Examination of Witnesses (Questions 20-39)
Tuesday 13 May 2003
MS JO
GARCIA, MS
SIMONE BAKER,
MS CHRISTINE
GOWDRIDGE, MS
JENNY MCLEISH
Q20 Dr Taylor: The Government, as
you may have realised, are very keen on taking the views of patients
and citizens, which is a tremendous move in the right direction.
Some of the information we have suggests that maternity services
liaison committees are really declining in number and effect.
Is that so? How do you feel that the actual pregnant ladies' views
should be best transmitted? Is it going to be through the new
Primary Care Trust Patient Forums or is there a place for maternity
services liaison committees to be resurrected? What are the views
of you all as a user?
Ms Baker: I sit on a maternity
services liaison committee in West Berkshire and I would say that
it seems quite an ad hoc arrangement. Nobody gets any kind of
expenses for attending meetings, which is fine, but consultants
and midwives are attending in their lunch breaks and the rest
of us are attending in our spare time, which we do not have very
much of. I think there is a great deal of value to be had if they
are properly structured.
Q21 Dr Taylor: Do you feel able to
make a difference through that meeting?
Ms Baker: I have made some small
differences, I think just by reminding them that there are other
groups that they do not always think about such as parents with
disabilities. My particular success was getting height-variable
cribs purchased for the maternity unit where I had my daughter.
I did not have that facility but I am happy in that small change
to know that disabled parents in the future have something that
I did not have. Ours works successfully in that you do not get
consultants ducking out; the consultants are round the table,
the anaesthetists are round the table and the maternity staff
are round the table all listening to what the issues are.
Q22 Dr Taylor: And they do listen?
Ms Baker: I think they do, yes.
I think they take on board what the issues are.
Q23 Dr Taylor: That is very encouraging
purely locally for you, but what is the picture across the country?
Ms Garcia: We have just tried
to survey all the maternity services liaison committees—I
sent that out just around Christmas for the National Service Framework
for Children inquiry. There are still more to come back in but
it looks as if, in some places, they are continuing to function
well but that, in other places, the change in service structure
means that it is not clear where they should be based. There is
a lack of clarity right now about what they should be doing. They
have been fantastically useful and they are also the one place
where women using the service can have a real impact. It is very
often a lay person chairing the committee and they have been incredibly
important, but I think that you need to look quite carefully at
how the new structure of services is going to affect that because
they are important and it has been difficult to get, for example,
any reimbursement for lay people on the committees and that depends
entirely on the local health authorities' approach and, now that
we are moving to PCTs, there is going to be a change there. I
think it is important. All the learning and skills and confidence
that has been built in gradually with these committees and lay
people needs to be kept in order that that role can continue.
Q24 Dr Taylor: Would you have a steer
on how this should fit in with patient forums, whether they are
PCT forums or hospital trust forums?
Ms Garcia: It feels to me worth
having something maternity service related in order that you have
the meeting between care givers( representatives and women with
special interest in that field. I do not know enough about local
arrangements; I am sure that they must vary a lot.
Q25 Dr Taylor: So, they should be
integrated into patient forums in some way?
Ms Garcia: I hope they will feed
into them, but it must be quite up in the air at the moment.
Ms McLeish: There is also the
question of whether that type of group is most likely to attract
the more marginal woman to have her voice heard on them. It is
pretty clear that that is not who is represented on them. If that
is the only mechanism for lay people to feed into maternity services,
I think that does leave a gap and it is a gap which is very difficult
to fill by definition. If an area is really serious about hearing
the views of its full local population and reflecting them, they
cannot simply rely on voluntary committees and groups of people
who are confident to come to groups and speak the language of
the group in doing that and they have to do much more by way of
local health assessments and needs assessments to work out who
they have in their population who is not being heard.
Q26 Dr Taylor: The aim of the Commission
for Public and Patient Involvement in Health is to target the
disadvantaged groups to get onto these forums, so one thing that
we certainly ought to say is to connect maternity services liaison
committees with the Commission for Public and Patient Involvement
in Health.
Ms Gowdridge: And it is timely
to be doing that. Also, it is probably worth revisiting some of
the work that the Changing Childbirth team did on accessing
particular women. We published a report with them—we held
four conferences nationwide—called Listen with Mother
that was looking at precisely those issues, so I would have thought
that report and the report of the Changing Childbirth team
on maternity services liaison committees would be useful for informing
your recommendations on that.
Q27 Dr Taylor: It is super to know
that yours is working.
Ms Baker: Yes.
Chairman: That moves us on to the next
topic. We have been slightly depressed by some of the evidence
about what the Government can do.
Q28 Dr Naysmith: Do you think that
the recent Children's National Service Framework is going to make
any difference in terms of the availability of resources in terms
of improving the services locally, particularly thinking about
access to maternity services?
Ms Gowdridge: I think it would
be difficult not to. I am optimistic about some of the process.
Again, it is a long-held concern of mine that women are only considered
when they are pregnant and the very name of the Children's National
Service Framework suggests that women are only important insofar
as they give birth to the children. If you have been smoking all
your life and suddenly someone is concerned about the fact that
you are smoking only because you are pregnant, I suspect that
you are less impressed with the advice to "give up now".
Q29 Dr Naysmith: It could also be
something to do with what Jenny was saying earlier on, that it
is a good opportunity for both child and mother.
Ms Gowdridge: Yes, I think that
is absolutely right.
Q30 Dr Naysmith: It is a fairly small
chunk of a maternity.
Ms Gowdridge: Yes.
Q31 Dr Naysmith: Smoking cessation
and depression and possible women-only day centres and things
like that.
Ms Gowdridge: I think it will
be more than that. I think it will be about organisation of maternity
services, or I am hoping it will. I think it will be more. I was
talking to someone who has been working with the NSF on hearts/cardiac
who was saying how exciting it is working with a national service
framework. I hope that it will give people within the maternity
services a feeling of excitement too because midwives really need
a bit of excitement with the pressures they are under. We are
still optimistic about it.
Ms McLeish: Another perspective
is that one of the modules within maternity or one of the sub-groups
within maternity is inequalities in access. They clearly have
that in mind. If the NSF makes a difference, it is likely to be
in the resources question, but the other half of the equation
is the people. The NSF is not going to change the hearts and minds
of people who are finding it difficult dealing with people who
are different and that is another whole angle and what national
policy ever could unless it was about actually going down and
training because the NSF is not going to legislate for unprejudiced
staff
Q32 Dr Naysmith: Just to finish off
this section, what would you recommend? I think you have already
made the recommendation, it is training, training and training.
Ms McLeish: For that problem,
yes.
Ms Garcia: But I want to know
if it works.
Q33 Sandra Gidley: That is the researcher
speaking and quite right too!
Ms Garcia: You can put a lot in
and you can make things worse. If you do not do it right, if you
train people in a way that is not, then you make them worse.
Q34 Dr Naysmith: How could you do
that?
Ms Garcia: I am not saying it
lightly but, if you are going to put money in—and you should,
I absolutely agree—to make it better for women at the point
that they interact with the service and to help the service reach
them and meet them, you have to find out what works. If sending
in a teacher to write on the blackboard is effective, then let
us do it, but it might not be the way and we need to think, how
do you communicate with people, care givers of all types, in a
way that makes a difference? Is it useful, for example, if, at
the end when a women is finished with maternity care, her experiences
get fed back? Does that help or is it really off-putting and makes
the midwife feel worse on the ward? It is a question. I feel very
passionately that you must try and find out what things are going
to make a difference and, in this country, nobody has really tried
to go back in and make a difference to that personal point at
which . . . The extreme examples, particularly as Jenny showed,
are asylum seekers and stretching right through to just casually
bad care where you do not get listened to, how do you stop that?
Ms McLeish: May I just add, to
be slightly more optimistic, that there is no systematic evidence
about that but there are examples of good practice. For example
in Manchester, when they changed the practice of caring for drug-dependent
women who had previously been sent off to social services and
the baby put in care to a much more holistic version of trying
to get the midwives to care for the woman as a woman and not to
take the baby away at birth and try and get her to solve some
of her social problems to assist her off drugs, before they did
any of that, they brought in in-service reflective training. In
other words, getting all the staff to be really open about their
attitudes and honest about what they did feel and why people felt
so repelled by offering good care to this group of women and did
not want to touch them and so on, and that did actually change
the attitude. Then they brought in the change to policy and it
has had really, really good results.
Ms Garcia: Thank you for helping
my scepticism. I know that I always take a bit of a sceptical
line, but it is great to hear good examples. It is just that you
do not want good practice not to be checked out to see what really
works.
Ms Gowdridge: Just to add to the
training issue, we held a conference a while back on parents with
disabilities and the midwives who came to that conference said,
"Goodness me, we are not told about parents with disabilities
having babies." You do not have to wait for the evidence,
Jo. That must help.
Ms Garcia: I am not trying to
be legalistic and say that you have to check everything out, I
am just saying that if you really want to make a difference, you
have to look and see what works and what really makes a difference.
Q35 Sandra Gidley: Are you talking
about audit? Audit was very, very trendy in the Health Service
about eight years or so ago and since and some organisations have
embraced it quite enthusiastically, but it is really a snapshot
of what is happening and unless you actually work on results to
improve them, you are aware that it is not worth doing. Has anybody
every audited maternity services in this way to find out what
women think about access and what the problems are?
Ms Garcia: There are some things
like audits and sometimes it is about audit just to say, if you
feel there is a category of women who are not getting reached,
can you improve that just by measuring across time? Sometimes
it is much more about more fundamental research just trying to
see what really makes a difference to women in terms of their
well being, health, attitudes and experiences and that may be
more difficult to set up.
Q36 Dr Naysmith: What do you think
are the main areas? What do you think are the main gaps in our
knowledge where you want to get three years' funding from some
social science research council?
Ms Garcia: I think it is quite
important, if we are worried about antenatal care, that you really
do need to know who is getting care, where they want it and whether
it is good enough. Let us take the example that I gave about antenatal
screening where there is clear evidence that women from South
Asian backgrounds are not getting good enough care, but we do
not know what the blocks are and we do not know whether they are
offered screening, so I really need to know that before making
a recommendation about changing the service. We need to know where
the gaps are happening. I think there are little hints about particular
categories, often women with language issues who do not get good
care, but we need to know in detail in order that we can change
it. That is one key area. For me, the other area that keeps coming
up is very young mothers and where, for example, as far as I could
find, there was very little evidence about smoking and breastfeeding
in relation to very young women and that ties into work about
adolescent health and if we could bring together people in the
NSF, for example, if they could bring together the interest in
teenagers, the very young mothers' interests within a maternity
group, that would be terribly helpful and then that would lead
to proper research about, say, what might be good to promote breastfeeding
to very young women. I am sure that it needs to be different and
thought out. What helps with smoking in young women? Those issues
have not been researched as far as I know, so that is a place
where one could have a very good interaction between those two
bits of the NSF and make a difference to a group of women who
we all know are not having as easy a time as they should be. That
is another key area for me.
Q37 Dr Naysmith: Finally on this,
when we had youngsters in we were talking about sex education
and they were very keen on peers coming in, going into schools
and talking about that. What would be the equivalent for you?
Would it be women who had undergone various procedures and were
dissatisfied with them? Would it be training midwives? Do you
think there would be any benefit in having that happen or having
that incorporated in a training module?
Ms Garcia: It is a good idea.
Q38 Dr Naysmith: Sort of peer experiences.
Ms McLeish: I think it is lot
to ask the women. It is a very interesting idea which you would
have to handle incredibly carefully because certainly my experience
with very, very vulnerable women is that they are so frightened
of the service providers; they feel so unequal to them; they do
not challenge them when bad incidents happen; they do not report
them to anyone; they do not go anywhere to say, "This has
happened to me". To get someone to go back into that environment
and stand up and put their head above the parapet . . . You do
get some very angry women who would absolutely love a chance to
confront people, but confrontation would not be the aim. I think
having the case histories available for discussion and reflection
within departments would be excellent. I think asking the women
themselves to go and do the training is something you would have
to think very, very, very sensitively about how you would protect
those women who were taking that role.
Chairman: Let us move on to particular
areas. We have talked quite a bit about ethnic minorities, asylum
seekers and refugees.
Q39 Sandra Gidley: I want to move
on to minority ethnic groups and would really like to begin by
asking, what evidence is there about the sort of inequalities
that might be experienced by women in these groups?
Ms Garcia: I think there is a
prima facie problem about not having language services
available. You cannot believe that care can be good if you cannot
communicate with the woman. That is almost a given and I do not
need anyone to prove that to me! Obviously, language is not everything
and racism and poor experiences of care because of ethnic background
are very important too and that takes us back to what we talked
about regarding training. That is on one side. In terms of evidence
that services are not meeting their needs, it is quite hard to
get that but the reviews that we have done show that particularly
women of South Asian origin— Indian, Pakistani and women
of Bangladeshi backgrounds—are probably not getting the
sort of antenatal care of the quality and perhaps pattern of care
that they should be. It will not be everywhere. It will be very
good in some places, but there may be some problem there that
needs to be dealt with, particularly in relation to screening.
A very good example is that screening for the haemoglobinopathies
appears not to work well in women from South Asian backgrounds.
Women of Cypriot and other Mediterranean origin are usually offered
and take up screening if they need it, but the women who may be
at risk from some other backgrounds, particularly, say, Pakistani,
do not get the service they should do. There are some very specific
areas which could be targeted and the National Screening Committee
is looking at those areas to try and improve that sort of service.
That is an area where I know there are likely to be problems.
Moving in to care in labour and postnatally, I do not have any
evidence, so I do not know what the problems might be, broadly
speaking, if you are looking at ethnicity across the whole of
England and Wales.
Ms McLeish: There is one small
bit of evidence that I am aware of which was the National Caesarean
Section audit which found that black African women are more likely
to have a caesarean irrespective of health. There has been no
attempt to explain that but that exists as a finding that needs
to be investigated as to why that should be.
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