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.
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