used to have a shift handover. We
are now on 12 hour shifts and there is a slight overlap at that
period and I think that, in the future, there will be definitely
a lot more midwives able to come. It was a pure staffing problem.
669. Are you saying that it is just not happening
because you are short staffed, medical and midwives? If it is
something important, all you have to do is make the organisational
arrangements.
(Ms Jones) Yes and we have put measures in place and
we have also made it part of the supervisory annual review and
it is documented now that they must at least attend once or twice.
We have actually focused on it quite considerably, but we have
had shift changes and we have had shortages, but I think we have
it in hand.
Chairman
670. I want to go back to the point that we
have users not knowing that different clinicians might think different
things and the idea that some of this is because consultants have
different thresholds. Is it all right for consultants to have
different thresholds? Should this not be all evidence-based and
is there not a evidence-base which says that this is where the
threshold should be and there should be an agreement between consultants,
midwives and users about where that threshold is?
(Mr Porter) No, I do not think there is agreement
and I think that is part of the issue. Just in the same way that
most of us are gynaecologists as well as obstetricians and we
are well aware of the fact that different people will have different
thresholds or, for example, doing vaginal repairs and so on and
so forth. Really, we are very familiar with the idea that different
people will have different views. To be specific, for example,
some people might have a very strong view about IVF pregnancies
and feel that, at the slightest deviation from the norm, an IVF
pregnancy should have a caesarean section. It is a point of view.
It is not one that I share but I know that some people do feel
that very strongly. It is difficult to see how you can legislate
that one out.
Sandra Gidley
671. Is there not a woman's choice issue here?
Some women who become well informed will take the time to find
out what attitudes are and may wish to choose a consultant because
they have a low risk of caesareans or even a high incidence of
cesareans if someone is thinking that way. Not every woman—I
am not saying I agree with this—necessarily wants a natural
birth.
(Mr Porter) Absolutely.
(Ms Beardsmore) I think that women are very vulnerable
and still believe what their doctors tell them. So, if you are
told, "This is a precious IVF pregnancy", twins or whatever,
"and our recommendation, for your safety and your baby's
safety, is that you have a caesarean", it takes a strong
woman to say, "Actually, I would like to have a go."
I think those are borderline. I do not think that excessive quantities
of those are being done but I think that, in the examples Mr Porter
was talking about where a different consultant would take a different
approach, the women could be swayed.
Dr Naysmith
672. It occurs to me that one of the interesting
things in this area we are discussing is that the National Institute
for Clinical Excellence will be reporting some time this year
on indications for caesarean sections. Are you saying that it
will not be possible to find a rational evidence-based recommendation
that will please everyone?
(Mr Porter) Everyone.
673. That invalidates what I am saying but the
personality, one person in your team who has a different view.
What would happen if NICE comes out with a recommendation that
(Mr Porter) I think it could be hugely helpful if
it comes out with sensible recommendations. I think we might be
able to draw in the boundaries a little and I think that would
be very helpful. I sit here as one who feels that the caesarean
section rate in this country is ludicrously high at the moment,
so obviously anything that could bring it down would be music
to my ears.
674. It might be a universally applauded recommendation.
You never know.
(Mr Porter) It is a very strange world that we live
in because, if you look further than the United Kingdom and look
right across Europe, you will see these enormous differences between
the countries of Europe. The rate in Italy is absolutely sky high
and the rate in Holland is still very low. Are we saying that
the women of Holland are built differently from the women of Italy?
Are they a different species?
Mr Hinchliffe: There is a north/south divide
in this country.
Chairman
675. May I just pick up the point Ms Beardsmore
was saying about women accepting what doctors tell them. What
needs to be done about that? Is there anything the Committee could
do to try and help tackle that issue?
(Ms Beardsmore) I think it comes back to starting
at the very beginning, that women are swayed initially by GPs
and so, as was raised in the other group, the initial point of
contact being the midwife would, I think, make a great difference.
I also think that not confirming place of birth until 32-36 weeks
because then women would have longer during the pregnancy to find
out good, robust information and they would not be being swayed
early on and having their minds set on it. The problem we would
have locally is the fact that we do not have universal notes and,
for women to have access to scans in Swindon, they have to have
Swindon notes and, if they want access to scans in Bath, they
have to have Bath notes, which is ridiculous. I do think that
starting that from the very beginning would make a big difference
and also I think that with building the midwife as a key information
giver for the women.
Mr Hinchliffe
676. I was going to ask Mr Porter and Ms Jones
who actually makes the decisions with regard to assisting or inducing
labour and caesarean sections?
(Mr Porter) The medical staff generally, almost exclusively.
677. And subsequently what will be discussed
in the audit procedure will be the nature of the decisions they
have made?
(Mr Porter) In terms of caesareans, yes.
678. And on inductions as well?
(Mr Porter) We have not looked at our induction rate
carefully. Our induction rate is 14% which is not particularly
high. We have never really felt that that was a major problem.
If we saw it rising, we would certainly home in on it.
(Ms Jones) Having said that, we have put into place
an idea—we are rolling out with it this year—that
direct bookings of induction are done by midwives and therefore
the counselling that goes with a booking will be done completely
by a midwife and we think that that might make a difference.
679. What would the criteria be for that direct
booking?
(Mr Porter) Post-dates.
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