Examination of Witnesses (Questions 720-739)
TUESDAY 1 APRIL 2003
MR RICK
PORTER, MS
HELEN JONES
AND MS
JULIANNA BEARDSMORE
Chairman
720. So, both you and the Trust agree that you
do not have enough doctors but the Royal College say—
(Mr Porter) We have never put it to the Trust because
the first thing is to get the recognition for the posts.
721. So, the Royal College say it is not fine
and you have less than other places.
(Mr Porter) We are aware of the fact that there are
huge pressures on middle-grade numbers because of the concerns
about flooding the market with middle-grade numbers about five
years ago, but we do have a slight problem there.
Dr Naysmith
722. I am still trying to explore whether you
have any difficulties in recruiting the reduced numbers you are
allowed.
(Mr Porter) No.
723. You can easily get the doctors you want?
(Mr Porter) Yes because in fact, if you were talking
about middle-grade numbers, that is national training numbers,
they are appointed through a central system. Those national training
number posts are fiercely sought after.
724. So, what you are saying is that you are
operating all the time with a much too small establishment.
(Mr Porter) That is what we would say, yes. We can
do it but we would like someone to recognise that—
Chairman
725. Might the problem be at the postgraduate
dean level rather than the Royal College?
(Mr Porter) No, I do not think so. I think it is an
issue of numbers; it is the allocation of numbers. I have been
there for14 years and, perhaps during the last 14 years, we have
not been sounding our trumpet loudly enough. I do feel that it
is rather unfortunate because, in n a sense, it is airing dirty
laundry, but you asked about staffing levels and we are tight.
Sandra Gidley
726. We have been quite interested in continuity
of care. How does that work in the Trust and what proportion of
women actually benefit from it? I can remember when I was first
pregnant, it never occurred to me that the midwife I first met
would not be the midwife who delivered my baby and that there
would be many in between. How does that system work in Bath?
(Ms Jones) Because of the complexity of the service,
it is quite different. All the high-risk mums come to the Princess
Anne Wing and you do not have a hope in hell to continue that
care. I think that the low-risk mums are very well catered for
because they are looked after in their local area by midwives
who work in the community and the community units. In Bath, they
have the teams of midwives looking after predominantly low-risk
mums, but they are taking on more and more slightly complicated
cases. The high-risk mums have an opportunity, as they come to
the acute unit sometimes throughout their pregnancy, to meet with
the teams of midwives who are going to look after them. So, we
have developed a system sort of based on team midwifery within
the unit in order that the team midwives on the ward go and do
their own antenatal care and we try and address it in that way.
We have drop-ins for mums who are going to deliver in the Princess
Anne Wing to come and meet their midwives. So, we have addressed
it that way. I would say that continuity of care is reasonable
antenatally and postnatally. Intrapartumly, it is not brilliant,
but the mums do not seem to mind because they are looked after
by teams and they get to know the teams.
727. If we can come back to the hospital unit
for a moment, that clearly is more difficult to arrange although
clearly you are trying. Is that difficult with the resources you
have? Is it a resource problem or is it just a practicality problem?
(Ms Jones) It is a geographical problem because the
mums live 20 miles away.
728. Do what extent do the GPs help with that?
How much liaison is there with GPs in order that you get a consistent
message?
(Ms Jones) Over the last 10 years, we have had a wonderful
relationship with our GPs. Our GPs have said, "Look, we do
not have the expertise in intrapartum care" and they have
withdrawn, so they do not have anything to do with intrapartum
care. They support us enormously. We have introduced a number
of different things, for example midwife one-twos and they have
helped with the training and we have introduced examination of
the newborn and they have helped with the training together with
the acute units, so we have worked in a very multi-discipline
way. So, that has improved communication. The GPs hold their hands
up in our area and say, "You are the experts, you are the
ones doing it day in and day out." Antenatally, I think we
are finding that they are leaving it to midwives as well.
729. And you are comfortable with that?
(Ms Jones) We are and they are. They were the ones
who made the decision. We said, "We will go with whatever",
but we do have very, very good communication systems and we have
wonderful multi-disciplinary working. We have always had a bit
of it but, when we introduced these two new initiatives, we were
really surprised at what that led to. The respect and the communication
pathways are marvellous. Rick, would you not agree?
(Mr Porter) Yes. We are where we are now largely as
a result of the steadfast support that we received over decades
from the GPs and, far from them disappearing into the darkness,
I think what they have done is give us a huge vote of confidence
in what we are providing and they have said, "We are happy
for you to fill the gap now. We are happy to withdraw because
we know that we are leaving it in the state that we handed it
on to you" and I think that is tremendously encouraging.
(Ms Beardsmore) It has also affected MSLC where quite
a number of MSLC chairs with whom I speak cannot get a GP to come
and, at the meeting last night, we had five GPs at one MSLC meeting.
So, even though they are not providing the care, they are actually
there in a very positive way.
730. If a woman was trying to decide where to
have her baby, who would be the most likely influence on her decision?
(Ms Jones) I think that GPs still do influence them.
When I came in, I heard the conversation you were having and I
think it would be marvellous if the midwives were the first point.
I think GPs can influence certainly first-time mums. We talk about
informed choice, but it is the way you say it at the end of the
day.
(Ms Beardsmore) I think it may be an increasing problem
because historically our GPs were involved in this area, the GP/midwife
led unit, so they feel quite good about them, but, as they move
up and the new GPs come in who have never had anything to do with
those units, then the message may be being diluted.
(Mr Porter) I am not sure that that is not a little
too pessimistic because I actually think that we have not noticed
any trends that lead us to believe that the uptake is reducing.
One of the most bizarre things—and we were just talking
about it last night at the Maternity Service Liaison Committee—is
that, about 12 years ago, just before the last Select Committee
investigation into maternity, we were under a lot of scrutiny
because there were various vested interests locally who were saying
that what we were doing was unwise and unsafe. The health authority
actually said they would stand by us but one of the conditions
that they set for that was to maintain the numbers that were delivering
in the community units at around 34%. At the time, it effectively
meant that we had to browbeat women and not only women but also
GPs, those GPs who were taking a stance that was against our views
as it were saying, "You can't, you can't" or "All
primigravidae cannot deliver in community units." We actually
said, "No, I am sorry, the health authority has stated that"
blah-blah "somebody who fits these criteria can deliver in
the community." We do not have to impose our wishes on women
and now we have complete freedom of choice. It could not be more
different from what it was 12 years ago and the numbers have not
changed at all. So, it seems as though we have achieved a number
that is just about where it is going to be in an area of free
choice and, although it is possible that GPs are going to start
interposing themselves again by saying, "I do not think that
I fully agree with this", I think it is fairly unlikely—and
maybe I am being starry-eyed about this—that they are going
to have the impact that Julianna thinks they will because—and
we have alluded to this earlier—a major part of the decision-making
process is the knowledge that exists in the community, the pre-existing
mind-set, the mind-set which says—and this was one of the
things that astonished me when I first started working in Bath
14 years ago—when you say to them, "And where are you
going to have your baby?" they say, "In Poulton, of
course. I live in Poulton." It is the basic assumption that
unless somebody has some reason for you to deliver in a consultant
unit 12, 20 or 25 miles from where you live, you will deliver
in your local hospital and I think it will take more than a few
anxious GPs to destroy that.
Chairman
731. Presumably some women in Poulton are choosing
to go to the main unit even though they do not clinically have
to and we know that one of the issues affecting closure of some
of your units will be low numbers, so there might be an issue
there about GPs having a "use it or lose it" sort of
philosophy and possibly encouraging more women to go to those
local units. Are you anticipating that that might happen at all?
(Mr Porter) It might but in fact one of the units
that is threatened with closure is Devizes which already has about
a 55-60% usage of the unit which is about as high as you could
ever expect to achieve. My reading of the experience in other
areas suggests that it is pretty hard to get much higher than
that.
(Ms Beardsmore) I think the problem there is that
there are a tranche of women who at present are not given the
option of coming to those units because of where the historical
boundary changed and that they could actually be given the option
in a much more pro-active way.
732. People outside your boundary?
(Ms Beardsmore) Yes, but still within the Kennet and
North Wilts Trust boundary, but that is fairly newish as well.
(Mr Porter) To explain that, effectively what happened
was that our boundaries closed where the old health district ended.
That meant that some of the units were within two or three miles
of the boundary. It is fairly obvious that some people will be
quite happy to travel much longer distances to come to a community
unit but previously they were the wrong side of the boundary,
they were in somebody else's purchasing area. So, what we could
do was encourage people where the natural flow might be to this
community unit to come over to us.
Sandra Gidley
733. I was going to move onto a situation where
a woman may be quite keen to have a baby in one of the local units
but her pregnancy might not go quite according to plan. Who would
actually make the decision to maybe refer to the hospital? Would
that be a midwife-led decision or how much team work is there
once there has been a referral? Who makes the final decision that
this women will go to the hospital?
(Ms Jones) Obviously depending on the complications,
the midwife will make the direct referral to the consultant for
an opinion and not necessarily for a change in booking and a consultant
who reviews the case may say, "Yes, okay, I understand all
about that but she feels pretty strongly and actually I do not
see any real reason, so, yes, she can go back" and we do
that regularly. So, just because they make a referral, it does
not mean that their booking changes.
734. So, it is ultimately a consultant decision?
(Ms Jones) I would say in collaboration with the midwives
because the midwives have to be happy.
735. Going along with that, what part does the
woman play? How active a role does the woman have in deciding
the course of her pregnancy?
(Ms Jones) I think she has the ultimate choice. She
is focused.
(Mr Porter) It is a very interesting question because
I do not think we see it in those terms. There would never be
a situation where we just said, "We do not care what you
think, you are going to do this." It is never really like
that. We do see it very much as part of coming together as a team
and working and the pivotal part of that team is the woman.
736. During labour, however good the antenatal
classes are, it sometimes all goes out of the window. Do you think
there is enough staff resource to actually take the time to be
with the woman to explain the possible options of anything that
might be happening to her?
(Ms Jones) In the community, absolutely, yes.
(Mr Porter) It depends on speed, does it not? We would
all love to be able to spend a long time going through the various
issues in great depth but, if you have a crashing foetal distress,
it is not really open to that kind—
737. I am talking about "should we speed
things up?", that sort of conversation where you have this
whole cascade of intervention.
(Ms Jones) The midwife takes complete control and
she will invite a medical opinion.
738. I am talking about the woman now. You have
just said that the midwife takes complete control.
(Ms Jones) I am sorry, I thought you were suggesting
that doctors walked in and took over.
739. I am trying to find out what it is like.
(Ms Jones) It is always in discussion with the woman.
We have many cases where we would recommend that somebody be induced
and the woman says, "Actually, I do not wish to be induced"
and we put a plan of action into play.
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