APPENDIX 37
Memorandum by Birmingham Women's Health
Care NHS Trust, Maternity Services Directorate (MS 40)
Birmingham Women's Hospital is a stand-alone
trust providing health care for women, including some 6,000 deliveries
per year. It provides tertiary maternity and neonatal services
for the West Midlands, with a regional Fetal Medicine service
and the Academic Department of Obstetrics and Gynaecology.
1. The collection of data from maternity
units. Obstetrics has led the way in the collection of national
outcome data. This has however been largely in relation to maternal
and fetal mortality, and, invaluable though this has been, it
does not offer a basis for assessing the effect of changes in
practice, or provide methods of measuring performance. Most maternity
units have some form of electronic data capture, but most systems
are antiquated and incompatible. It is imperative that there should
be a national standard data set, and preferably a nationally developed
software package. Existing local and national efforts need to
be co-ordinated, and strong leadership is essential.
2. The staffing structure of maternity care
teams. The structure of maternity care teams must take into account
the dual needs of mothers and babies for unobtrusive support in
the majority of cases and a high technology safety net for the
minority. The backbone of the service is the midwives, neonatal
nurses and support workers, but there is an increasing demand
for instantly available skilled medical attendance. In our hospital
we aim to separate as far as possible the low-risk "normal"
mother from those with special needs for antenatal or perinatal
care, with greater emphasis on midwifery-led care and the development
of a dedicated midwifery unit adjacent to the high-risk delivery
suite.
There are several conflicting goals in designing
the staffing structure. There are shortages of all grades of staff,
perhaps most obviously of medical staff, produced by the sudden
reduction in hours of work of the training grades. It is therefore
essential to devolve aspects of care as far as possible, with
eg midwifery assistants. Unfortunately this principle often founders
on the lack of staff to take up the load. Many traditionally medical
tasks may be performed by midwives, but there are not nearly enough
of them. There are many reasons for aiming for a high degree of
continuity of care, but restrictions to working hours and lack
of numbers make this difficult to achieve. Ultimately, the most
important thing is to have the necessary skills available to ensure
a successful outcome. In our unit, we seek to tackle the problems
in a number of ways:
— integration of the community and
hospital midwives;
— initial patient contact and "booking"
with the midwifery teams, with continuing midwife care or referral
for consultant booking as indicated;
— the development of generic antenatal
clinics and subspecialty teams;
— dedicated consultant sessions on
the delivery suite;
— daily consultant led elective caesarean
section lists; and
— increased out-of-hours consultant
input.
The principles for designing the medical workforce
were set out in the RCOG report "A Blueprint for the Future"
(December 2000) as follows:
— Sufficient trained specialists to
provide the basic service in obstetrics and gynaecology.
— Sufficient trained specialists with
advanced expertise in the different areas of practice to provide
care at the level currently referred to as "special interest/special
skills".
— Specialists trained to `subspecialist'
level to provide tertiary care and some services that it may be
appropriate to provide only at this level, such as oncology, assisted
conception, fetal medicine; 10-15% of consultants will be subspecialists.
— Specialists to take the lead role
in clinical governance, shaping services and training.
— Academic specialists who, in addition
to all of the above, can devote more time to research and lead
undergraduate education.
The committee is referred to this report for
more detail, but a key issue is the definition of a "trained
specialist" in this context. Despite the protests of trainees'
representatives, there is a strong argument that every aspiring
obstetrician should spend time after basic training consolidating
their skills and developing additional expertise prior to taking
on the traditional "consultant" role. Obstetrics is
a highly practical discipline where there is no substitute for
experience, but also demanding the stamina of youth. As services
become ever more "consultant-based" it will be essential
to maintain a balanced workforce, and if all young practitioners
remain in, and grow old in, the same unit throughout their working
lives, this will not be possible.
3. Caesarean Section Rates. This topic is
hotly debated, without agreement even on whether it is a good
or a bad thing. Lack of accurate national data (vide supra)
makes rational assessment difficult. There are however several
factors which may be implicated:
— Diminishing acceptance of risk.
— Increasing awareness of certain risks—eg
breech delivery, twins.
— Loss of manipulative skills especially
in forceps delivery.
— Rejection of rotational forceps in
favour of vacuum extraction— ?justified.
— Less-skilled intermediate medical
attendants.
— Multiplying effect of previous sections.
The outcomes of childbirth in the UK are actually
relatively good, and any crusades to change aspects of practice
such as the caesarean section rate should be approached with caution,
and only on the basis of reliable data and sound argument. It
is likely that a small reduction could be achieved with round-the-clock
care by old-school experienced obstetricians, but these are not
going to be available, and we shall probably have to aim for the
safest care with the resources which we have.
4. The provision of training for health
professionals who advise pregnant women and new mothers. The structure
of maternity care teams has been referred to above. Training must
reflect the evolving nature of the team approach to care, so that
all grades can make best use of their skills. Midwifery assistants
are being trained, and there is some progress towards training
operating department assistants to scrub for caesarean sections.
Medical training in obstetrics is however in some disarray following
Calman, the Temple Plan, and the European Working Time Directive.
There have been considerable improvements in formal teaching and
facilities for learning, but the highly restrictive working practices
resulting from all these changes have destroyed medical team-working
and the apprenticeship aspect of training which is so important
to the "craft" aspect of our discipline. The creation
of a "specialist" grade alluded to above would go some
way towards repairing the damage to training, as well as rapidly
producing more "trained" doctors to provide care.
The Temple Plan was sadly geared more towards
rectifying a perceived imbalance between training and service
grades than towards fulfilling service needs. While there has
been a modest increase in consultant numbers, there are currently
insufficient trainees for our needs. Similarly, we need to train
more midwives and more neonatal nurses. The calculations can only
be carried out on the basis of a proper assessment of future needs
and realistic service planning, with a firm political commitment.
ADDITIONAL COMMENTS
Resources are scarce. The configuration of maternity
services throughout the land owes more to history and politics
than to rational planning. Undoubtedly there could be some re-alignment
to make the best use of scarce manpower. We eagerly await some
national guidance on service configuration, and inevitably will
require some additional funding to engineer the necessary changes.
Specialist neonatal services are a particularly acute problem,
and lack of intensive care cots is leading to patients being shunted
back and forth across the country. This cannot be addressed by
rationalisation or re-alignment, but only by increased resource,
and the manpower does not currently exist.
February 2003
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