APPENDIX 6
Memorandum by British Association of Perinatal
Medicine (MS 11)
The British Association of Perinatal Medicine
is the largest multi-disciplinary professional association in
the UK relating to perinatal care. There are approximately 650
active members most of whom are practising obstetricians or neonatologists.
In relation to the particular areas the Sub-committee wish to
consider, we would like to make the following points:
1. The collection of data from maternity
units. It has been a matter of the utmost concern to the Association
for some time that the routine data collected in relation to childbirth
consists of a very limited number of items focusing on whether
the mother and her baby survive. As a result of the very limited
scope of these data, it has been impossible to fully understand
the effect of important changes in practice in the last 20 to
30 years. For example the recent rise in caesarean section rates
may have resulted in a reduction in infant and maternal morbidity
but the data to support or reject this theory are simply not collected
by the NHS. Our view is that childbirth should be associated with
the collection of a simple dataset relating to the care of the
mother and the baby which would allow a much greater understanding
of the quality of this service. It would be entirely feasible
to provide these data in an understandable form to the public.
We strongly advocate that any such dataset should be simple for
staff to collect and composed of the minimum number of data points
possible whilst fulfilling the aim of allowing the service to
be understood and monitored. (We ourselves have developed a dataset
which we feel would fulfil this role and the NHS Information Authority
has undertaken complementary work in this area). The present lack
of such a system is almost certainly related to the fact that
there are currently no significant targets set by the NHS in relation
to perinatal care. The introduction, on 29/10/02, of NHS number
allocation to babies at birth and the current work on the maternity
modules of the children's NSF provide both the essential infrastructure
and mechanisms to allow progress in this area, which had previously
been considered too difficult.
2. The staffing structure of maternity care
teams. Existing work in this area is available in "Changing
Childbirth" and from the Royal College of Obstetrics and
Gynaecology (1). The Royal College of Paediatrics and Child Health
have similarly done considerable work in relation to future provision
of staff caring for the baby. The issue is also being addressed
currently by the relevant working groups of the Children's NSF.
It is anticipated that that document will make important recommendations
about this topic, in particular changes to some of the more traditional
roles. However, the current widespread shortages of midwifery
and nursing staff are unlikely to be addressed simply by reorganisation
and, hopefully, increased job satisfaction. Ensuring that staff
have access to a realistic career structure with appropriate rates
of pay is of equal importance.
Research carried out by our own organisation
has indicated the practical consequences of current staffing problems.
In a three month survey of the UK's major neonatal units we found
that none had sufficiently robust staffing to permit them to reliably
offer cots to the babies of women booked to deliver in that hospital.
Inevitably those trying to access specialist care from outside
were at a further disadvantage. Those who could not find a cot
in a specialised unit often ended up in a less specialised setting
and sometimes a great distance from home (2&3).
3. Caesarean section rates. There has been
much speculation about the rise in caesarean section rates in
recent years and it would seem to our members that there have
been a number of influences leading to this change:
(a) Changes to the staffing of labour wards leading
to less experienced professionals making decisions regarding the
correct mode of delivery;
(b) An increasing tendency to practice defensive
medicine;
(c) Greater "consumer choice" in choosing
when and how to deliver.
Whilst there is undoubtedly both increased cost
and, probably, morbidity attached to this change our existing
poor routine data systems mean that it is impossible to assess,
in anything like a scientific fashion, both the real drivers and
the impact of this change.
4. The provision of training for health
professionals who advise pregnant women and new mothers. Although
there have been major developments with regard to medical staffing
in all fields of medicine, in recent years there are a great many
others "in the pipeline" such as the European Working
Time Directive, changes to the SHO role and the nature and duration
of specialist training. Although the relevant sections of the
Children's NSF are likely to comment on these issues it is fair
to say that at present there is no clear plan in relation to how
medical staffing of obstetric and neonatal areas should look in
the next 10 years. Plans for numbers of training places are therefore
subject to much imprecision. The nature of specialist medical
training is more clearly defined than in the past but may have
to change once a clear model for the service and its medical staffing
emerges.
These uncertainties about medical staffing both
mirror and impact on similar problems in midwife and neonatal
nurse training. To give a specific example, in the neonatal service
it is widely anticipated that many traditional junior medical
roles will be done in the future by advanced neonatal nurse practitioners.
However, there are no estimates of the numbers of such individuals
who should be trained, no plans to expand the present limited
number of training programmes available and no career structure.
CONCLUSION
Finally, we would wish to draw the Committee's
attention to the current planning blight in relation to specialist
obstetric and neonatal services. In 2000-01, the Dept of Health
set up both Regional and National reviews of neonatal care with
the aim of producing a national plan for neonatal intensive care
in England and Wales. Given the close interdependence of obstetric
and neonatal care this plan had important implications for specialist
obstetric services. The document giving details of the proposed
future shape of these specialist services was completed and was
ready for consultation at the end of 2001. The contents were discussed
with representatives of the Regions by officials from the DoH
in the early part of 2002. The Minister announced in The House
that the Document would be released but at the time of submitting
this evidence no publication date has been put forward. As a result,
a service with many problems finds itself across the country unable
to move forward because Commissioners, not unreasonably, are reluctant
to make new developments until they are sure they will be compatible
with the national plan.
If the Association can be of assistance by giving
oral evidence to your Inquiry, we would be happy to do so.
David Field
11 February 2003
References:
1. RCOG Standards. http://www.rcog.org.uk/resources/pdf/WP—standards.pdf.
2. Parmanum J, Field D, Rennie J, Steer
P. National census of the availability of neonatal intensive care.
BMJ 2000; 321: 727-729.
3. Bennett C, Lal M, Field D, Wilkinson
A. Maternal morbidity and pregnancy outcome in a cohort of mothers
transferred out of perinatal centres during a national census.
BR J Obstet Gynaecol 2002; 109: 663-666.
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