Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 180 - 199)

TUESDAY 24 JUNE 2003

DR STEPHEN LADYMAN MP, LINDSAY WILKINSON, CATHERINE MCCORMICK AND DAVID AMOS

  Q180  John Austin: I was just going to say informed choice implies that the women has the information. If, for example, it is a breech birth and there is not a midwife to talk her through the possibilities other than a surgical intervention, then there is not really an informed choice, is there?

  Dr Ladyman: Can I just step in here? I think you are pressing my officers to make a political preference and the political preference is for me and for my colleagues to make. We will reflect on whether we want the National Health Service to allow this as an option and then we will put it to Parliament when we have made that decision. So I think it is unfair to press officers to—

  John Austin: I was not going down the line of women electing as a choice to have a caesarean. I am suggesting I am convinced by the evidence that we have had that the increase is not due to informed choices and lifestyle choices. All of the evidence that we have seen so far is that the choice is possibly the choice of the obstetrician and the unit and the limited choice that women have—

  Q181  Julia Drown: Or the women's choice is a small part of the other issues.

  Dr Ladyman: Sorry, I misunderstood the thrust of your questioning. That is why we need the NICE guidelines to actually set down for us what the best practice suggest should be the limits within which caesareans are offered and then we need to make sure that both those guidelines are being followed and that the women is empowered, in every sense of the word, to take a full part in that decision.

  Q182  John Austin: When Baroness Cumberlege had a debate in the Lords, she was suggesting that the pamphlet and the advice to women should not be one about when a caesarean should be carried out but should be rather along the lines of how to avoid a caesarean section. I know we are waiting for the NICE guidelines, but—

  Dr Ladyman: I would put if slightly differently. I would want women to be given sufficient information that they can make that judgment for themselves, not directional information. And that needs to be part of a package of information, including advice from the clinician who is helping the woman who is make that decision. So I would hope that one of the things that the NICE guidelines, or if not the NICE guidelines the NSF will set out, is the sorts of conversations that should be taking place between the woman and the clinician in order that the woman is really in control of that decision herself.

  Q183  Dr Taylor: Should individual consultant caesarean section rates be publicised?

  Dr Ladyman: With this caveat; that I would want to see the NICE guidelines and to see what NICE suggest are the limits and the levels of discretion that should be involved. But my instinct is yes.

  Q184  Julia Drown: Over the last years we have seen the caesarean rate increase and it would be interesting to know what the Department has done. I mean we have picked up quite strong evidence that good midwifery skills and a strong midwifery presence can reduce the caesarean rate. We were also quite shocked to hear that basic practice guidelines like with a breech birth the women not being offered the choice to turn the baby which is successful in half of those cases, was not offered to two thirds of women across the country in that position. What has the Department done to try and address those issues?

  Ms McCormick: There has been quite a lot of activity and the Department has shared the concerns that everyone else is concerned about; the rising caesarean section rates. And that was partly why the NICE guidelines were commissioned on electronic foetal heart monitoring and on induction of labour, obviously two things that influence the caesarean section rates.

  Q185  Julia Drown: But what about issues like the fact that two thirds of women are not offered the chance to have their babies turned round when they are presenting with a breech birth?

  Ms McCormick: I cannot comment on that.

  Dr Ladyman: Can I just say that this is one of those areas which I think highlights what I was just saying about a woman making an informed choice. If the clinician simply says to the mother "The baby is in the wrong position, this is abnormal. We are thinking about a caesarean section" the chances are that the woman will say "Oh yes, please". Whereas if the clinician actually takes the time and trouble to say "Here is what has happened. Here is the opportunity to turn the baby around and have a normal delivery. Here is what might happen during the course of that process", then the woman is then empowered to make that decision for herself. And that has ultimately got to be the key to it.

  Julia Drown: Yes. It seems that it is clear from what we said so far that we think more needs to be done on that and we know that you will be responding to that in response to our first report. Moving on to other issues—Doug?

  Q186  Dr Naysmith: Some women choose to have an independent midwife look after their confinement and so on and to be cared for by an independent midwife, even if they go into a National Health Service unit to have their baby. Now, because independent midwives are regarded as independent contractors to the National Health Service, there is some problem in some places about the National Health Service indemnity arrangements and is the Department aware of this and what view is it going to take?

  Dr Ladyman: We are aware of it. It is a serious issue because there is no question that independent midwives do not have the NHS indemnity and that is a serious issue both when the NHS is contracting with an independent midwife to provide services or when an individual is doing it themselves. The Chief Medical Officer is currently working on a report which will shortly be presented to the Secretary of State detailing how these issues of indemnity should be dealt with. I cannot really comment—

  Q187  Dr Naysmith: So we are waiting for the report?

  Dr Ladyman: I am afraid we are waiting for his report before we can make a decision. But we are aware that it is an issue and that it has got to be dealt with.

  Q188  Dr Naysmith: But of course it is happening in some places at the moment, is it not?

  Dr Ladyman: It is.

  Q189  Dr Naysmith: In some places it does and some places it does not.

  Dr Ladyman: Well, there is no question it would be a significant issue and again it is one that a mother needs to be aware of when she is making those choices at the moment. All we can do is work out the best way of dealing with it and then put proposals to the—

  Q190  Dr Naysmith: So basically we should get these proposals fairly quickly because some people could be in a dangerous situation?

  Dr Ladyman: Yes.

  Q191  Mr Amess: Evidence from each of our three inquiries have indicated clearly that Maternity Services Liaison Committees are active and effective in representing the views of service users, others are less active and have been disbanded. Now, what is your role, Minister, on these Committees and do you intend to take steps to ensure that they continue to function in all areas?

  Dr Ladyman: As a general principle we have set out as a Government that we want patient involvement at all levels in the National Health Service. Now, that was not just a political decision, it was also the response to the Bristol Royal Infirmary Report which suggested that we need to have a patient's voice on the inside at all levels of the National Health Service. Now, I take that to mean at all levels and in all parts of the National Health Service. So it follows that I regard it as vitally important that in all communities there is a very clear voice from the local community and from patients about how maternity services are being delivered. Now, at this point, after only a week in the job, I am not able to say what consistency there is across the country and what is working and what is not working. I will let officers comment to see what their view of what is and what is not working. But all I can assure you is that it is right there on my agenda and is one of my tasks to make sure that sort of involvement is in place everywhere. And if that means that some of these organisations have got to be set up again, well we will have to look at that as an option. Do you want to comment?

  Ms Wilkinson: Yes. The NSF Maternity Module is broken down into different bits and we have already gone into quite a few of them. One of them is on user involvement and the User Involvement Sub-group is going to come up with quite a strong recommendation that we look at the benefits of MSLCs and that we consider how they can be enhanced and how they can be used and the benefits to the locations in which they operate. They are definitely going to recommend to us that we look carefully at this model. I do not think one has to say it has to be an MSLC, but something that looks quite a lot like it is very advantageous. But there are obviously locations in which these work well, there are locations in which they work less well and there are other activities around patient involvement that might actually be better ways of taking this forward for a particular area. But there will be a strong recommendation from that sub-group that MSLCs can work very well.

  Q192  Mr Amess: And could you finally give us any indication how you feel the Government could support local authorities in ensuring that these Committees in particular help the families and women of disadvantaged groups?

  Ms Wilkinson: Yes, I mean it is quite a big issue. A lot of engagement of disadvantaged groups is a big issue and it is arguable that MSLCs can be given a specific role in that. But actually the way a lot of them operate it may not be particularly attractive. A lot of people who are not particularly articulate will not want to go along to the Committee, for example. We have actually held a couple of events specifically as part of the NSF to look at user involvement with a particular reference to disadvantaged groups and we have gathered quite a lot of ideas. We have also got an equalities bit of the NSF looking at that, which is also looking at the same kinds of things. It is quite a tough issue and it is one where a lot of different solutions have to work, depending on who you are trying to engage, but I think that the message is very strong that the engagement is very, very important.

  Dr Ladyman: I think that we have to acknowledge the challenge that those people within our local communities who most need to have their voices heard are often the ones who it is most difficult to make express their views. And that is one of the strengths, I think, of having local government involvement in these decisions because at least those people have got a councillor who is right there on their doorstep and who should be involved in helping to contribute to inform these decisions. But I take your point very seriously. It is a big issue for us and it is something that we have got to put a lot of thinking into over the next few months.

  Q193  Julia Drown: What about best practice? We heard very strong representations from a parent with disabilities who had succeeded by her MSLC to get her unit to have height variable cots for people with disabilities. That was a struggle and a battle that she won. But when asked had it gone beyond West Berkshire where she was, she thought not. And yet if you go back to Changing Childbirth 10 years ago, it was made clear that maternity services should be made accessible for people with disabilities. In fact, once you have got a height variable cot it is better for everyone, not just people with disabilities. Why is there is a problem about spreading best practice and what is the Department doing to try and improve that?

  Ms Wilkinson: It is part of both of those modules you talked about. We held these particular two events precisely to do that kind of thing and actually the story is beginning to sound a bit familiar. I think that the lady in question might have spoken at one of those events to try to do that. There is quite a strong effort, as part of this process, to gather best practice and as you were speaking I was remembering that Catherine and I went to Blackburn and visited. They have got a fantastic—this is not about disabilities, but they have got a fantastic system of taking antenatal information and maternity information out to community centres which are used by particular ethnic communities. I think it we have pleaded with a lot of people to send us good practice and it is something we are going to deal with. I do not want to pre-judge what actually happens in the NSF, but it is certainly something that I would hope to see that some examples of good practice would be in there.

  Q194  Julia Drown: Okay. But is it about getting a method of ensuring new practice keeps on being shared?

  Ms McCormick: Certainly from the midwifery perspective we have just launched a publication called "Delivering the best" midwives' contribution to the NHS plan and it is now currently on the NHS web site. And on that web site there are a lot of examples of good practice which actually look at some of the areas you are talking about; engaging women who currently do not access mainstream maternity services and how particular groups have done that.

  Dr Ladyman: Can I just make a general point about the NSF as well? Because of course the final published NSF will clearly be a fairly concise document, but one of the things that I was campaigning for before I became a Minister, and which I do not see any reason to not take into my ministerial duties, is that I am aware that all the components of the NSFs that are being produced there is a huge amount of experience being shared in those groups, a great deal of learning being pulled together, some fabulous and comprehensive work and I am absolutely determined that that is not going to be lost in a process of distilling some glossy document that will be the NSF. So one way or another I will find a way of publishing that, even if it is only published on the Internet, so that we can have a real useful tool for professionals to share this good learning.

  Q195  John Austin: We have heard about Bath and where the maternity services are provided under the auspices of the PER CENT and staff have told us that the location of maternity services in primary care promotes much better and closer working of, say, midwives with health visitors and other professionals and has enabled more choice in the service that is available. Do you accept this analysis and is the Department considering this as a possible option?

  Dr Ladyman: I do not know enough about it to accept it or not, but I will ask the others and I will undertake to go and visit Bath and listen to their views myself.

  Ms McCormick: I think that the real issue is to ensure that maternity care is an integrated service and where midwives work in a way or who employs them or who employs anybody is not the great relevance. The relevance is that they can provide or a service can be provided across hospital and community and that women see it as a seamless service. In Bath obviously that is an area of good practice. It is an area that is quoted frequently with regards to women's satisfaction and the satisfaction of the people who provide the services. It fits in that area. It would not necessarily fit in in Greater London, for example. So the service really needs to fit the locality, but I think I would want to stress the integrated service and not losing that across the acute and community trusts.

  Dr Ladyman: As a scientist I am always loathe to extrapolate from a single point of data and say this is a trend. And whilst I acknowledge that Bath have clearly got some good experience, I am sure that we could go and find services structured within a hospital trust that could say that they had equally good practices. If I can just give you the example of the hospital just over the river there, which I visited last week and I was really struck as I went round by the people there who, as often as they were lauding the facilities they offer in that building, were telling me about the work they are doing out in the community. The midwives getting involved in refugee groups and other disadvantaged groups out in the community. So this sort of good practice you are talking about does not just occur in that particular place, but I will certainly undertake to look at their experience and make sure it is built into—

  Q196  John Austin: Can I just follow on from that because you were talking earlier about the need to ensure that it is not just the articulate middle classes who have choice, but all of those who feel not empowered or disadvantaged or whatever. The evidence we have had suggests that for some of the disadvantaged groups they perceive that the priority is the risk to the baby rather than to the detriment of their experience of childbirth and that we have had representative voices from disabled people who feel that they are excluded from the choice because choice is made for them and you have referred to refugees and other groups. There are some good examples out there of work with community maternity assistants and Doulas and other such practices. Is the Department looking at those examples of good practice and seeking to disseminate them?

  Dr Ladyman: It certainly is, yes. And I will ask the officials to give some details in a minute, but one of the things that I learned within the first few hours of taking this job is do not make assumptions because if you are going to give people choice, then it has to be their choice you must not even begin to start to assume you know what their choice is going to be. I mean there are various ethnic communities that I thought would actually instinctively prefer home births rather than hospital births and it actually turns out to be entirely the other way around, they are hugely in favour of hospital births rather than home births. And other communities are the other way round. So one of the things that we absolutely have to do is make sure we assume nothing and that choice is a real local and personal choice.

  Ms Wilkinson: As part of the work of the Inequalities Sub-group of the Maternity NSF we have got some work together with the Maternity Alliance about all the available evidence on inequalities. It is sometimes quite difficult to pull all that stuff together, but if you look at not just the big trials but lots of the other stuff and you can actually start to work out what the risk factors are associated with particular group. It is not the same thing as being prejudiced and looking at somebody and saying "Well, you are obviously part of this community, therefore you will want this" but you can say, if you are looking at the plans for your local population, if you have got a high proportion of these people, be they teenagers or whatever they are, these are the risk factors associated with being in that group and you are going to have to think about how to plan your services appropriately for those groups of people. And I think pulling together that evidence has been very, very informative to me, but I think it will inform the NSF quite a lot as well.

  Q197  Julia Drown: And what liaison is there between the Department of Health and other Departments like the Home Office or the Deputy Prime Minister, for example, on asylum seekers or homeless people where we have picked up strong evidence that those women might be dispersed through the asylum process and therefore lose contact with midwives. Homeless people get moved from one place in London to another place in London, for example, and again that continuity of care that can be so important in maternity services gets lost. Is there some work going on on that issue? Because we heard some pretty serious evidence about people just being lost in the system through that.

  Ms Wilkinson: Yes, it is among the risk factors and there are people within the Department who liaise most directly with the other Government Departments you have mentioned. But yes, this is the kind of evidence that we are pulling together about what happens when people are dispersed when they are pregnant and what the kind of negative consequences of that might be.

  Q198  Julia Drown: On the wider issue John mentioned about other types of staff; maternity care assistants, Doulas, issues like that, whether it is for disadvantaged populations or not. Is that something that the Department is looking at or do you think that the current roles that we have within the professions largely at the moment are the right ones?

  Ms McCormick: I think I have mentioned previously about certainly around the NSF post-birth area, we are doing a lot of work around both the multi-disciplinary professionals that need to be involved in the providing care, but also looking at maternity care support workers, voluntary organisations and local community leaders and religious groups who might have an involvement in whatever type of care the woman needs.

  Q199  Julia Drown: Is that limited to post-natal care?

  Ms McCormick: No, it will not be limited to post-natal care, but actually most of the support is required post-birth. I mean clearly there is ante-natal advice and information, but the actual support is seen to be mostly required post-birth.


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2003
Prepared 23 July 2003