WRITTEN EVIDENCE
Memorandum by the Department of Health
(MA1)
1. INTRODUCTION
1.1 Tackling Health inequalities has been
a priority for the Government since coming to office in 1997 when
they commissioned Sir Donald Acheson's Independent Inquiry into
Inequalities in Health Report, published in 1998.
1.2 The Acheson Inquiry Report provided
a broad analysis of the social, economic and environmental determinants
of health inequalities. It identified support for mothers with
very young children as one of the top three priorities, highlighting
the importance of:
— a focus on the health of mothers
and young children in addressing infant mortality; and
— in the long term, breaking the intergenerational
cycle of health inequalities.
1.3 Care for mother and baby throughout
pregnancy and the early postnatal period can have a marked effect
on the child's healthy development, and on their resilience to
problems encountered later in childhood. There are many correlations
between the health of mothers and their babies. For example, there
are clear links between smoking in pregnancy and low birth weight,
which is in turn related to poor health outcomes for a child.
1.4 The NHS Plan, published in July
2000, set out a plan for investment and reform for the NHS. The
Plan made health inequalities a priority and contained a commitment
to establish the first ever national health inequalities targets.
These headline targets, chosen as high level measures of progress,
were announced in February 2001 in the areas of life expectancy
(by geographical area) and infant mortality (by social class).
1.5 For maternity services, this means knowing
where pregnant women are and how they want and need their care
delivered and configured. It means understanding the local patterns
of disadvantage and exclusion; and designing services that reach
out to ensure those most in need have prompt access to the support
they need.
1.6 The Maternity External Working Group
of the Children's National Service Framework (NSF) is working
to develop flexible models for maternity care, especially in the
antenatal and postnatal period, that support and strengthen universal
access; but at the same time, find new ways of providing accessible
and appropriate services for hard to reach and disadvantaged women,
their partners and babies.
1.7 Overcoming inequalities in outcomes,
some of which can be helped by improving access to antenatal care
services is perhaps the biggest and most important challenge addressed
by this NSF. We know that women from the most vulnerable groups
of society often find it difficult to access, or maintain access
with maternity services. We also know these groups of women have
the poorest maternal and neonatal outcomes. Excluded women also
tend to have a multiplicity of problems in conjunction with their
pregnancy.
1.8 The following sections detail major
areas of work that the Department of Health either sponsors or
knows about. Section two sets out the context of the cross Government
health inequalities strategy and how this will impact on inequalities
in maternal and child health. Section four describes the maternity
module of the NSF that will be the main vehicle for drawing all
of the areas of work together into a single coherent vision for
maternity services over the next ten years. Section five of the
memorandum sets out the range of services that are available for
disadvantaged groups.
2. HEALTH INEQUALITIES
STRATEGY—THE
CONTEXT FOR
ACTION
2.1 The Government has given a high priority
to tackling the causes and consequences of health inequalities
as part of its commitment to deliver social justice and economic
prosperity. This includes action on poverty, social exclusion
and inequality. In particular, it is committed to making substantial
progress towards the eradication of child poverty to break the
intergenerational cycle of health inequalities and poverty and
deprivation that begins at birth and continues throughout life
by reducing the number of children living in poverty by a quarter
by 2004.
2.2 Tackling health inequalities is part
of this overall approach across DH, the NHS and other government
departments is contributing to a wider strategy shaped by the
first-ever national health inequalities targets on life expectancy
and infant mortality. This includes addressing barriers and obstacles
to the use of services, including health services, that will have
an adverse effect on health. This will require more targeted services
and programmes to address the health needs of disadvantaged areas
and population groups. This includes setting new standards for
service provision and quality of care through The Cancer Plan
and NSFs on CHD, mental health and diabetes.
Infant mortality rates—current data
2.3 The Government has made it a priority
to tackle inequalities in infant mortality rates, and has set
a target in this area (see paragraph 2.7).
2.4 The infant mortality (by social class)
target presents a high degree of challenge, and action will be
needed across Government. Current data do not yet reflect on action
since the setting of the target, but do indicate that for infant
mortality, the gap continues to widen, confirming the difficulty
of turning around long-term social trends.
2.5 Latest data for 1999-2001 showed a continued
widening of the gap between "manual" groups and the
total population. Based on current trends, this gap is projected
to widen further by 2010. Latest out-turn figures overlap the
setting of the target, therefore it is not yet possible to comment
on changes in performance since the time when the target was set
(Feb 2001).
Department of Health initiatives/action
The Acheson Inquiry
2.6 Sir Donald Acheson's Independent
Inquiry into Inequalities in Health highlighted inequities
in access to health care and treatment and acknowledged that communities
most at risk tend to experience the least satisfactory access
to the full range of service provision, the so called "inverse
care law", although it did not specifically discuss inequalities
in access to maternity care. The Inquiry Report recommended that
providing equitable access to effective care in relation to need
should be the governing principle of all policies in the NHS.
Tackling Health Inequalities—Consultation
on a plan for delivery
2.7 In August 2001 the Government published
Tackling Health Inequalities—Consultation on a plan for
delivery. The document highlighted examples of good practice
and sought views on the actions needed to tackle health inequalities
and to meet the national targets that were a commitment from The
NHS Plan. One of the priority themes in the consultation document
was the need to produce a sure foundation through a healthy pregnancy
and early childhood. A follow up document, Tackling Health
Inequalities: The results of the consultation exercise, published
in July 2002, confirmed that there was strong support for the
priorities set out, including the focus on maternity, infancy
and early years.
Cross-Cutting Spending Review on health inequalities
2.8 In summer 2002, the Government completed
a Cross-Cutting Spending Review on health inequalities. This provided
an opportunity for the whole Government to focus on health inequalities
and establish priority areas for action to deliver the national
targets. A summary of the main findings, Tackling Health Inequalities:
Summary of the 2002 Cross-Cutting Review was published in
November, and set out the Government's long term strategy for
tackling health inequalities.
2.9 The Review identified the priority interventions
likely to make a major impact on the infant mortality target and
on early years development:
— building on Sure Start in improve
early years support in disadvantaged areas;
— reducing smoking in pregnancy;
— preventing teenage pregnancy, and
tackling its causes and effects;
— improvements in housing conditions
for children in disadvantaged areas;
— other forms of early interventions
for the NHS, for example to increase immunisation rates and breastfeeding,
improve diet, family support and education about infant sleeping
position.
National health inequalities targets
2.10 As part of the Spending Review 2002,
the two national targets were combined into one overall Public
Service Agreement (PSA) and this single target has also been included
in the National PSA for Local Government:
— By 2010 reduce inequalities in health
outcomes by 10% as measured by infant mortality and life expectancy
at birth.
2.11 The single target is supported by targets
on life expectancy and infant mortality, revised to reflect changes
in social class definitions and the abolition of Health Authorities:
— Starting with children under one
year, by 2010 to reduce the gap in mortality by at least 10% between
"routine and manual" groups and the population as a
whole. [The "10%" figure is subject to review of the
historic data, when available, to ensure that this target is still
realistic and challenging]
— Starting with Local Authorities,
by 2010 to reduce the gap by at least 10% between the fifth of
areas with the lowest life expectancy at birth and the population
as a whole.
2.12 Tackling health inequalities is a key
strand of the Government's Modernisation Programme designed to
develop responsive, effective public services and action is being
mainstreamed through programmes in the NHS and across Government.
Priorities and Planning Framework for the NHS,
2003-06
2.13 The Framework, published in October
2002, described the vision for services over the three years from
2003, and how national commitments translate into priority areas
and targets for the NHS and social services, and set out a summary
of the new system for planning and performance management. Health
inequalities have been given a high profile within the Framework,
sending a clear message to the service of the importance attached
to narrowing the gap in health outcomes. The Framework focuses
on reducing the gap in infant mortality and life expectancy at
birth, and on reducing teenage pregnancies. It contains supporting
targets including:
— Deliver a one per centage point reduction
per year in the proportion of women continuing to smoke throughout
pregnancy, focussing especially on smokers from disadvantaged
groups as a contribution to the national target to reduce by at
least 10% the gap in mortality between "routine and manual"
groups and the population as a whole by 2010, starting with children
under one year.
— Deliver an increase of 2 per centage
points per year in breast feeding initiation rate, focusing especially
on women from disadvantaged groups.
— Achieve agreed local teenage conception
reduction targets while reducing the gap in rates between the
worst fifth of wards and the average by at least a quarter in
line with national targets.
All-Government Delivery Plan on Health Inequalities
2.14 The Government has recognised that
health inequalities cannot be tackled by the NHS alone, but will
need a concerted effort across the whole of government, working
with a range of partners in the community, voluntary and business
sectors.
2.15 The Department of Health has lead work
to develop an All-Government Delivery Plan on health inequalities,
describing the complex health inequalities problem; the Government's
strategy to tackle it; the impact in communities of programmes
committed to the strategy; and how the implementation of the strategy
will be managed. The main findings of the Spending Review and
the health inequalities consultation have been fed into the Delivery
Plan, which will be published shortly.
Progress to date
2.16 Progress made to date includes:
— Reducing the number of children in
poverty—there are over 400,000 fewer children in low income
households since 1998
— improved maternal and child health
care—where work on the National Service Framework for children's
health and social care is well advanced, with inequalities in
health and social care provision a priority
— improved support for child development
through 439 local Sure Start programmes and related initiatives
— smoking througout pregnancy decreased
from 23% in 1995 to 19% in 2000 in England and an increase in
breast feeding initiation from 68% in 1995 to 71% in 2000 in England
and Wales (although a significant social variation remains)
— the establishment of the Teenage
Pregnancy Unit in 1999 to implement the strategy in the Social
Exclusion Unit report on Teenage Pregnancy. The NHS Plan stressed
the Government's commitment to reduce the rate of teenage conceptions
by 15% in 2004 and by half in 2010. A third of teenage mothers
aged 16-19 now participate in education, training or employment,
double that since 1997
— falls of 9% in the under 18 conception
rate and 10% in the under 16 conception rate since 1998, (the
baseline year for the Teenage Pregnancy Strategy)
3. WHY MOTHERS
DIE 1997-99: THE
CONFIDENTIAL ENQUIRIES
INTO MATERNAL
DEATHS (CEMD)
3.1 Although very few mothers die in childbirth
CEMD investigates every case in detail and is a trusted evidence
base for continuous service improvement. Unlike previous CEMD
reports the latest has moved from looking at purely medical issues
into the wider aspects of health and inequalities. The Report
is timely in that the results can feed in to the National Service
Framework for Children.
3.2 Adverse pregnancy outcomes for both
mother and child are strongly linked to vulnerability, social
exclusion and deprivation. The latest CEMD found the maternal
death rate amongst excluded women to be 20 times higher than for
women in the highest two social classes, and problems with severe
complications of pregnancy are also more common for these women.
These findings are similar to those in other developed countries.
Whilst maternal deaths are, fortunately, extremely rare they represent
the tip of the iceberg of women who survive severe complications
of pregnancy which may have long lasting physical and emotional
consequences. Here again these poor maternal outcomes have been
shown, in many cases, to be increased in women from the same vulnerable
communities.
3.3 Children born to women from the more
vulnerable groups also experience problems with pre-term labour,
intrauterine growth restriction, low birth weight, low levels
of breast feeding and higher levels of neonatal complications.
3.4 Socio-economic deprivation is associated
with less effective health care service use and poor health status
and other factors which adversely influence pregnancy outcomes,
such as drug abuse, also correlate with social deprivation. Underlying
factors which impact on maternal and child health also include
smoking, poor nutrition and obesity.
3.5 The CEMD report showed over one-fifth
of the women who died did not receive adequate care, in that they
first sought care, or "booked", late in their pregnancy
or found it difficult to attend for regular care. In the vast
majority of cases these women were not actively followed up when
they failed to re-attend the clinic. 20% of the women who died
"booked" after 20 weeks of gestation. Virtually all
had multiple indicators of social exclusion and a disproportionate
number were also from non-white ethnic groups. Hospital Episode
Statistics (HES) data show that in general, women from non-white
ethnic groups are twice as likely to "book" later than
20 weeks of gestation. Late "bookers" constitute about
8% of the white pregnant population and 17% of the non-white pregnant
population.
3.6 This new knowledge has underpinned the
work of the Pre-Birth and Inequalities Sub Groups of the NSF,
and formed the basis for the inequalities delivery priority element
and the need for early antenatal booking.
4. NATIONAL SERVICE
FRAMEWORK FOR
CHILDREN
4.1 The general NSF programme is part of
an overall Government programme to improve quality and drive up
standards of services within a framework of explicit national
standards. This includes addressing fundamental inequalities in
access to services.
4.2 The NHS Plan set out a vision of a service
designed around 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.
4.3 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".
4.4 The aim of the maternity module of the
Children's NSF is to define standards that will enable childbearing
women and babies to achieve optimum health and wellbeing. The
maternity module will develop national standards of care to cover
the provision of antenatal, delivery (intrapartum) and postnatal
services; and will look at how to make maternity services more
flexible, accessible and appropriate for all, including the socially
disadvantaged.
4.5 Developing the maternity module is the
Maternity External Working Group (EWG) which is co-chaired by
Heather Mellows the Junior Vice-President of the Royal College
of Obstetricians and Gynaecologists and Meryl Thomas honorary
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
4.6 The EWG's work is being taken forward
through five sub groups.
— Inequalities and access.
4.7 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.
4.8 This information is set out in Getting
the right start: The National Service Framework for Children,
Young People and Maternity Services—Emerging Findings published
on 10 April 2003. This report sets out the overall direction of
travel for the NSF, prior to its publication in 2004, to help
local health communities planning and improving services. This
report is available on the following website address www.doh.gov.uk/nsf/children/gettingtherightstart
Care pathways
4.9 The NSF will promote the use of flexible
care pathways to deliver high quality equitable services. Care
pathways have emerged in the past decade as an important technique
for continuous quality improvement in healthcare and are increasingly
seen as a key NHS resource for implementing an NSF. Care pathways
formalise protocols and guidelines into direct, individual women
centred care. The emphasis is on the woman (and her unborn child)
being at the centre of the process rather than some one to whom
services "just happen" in a haphazard or uncoordinated
way. They can be used to describe the routine progression of a
woman through the antenatal period as well as illustrating tracer
conditions or situations which can be used to illustrate how the
standards will be implemented in particular circumstances.
4.10 The use of these pathways should thus
result in the same standard of care being provided for all women,
and more importantly, if given or explained to the woman will
enable her to understand exactly who and, what may be required
to provide or offer additional services to her should the need
arise and where these still exist.
4.11 The development of a particular pathway
will involve a multidisciplinary approach with agreement with
all those likely to be involved in providing care. Pregnant women
may require care from a variety of sources or professionals, provided
through clinical or social networks. Knowing which path to follow,
and who is responsible for providing what, will help to reduce
clinical variation, eliminate duplication of services, maintain
quality care and adherence to clinical or other guidelines and
give professionals agreed control over the care of the delivery
process.
Open Forum Events
4.12 The User Involvement Sub Group held
two Open Forum meetings in Leeds and London (January 2003) for
people who have used maternity services and now act as representatives
for their local community. Speaking at the events were women with
disabilities who had been recent users of maternity services.
4.13 Issues addressed at the events included
the changes needed to improve maternity care and postnatal services
for women and their families, how a broad range of parents and
user representatives can best contribute to the planning and monitoring
of maternity services in the future and examples of good practice
in listening to users and using their views to change the way
that care is delivered. The issues discussed at the events are
being fed into the developing maternity module at the NSF.
4.14 Following the Open Forum events the
User Involvement Sub Group is also developing a database of good
practice initiatives that improve the quality of local maternity
services in any or all of the following ways: improving access
to maternity services, increasing user involvement, reducing health
inequalities, improving public health. These will be included
in the NSF and will be useful for those developing local services.
Inequalities and Access Sub Group
4.15 This sub group will ensure that the
maternity module addresses all areas of inequalities for all groups
of women including those who find it hard to access services.
This group has identified that there are two dimensions to inequality
that must be addressed. How do services find the hard to reach
and how do these services respond when these women do attend?
Care needs to be individual and personal for each woman. Carers
should not make assumptions about a woman's needs from her appearance,
ability to communicate and her past history. This sub group will
examine existing models of good practice. Staff in NHS maternity
services cannot be expected to know about every service available
from every agency in great detail. However the NSF will act as
a signpost to enable them to refer vulnerable women to other professional,
voluntary groups and agencies who have a specialist interest.
4.16 It is also clear to all sub groups
that they must and will address inequalities throughout their
own considerations and topic areas. Models of postnatal care that
are working for some "hard to reach" communities have
been developed by local Sure Start programmes and we are seeking
more information on reasons for non-attendance at antenatal appointments
and pressing for generic solutions in the NSF. For example care
pathways that describe the journey of a pregnant woman through
the services whatever her circumstances.
5 SERVICES FOR
DISADVANTAGED GROUPS
A. Minority Ethnic Groups
5.1 The CEMD report highlighted the fact
that women from ethnic minority groups appear to be at greater
(twice) the risk of a maternal death. There are many issues affecting
minority ethnic groups. Some of these are poor health outcomes,
for example Pakistani women are more likely to have a stillbirth
or a death in infancy and Somali women are more likely to have
a low birth weight baby. Other issues include the attitudes of
NHS staff and cultural expectations. Some women's cultural expectations
will require exclusively female care staff; others may prefer
to have care led by a doctor rather than a midwife.
5.2 The NHS Plan has signalled to the service
the need to become more responsive to black and minority ethnic
communities and to provide services which take account of their
religious, cultural and linguistic requirements.
5.3 Access to maternity can be a problem
for this group. Out of the cases investigated in the CEMD report
more than 25% of women from ethnic communities either contacted
the maternity services for the first time when they were more
than five months pregnant or missed four or more routine appointments.
Some were also newly arrived in the UK. Access to care was also
an issue for the disadvantaged white women and this is a general
issue that will need to be addressed in the forthcoming NSF.
5.4 There are a number of reports, including
Mothers in Exile produced by the Maternity Alliance, highlighting
the need for NHS staff to be aware of cultural differences and
the need to provide culturally sensitive, non-judgmental services
that meet the needs of the woman and her family. The findings
of these reports are being considered by the maternity module
of the Children's NSF.
5.5 The NHS Plan recognises the need to
tackle disadvantage in all its forms, including the specific health
needs of specific groups including minority ethnic groups. The
NHS will shape its services around the need and preferences of
individual patients, their families and their carers, including
challenging racial discrimination. Furthermore, the Race Relations
Act, as amended 2000, places a duty of public authorities to promote
race equality. Public authorities must have due regard to the
need to eliminate unlawful racial discrimination, promote equality
of opportunity; and promote good relations between people of different
racial groups. Delivery on the Race Relations Act is a core part
of the Department's vision of equality and fair treatment for
patients and staff. Achieving sustainable improvements in health
and services for black and minority ethnic people is an integral
and vital aspect of the Department's programme of investment and
reform.
B. Refugees and Asylum seekers
5.6 Persons with an outstanding application
for asylum in the UK are entitled to full use of the NHS without
charge. This includes maternity services.
5.7 Asylum applicants may apply for support
and accommodation from the National Asylum Support Service (NASS).
If accommodation is required, asylum applicants are dispersed
to available accommodation around the UK. The Home Office is responsible
for asylum and NASS support applications.
5.8 Pregnant asylum applicants may be in
a particularly vulnerable condition. They may have undertaken
a long journey while pregnant; the pregnancy may have been the
result of rape in their country of origin; they may not be able
to speak English; they are unlikely to have family/friends around
them for support; and their future in the UK may not be certain.
For these reasons and others, pregnant asylum applicants commonly
show signs of psychological distress.
PMS
5.9 Many PCTs have set up PMS (Personal
Medical Services) pilots. PMS is an alternative model of primary
care provision that has been developed by the Government to allow
flexible use of funding to provide care for vulnerable populations
such as asylum seekers. Many successful models are now in existence
around the country of PMS pilots providing dedicated services
to asylum seekers. PMS practices often act as a first point of
contact for asylum seekers requiring healthcare on arrival in
a city.
Induction Centres
5.10 The Government is developing a network
of induction centres, where asylum seekers will stay for short
periods upon arrival in the UK, before they are dispersed around
the country. As part of the induction process, asylum seekers
will receive a health assessment. This will identify health needs
at an early stage so that appropriate care/treatment can be commenced
as soon as possible and enable health factors to be played into
the dispersal process. The first induction centre is up and running
in East Kent, others will follow over the coming year.
DH Guidance
5.11 Caring for asylum applicants in all
contexts can be challenging for frontline health staff. The Department
of Health is developing, with the Refugee Council, a resource
pack for the NHS and social services that will include reference
to maternity services. The pack will be launched in the summer.
Translated resources
5.12 Providing adequate interpreting and
translation services for asylum applicants is challenging for
local health organisations—particularly in view of the huge
variety of languages spoken by many of those entering the UK.
To help offset this challenge the Department of Health are working
with HARPweb (www.harpweb.org.uk) on translated web based health
resources. At the moment a "multi-lingual" appointment
card is available at this site to download in over 30 languages.
Plans are also afoot to provide a range of other translated materials
which will include leaflets on vaccines & immunisations, child
protection/abuse, domestic violence and breast feeding/bottle
feeding/weaning.
Extra Payments
5.13 Families receiving social security
benefits, specifically Income Support or an income based Jobseeker's
Allowance, are eligible to receive milk tokens which can be exchanged
for infant formula. However, asylum seekers do not receive milk
tokens because they are not eligible for social security benefits
(destitute asylum seekers are supported by NASS). In appreciation
of this, on 5 November 2002 the Home Secretary announced that
additional payments would be made to pregnant women and children
aged under three in receipt of support by NASS. Pregnant women
and children aged 1-3 now receive an additional payment of £3
per week. Babies under 1 will receive an additional £5 per
week.
5.14 In addition, asylum seekers may be
able to access formula milk free or at reduced prices through
local schemes operated by community clinics or hospital services.
A pilot scheme has been launched in Lambeth, Southwark and Lewisham
that aims to provide sterilising equipment and one year's free
access to formula milk for HIV-infected women experiencing financial
hardship. Asylum-seeking mothers are just one of the vulnerable
groups that will be helped by the scheme.
C. Those who do not speak English as their
first language
5.15 The CEMD report highlighted the dangers
of using family members to act as translators. Translation services
were not available to many ethnic minority women and in some instances
children were used and key items of information were lost because
the woman felt unable to pass on intimate personal health or personal
concerns to her health care workers. Women may also need to be
put in touch with voluntary organisations that provide the sort
of social network that will assist and support them when they
are pregnant. The provision of translation services is an enormous
challenge for those areas of the country with few ethnic communities.
The maternity module of the NSF will address this issue.
The work of NHS Direct
5.16 NHS direct is doing much work in this
area. Each call centre has a contract with an interpreting service
provider, ensuring that callers who do not speak English as their
first language can have a telephone interpreter present during
their consultation, whether the consultation is with a nurse for
a symptomatic caller, or with a Health Information Advisor. The
interpreting service provides interpreters in whatever language
is required, and the service is available 24 hours a day, seven
days a week.
5.17 Call centre staff have desktop access
to a comprehensive computerised health information database that
contains detailed records of all health information resources
held at site level. These resources include topics such as maternity
service access, information on pregnancy and care of the newborn,
and conditions and treatment of particular relevance to babies
and young children. Parents, carers and any other callers can
request relevant resources to be read out over the telephone,
or to be posted to them, and information will be made available
in languages other than English when ever it is possible to source
it from trusted information providers. Information can also be
made available in formats other than print, including, for example
in Braille or on audio tape. All patient information is subject
to quality assessment. In addition, each site has comprehensive
information in the database, backed up by information on nhs.uk,
on local health and social care services, including statutory
and voluntary service provision. Callers can be provided with
details of all general and specialist services, and this would
include maternity services and other provision for pregnant women,
parents, and babies and small children.
5.18 NHS Direct is seeking to improve access
to information for those who do not speak English as their first
language by establishing an Ethnic Health Information Resource
Centre at one site, which will hold stocks of all materials available
in languages other than English. In addition, they are reviewing
their interpreting and translations service provision, and will
be moving to commissioning one national contract for this service,
thereby achieving economies of scale and improved quality assurance
and training standards. The Department has commissioned consultants
to undertake a review of effective service delivery models for
providing translation and interpreting support services. The review
will assist NHS Direct in developing a tender specification for
its national contract and provide a basis for considering how
to ensure wider service improvement.
D. Poverty
5.19 The effects of poverty on maternal
health are well documented. Poor diet and nutrition can lead to
low birthweight babies and poor maternal outcomes. Lack of access
to public transport can make it extremely difficult for some women
to attend antenatal appointments particularly if they have other
young children to look after. Loss of income from missing work
to attend such appointments can have a dire effect on poor families'
budgets.
Reform of Welfare Food Scheme
5.20 Proposals to reform the 63 year old
Welfare Food Scheme were recently put out for consultation following
the NHS Plan commitment to reform the Scheme by 2004. The proposals
reflect the evidence of the 1999 Committee on Medical Aspects
of Food and Nutrition Policy (COMA) scientific review that recommended
broadening the nutritional basis of the Scheme in order to ensure
that mothers and children in poverty have access to a healthy
diet. The proposals also aim to provide increased support for
breastfeeding. A report on the responses to consultation will
be published in March 2003.
5.21 It is proposed that the reformed scheme
be renamed "Healthy Start" and will come into effect
in 2004. In line with the Government's commitment to tackling
health inequalities the reformed scheme would provide better nutrition
and greater choice in a healthy diet for over 800,000 people in
low income families—making the most effective use of the
£142 million funding each year in England, Scotland and Wales.
Sure Start
5.22 Sure Start demonstrates the Government's
commitment to deliver the best start in life for every child,
better opportunities for parents, affordable, good quality childcare,
stronger and safer communities and a cornerstone in the Government's
commitment to halve child poverty by 2010. The first Sure Start
programme, which was announced in 1998, has worked by bringing
together early education, childcare, health and family support
to give a sure start to young children living in disadvantaged
areas. The Government invested £452 million in Sure Start
during the period 1999-2000 to 2001-02. The Spending Review in
July 2000 announced an extra £580 million for Sure Start
over the period April 2001 to March 2004. This includes £60
million to extend Sure Start to pregnant women and their partners,
from the time of conception rather than birth.
E. Homeless
5.23 The NHS seeks to offer all patients,
ordinarily resident in the UK—including the homeless who
so wish, access to free treatment by a GP. This is important for
women of childbearing age. A GP is usually the first point of
contact when a woman becomes pregnant and the GP acts as a gateway
to other services. The Department reminded GPs, in the monthly
GP newsletter for February 2003, that a patient does not need
to have a permanent address to register for services.
Action to increase access to health care services
for homeless people
5.24 Personal Medical Service Contracts
are improving access to primary care by helping the homeless register
with GPs. Currently around 86 pilot schemes have the homeless
listed as one of their priority objectives. Substantial service
improvements are provided across these schemes, particularly with
regard to access. Plans are in place for some of the schemes to
extend surgeries and clinics, appointment times and consultation
times. Closer liaison with Social Services and other stakeholders
is also planned.
5.25 Local Development Schemes (LDS) provide
financial support which enables PCTs to use their power to tailor
GP contracts to take account of the special needs of particular
client groups—eg the homeless. Model LDS schemes were published
in 1999 in HSC 1999/107.
5.26 NHS Walk in Centres are also a key
player in the drive to improve access to primary care. Patients
can receive immediate, high quality NHS walk in treatment and
advice, without having to register, which is of particular benefit
for the homeless. Many Walk in Centres are tackling inequalities
through nurses developing good relationships with support workers
and undertaking outreach work with the homeless to inform what
services they can access at the Centre. The national evaluation
report published in July on the University of Bristol website
showed that they are safe, popular, improved access and reached
a different population from traditional general practice. There
are currently 42 Walk in Centres in England covering 11 million
people.
F Domestic Violence
5.27 Violence against women encompasses
physical, sexual, emotional and psychological abuse. It is rarely
an isolated event and can escalate in severity and frequency during
pregnancy. In the context of obstetric care it can cause recurrent
miscarriage, stillbirths and maternal deaths. Women who suffer
violence are also far less likely to attend for routine antenatal
care. It is difficult to ascertain the prevalence of domestic
violence as it remains largely unrecognised but the last report
of the Confidential Enquiries into Maternal Deaths (CEMD) estimated
that about 30% of domestic violence starts during pregnancy and
existing abuse often intensifies when a woman is pregnant. As
a result, the CEMD has advocated routine questioning about domestic
violence during pregnancy, a recommendation the DH is taking seriously.
Departmental initiatives/action
5.28 In taking this strand of work forward,
the Department has recently agreed programme funding for a pilot
project to introduce routine questioning on domestic violence
during the antenatal period. The University of the West of England
and the North Bristol NHS Trust is undertaking this pilot. 80
midwives have been recruited to the study. Outcomes of the Bristol
Pilot will be fully evaluated. DH will look closely at emerging
findings and consider national roll out as part of the maternity
element of the Children's National Service Framework. In the longer
term, the maternity module could provide opportunities to extend
routine questioning to other areas of the NHS, eg A&E.
5.29 Prior to this, the Department published
"Domestic Violence: A Resource Manual for Health Care Professionals"
(March 2000). The Manual gives comprehensive advice and guidance
to all health professionals and managers for dealing with domestic
violence, including routine questioning of patients. Individual
Trusts and Health Authorities are being encouraged to use the
Manual in developing their local domestic violence policies and
protocols. The Department is funding the Women's Aid Federation
of England (WAFE) to help raise awareness of domestic violence
and to help implement the Manual in the NHS. A baseline survey
of Health Authorities, Trusts and PCGs/Ts in 2000-01 on the extent
to which they have policies, protocols and guidelines for good
practice indicated some progress over the past few years. For
example, over half of all Health Authorities has a designate member
of staff for domestic violence issues. DH will look closely at
the findings of the latest survey and consider what further steps
need to be taken.
5.30 The Department is also providing funding
to the Maternity Alliance Educational and Research Trust to develop
training materials for health professionals. Based on women's
views and experiences the materials will help health professionals
to support their clients who are experiencing domestic violence
during pregnancy and early parenthood.
G. Travellers
5.31 The CEMD Report found that a disproportionate
number of women from the traditional travelling community died
in pregnancy or after childbirth. Their relationships with service
providers can be strained by mutual distrust and suspicion and
this can have a detrimental effect on the health services they
receive and influence the take up of services. The maternity module
of the Children's NSF will examine how to make services more accessible
for this group.
5.32 The Department of Health is funding
the Maternity Alliance (2003-04 £23,700 2004-05 £16,000)
to undertake a project on Service take up. The project will work
with gypsy and traveller groups, consult with women and with health
professionals and produce guidance on service delivery and information
materials to encourage these women to make better use of the maternity
services.
5.33 The Department of Health is also funding
the organisation Action on Pre-Eclampsia (APEC)—£9,450
for the Pre-Eclampsia Advice for Travellers and Gypsies Project.
This project will provide an easy to understand leaflet aimed
at travellers and gypsies together with a pamphlet designed for
use by community health workers and support groups involved in
their welfare. The leaflet will provided information on the signs
and symptoms of the condition and where help can be sought.
H. Mental health
5.34 The occurrence of mental ill health
at or around childbirth is common and any type of disorder may
occur postnatally and about twenty are described. The most common
is postnatal depression and the most serious puerperal psychosis.
5.35 It is important to distinguish between
the relatively normal occurrence of the "baby blues"
and postnatal depression. Baby blues usually occur shortly after
childbirth and while they are potentially very distressing to
the mother and her family, tend to be self-limiting, short-lived
and mild in nature. Estimates of prevalence range from 26-85%
depending on how the condition is assessed.
5.36 Postnatal depression usually begins
in the first 12 weeks after birth although it can be emerge any
time in the first year. Quoted prevalence rates vary between 10
and 15%, 3 to 5% meet the criteria for depression.
5.37 Puerperal psychosis is a serious disorder
in which depression or mania occurs in the first six weeks after
birth; onset is often in the first week postpartum. About two
per 1,000 women delivered are admitted to hospital with the condition.
There is a greater risk of recurrence of puerperal psychosis and
psychotic relapses may also occur postpartum in women who have
existing psychotic illnesses such as schizophrenia. Estimates
suggest that two per 1,000 of women delivered will be suffering
from severe, chronic or enduring mental illness.
5.38 The women's mental health strategy
consultation document that was published in Autumn 2002, highlights
that is likely that having a mental health practitioner in each
specialist mental health service with an interest in perinatal
mental health will lead to the improvement of local service provision,
both at primary and specialist level. They could help to develop
a community-based multi-disciplinary/multi-agency perinatal mental
health service, working in partnership with local communities
to build capacity for early identification, support and treatment.
This could be underpinned by a care pathway approach for all pregnant
women from the booking-in phase, covering mental health promotion,
early intervention for vulnerable mothers and follow-up. Care
plans for mothers in contact with specialist mental health services
should specifically address needs related to their pregnancy.
5.39 The Implementation Framework for the
Strategy that will help services better address the needs of women
across a wide range of services will be published in the summer.
5.40 With regard to more specialised services
that, by their very nature, are provided from relatively few providers,
PCTs will increasingly have collaborative commissioning arrangements.
This will enable them to pool expertise and ensure sufficient
dedicated capacity to develop effective health needs assessments,
and plan and secure delivery of services. In addition, there is
the flexibility within the NHS of making referrals into the private
sector if, in the judgement of clinicians and commissioners, an
individual's needs warrant this, and the service is an appropriate
one. The National Director for Mental Health, Professor Appleby,
is leading a review of provision of all specialised mental health
care, including Perinatal Psychiatric Services (Mother and Baby
Units) and will make recommendations within the next year.
I. Learning Disabilities
5.41 The number of people with learning
disabilities who are forming relationships and having children
has steadily increased over the last 20 years. Parents with learning
disabilities are amongst the most socially and economically disadvantaged
groups. They are more likely than other parents to make heavy
demands on child welfare services and have their children looked
after by the local authority. People with learning disabilities
can be good parents and provide their children with a good start
in life, but may require considerable help to do so. This requires
children and adult social services teams to work closely together
to develop a common approach. Social services departments have
a duty to safeguard the welfare of children, and in some circumstances
a parent with learning disabilities will not be able to meet their
child's needs. However, we believe this should not be the result
of agencies not arranging for appropriate and timely support.
The maternity module of the NSF will address the individual needs
of these women.
5.42 The Government White Paper Valuing
People: A New Strategy for Learning Disability for the twenty-first
Century (2001) is based on four key principles—rights,
independence, choice and inclusion. It includes a section on parents
with a learning disability. Support for disabled parents, including
those with learning disabilities, is patchy and underdeveloped
as confirmed in the Social Services Inspectorate inspection "A
Jigsaw of Services." In 2002 the DH published good practice
guidance on health action plans and health facilitation—key
elements of the Valuing People White Paper strategy for reducing
the health inequalities faced by people with learning disabilities.
Government funded projects
Maternity Alliance "Parents with Learning
Disabilities" Section 64 project
5.43 Maternity Alliance is in receipt of
Section 64 project grant totalling £71,000 over three years
(1999 to 2002). This project is linked to an earlier three-year
initiative "Right From The Start" which sought to gather
information on ways the maternity services could adapt to meet
the needs of parents with learning disabilities. The project included
the production of an information guide on effective resources
such as benefits, housing and so forth, and aimed for the following
specific outcomes (1) cross disciplinary work facilitated in the
field of learning difficulties (2) increasing awareness of health
professionals' of the needs of parents with learning difficulties
(3) better maternity care and support for parents with learning
difficulties.
Change North
5.44 Change North recently received a Department
of Health grant to produce a booklet for people with learning
disabilities entitled "Planning a Baby".
J. Physical Disabilities
5.45 Disabled people, when choosing to become
parents, often face negative attitudes, an inaccessible environment
and support which is inappropriate. The maternity module of the
NSF will take into account the needs of women and their families
with disabilities.
5.46 The Government has made its commitment
to supporting comprehensive, enforceable civil rights for disabled
people and extending basic rights and opportunities in its 1997
and 2001 Manifestos.
Disability Discrimination Act (DDA) 1995
5.47 Part III of the DDA states that from
October 1999, service providers must take reasonable steps to
change practices policies, or procedures that make it impossible
or unreasonably difficult for disabled people to use a service.
From 2004, service providers will have to take reasonable steps
to remove, alter, or provide reasonable means of avoiding, physical
features that make it impossible or unreasonably difficult for
disabled people to use a service.
5.48 The NHS Executive issued management
guidance to NHS Trusts, Health Authorities and Primary Care Groups
on implementing Part III of the DDA in July 1999. Health Authorities
were asked to develop a strategy to ensure that Section 21 of
the DDA was implemented across their premises including hospitals,
primary care premises, health centres and clinics. Consultation
with disabled people about the development of the strategy needs
to be built in at all stages of the programme, including monitoring
and review.
NHS Plan
5.49 The NHS Plan commits the Department
of Health to ensuring that public services are equitable and accessible
for disabled people. Existing and forthcoming legislation means
that DH must take action to:
— promote human rights and combat discrimination
in all its forms;
— support the social and economic integration
of disabled people;
— increase overall awareness of disability
issues and promote the exchange of good practice.
5.50 Doubly Disabled is a guide to
help NHS managers and staff improve their awareness of the needs
of disabled people whether they are patients, carers or employees.
The guide has five sections and each includes suggestions for
specific issues that may require particular attention.
6. CONCLUSION
6.1 The focus of the Department's work to
reduce inequalities and modernise maternity services will be delivered
through the development of the Maternity Module of the Children's
NSF.
6.2 The NSF will develop high quality maternity
services which:
— reduce health inequalities and inequalities
of access;
— are woman focused: involving users
in all aspects of care and service provision;
— maximise normal births;
— meet minimum standards for all women
and babies;
— develop the workforce's skills and
competences to provide appropriate care and carer;
— enhance communication and teamwork
between healthcare professionals and with women;
— facilitate maternity information
and data collection;
— enhance women's choices.
6.3 The maternity module of the NSF will
look at how to make maternity services more flexible, accessible
and appropriate by providing a package of care to meet the particular
needs of the individual woman and her baby. Emphasis will be made
on women's choices in the planning of not only her own care but
also the planning of local maternity services.
6.4 The Maternity Services Module of the
Children's National Service Framework is being developed within
the context of other Government policy initiatives and is also
being developed using the best available evidence, including guidelines
issued by the National Institute for Clinical Excellence and drawing
on examples of existing good practice.
May 2003
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