Examination of Witnesses (Questions 160
- 179)
TUESDAY 24 JUNE 2003
DR STEPHEN
LADYMAN MP, LINDSAY
WILKINSON, CATHERINE
MCCORMICK
AND DAVID
AMOS
Q160 Mr Amess: Can I come in on that
point because I am very interested in—I know the Minister
said we are going to ask questions about recruitment and retention,
but it is not really down on the script. But I am slightly confused
now about consultation and working with the Royal College of Midwives.
Now, this serious situation has not suddenly happened. This has
been happening over a period. So is it that we have not been consulting,
we have not been listening? I mean we all know it is about pay
and conditions and all this. I mean to suddenly pluck it out of
the air that this has suddenly happened is ridiculous. Now, what
is being done pro-actively not only to consult the Royal College
of Midwives but to actually make it happen? Because otherwise
it is just going to get worse and worse.
Dr Ladyman: I will let the officers
comment on that in a minute, but I challenge the notion that it
is all about pay and conditions. Of course pay and conditions
is always a factor. I do not want to become overly political,
but the previous Government did seriously cut the number of training
places available for midwives and that is one of the problems
we are now having to deal with and put right. There are other
issues as well. I think we have to look at the sort of holistic
position in which midwives find themselves. There are all sorts
of issues which influence whether midwives stay in the service
or will return to it, including the fact that I think Dr Naysmith
mentioned that if there is an advanced local birth centre it is
very much easier to get midwives that want to come and work in
that sort of environment than perhaps in some traditional environments.
There can be issues over—one of the things in my conversations
with various midwives it has become clear to me very, very quickly
is that there can often be issues over the relationship between
midwives and obstetricians. If midwives feel that obstetricians
are being too intrusive, that can lead to difficulties. So you
have got to create a very good teamwork environment if you really
want to retain your midwives. So there is all sorts of issues
that have to be considered. The number of training places, yes,
the pay and conditions, but then the environmental issues in which
midwives find themselves and it is not as easy as—
Mr Amess: All of that I understand, I
just think after six years the impression that I was being is
that now we are sort of working with the Royal College of Nursing,
listening, etc. I mean this is six years, surely this has been
ongoing and I mean it obviously is a very, very serious situation.
Q161 Julia Drown: Mr Amos was saying
that with expansion in the number of training places you felt
that it would start picking up in terms of numbers of midwives
overall. Because in your evidence to us in the first session,
you did say that there were more midwives working overall, but
would I be right to think that actually more of those midwives
are working part time, so in terms of whole time equivalent we
are in pretty much of a level playing field? Is that something
that was expected or because that has happened is that again something
that might mean you as a Department have to do something more?
Mr Amos: I think the ideal state
depending on what is decided is needed locally, is more in terms
of head count. So that is regardless of how many hours you work.
And as you have spotted, that has gone up by some six or 700.
So I think progress is already happening. It is not something
that we are looking forward to starting. And the whole time equivalent
is no higher than five or six years ago, although I should say
two or three years ago it has dropped substantially. So whilst
the sort of net position between now and six years ago looks the
same, you have actually two or three years of substantial increase
in the whole time equivalent. And all our evidence is that that
should continue. So the prospects are good on whole time equivalent.
They are already good on head count. If you appreciate the reduction
in training places and various other issues meant we saw a decline
in whole equivalent. And I should say that—
Q162 Julia Drown: Sorry, were you
saying on whole equivalent the numbers have gone up?
Mr Amos: If you look at the period,
say, over the last five years, whole time equivalent, that is
midwives working a full working week, it has actually dipped and
since `99 it has started to come up again. And that is reporting
on 2001. Our indications are that for the period up to the end
of 2002, which will be published fairly soon I think, will indicate
a further growth. So there is already progress in both whole time
equivalent, which is rescuing a position which declined two or
three years ago for the reasons that have been discussed, and
then head count which is significant in terms of having more permanent
members of staff. I was talking to a Trust this morning in Lewisham
that has increased its establishment by 10 midwives on something
like 110, which is just under 10% and that is a good example of
where they have made the case locally that they need more midwives
to deliver on the sorts of issues that you have been discussing.
And they are having trouble recruiting permanently, but they filled
all that funded establishment by bank midwives. They have actually
seen a reduction in agency midwives and a substantial increase
in bank. So these are people who regularly work as midwives and
I would argue that that is an increase in service which helps
the sort of quality, service and workload issues that we are talking
about. So it is happening already.
Dr Ladyman: Can I just ask Catherine
to add to the specific point about working with the Royal College?
Ms McCormick: Yes, Mr Amess's
point about working with the Royal College of Midwives; it has
not just started to happen. I can show you the Department of Health
has worked very closely with the Royal College of Midwives on
recruitment and retention issues certainly as long as I have been
post, which is five years. So it is not just yesterday. And I
think we have worked very closely not just on recruitment and
retention but return to practice and worked very closely with
them on developing a return to practice distance learning pack.
So I think there has been a lot of initiatives, but that is just
one example.
Q163 Dr Naysmith: I was going to
raise that and Baroness Cumberlege in the previous section said
something that was very apposite to what we are talking about
now. I think she said only 20% of those qualified are on the active
register and if we could only double that then we could make a
huge difference. So what kind of actions are being taken to encourage—you
have just mentioned them, but what are they?—to try and
get people who are not currently working as midwives to come in
and practice again?
Ms McCormick: One of the first
pieces of work that we did with the Royal College of Midwives—I
am not sure I am going to get this title right—was "Bring
back a midwife" which the Royal College of Midwives supporting,
getting their membership to try and encourage a colleague who
is not currently in practice to come back into the NHS. And we
have built on that with the "Return to practice" initiative.
Mr Amos is much more knowledgeable about recruitment and retention
issues than myself, but we have also been working and now have
a national recruitment and retention lead and return to practice
lead who will look at the current Nursing and Midwifery Council
register for hopefully working with them looking for names of
people who might be encourage back onto the register and I think
the plan is to write to them to see what it is that we can do
to encourage them back.
Q164 Dr Naysmith: Is it not better
to send somebody to go and see them?
Dr Ladyman: We also have specific
arrangements where we have specific arrangements where we have
specific problems. So in London and the South East there is an
R and R officer that has been appointed; recruit, return and retain,
who is looking specifically at local issues because the complexity
of this is that there are a lot of specific local issues and just
for the information of the Committee, in Mr Austin's constituency
there is an 11.6% vacancy rate whilst in the Chair's constituency
it is only 1.5%. So there are different issues that we have to
address in different areas and different initiatives we have to
put in place in different areas and that is what we are doing.
Q165 Julia Drown: With your targets
of number of extra midwives that you hope to get by whatever year—
Mr Amos: 2006.
Q166 Julia Drown:—will that
then achieve one to one care for women in labour?
Mr Amos: I cannot say yes or no
on that. I know that what we have done as another example of working
with the Royal College of Midwives is the Birth Rate Plus work
force planning—it sounds a rather dry modelling system,
but it is a practical way—and it might be something that
you want more information on—to assess locally, given a
whole series of conditions, and that does relate to the case mix
of the mother in terms of high, medium or low risk. And I think
that that is probably the best way of answering the question which
is not a national one to say precisely what will happen as a result
of those additional 2,000 midwives. But looking locally and modelling
I know that there is a document that might have come in to you
from the Royal College of Midwives, this is how closely we work
together, because I launched it at their conference a couple of
weeks ago, which I think is full of good examples which includes
how two Trusts have used Birth Rate Plus to make a case to increase
their staffing levels. And I assume that that standard includes
one to one wherever it is possible.
Dr Ladyman: The answer is broadly
yes.
Q167 Julia Drown: Okay. Because if
it is—and Ministers have made a commitment to wanting to
get to one to one care—then there is not going to be much
difference, even if it would be clear that home births would be
cheaper because you do not have to pay for an establishment, to
provide home births where somebody wants one. And I do note that
also in May of 2001 the Secretary of State for Health did say
"Our standard must be an end to the lottery in childbirth
choices so that women in all parts of the country not just some
have greater choice, including the choice of a home birth".
Might that be overtaken by the NSF which might take that away?
Or is that something the Department is determined to make sure
happens?
Ms McCormick: What the previous
Secretary of State said at that time as being one of the major
considerations of the birth sub-group of the NSF and maternity
services module of the NSF. So there is not currently any ideas
to change that.
Q168 Julia Drown: So do you expect
that to come out about—
Dr Ladyman: I think that one has
to look at that as part of their terms of reference.
Q169 Julia Drown: And just quickly
about what Catherine McCormick was saying earlier about the letters
going to particular individuals saying that "We do not have
the skills", I mean if those people do not have the skills
to give home birth, would it be a question about whether those
people have the skills to support a birth in hospital? How different
are the skills required?
Ms McCormick: I would not wish
to comment on individual skills. I just feel that for a Trust
to write a letter to a women saying that they do not have midwives
who are skilled to provide birth at home is not acceptable and
it is a practice issue, it is a registration issue or a regulatory
body issue, not one for the Department. The NAC regulates midwifery
practice etc and that is why I pass the letters on because clearly
it is really important that those midwives in that unit, if that
is really the case, are assisted to re-skill.
Q170 Julia Drown: Sure. Arguably
they need the skills to help people in hospital as well?
Ms McCormick: Wherever they deliver
babies, indeed.
Q171 Dr Taylor: Can I throw a spanner
in the works as far as the staffing issues go? Because we are
continually hearing about the European Working Time Directive
as it will affect the level of staffing, but in this particular
inquiry we have heard what junior doctors have actually said to
me in other specialities that the shortage of time that they are
actually allowed to work is impacting on the quality of the training
that they actually get and the actual experience. And one can
imagine this leading to less experienced doctors pushing for caesareans
before the more experienced ones would. How can you cope with
the European Working Time Directive as far as it goes for midwives
and doctors in keeping choice before the ladies who come to the
units? It is a problem that exercised lots of our witnesses and
we are just not convinced that the Government is really getting
to grips with the full difficulties of the situation.
Dr Ladyman: Let me give a high
level answer to that before Mr Amos gives you a specific answer.
Broadly speaking, we see the Working Time Directive as an opportunity
as much as a problem. It will allow us to reconstruct, if you
like, the environment and the working conditions for particularly
midwives and create an environment in which it will be much easier
to recruit midwives because they will no longer have to go through
some of the arcane working practices that perhaps they did in
the past. So whereas there are certainly costs involved and it
will impact on resourcing, we should not look at it as entirely
negative. I think that the training issues that you have mentioned
are certainly true and of course that is one of the rationales
behind re-configuration of hospitals which is a matter of some
controversy and I know of some interest to yourselves. So there
are issues there, but I would not like you to think that we are
not thinking about them very carefully and trying to use them
to our best advantage. Mr Amos can comment specifically.
Mr Amos: Well, we are running
a number of exercises to deal with the very real obstacles and
problems that you have identified that need to be sorted to ensure
that all the right staff are working in the right place and reducing
hours for doctors, which I am sure the Committee supports. There
is a good example in St George's in London, which I think recently
won some award for its efforts through multi-disciplinary working
involving doctors and midwives, the support staff, the managers
sitting down together to work out how, through changing the way
that people work, the doctors can meet their New Deal targets
and, what appears to be the case, midwives can actually have more
fulfilled roles, not just not doing what doctors do, but taking
on the kind of roles that midwives want to and I think it is an
illustration of the Minister's point that the Working Time Directive
has been the pressure to get the teams to sit down and work out
how best to re-organise so that actually all professional groups—and
I would suggest that St George's is one good example which obviously
we are now trying to encourage right across the country, as we
are in other specialties, to make sure that there is an advance
in that.
Q172 Dr Taylor: Is there not a risk
that consultants are going to feel they have got to cover for
the shortage of juniors and there is going to be a huge amount
of pressure on consultants to actually start living in when they
are on?
Mr Amos: I think it is important
to take other factors that we are also seeing an increase in consultant
numbers, something like 21% increase in obstetricians and gynaecologists,
over the last five years or so. And also it is—
Q173 Dr Taylor: I rather thought,
but I may be wrong, that obstetrics was getting rather less popular
because of the tremendous litigation sort of risks. Is that not
borne out by fact?
Mr Amos: The last time we reported
on vacancy rates for medical staff, which is the period March
2002 obstetricians and gynae was 1.7% long term vacancies, which
is tiny. It is about half the national average, which is pretty
low in medical staffing generally. So the indications are that
the places remain popular and that we are able to fill them and
that is in a time of expansion in both junior doctors, doctors
with their consultant certificate and those wanting to be consultants.
Dr Ladyman: From memory, I think
we are expecting something like a quarter increase in the number
of obstetricians that will be available to become consultants
in two years time.
Mr Amos: Yes.
Q174 Julia Drown: But is one of the
concerns the length of training? That if actually the junior doctors
are working—which is good, they should have a better life,
that they are doing less hours training. Is there not an argument
actually they need to train for longer in order to get the same
experience?
Mr Amos: Yes. There are a number
of issues there. We have got a major initiative working with the
Royal Colleges and the appropriate national bodies to look at
how the length of training can be reduced. And that needs to be
very much led and influenced by colleagues in the medical profession
on the basis that if you re-organise some aspects of education
and training, you shorten the amount of time particularly at the
senior house officer level and there is a major exercise being
led by the Deputy Chief Medical Officer, Professor Aidan Halligan,
to look at by perhaps putting better management into that period
of training you can actually reduce—as has been the case
with specialist registrars.
Dr Ladyman: I accept that as a
theory for why people may be reverting to caesareans more quickly.
It is something that we have got to look at. But certainly I have
not seen any evidence across my desk in the last week that suggests
that we actually have any evidence to suggest that is the case,
but I perfectly accept that it is a theory, it is worth testing.
Q175 Julia Drown: Certainly I think
that there is a real worry that we have picked up in the inquiry
that the less experienced doctors are likely to go for interventions
earlier.
Dr Ladyman: To be frank with you,
I do not see why that would be. I mean a caesarean section is
a very serious medical procedure. You are suggesting that the
doctor might avoid the easy option and go for the more difficult
one because he is inexperienced. That does not—
Dr Taylor: You need nerve to watch a
mother going through a very difficult labour and to know exactly
when the right moment is to step in and to hold back from it.
So that is experience and you cannot get that without years of
seeing it happening.
Q176 Julia Drown: Can I just go through
the numbers again? Because if you look, 21% in the number of consultants
sounds good, but then if you look at the huge fall in junior doctor
hours going from 80 hours to 50 hours, one is not going to compensate
for the other. I mean are you really confident that you have got
the numbers right in terms of keeping the medical staffing there
on the wards and in the delivery suites?
Mr Amos: That is a judgment we
would make nationally, how many more places in all the relevant
professional groups, big increase in medical students as well
and the lead in time is obviously even longer than the groups
you have been talking about. But the targets we have got for growing
the medical work force; 10,000 by April and more beyond that,
midwives by 2,000, our judgment is that at that level we have
got the numbers right in terms of training places. But that is
going to require a lot of effort locally to recruit and retain
and keep people plus, in some cases, a contribution from international
recruitment and so on, in order to meet those demands.
Q177 Julia Drown: And might there
be an issue that they might be doing the gynaecology but not the
obstetrics?
Mr Amos: I hope that that is where
local work force planning which the NHS is sort of getting its
teeth into with the local delivery plans would help to make a
good judgment.
Ms McCormick: If I could just
say something about early intervention. I think one of the issues
that will help to deal with that is the NICE clinical guidelines
in caesarean sections that we know will be published later on
in the year.
Q178 Dr Taylor: Yes. We are very
aware that those were coming out. Going on to continuing with
the rising caesarean rate which is worrying, in a report we did
talk a little about lifestyle caesareans and, just as I asked
Baroness Cumberlege, I wonder what your views are? We put in the
report "We would like to see a distinct shift in emphasis
to ensure that elective caesareans as a lifestyle choice are not
supported by the NHS and that caesarean sections should be a procedure
undertaken only when medically or psychologically necessary".
What are your views on that?
Dr Ladyman: I am not going to
give you a firm position after only seven days in this job. I
will reflect on that. My instinct is in line with your suggestion,
that it should not be an option. I do not think it is very often,
from the evidence I have seen and from the evidence which you
collected, it is only suggested that in 7% of caesareans it was
potentially a lifestyle choice, which I agree would be too high
even if it is 7%. So it is something I am reflecting on, but my
instinct is that it is not the way the National Health Service
should be working and we should be giving better counselling and
advice and support to women.
Q179 Dr Taylor: Is there a gender
shift in our witnesses? Do the ladies think the same?
Ms McCormick: My comment would
be that we would hope women made informed choices and not just
a choice that is not really deeply informed.
Dr Taylor: Changing the subject slightly—
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