APPENDIX 14
Memorandum by the Department of Health
(MS 20)
CONTENTS
1. Introduction.
2. Collection of data from maternity units.
3. Staffing structure of maternity care
teams.
4. Caesarean section rates.
5. Provision of training for health professionals.
6. Conclusion.
7. Appendices.
1. INTRODUCTION
1.1 Care surrounding pregnancy and childbirth
takes place in circumstances that distinguish it from many other
areas of clinical practice. Pregnancy is not an illness and maternity
services are there to provide care and support for a predominantly
healthy population through a normal life event. The majority of
pregnancies end with a healthy mother and baby and without complication.
1.2 It is for Strategic Health Authorities
and Primary Health Care Trusts to decide on the best pattern of
local service provision taking into account the needs and wishes
of local people, the local geography, the need to provide effective
evidence based care and available local resources. Local models
of maternity services have therefore evolved in response to a
combination of factors related to local circumstances and requirements,
the advice of health professionals and national guidance.
1.3 The NHS Plan set out a vision of a service
designed round the patient. To achieve that vision the NHS is
undergoing radical change, supported by a major programme of investment
and reform. Within this, various strands of work are currently
being taken forward to improve maternity services. The most fundamental
to this process is the development of the Children's National
Service Framework (NSF) which will include a module on maternity
service provision.
1.4 Announced in February 2001, the Children's
NSF highlights this Government's commitment to high quality maternity
services for all. In the new architecture of the NHS the setting
of national standards through the NSF will be the most effective
way of ensuring consistency of service provision to all groups
of women, including those who use the current services least,
and quality in a devolved health care system; whilst at the same
time continuing to allow local health systems to develop a "best
fit".
1..5 The maternity module of the NSF will
help derive national standards of care to cover the provision
of antenatal, delivery (intrapartum) and postnatal services. The
module will look at how to make maternity services more flexible,
accessible and appropriate for all, including the socially excluded.
1.6 To help us get this right a Maternity
External Working Group (EWG) has been formed. It is co-chaired
by Heather Mellows the Junior Vice President of the Royal College
of Obstetricians and Gynaecologists and Meryl Thomas Vice-President
of the Royal College of Midwives. Members are drawn from a wide
range of backgrounds including medical and midwifery professionals,
research experts and user groups. Further information on the NSF
is available at http://www.doh.gov.uk/nsf/children.
1.7 The EWG's work is being taken forward
through five sub groups:
— Inequalities and access.
1.8 The Department considers it vital that
as many as possible of the stakeholder groups, with an interest
in the maternity services, are given the opportunity to input
to this important exercise and this is reflected in the sub group
membership. The first module of the National Service Framework,
covering children in hospital, will be published shortly. The
other modules, including maternity services, are expected to come
out towards the end of the year. A report of the emerging findings
of the work done on the Children's NSF is expected to be published
shortly.
Committee to please note:
1.9.1 As requested by the Committee, the
Government provided a very detailed note in June 2002 on the current
situation in maternity services in the context of the over 100
recommendations of the Health Select Committee's earlier Report
(1991-92 session), following their enquiry into Maternity services.
1.9.2 We have been given a strong steer
by the Committee Clerk that this memorandum therefore need only
cover the issues raised in the Terms of Reference and a copy of
the note referred to above, is submitted as an aide-memoire (attached
as a separate document with this memorandum for ease of reference).
1.9.3 This memorandum addresses the four
particular issues that the Committee has indicated will be covered
in this inquiry.
2. COLLECTION
OF DATA
FROM MATERNITY
UNITS
Background
2.1.1 The Department of Health collects
information about deliveries that occur in maternity units through
the Hospital Episode Statistics (HES) system.
2.1.2 Locally, data may be held on computerised
maternity modules that are part of wider all-condition based patient
administration systems (PAS) or alternatively are stand-alone
and do not link to the hospital PAS. In a very few units, maternity
data are held on paper and are not computerised.
2.1.3 Data about patients flows from service
providers to commissioners through the NHS-wide Clearing Service
(NWCS). These data are in the form of records about individuals
that include patient details, administrative items, diagnostic
details and information about procedures carried out. An extract
of selected items from each record is downloaded at the NWCS.
This forms the HES dataset.
2.1.4 Maternity records differ from other
patient records. In addition to the core record described above,
a set of clinical data items that relate specifically to delivery—eg
birthweight and method of delivery—is appended to the core
record. This extra set of data items is known as the "maternity
tail".
Availability of data
2.2.1 As the total number of deliveries
that occur at any hospital is known through Birth Registration,
the proportion of deliveries that generate a HES record may be
estimated. Since 1992-93, about 95% of deliveries in each year
have at least a core record. In 2000-01, 14 hospitals/trusts accounted
for the majority of the missing records.
2.2.2 Even where a HES record is present,
the clinical data may be missing. In 2000-01 out of 197 hospitals/trusts
with deliveries, 52 did not submit any clinical details at all.
Overall, clinical details were missing from 34% of registered
deliveries.
2.2.3 The majority of problems occur where
maternity record systems are paper only or where the clinical
details are held on a stand-alone system. There are also transitional
problems as hospitals change the systems they use. Incompatibility
of stand-alone systems with the hospital's PAS is a major reason
for missing tail data; the strict data transmission standards
of the NWCS have also, since 1996, resulted in failure of existing
tail data to be captured by HES.
Quality of data
2.3.1 Where data are provided and can be
cross-checked, quality is good with only 2% or less of items apparently
incorrectly coded. National estimates based on the 66% of records
that do have clinical data are in line with similar figures obtained
from RCOG audits and other sample studies.
Improving data coverage
2.4.1 The historical reason for incompatible
or non-existent maternity data systems is that implementation
of the HES maternity tail came two years after implementation
of HES generally, and by then many providers did not have sufficient
resources for what was and remains a significant investment in
computing. This lack of resources to implement a compatible maternity
HES continues.
2.4.2 Two developments are currently being
pursued to overcome this. Firstly, the Department is acting as
intermediary in negotiations between Trusts and the NWCS aimed
at reducing the incompatibilities between data systems. This has
already resulted in a dozen Trusts being able to contribute to
2001-02 maternity HES where they had not in recent years. It is
estimated that coverage will go up from 66% in 2000-01 to 70%
in 2001-02 and initial reports suggest further improvement in
2002-03.
2.4.3 Secondly, the whole HES system is
currently being re-commissioned. Options being explored as part
of this include alternative methods of submitting maternity data
that would work around existing incompatibilities. Taken together,
these developments should substantially improve maternity HES
coverage within the next two years.
3. STAFFING STRUCTURE
OF MATERNITY
CARE TEAMS
3.1 As indicated above the NHS Maternity
Statistics, England summarizes information from the Hospital Episode
Statistics (HES) system relating to NHS maternities and births.
The latest HES data, covering 2000-01, published in April 2002
indicates that about 560,000 deliveries took place in England
in 2000-01. The number has declined steadily since a peak of 650,000
in 1990-91 (England).
Place of delivery
3.2 The vast majority of deliveries occur
in NHS facilities, though about 2% of women are delivered at
home and 0.5% in private hospitals. Almost all NHS facility deliveries
occur in designated consultant obstetric units with a small but
growing number in midwifery led units. In 2000-01 2% of deliveries
were reported as being on GP wards and 2% on midwife wards.
Person conducting delivery
3.3 In 2000-01, about 33% of deliveries
were conducted by hospital doctors and 66% by midwives although
a midwife was present at over 99% of all births. The overall balance
between the professions has shifted steadily since 1989-90 when
about 24% of deliveries were conducted by doctors and 76% by midwives.
This shift reflects the changing pattern of delivery method and
the impact of medical interventions. Virtually all spontaneous
(natural) deliveries are conducted by midwives; doctors conduct
caesareans and all but about 10% of instrumental deliveries.
Type of delivery
3.4 he proportion of all hospital deliveries
that occurred spontaneously in 2000-01 was about 67% having fallen
steadily from 78% in 1989. In the same period over 21% deliveries
were by caesarean section—more than half of these were emergency
caesareans. Also about 11% were instrumental deliveries. Throughout
the 1990s, the proportion of instrumental deliveries has remained
around 10%. Within this, there has been a marked shift in the
type of instrumental delivery. In 1989, forceps were used in 83%
of instrumental deliveries and ventouse (vacuum extraction) in
only 17%; by 2000 65% of instrumental deliveries were by ventouse.
Care is currently delivered as follows:
3.5.1 Antenatal care—Antenatal
care is currently mainly provided by a system of what is traditionally
called "Shared Care. Under this system women receive the
majority of their care from a midwife in a community or GPs surgery,
sometimes jointly with a GP, with occasional visits to the hospital
for hospital based tests such as ultrasound. They also routinely
see a doctor in the clinic of the consultant under which they
are "booked" for care. However, in a move the Department
welcomes, more women with anticipated low risk pregnancies are
now experiencing fully midwifery led care during the antenatal
period. Under this system the midwife takes the professional responsibility
for the care of the women, and only referring them to the hospital
for tests not available in the community clinic or if potential
problems are identified. Women with higher risk pregnancies will
be offered care from midwives and specialists in the hospital
setting, where there is also access to a number of other services
which will to help provide optimum care for the women and for
their babies.
3.5.2 Births /Intrapartum care—Births
take place in a variety of settings. This could be:
— either a "stand alone"
midwife-led unit with no obstetric cover on-site and possibly
some miles from the nearest District General Hospital;
— or a midwife-led unit on the
same site as a district general hospital (DGH) consultant led
unit, which provides medical cover for obstetrics, paediatrics
and anaesthesia;
— in a hospital with a consultant-led
maternity service including obstetrics and anaesthesia, and a
neonatal unit offering a range of care for neonates ie special
care, high dependency care, and possibly a small volume intensive
care service; or
— in a more specialist maternity unit
which also has access to high volume neonatal intensive care able
to provide care for those babies with the most complex needs.
3.5.3 Postnatal care: All women will
receive postnatal care and support from a midwife either in her
home or the hospital environment. The pattern and content of post
natal care varies from area to area, but the midwife currently
has a statutory responsibility to provide care for a minimum of
10 days and up to 28 days depending on the individual need of
mother and baby.
The midwife will provide health promotion advice
and also support with parenting and help with the chosen method
of infant feeding.
Current work programme on the structure of maternity
services
3.6.1 As indicated in the note submitted
to the Committee last summer, there are various strands of work
going on within the Department currently relating to workforce,
staffing structure and configuration of maternity services. Work
had also been commissioned through the National Institute for
Clinical Excellence on aspects of quality and clinically effective
care. But the main strand of the work will be achieved through
the development of the Children's National Service Framework.
The staffing and configuration of maternity services within the
NHS cannot be considered in isolation from the provision of related
services eg, neonatal care, paediatrics, anaesthetics, and intensive
care. At the same time the implications of the new deal for doctors
in training and the European Working Time Directive have resulted
in a new focus on those sectors of the workforce who provide out
of hours cover, which is particularly relevant to maternity services.
Other strands of related on- going work includes:
3.6.2 The Maternity and Neonatal Workforce
Group which was set up in 2001. The Group's Report to the Department'
s Children's Taskforce was issued on 29 January 2003 as part of
the interim work in process to address the complex workforce issues
in the various models of maternity care. The findings in this
report will feed into other ongoing work being led by the Department.
The Report is available at http://www.doh.gov.uk/maternitywg.
3.6.3 The Children's Care Group Workforce
Team (CGWT) which has been established to work through the implications
for workforce development of the Children's National Service Framework,
placing these in the context of broader workforce considerations.
Maternity and neonatal services are high on its priority list.
3.6.4 The CGWT has developed a workforce
model illustrating at a national level the overall demand and
supply implications of a number of maternity services configurations
for discussion within the Maternity and Neonatal Workforce Group—referred
to at para 3.6.2 above. While engaged in this work it has reviewed
the methodology and findings of Birthrate Plus, a local workforce-planning
tool for midwifery services. The Children CGWT will support the
Maternity Module of the Children NSF and will take forward the
work of the Maternity and Neonatal Workforce Group.
3.6.5 More specifically, the Children CGWT
have commissioned a scoping exercise to identify new ways of working
in caring for newborn babies and their families. Following this
exercise, a pilot was set up to look at the implementation of
selected new or amended roles in the immediate post-birth care
of new-borns (including resuscitation and care in special care
baby unit). The pilot considers work within a neonatal care network
and retrieval/transfer to the appropriate level of care, acknowledging
the different levels of cover to meet EWTD compliance. The pilot
will review new or revised job roles, which more clearly meet
the needs of the individuals and use the skills of staff more
effectively, resulting in improved access and quality of care
for patients and improved staff recruitment and retention. These
will subsequently be spread across other pilot sites and networks
wishing to implement the model.
3.6.6 The Changing Workforce Programme which
is a pioneering NHS project that is helping health and social
care organisations improve patient services, tackle staff shortages
and ensure greater job satisfaction. This is being done by supporting
organisations to redesign staff roles either by combining tasks
differently, expanding roles or moving tasks up or down a traditional
uni-disciplinary ladder.
3.6.7 The Working Time Directive Project—which
is a national programme of pilot projects, is being commissioned
to support implementation of the European Working Time Directive.
The Health Service Circular 2003/001 guidance on implementing
the EWTD (European Working Time Directive) for doctors in training
was published on 3 January 2003 and a programme of pilot projects
in NHS Trusts to develop and test innovative solutions to implementing
the EWTD was announced. The Health Service Circular together with
details of pilot projects and supporting guidance is available
on the DH website: http://www.doh.gov.uk/workingtime.
3.6.8 The Children Care Group Workforce
Team has also been working closely with the Changing Workforce
Programme and the European Working Time Directive Project Team
to set up a pilot site to look at how issues arising from the
implementation of the European Working Time Directive can be addressed
in Maternity, Neonatal and Paediatric Services. Further work on
this will take place during 2003.
3.6.9 The Configuring Hospitals in Health
and Social Care Systems Project, which is developing a framework
to inform proposals for, service change at local level. The project
is bringing together new policy developments, such as new arrangements
for patient and public involvement in health, with innovative
ideas for delivery of services, to show how the modernisation
agenda can be harnessed to maintain effective services in a manner
consistent with clinical governance and EU Working Time Directive
requirements. Work is ongoing to identify sustainable models
for delivery of maternity services.
3.6.10 Again the Children CGWT and the Configuring
Hospitals project team are planning to work together to set up
a pilot site and research project in relation to Maternity, Neonatal
and Paediatric Services. The exact scope of such work is currently
being refined but is likely to review the impact of more effective
marketing on the uptake of midwife-led unit model of care among
women for whom that care is clinically appropriate, neonatal network,
and inpatient activity in paediatric units. More information is
available at the Configuring Hospitals website www.doh.gov.uk/configuringhospitals
3.6.11 The National Institute for Clinical
Excellence (NICE) which is developing clinical Guidelines on several
important aspects of maternity services, eg routine ante natal
care and use of caesarean sections. Both these are expected to
be issued later this year or early next year. The Department is
also considering commissioning other guidelines of immediate relevance
to the development of the maternity module of the Children's National
Service Framework.
Drivers for change
3.7.1 The Department recognises that further
improvements are needed in maternity services to improve outcomes
for both mother and baby as well as to provide more choice. The
drivers for national change include:
— The drive to tackle inequalities.
— The setting of national clinical
standards for maternity and neonatal care.
— High costs of litigation.
— European Working Time Directive.
3.7.2 Locally the action taken to implement
the national drivers may also differ and here additional local
drivers may exist. Local drivers for change may include:
— Shifting professional boundaries.
— Local hospital reconfigurations.
— Recruitment and retention.
Towards the future
3.8.1 The 1997 Audit Commission Report established
that there is a high level of satisfaction with maternity services—90%
of women said they were pleased or very pleased with the services
they received. Many women are able to exercise a fair degree
of choice over their care throughout pregnancy, birth and beyond.
The last English National Board's Report on Midwifery Practice
Audit 2000-01 found that 78% of units provide one to one care
to all women in established labour. However, the Department recognises
that there are pressures on some maternity services and is working
to reconcile these into new and innovative patterns of care.
3.8.2 The Children's NSF is an opportunity
to set national standards which drive up quality and make the
service as responsive and flexible to the needs and wishes of
individual women and local communities. The aim is to provide
the best possible outcomes for mothers and their babies as well
as reducing inequalities in access to care. These issues are being
worked through the relevant Subgroups of the Children's NSF. The
External Working Group will suggest appropriate standards for
the provision of services that are safe, meet local needs and
are evidence based. There are several principles and options that
can be considered to achieve this, but the Department is committed
to ensure that the following principles are included:
Pregnancy as a life event:
3.8.3 For the majority of women, pregnancy
and childbirth are normal life physiological processes/events,
facilitated by health professionals and during which evidence
based medical interventions should be offered only if they are
to benefit mother and/or child.
3.8.4 A significant minority of women (25%)
may be at risk of, or may develop, clinical problems during pregnancy
or labour for which additional, more specialist help is required.
These services should be provided, where possible, within the
ongoing care pathway the woman has chosen, and within a managed
clinical network.
3.8.5 Supportive midwifery and obstetric
care should not be based solely on providing good clinical outcomes,
but must also recognise the equal importance of helping women
and their partners prepare for parenthood.
Needs and expectations of women and their partners:
3.8.6 The needs and wishes of women and
their partners are the basis upon which modern maternity services
should be developed. These needs and wishes may change throughout
pregnancy and local services should be flexible enough to accommodate
this.
3.8.7 Information about local services must
be made available to, and discussed with, all women and their
partners to enable them to choose the pattern of care they feel
most comfortable with. There is no "best" pattern of
care.
3.8.8 Rigid patterns of care with which
women are expected to conform may be inappropriate and alienate
some more vulnerable women who may benefit most from regular contact
with the maternity and other services. Involving these women in
planning their services can improve their access to services.
Workforce Numbers
3.9 (a) Obstetrics and gynaecology
— As at March 2002, there were 1,245
consultants in O&G. This represents an increase of around
215 or 21% since September 1997.
— There are significant numbers of
doctors in training in O&G—950 in the registrar group
as at September 2001.
— The vacancy rate for the speciality
as at 31 March 2002 in England was 1.7%, a slight increase of
0.2% since 31 March 2001. The vacancy rate for England across
all specialities in March 2002 was 3.8%.
3.10 Action to increase numbers
— The current workforce projections
suggest that by 2004, over a 2000 baseline, there may be around
470 additional trained specialists in O&G available to take
up consultant posts.
— We have adopted a new NHS-led approach
to maximising the numbers of Specialist Registrars trained within
existing resources. Central funding will be available to support
the implementation of additional SpR posts. In addition, Trusts
will be given the opportunity to fund additional posts locally,
up to a maximum number. This new flexibility offers considerable
opportunity to further increase SpR numbers.
3.11 (b) Paediatrics
— As at March 2002, there were 1,530
consultants within the speciality of paediatrics (including paediatric
neurology). This represents an increase of around 320 or 26% since
September 1997.
— There are significant numbers of
doctors in training in paediatrics (including paediatric neurology)—1,090
in the registrar group as at 30 September 2001.
— The vacancy rate for paediatrics
as at 31 March 2002 in England was 1.8%. Paediatrics was not collected
in the 2001 vacancy survey, so a comparable figure is not available.
The vacancy rate for England across all specialities in March
2002 was 3.8%.
3.12 Actions to increase numbers
— Current workforce projections suggest
that by March 2004 there may be sufficient trained specialists
to increase numbers in the paediatrics speciality (including paediatric
neurology) by around 690, over a 2000 baseline. This takes account
of expected numbers of additional recruits and numbers leaving
due to retirement.
— We have adopted a new NHS-led approach
to maximising the numbers of Specialist Registrars trained within
existing resources. Central funding will be available to support
the implementation of additional SpR posts. In addition, Trusts
will be given the opportunity to fund additional posts locally,
up to a maximum number. This new flexibility offers considerable
opportunity to further increase SpR numbers.
3.13 (c) Anaesthetics
— As at March 2002, there were 3,700
consultants in anaesthetics (including intensive care). This represents
an increase of around 930 or 33% since September 1997.
— There are significant number of staff
within the registrar group 1,690 as at September 2001 (including
intensive care medicine).
— The vacancy rate for anaesthetics
as at 31 March 2002 in England was 2.2%. The vacancy rate for
England across all specialities in March 2002 was 3.8%.
3.14 Action to increase numbers
— The current workforce projections
suggest that by 2004, over a 2000 baseline, there may be around
1,000 additional trained specialists in anaesthetics (including
intensive care) available to take up consultant posts.
— We have adopted a new NHS-led approach
to maximising the numbers of Specialist Registrars trained within
existing resources. In addition to central funding to support
the implementation of additional SpR posts, Trusts will be given
the opportunity to fund additional posts locally, up to a maximum
number in each speciality. This new flexibility offers considerable
opportunity to further increase SpR numbers.
— In 2002-03, central funding was provided
to support the implementation of 23 additional SpR posts in anaesthetics
and seven additional posts in anaesthetics with an intensive care
medicine component. Considerable scope was also given to Trusts
to fund posts locally themselves.
3.15 (d) Midwives
— There are 700 (3%) more midwives
working in the NHS today than there were in 1997.
— There has been an overall increase
of 510 midwives between 2000 and 2001.
— There were 356 (54%) more pre registration
training places available for midwives in 2001-02 than there were
in 1996-97.
— The 2002 Vacancy Survey shows a slight
increase in the vacancy rate for midwives from 2.6% in March 2001
to 2.8% in March 2002. This is in part due to increased investment
in the NHS creating new posts ahead of the expansion in the workforce.
We are confident that the increase in numbers going in to training
and the recruitment and retention initiatives will lead to growth
in the workforce and a reduction in vacancies.
Speaking at the Royal College of Midwives Conference
on 2 May 2001 Secretary of State announced that;
— by the end of 2002, there will be
an extra 500 midwives working in the NHS;
— with an extra 2,000 within the next
five years.
Latest figures show that we have made good progress
towards achieving the target. The 2002 Non Medical Workforce Census,
due for publication in February, will show whether the target
has been reached.
3.16 Statistics
MIDWIVES EMPLOYED IN THE NHS 1996-2001
| 1996 | 1997
| 1998 | 1999 |
2000 | 2001 |
| Headcount | 22,600 | 22,380
| 22,840 | 22,800 | 22,570
| 23,080 |
| Wte | 18,260 | 18,050
| 18,170 | 17,880 | 17,660
| 18,050 |
NUMBER OF STUDENTS ENTERING MIDWIFERY TRAINING
| 1996-97 | 1999-2000
| 2001-02 |
| Degree | 161 | 395
| 621 |
| Diploma | 498 | 620
| 525 |
| Other | 993 | 757
| 732 |
| Total | 1,652 | 1,772
| 1,878 |
Source: Quarterly monitoring / Financial and Workforce
Information Return
3 month vacancies and vacancy rates 1999-2002
| 1999 | 2000
| 2001 | 2002 |
| Vacancy Rate | 2.1% | 2.8%
| 2.6% | 2.8% |
| Number of vacancies | 400 |
510 | 470 | 530
|
TEENAGE PREGNANCY
3.17.1 The Government's Teenage Pregnancy Strategy has
two main goals:
— to halve the under 18 conception rate by 2010,
with an interim 15% reduction target by 2004 set out in the NHS
Plan;
— to increase to 60% the proportion of teenage parents
in education, training and employment to reduce their long term
risk of social exclusion.
Delivery of the strategy goals contributes to the National
Inequalities Target of a 10% reduction in infant mortality by
2010.
3.17.2 Each top tier local authority has its own local
teenage pregnancy strategy and 10 year action plan, developed
by local authority and health partners to deliver locally agreed
targets. The strategies are managed by Teenage Pregnancy Partnership
Boards, led by a Teenage Pregnancy Co-ordinator.
3.17.3 The Social Exclusion Report on Teenage Pregnancy,
which informs the national strategy, identified increased health
risks to babies born to teenage mothers. These include a doubling
of the risk of infant mortality, greater incidence of low birth
weight and increased risk of pre-eclampsia and premature labour.
However the report recognised that there is no reason why a teenage
pregnancy should not have a good outcome if it is well managed.
The problem lies in the fact that teenage mothers tend not to
have well managed pregnancies. The SEU report cited the following
reasons:
— teenagers usually go to their doctors much later
in pregnancy and miss out on important pre-conception and antenatal
care;
— many teenagers do not take up antenatal care because
they anticipate disapproving staff and "scrutiny" by
older mothers; these obstacles are exacerbated for more vulnerable
teenage mothers such as those who are looked after or have education,
housing and financial problems;
— during pregnancy, teenage mothers are the most
likely of all age groups to smoke—nearly two thirds of under
20s smoke before pregnancy and almost a half during it.
3.17.4 A key strand of the Teenage Pregnancy Strategy
is therefore to increase pregnant teenagers' uptake of antenatal
and postnatal care by improving and tailoring services to better
meet their needs.
3.17.5 Twenty Sure Start Plus pilots have been established
to provide tailored support to pregnant teenagers and young parents.
The pilots provide a Personal Adviser to support pregnant teenagers
to help improve health outcomes and provide support to help teenage
parents access education, training and employment. Evaluation
of the Sure Start Plus programme, due in Spring 2004, will include
effective ways of delivering antenatal and postnatal care. Emerging
good practice will be disseminated this summer.
3.17.6 The Teenage Pregnancy Unit is also supporting
a Teenage Parents Midwifery Network to help develop and share
models of good midwifery practice. The Network has a midwife membership
of 350 and meets three times a year. Plans are underway to run
two seminars for Heads of Midwifery during 2003-04 with the Royal
College of Midwives and to produce a best practice resource on
effective staffing arrangements to provide tailored care for teenage
parents. The best practice models will ensure compatibility with
the standards set out in the Maternity Module of the Children
and Young People's NSF.
3.17.7 Models of emerging good practice include:
— dedicated midwifery teams providing care for teenagers
on a caseload basis; and
— a dedicated lead midwife responsible for developing
and delivering tailored care for teenage parents.
3.17.8 Both models allow flexibility in the delivery
of care including the provision of teenage specific booking and
scan clinics; antenatal and postnatal care for teenagers in their
own homes or other preferred locations; and dedicated teenage
parent education classes held at times run at teenage friendly
times and settings. Services providing tailored services report
increased and sustained attendance by teenage parents.
4. CAESAREAN SECTION
RATES
General
4.1 Optimum rate—Caesarean delivery rates have
continued to climb steadily in the last 40 years from a level
of under 3% in the 1950s, the proportion of deliveries that were
by caesarean section rose to 9% by 1980, and 12% by 1990. During
the 1990s the rate has increased more rapidly, reaching 21% by
2000. While we know that the CS rates are rising, at present there
is not sufficient evidence or medical consensus about the desirability
and what the optimum caesarean section rate should be. This is
why the Department funded a sentinel audit into caesarean sections
and commissioned the National Institute of Clinical Excellence
to provide clinical guidelines on its use. More details are at
paragraphs 4.9.8 and 4.9.18 below.
4.2 The Department is well aware of the on-going professional
and public debate about the rise in caesarean section rates. Some
professionals argue that the procedure is very safe and a planned
caesarean can be preferable to a potentially painful and lengthy
vaginal delivery, which may necessitate medical treatment to repair
damage caused by a difficult labour or birth. Other professionals
and groups argue that caesarean sections are often medically unwarranted,
cause clinical and social morbidity for the mothers and that woman
are often pressurised into having a section.
4.3 The reasons for the increase in CS rates are complex
and not well understood. Over the last 20 years, technical advances
have enabled obstetricians to identify complications at earlier
stages, so that intervention is now a more appropriate option
than it once was. Increased safety of the procedure is a further
factor. Other reasons cited for the increase include changes
in the age profile of the obstetric population and women's choice.
Almost half of all Caesareans are planned in advance because
of factors identified during pregnancy.
4.4 Elective/Emergency—The latest HES data indicates
that during 2000-01, over 21% of deliveries were by caesarean
section; of which 12.7 per cent were emergency caesareans and
8.8% were elective. An elective section means one, which can
be planned in advance (following consultation between obstetrician
and mother) because the clinical reasons for it are known in advance.
A caesarean section, which is performed at maternal request, is
one, which is not clinically indicated but is performed because
of the woman's preference for this type of delivery.
4.5 WHO has suggested a global overall rate of 15%—The
Department of Health requires all guidelines to the NHS be evidence
based. The WHO recommendations are several years old and apply
to all countries—developing and developed, many of which
have entirely different health care systems.
4.6 England compared to other countries—The maternity
data collection in other countries is not the same as UK so it
is difficult to make accurate comparisons. Broadly speaking we
have a lower rate than the US but a slightly higher rate than
amongst some other European countries.
4.7 International Caesarean Section Rates
| Country | Year
| Caesarean Section Rate |
| Englanda | 2000 | 21.3%
|
| Walesa | 2000 | 24.2%
|
| Northern Irelandb | 2000-01
| 23.9% |
| Scotlandc | 1999 | 19.3%
|
| USAd | 1999 | 22.0%
|
| Denmark | 1999 | 13.7%
|
| Norway | 1999 | 12.6%
|
| Sweden | 1999 | 12.2%
|
| Finland | 1999 | 15.1%
|
| France | 1999 | 17.5%
|
| Italy | 1999 | 22.5%
|
Source:
(a) NSCSA-data collected May-July 2000
(b) NSCSA-data collected Dec 2000-Feb 2001
(c) Scottish health exec report
(d) Final report CDC14
PROGRAMME OF
WORK
4.8 The Department has set in place an extensive programme
of work, to address some of the already identified issues surrounding
the rise in caesarean section rates. These include the following:
(a) Commissioned NICE Guidelines on the use of Electronic
Fetal Monitoring (EFM)
4.9.1 In May 2001 the National Institute for Clinical
Excellence issued clinical guidance on the use of Electronic Fetal
Monitoring (EFM). The short form guideline published by NICE was
derived from a full guideline published by the Royal College of
Obstetricians and Gynaecologists. Electronic Fetal Monitoring
is used to monitor a baby's heartbeat continuously during labour.
Sensors are placed against the mother's abdomen and are connected
to a heart rate monitor, which produces a record of the baby's
heartbeat.
4.9.2 The guideline makes a series of recommendations
for clinicians on when it is appropriate to use EFM for women
in labour. The main aim of the Royal College of Obstetricians
and Gynaecologists' evidence based clinical guidelines, is to
help ensure that the technology is appropriately used in clinical
practice and those using it are competent in the interpretation.
4.9.3 Ensuring that the technology is appropriately used
should result in a reduction in unnecessary caesarean sections
and instrumental deliveries.
(b) Commissioned NICE Guidelines on the Induction of
Labour
4.9.4 In June 2001 the National Institute for Clinical
Excellence issued clinical guidelines on the Induction of labour.
This is a common procedure, and about one in five women have their
labour induced. The summary guideline published by NICE was derived
from a full guideline developed by a multidisciplinary group and
published by the Royal College of Obstetricians and Gynaecologists.
4.9.5 The guideline provides a series of recommendations
based on the evidence, ranging from indications for Induction
of Labour, the methods that can be used, through to the care that
should be provided during induction. The aim of this guideline
is to provide clinicians in maternity units with recommendations
for safe practice. The guidelines will help reduce variations
in clinical practice.
The latest available HES data does not yet reflect the impact
of either of the above guidelines
(c) Publication of Data for Trusts
4.9.6 The Department fully supported the recommendations
of the Audit Commission report A First Class Delivery,
published March 1997, that a detailed retrospective audit by obstetricians
of all caesarean sections should be routinely performed.
4.9.7 Since 1999 the HES Maternity Statistics Bulletin,
includes figures for elective and emergency CS deliveries for
health authorities and individual hospitals in England.This information
is further helping to strengthen the local audit process.
(d) Commissioned the National Sentinel Caesarean Section
Audit (NSCSA)
4.9.8 In order to consider the full implications of the
rise in CS rates, it is important to understand why CSs were being
performed. That is why the Department commissioned the biggest
National Sentinel Audit of caesarean sections in the world, which
was also the first of its kind. In 1999 the Royal College of Obstetricians
& Gynaecologists were commissioned to carry out a multidisciplinary
audit. This was carried out in 2000 and the Report of the findings
was published in October 2001. The data presented in this report
represented the most comprehensive data collected to date in the
world, and represented 99% of all births in England, Wales and
Northern Ireland that took place during a three month period.
Data collection was completed by 213 NHS consultant-led units,
20 NHS midwifery led units and three private maternity units
4.9.9 The aim of this Audit was to attempt to relate
CS rates to specific underlying patient characteristics. This
will then enable the development of standardised CS rates for
particular patient groups which will eventually lead to a more
informed approach to determining what the appropriate CS rates
should be for any particular maternity unit. The audit will help
trusts interpret their own figures, as all maternity units were
given their own audit results to examine them in the context of
the national results to see whether any changes in practice are
indicated.
THE KEY
FINDINGS OF
THE AUDIT
4.9.10 The key findings in the report indicated that:
— Overall Caesarean section rate for England &
Wales 21.3% of which 37% are elective; 62.9% emergency (0.1% data
missing).
— Over 70% of caesarean sections can be attributed
to the following 4 indications:
— dystocia (failure to progress);
— breech presentation; and
— Repeat caesarean section.
— Maternal request as reported by the clinician
was the primary indication for performing 7% of caesarean sections.
The results of the Audit provided valuable data and information.
The study does not show that Caesarean Section is unsafe.
(e) Commissioned NICE to issue Clinical Guidelines on
the use of caesarean sections
4.9.11 Besides commissioning the National Sentinel Audit,
in November 2000 the Department also asked the National Institute
for Clinical Excellence to draw up clinical guidelines on the
use of caesarean sections, using the extensive information collected
in the Sentinel Audit. The anticipated launch of the guidelines
is January 2004.
Remit for the Guideline on Caesarean Section
4.9.12 NICE received the following remit from the Department
of Health and National Assembly for Wales in January 2001 as part
of the Institute's second wave programme of work.
"An audit is being funded by NICE and the preliminary
results should be available towards the end of the year. Following
the results of the audit, which is looking at a vast number of
variables, we would like NICE to produce a set of evidence based
guidelines for when a CS is appropriate and the circumstances
under which routine procedures in normal labour may be unnecessary".
Objective
4.9.13 The Institute's clinical guidelines will support
the implementation of Children's National Service Frameworks (NSF)
in those aspects of care where a framework has been published.
The clinical guidelines and technology appraisals published by
the Institute after a NSF has been issued will have the effect
of updating the framework.
Clinical Practice
4.9.14 Caesarean section is indicated when it is agreed
that the foetus or mother will benefit from a higher probability
of a healthy outcome than if a vaginal birth were attempted. However,
there is little robust evidence documenting the magnitude and
balance of short or long term risks or benefits, associated with
either caesarean section or vaginal birth.
Population
4.9.15 The guideline should offer best practice advice
on the care of women during pregnancy, birth and in the postnatal
period who may need or have a caesarean section. The guideline
will not offer advice on the risks and benefits of caesarean section
as a therapeutic intervention for specific clinical conditions
arising during pregnancy. Also it will be beyond the scope of
the guideline to address the needs of pregnant women or babies
with rare conditions, or with complex or unusual co-morbidities
eg maternal congenital heart disease.
Health care setting
4.9.16 The guideline will cover the care that is received
from primary, community and secondary health care professionals
who have direct contact with and make decisions concerning the
care of women during pregnancy, birth and in the postnatal period.
Interventions and treatment
4.9.17 The guideline will include:
(i)
Indications and contra-indications for caesarean section including
(eg breech birth, vaginal birth after caesarean section, and multiple
births).
(ii)
Preoperative assessment including alternative effective management
strategies which avoid caesarean section.
(iii)
Evaluation of the risk and benefits of caesarean section including,
where there is evidence to support it, long term maternal medical
and psychological problems.
(iv)
Interventions or clinical practice likely to reduce maternal and
neonatal physical and psycho-social morbidity from caesarean section—including
those associated with anaesthesia.
(vi)
Postnatal management of mother and baby including (eg pain control,
postnatal help from professionals and family, and feeding).
(vii)
Aspects of organisation and environment which directly relate
to the improvement of outcomes and the reduction of caesarean
section rates where appropriate.
Presentation
4.9.18 The guideline will be available in three forms:
— The full guideline containing the evidence base
used by the developers.
— A short form version, using a standard template,
which will form the Institute's guidance to the NHS including
a clinical practice algorithm.
— A version prepared specifically for pregnant women
and their partners will interpret the recommendations made in
the Institute's short form version and will be designed to help
patients to make informed choices about their care.
(f) Children's National Service Framework
4.9.19 The next step in the process is the development
of the maternity module of the Children's National Service Framework
which will cover the wider issues around caesarean sections, and
will use the extensive data collected in the Sentinel Audit as
well as other available research. As part of the process to develop
national standard of intrapartum care a Birth Sub-group has been
set up which includes members with a wide range of experience
and professional backgrounds ie users, midwives, obstetricians
and anaesthetists.
4.9.20 The Group will consider the development of a care
pathway for women with the emphasis on normalising the birthing
process, even for those women who may have an underlying or pre
existing medical condition. The group has identified a number
of key themes where they feel the most impact can be made to improve
the care for women which may include one to one care in labour,
pre or early assessment of labour, etc.
OTHER ISSUES
One to one care during established labour
4.10.1 The Department is aware of research—in particular
the Ellen Hodnett research (Canada) which shows that one to one
care in labour, has a positive impact on CS rates whether supported
by midwife, auxiliary nurses or other staff. As it is for each
health community to decide on the pattern of local service provision,
it is for Trusts also to be more flexible in planning relevant
and appropriate staffing to provide one to one care in labour.
The last English National Board's Report on Midwifery Practice
Audit 2000-2001 found that the percentage of units not able to
provide one-to-one midwifery care to each woman in labour, reduced
from 28% in 1999 to 22% in 2000 ie 78% do provide one to one care
to all women in labour.
4.10.2 The Report of the Sentinel CS Audit indicated
that direct extrapolation to the provision of one to one midwifery
care and caesarean sections, should not be made from the extensive
data collected in the Audit. However, there is some evidence from
other studies that continuous support for women in labour leads
to a reduction in CS rates, but these studies have included support
from both professional and lay people. The Department has already
said that the gold standard for maternity care should be that
every woman should have access to one to one care when in established
labour 100% of the time. The Children's National Service Framework
will set out how best we can achieve this gold standard and a
timetable for doing so.
Information to women
4.11 The Department has also improved the provision of
information to women on caesarean sections. From September 1999,
The "Pregnancy Book", which is distributed free
of charge to all first time mothers contains additional information
on CS.
5. THE PROVISION
OF TRAINING
FOR HEALTH
PROFESSIONALS
Education and training
5.1 Nursing and Midwifery Council 2002 requirements for
educational programmes leading to health visitor registration
specify a number of competencies relevant to supporting women
in the ante and post-natal period. These include:
— Managing changes and transitions such as parenthood.
— Identifying needs relating to physical health
and well-being eg growth and development.
— Providing accurate, up to date and evidence-based
information on health and social well-being, the factors that
affect it and services and resources to promote health and social
well-being.
5.2 Health visiting practice has a strong family focus
and this is likely to be reflected in the theoretical and practical
elements of most pre-registration courses. The content of health
visitor training is likely to be further reviewed once the Nursing
and Midwifery Council has determined the format of the professional
register.
5.3 The post registration training needs of health visitors
are determined locally through skills auditing of teams against
priority local needs and through the appraisal process. As a result
a proportion of health visitors will have undergone a range of
additional training around provision of parenting support.
Workforce
5.4 The vacancy rate for health visiting posts amounted
to 2.7% in 2002. However, there is considerable variation across
the country. Whilst many PCTs report no vacancies some inner city
PCTs report rates that are significantly higher than the national
average. There is planned expansion in commissions for health
visitor training places over the next two years. Overall nursing
numbers have increased by 39,500 between 1997 and March 2002,
increasing the pool from which community practitioners, including
health visitors, can be drawn.
Current Department work
5.5 The Department of Health has run a three-year development
programme to strengthen the family centred public health role
of health visitors. Supporting practitioners to better target
their services towards priority health issues and disadvantaged
groups and communities has been a major thrust of this work.
This is coherent with evidence on the importance of improving
family support for people from low-income backgrounds in narrowing
the health gap and achieving the health inequalities target on
infant mortality. The Children's National Service Framework currently
in preparation should provide further impetus for improved family
support.
Workforce
5.6 A Primary Care Recruitment, Retention & Return
project, led by the South Yorkshire Workforce Development Confederation
has been established to support PCTs in recruitment and retention
of health visitors and other community practitioners. The taskforce
is engaging with a wide range of stakeholders including the CPHVA,
Leadership Centre, Modernisation Agency and Changing Workforce
Programme. A dedicated recruitment and retention leaflet and a
tactical advertisement aimed at community nurses and health visitors
have been developed in partnership with the CPHVA.
Modernisation Of Pre-Registration Education and Training For
Allied Health Professions (AHP's) Including Physiotherapy And
Diagnostic Imaging
5.7.1 This programme of work includes:
— Physiotherapists need to be included given their
role in antenatal services.
— Meeting the Challenge, A Strategy for the Allied
Health Professions, (November 2000.) Announced the modernisation
of pre-registration AHP education and training.
— In August 2001, 13 sites were selected as the
first wave of modernising AHP pre-registration education and training,
working in partnership with 11 Workforce Development Confederations
(WDC's).
— Eleven modernisation sites include undergraduate
physiotherapy education and seven include undergraduate radiography/diagnostic
imaging. Please see appendix 1 for details.
— £3.3 million of development funding is being
invested in these first wave courses from 2001/02-2003/04. The
first student intakes were in 2002.
5.7.2 Professions covered in the first wave include:
— Physiotherapy—who play a role in maternity
care to ensure well being of mother;
— Diagnostic and Therapeutic Radiography—who
also provide ultra sound services.
Undergraduate Medical Education
Selection, Admissions and Curriculum Content
5.9.1 Undergraduate (pre-registration) medical education
is primarily the responsibility of universities funded by the
Department for Education and Skills through the Higher Education
Funding Council for England (HEFCE).
5.9.2 All aspects of selection and admission are the
responsibility of individual universities and medical schools.
The Council of Heads of Medical Schools produced nine "Guiding
Principles for the Admission of Medical Students" in 1999.
Medical under graduate curriculum
5.9.3 Individual university medical schools determine
their own undergraduate medical curriculum in the light of recommendations
from the General Medical Council's Education Committee, which
has the statutory responsibility to determine the extent and knowledge
and skill required for the granting of primary medical qualifications
in the UK.
5.9.4 The Education Committee's most recent recommendations
on undergraduate medical education are contained in "Tomorrow's
Doctors" which was published in July 2002. The GMC's recommendations
provide the framework that UK medical schools use to design detailed
curricula and schemes of assessment. They also set out the standards
that the GMC will use to judge the quality of undergraduate teaching
and assessments when they visit medical schools and ask for written
information.
Postgraduate medical training (See Annex 2)
5.10.1 The content and standard of postgraduate medical
training is the responsibility of the UK competent authorities,
the Specialist Training Authority (STA) for specialist medicine
and, for general practice, the Joint Committee on Postgraduate
Training for General Practice (JCPTGP). Their role is that of
custodians of quality standards in postgraduate medical education
and practice. They are independent of the Department of Health.
In addition, the General Medical Council's Education Committee
has the general function of promoting high standards of medical
education and co-ordinating all stages of medical education to
ensure that students and newly qualified doctors are equipped
with the knowledge, skills and attitudes essential for professional
practice.
5.10.2 All of these bodies have a vested interest in
ensuring that doctors are equipped to deal with the problems they
will encounter in practice—both in hospital and in general
practice including the provision of maternity services. It is
not however practicable or desirable for the Government to prescribe
the exact training that any individual doctor will receive.
5.10.3 The General Medical Council has recommended that
at the end of their undergraduate course, all students will have
acquired a knowledge and understanding of, among other things,
reproduction including pregnancy and childbirth, fertility and
contraception and the psychological aspects of this.
Nursing & Midwifery
Modernising Midwifery Education
5.11.1 The Department and the Royal College of Midwives
(RCM), in consultation with the UKCC and English National Board,
prior to their demise, considered ways in which we can both consolidate
and continue to progress the modernisation of midwifery education.
5.11.2 We (DH and RCM) issued a joint Statement of Intent
in July 2001 which set out some of the key principles relevant
to midwifery education, such as a health focus to the programme,
ensuring progression of experience, lifelong learning and the
integration of theory and practice. These principles are key to
the midwifery philosophy and also complement and support the policy
service modernisation developments in the NHS.
5.11.3 ENB then hosted two workshops, in October 2001,
for key stakeholders in midwifery education across England. The
aims of the workshops were to facilitate joint exploration of
the implications of the Statement and identify what action must
be taken by the midwifery profession, alongside that already underway,
to address future challenges.
5.11.4 The DH and RCM are now considering reissuing an
updated version of the joint Statement of Intent.
Communication Skills
5.12.1 Demonstrating competence in communication skills
is a pre-condition of qualification to deliver patient care (NHS
Plan), of which maternity services are one element. A joint statement
relating to communications skills is in the final stages of preparation
following discussions between the Department of Health, Universities
UK, the Health Professions Council (HPC), the General Medical
Council (GMC) and the Nursing and Midwifery Council (NMC). It
sets out guiding principles relating to the commissioning and
provision of communication skills training, and the support for
healthcare students at pre-registration and undergraduate level.
The statement support the recently introduced Quality Assurance
Agency benchmark statements for education which contain generic
and profession specific communication skills standards, such as
those for Midwifery, and is due to be issued late February/March
2003.
5.12.2 Ensuring that healthcare students are suitably
prepared for their first post is only the foundation on which
they will continue to build during their careers. The NHSU are
currently working on communication skills for all healthcare staff
including an induction and communication skills programme for
all new NHS staff, and an advanced programme for clinicians in
specialist practice areas initially working with Cancer patients
but likely to be the blueprint for other speciality practice.
However at the point of professional registration, and seeking
their first post, all healthcare students as a minimum should
have the proven ability to:
5.12.3 Identify and apply the communication skills required
in practice to improve patient care management and patient satisfaction
with their care.
Communicate effectively with fellow professionals and other healthcare
staff.
Recognise their communication skill limitations in specialist
practice and be committed to personal development in these areas
through post registration and continuing professional development
opportunities throughout their careers.
Post-Education Training (See Annex 3)
5.13.1 The Government's approach to post-registration
learning and development in delivering the modernisation agenda
for the NHS is to encourage integrated service and workforce development,
with the commissioning of learning and development being more
directly informed by service plans and the needs of patients.
This implies less emphasis on uni-professional, nationally driven
curricula, and more on a multi-professional, competence-based
approach.
5.13.2 It is of course crucially important that professional
standards are maintained and continuing professional development
(CPD) appropriate to support re-registration is commissioned by
Workforce Development Confederations (WDCs) and local NHS employers.
The Department of Health has now gone out to tender to develop
a framework for health professional learning beyond first registration,
and we anticipate that the work will be completed by July 2004.
It will support WDCs in commissioning more innovative ways of
providing learning, more appropriate to the patient-centred approach,
while ensuring that standards are maintained and CPD needs are
met.
Quality Assurance
Pre-Registratation
5.14.1 Pre-registration education and training programmes
for midwives are usually provided through the Higher Education
Institution (HEI) and must be already approved by the Nursing
and Midwifery Council (NMC). Although individual programmes vary
they must all comply with the standards and requirements set down
by the NMC. In addition such programmes are quality assured by
the NMC, by the HEI and by the workforce development confederations
(WDC). They must also meet with the Quality Assurance Agency
(QAA) midwifery benchmark statements and codes of practice.
5.14.2 The QAA, under contract with the DH in England,
has conducted six prototype reviews of NHS funded programmes including
midwifery within six higher education institutions, prior to a
full roll out of reviews in 2003-06. The Department of Health
is working in partnership with the NMC and WDC's to facilitate
the development of this new streamlined and integrated approach
to quality assurance.
5.14.3 A number of factors, including the advent of benchmark
statements for higher education programmes, have combined to create
the opportunity to sharpen the focus of quality assurance of NHS-funded
nursing and allied health professional programmes. In 2000-01,
the Department of Health contracted the QAA to produce benchmark
statements in health related subjects. Stakeholders worked collaboratively
to develop benchmarks for healthcare educational programmes covering
11 professions that include amongst others midwifery. The 11
sets of benchmark statements have been produced to a standard
format and within an emerging shared health professions' framework.
Post-Registration
5.15.1 Qualified practising midwives are obliged to undertake
continuing professional development, as specified by the NMC regulations
for midwives to ensure that their practice is up to date. In
addition there are a number of post registration programmes for
midwives that are quality assured by the Nursing and Midwifery
Council, Higher Education Institutions and Workforce Development
Confederations.
6. CONCLUSION
6.1 The focus of the Department's work to modernise maternity
services—the Children's National Service Framework and accompanying
work to modernise maternity services, will aim to ensure the following
principles under pin maternity care in the future:
— The service provides the best possible care for
both mother and child. Services should be based on the best available
evidence and good practice guidelines.
— The planning and delivery of maternity services
should focus on approaching each woman as an individual with different
social, physical and emotional needs as well as specific clinical
factors that may affect her pregnancy. Her pregnancy must not
be viewed in isolation from other important factors that may influence
her health or that of her developing baby.
— Maternity services should be as safe as possible,
acceptable to women and flexible enough to accommodate a woman's
choice or changing circumstances.
— If women or babies do develop problems, or are
sick, they need prompt access to high quality, comprehensive medical
services.
— Modern maternity services should be provided in
a variety of settings and imaginative in their approach.
— Modern maternity services should ensure, care
is fully integrated with the overall health needs of a woman and
her family.
— Modern maternity services should make the best
use of available skills and contribute to extending professional
roles and competencies and recognises the needs and expectations
of health care workers.
— The service should recruit and nurture clinical
leaders who are committed to and effective in implementing evidence
based best practice, continuous quality improvement and new initiatives.
— The service takes pride in a high spontaneous
birth rate, and good outcomes for both mother and baby.
February 2003
Annex 1
MODERNISATION SITES
| First Wave Site | Lead WDC
| Professions/Programmes Covered |
| University of Teeside | Durham & Teeside
| Physiotherapy
Occupational Therapy Diagnostic Radiography Chiropody/Podiatry
|
| University of Northumbria | Northern England
| Physiotherapy Occupational Therapy |
| University of Salford | Lancs & South Cumbria
| Physiotherapy
Occupational Therapy
Diagnostic Radiography Chiropody/Podiatry
|
| St Martins College Carlisle |
| Occupational Therapy
Diagnostic Radiography
|
| York St. John College | North & East Yorks
| Physiotherapy
Occupational Therapy |
| University of Huddersfield | West Yorkshire
| Physiotherapy
Chiropody/Podiatry |
| Sheffield Hallam University | South Yorkshire
| Physiotherapy
Occupational Therapy
Diagnostic Radiography
Therapeutic Radiography
(With links to Nursing, Social Work and Operating Department Practice)
|
| University of Coventry | West Midlands North
| Physiotherapy
Occupational Therapy |
| Christchurch Canterbury University College |
Kent, East Sussex
and Surrey | Physiotherapy;
Occupational Therapy
Diagnostic Radiography
(with links to nursing and medicine)
|
| University of Brighton | |
Physiotherapy
Occupational Therapy
Chiropody/Podiatry
|
South Bank University/
Kings College London
| South East London | Physiotherapy
Occupational Therapy
Diagnostic Radiography
Therapeutic Radiography
|
Universities of Exeter & Plymouth, St. Loye's Foundation, College of
St. Mark & St. John
[Peninsular Collaboration]
| Somerset, Devon & Cornwall | Occupational Therapy
Chiropody/Podiatry
Speech and Language Therapy
(with links to nursing, midwifery and medicine)
|
| University of Southampton/University of Portsmouth
| Hampshire, Isle of Wight & West Surrey
| Physiotherapy
Occupational Therapy
Diagnostic Radiography Therapeutic Radiography Chiropody/Podiatry
|
Annex 2
BACKGROUND ON
POSTGRADUATE MEDICAL
TRAINING
Pre-registration Year
1. Following graduation from medical school doctors are
given provisional registration with the GMC and must spend a year
in general clinical training. This period is also the responsibility
of the university of graduation and, if completed successfully,
the doctor is eligible for full registration with the GMC. Training
is supervised by the postgraduate dean and usually takes place
whilst employed as pre-registration house officers (PRHOs) in
approved hospital placements and in some general practices.
Basic Specialist Training
2. Following the PRHO year and full registration, doctors
ideally spend two to three years in the Senior House Officer (SHO)
grade during which they acquire increased but supervised responsibility
for patient care and develop a wide range of general and basic
specialist skills needed for their chosen speciality. Work is
underway to introduce a number of improvements to the educational
content of the SHO experience without compromising the very significant
service contribution that these doctors provide. After basic
specialist training doctors either enter specific vocational training
for general practice or a particular higher specialist training
programme.
Vocational training for general practice
3. Vocational training for general practice, which has
as its end point award of EC recognised certificates of prescribed
or equivalent experience, has been mandatory for GP principals
since 1979. This phase is usually one year in addition to two
years Basic Specialist Training. Since January 1995 all GPs must
either be vocationally trained or possess an "acquired right"
to continue to work in general practice. No doctor may now enter
general practice, other than as a registrar (trainee), without
an appropriate certificate. Compulsory summative assessment was
introduced in January 1998 as a precursor to certification. This
is a major and much welcomed development.
4. Doctors from other EEA member states are entitled
to work in general practice in the UK if they possess a vocational
training certificate or an acquired right issued by their home
state. Some EEA countries have been much more liberal with the
issuing of categories of acquired rights than the UK, and cases
have been encountered of doctors who possess an acquired right
to work in general practice despite having neither experience
nor training. At the same time, doctors from outside the EEA (mainly
from Australia or New Zealand) who do not have the requisite certificate,
are usually unable to work in UK general practice in any form
without undertaking some UK training.
Higher Specialist Training
5. Doctors entering higher specialist training compete
for appointment to one, or occasionally two, of 65 different specialist
training programmes. Higher Specialist Training normally lasts
years but, depending on the specialty, can range between 3-6 years
in length. The recommendations of the 1993 report Hospital
Doctors: Training for the Future (known as the Calman Report)
have been implemented throughout the NHS. These represented a
major reform of higher specialist training. Doctors entering higher
specialist training now have:
— a fully structured training programme;
— their placements planned as part of this programme;
and
— are required in many specialties to pass a test
of competence before they are eligible to apply for consultant
posts.
Annex 3
POST-EDUCATION
TRAINING
1. The Department of Health's approach to learning and
development for health professional staff is to establish a robust
system within which service and workforce planning and the development
of skills and expertise can be fully integrated. In practical
terms, local service plans, informed by the needs of patients
and what is required to deliver NHS Plan, NSF and other service
commitments, should determine the skills and competences needed
in the whole care team. This, in turn, should inform the Workforce
Development Confederations' (WDCs') education commissioning decisions.
The key is to facilitate flexible team working, focussed on the
needs of service users.
2. There is clearly a need to make sure that standards
of professional clinical competence are maintained, especially
when we are considering new roles and role expansion. This is
as important a consideration for employers and WDCs as for the
professional and regulatory bodies, given their responsibility
for clinical governance, but we recognise that it needs support.
Since the closure of the ENB, it is for the WDCs and HEIs to satisfy
themselves that programmes continue to meet standards that are
consistent with those established through the ENB approval process.
This was covered in guidance issued in November 2001. The guidance
stated that this approach should continue until such time as a
framework for supporting common standards could be developed.
3. We have now begun the process to develop a shared
framework for post-registration learning, which will be taken
forward in collaboration with all stakeholders, in particular
the professional and regulatory bodies, HEIs and WDCs. It will
set out the standards and processes that need to be adhered to
when developing learning provision for professionals, either with
formal education providers or within the workplace. It will provide
a common approach to accreditation and quality assurance, to support
portability of skills across employers and team roles. It will
support maintenance of national standards but will not be prescriptive
about the content of courses. It is intended that the framework
should be available in about eighteen months time. The framework
will also provide a robust multi-professional structure within
which the best use can be made of existing or developing competence
frameworks, standards assessed and learning accredited. The work
will be done in collaboration with all the stakeholders.
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