Examination of Witnesses (Questions 80
- 85)
TUESDAY 17 JUNE 2003
MS BEVERLEY
LAWRENCE BEECH,
MS SARAH
MONTAGU, MS
ANNIE FRANCIS,
MS BELINDA
PHIPPS, MS
LOUISE SILVERTON
AND PROFESSOR
WILLIAM DUNLOP
Q80 Julia Drown: There is not enough
access at the moment?
Ms Phipps: Physically there need
to be the pools and that is a problem in some places but over
and above that they may be there in some places but they are not
being used.
Ms Montagu: It struck me as quite
bizarre that it seems optional for management that if midwives
from a unit feel they do not want to support women in water, they
do not feel they can force the midwives to train to look after
women in water. If a midwife said, "I do not feel I want
to look after women having epidurals or Caesarian sections"
the managers would tell them not to be stupid and that it was
part of their job.
Professor Dunlop: I wonder if
I could ask my colleagues whether they feel that a water birth
is a normal labour.
Ms Beech: Women are perfectly
capable of having a normal labour in a pool.
Professor Dunlop: Is it not a
form of intervention?
Ms Beech: Yes, but unlike drugs
it has no adverse effects.
Q81 Julia Drown: What about the TENS
machine issue? Some women are able to bring in their own TENS
machines. Is there any evidence that some people are put off because
of the costs?
Ms Francis: The idea is that you
put a TENS machine on quite early in labour. If you are trying
to access it through a maternity unit, hopefully you are not going
in until you are further down the road. Unless it was available
through antenatal clinics, where they will be able to show women
how to use them, they are not going to be of much use.
Q82 Julia Drown: On wider staffing
issues, we have evidence from many people in many different professions.
I wondered from your point of view whether there are other staffing
issues? We have talked about midwives but are there other issues?
Somebody mentioned a neonatal review. We have had mention that
there could be advanced nursing, neonatal practitioners, who will
in future take on more roles that junior doctors are currently
doing. Is that a big issue that we need to look at? We have had
evidence from anaesthetists saying we need more consultant anaesthetists
and that some of the work consultant anaesthetists do in terms
of giving women information about analgesia could be done by other
people, say, physiotherapists. Physiotherapy services are not
always available in labour as much as they should be. From your
perspective, are these issues that come up in your organisations?
Ms Silverton: To go back to midwifery,
separate from the shortage of midwives, we have very uneven coverage
of consultant midwives. Some units might have four. Other units
have areas where there are not any at all. For the most part,
the consultant midwives are in posts which enhance the role of
the midwife. They are in labour wards looking to encourage normal
labour. They are running active birth centres attached to consultant
units. They are in public health posts, increasing breast feeding
rates, working with disadvantaged communities, and we would like
to see many more consultant midwives.
Professor Dunlop: There is a crisis
facing the health service but in particular the maternity service
in relation to the European Working Time Directive. There will
be problems in 2004. There will be a major crisis in 2009. Part
of the problem is that a lot of care in this country is delivered
by untrained doctors in sharp contradistinction to most of the
rest of Europe and North America. We have relied for far too long
on people who have not completed training to give care and that
cannot continue under the new regulations. There is a big need
to increase the number of trained individuals to provide care.
We are not going to be able to do that in the timescale we are
talking about. There have to be other ways found of trying to
find specialists. One of the things we have been suggesting very
strongly to the Department is that we know there are 180 doctors
who were sent letters by the Specialist Training Authority at
the time of the transition into the new arrangements of the Caman
training scheme, who were told that they required two additional
years of training to complete their training to get on the specialist
register. I am not suggesting that all of these individuals would
necessarily become specialists but there is a group of people
who could very rapidly train and we are trying to address that.
For years we had a very effective overseas doctors' training scheme
which brought may overseas doctors to this country where they
completed training and many of them remained in consultant posts.
That scheme has effectively been dismantled. We now have an overseas
doctors' fellowship scheme which caters for very much smaller
numbers of more highly selected individuals. Looking at overseas
recruitment, it would be much more profitable to look at doctors
who require a small amount of training in this country to complete
their training than to try to import specialists.
Ms Francis: It would seem sensible
on that basis that anything that reduced obstetric intervention
and the Caesarian section rate would help that problem.
Professor Dunlop: I do not think
that is the case. That is an over-simplification. We are talking
about staffing a reducing number of consultant units day and night
by a trained obstetrician. I do not think that reducing intervention
will make the slightest difference to that. We still need people
on the ground, 24 hours a day, seven days a week, in order to
provide emergency care.
Q83 Dr Taylor: I think we are very
well aware of that and a number of us are trying to get an adjournment
debate that will bring in just this subject. When we are looking
at the future work that the Committee is going to do, I and perhaps
others will be pushing this as something we ought to look at because
it does threaten hospital services as we know them in all specialties.
Professor Dunlop: Yes. It is important
to realise that obstetrics is different from many other specialities.
There are initiatives looking at covering the acute hospital at
night, for example, that will not apply in maternity care. The
same is true of paediatrics. There is one hospital in this country
where there is a group of advanced neonatal nurse practitioners
providing care. It is not certain that that is economically viable
or sustainable and at this stage I do not think we would be backing
it. When we asked our members, both registrars and consultants,
whether they thought an obstetric unit should have 24 hour neonatal
cover, the answer was yes.
Ms Beech: There are two issues
here. One, if we accept that 80% of women are expecting to have
normal births and that the midwives are responsible for referring
on, why have we consultants covering 100% of women? We really
need to be looking at what precisely the consultant is there for.
As I understood it from the report that recommended 40% increase
in consultant cover, it was for high risk women and the low risk
women would be looked after by the midwives. The very serious
problem that we have is this dreadful shortage of midwives. That
is an even greater problem than the shortage of obstetricians
and trainee doctors. It does not seem to surface anywhere.
Ms Silverton: I would support
that. Midwives do a considerable amount of on-call. If we are
going to go to different models of care with core staff and midwives
providing case load or small team care, the level of on-call will
increase. Shortly, midwives will not be able to be rostered to
be on duty the morning after they have been on call so it is going
to further exacerbate the shortage of midwives.
Ms Phipps: We have omitted a really
important part of the whole birth and parenting process and that
is fathers. I do not think we need a different sort of member
of staff to support fathers but fathers definitely do need support.
I would urge that our midwives are better trained to communicate
directly with men. They tend to communicate with fathers through
women and we know that is not satisfactory for men. It is really
important for families that dads feel very involved and able to
support the mum and the new baby after the birth and to feel part
of the whole process.
Ms Beech: Going back to choice
and home births, one of the issues that concerns AIMS at the moment
is the numbers of women who are having unattended home births
because they cannot get the staff to attend them or they lose
confidence with the discussions and arguments with the trusts
about what is or is not allowed, what they will or will not do.
We are seeing more women saying, "I do not trust the midwives
to do what I want them to do." They are fixated on the hospital
policy and if you look at the Nadine Edwards PhD research on the
negotiations that women and midwives have to do there is huge
pressure on midwives when they come out to a home birth if it
does not fit this very restricted criterion of low risk. The midwife
is then trying to balance between trying to give the woman the
service that she wants and trying to keep the director of midwifery
off her back or the Trust off her back, and who is criticising
her for staying out there. It puts so much stress and strain on
some women that they say, "I am going to give birth on my
own and I am going to call them afterwards."
Q84 Julia Drown: That is actually
happening?
Ms Beech: Yes.
Q85 Julia Drown: The solution to
that is obviously better training and using independent midwives.
Ms Beech: If we have targets for
home births and we have a community based midwifery service and
the ability for independent midwives to contract in, I think we
will then get more midwives who are going to be confident at helping
women birth at home.
Ms Francis: As independent midwives
we would be very keen to be involved in apprenticeship schemes
or some sort of training where students can come out with us.
Professor Dunlop: We have heard
a great deal about roles this afternoon and I think we should
be concentrating on team work. We have not heard nearly enough
about that.
Julia Drown: To comfort you, I am pleased
to say that when we have had each unit we have had that really
strong team approach. Can I thank you very much for all your evidence
today? We do appreciate all the information you have been able
to give us.
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