THURSDAY 6 MARCH 2003

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Members present:

Julia Drown, in the Chair
Mr David Amess
Andy Burnham
Mr Simon Burns
Sandra Gidley
Dr Doug Naysmith
Dr Richard Taylor

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PROFESSOR LESLEY REGAN, Consultant Obstetrician, MS LYNNE PACANOWSKI, Head of Midwifery, MS CATHERINE ECCLES, Chair, Maternity Services Liaison Committee, St Mary's Hospital Paddington, MS BETTY LARKIN, Midwifery Manager, MS KAY BARBER, Senior Midwife, MS SELENE DALY, user representative, Edgware Birth Centre and MS CATHY ROGERS, Consultant Midwife, Barnet and Chase Farm Hospital, examined.

Chairman

Good morning. May I extend a big welcome to everyone who is both attending to listen today and particularly to our witnesses who are from St Mary's Hospital Paddington and Edgware Birth Centre. This is the first of the Committee's new inquiry as a Sub-Committee into Maternity Services across the country. This part of the inquiry is particularly looking at the differences in provision of maternity services across the country, even in relatively close neighbourhoods to each other, trying to understand why there are differences across the country and picking up some of the national issues with that too, about the rising concerns over the rising Caesarean rate and so on. Over the next hour we would really appreciate your input to our inquiry. We are going to start by picking up some issues on data.

Dr Taylor

In the evidence that we have already had from a wide variety of people, we have gathered that it is obviously pretty unsatisfactory. There are some places that still rely on manual records and that there are many problems with the computer systems that some of you do have. Really, I would like to start with St Mary's. What facilities do you have for data collection? How does it work? How pleased - or otherwise - are you with it?

(Professor Regan) We have an electronic data collection system called SMMIS, the St Mary's Maternity Information System, which was - I think it is fair to say - one of the pioneers of maternity data collection in the UK. However, the infrastructure needs for such a data collection to be updated fall far short of what is required. At the moment it is almost impossible to use the data that is inputted by the midwives on the labour ward as a delivery occurs or as an event occurs. By contrast, just down the road there is another hospital, the infrastructure is such that they have updated the same programme by purchasing all sorts of hardware and new equipment and therefore they are able to not just input but also to output and to audit their practice. I think there are large inequities between hospitals throughout the country. I am just talking about a snapshot in central London.

So you have your own system. We are told that there are three commercially available systems that are used quite widely: Euroking, Protos and Ciconia, but you do not even use one of those.

(Professor Regan) No, we do not. We do not have the resource to purchase that and to use it on a day to day basis, although Ciconia is based on the SMMIS system.

Is yours compatible with any other systems? Does it interface with your PAS system? Can you transmit information to the Department of Health?

(Ms Pacanowski) It does interface with the PAS system but only for demographics. We take data from the SMMIS system for the HES data (the Hospital Episode Statistics). Again, it falls short of requirements that we have.

How old is your system?

(Professor Regan) Fifteen to twenty years old.

How often does it crash?

(Professor Regan) Regularly.

So you have huge deficiency even though you have a system.

(Professor Regan) Although you can speak to PAS about the demographics, there is no way that PAS can actually pick up episodes or outcome data. It cannot even pick up numbers of babies born. It can only tell you, for example, the ethnic origin and the area in which a woman was booked.

We have had evidence from one group who still rely on paper. It is appalling. How about at the Birth Centre, how computerised are you?

(Ms Rogers) Like our colleagues, there is a lot of room for development. We have the St Mary's system as well so we use that system. In addition, because of the deficiencies in the St Mary's system and in order to monitor outcomes and transfers from the Birth Centre we have devised a number of other tools - which we refer to in our report - to collect data relevant to informing future practice. We are currently moving in the Trust to the EPR (Electronic Patient Record system) and we are devising a package that hopefully will be a bit more sensitive and responsive to information and requirements in relation to maternity care. There are some concerns in that. I think we are probably the second maternity. There are not many maternity units nationally that are going for the EPR and the lack of national database on maternity care is---

Sorry, did you say not many are going for it?

(Ms Rogers) I cannot give you the figures, but I know of two units that are looking at developing the EPR. You have to develop the package for EPR; it is not developed yet. There may be issues in terms of making national comparisons if we are not all inputting the same data.

Some of the written evidence we have had suggests that maternity is one of the ideal fields in which to get the Electronic Patient Record up and working soon. Would you agree with that?

(Ms Rogers) Yes and I think it would be very useful if we had a national lead in terms of the development of the database. I can only speak for my own Trust, but in our Trust we have a group of core people working on development of the things that we want included in EPR, and it would be nice if perhaps nationally we had a group of key people developing the database. I do not know if that makes sense, really.

(Ms Barber) Can I say that we also have a separate data collection tool that we have used for every woman who has accessed use of the Birth Centre. Initially it was when we were in a project period, but we continued that. Although we take those details manually it is all entered onto the computer so we have continuing statistics.

Do you know what the current national data set is?

(Ms Barber) No, I do not.

St Mary's? No. It is rather nice not to be faced with a huge majority of Government MP's at the moment, because the Government has the most amazing plans for the development of computerisation across the whole NHS in a very short space of time.

(Ms Pacanowski) For the EPR it is 2004.

It just is not realistic, is it? Or do you think it could be?

(Ms Pacanowski) I do not think it is realistic if you look at some of the systems. In Trusts there are so many data systems looking at different aspects of care. You have the PAS system, we have SMMIS system, there are A&E systems, there is ORSOS for theatre systems. All of these different data systems can give you some data; they just do not talk to each other.

What would you like to see first? What would be your first priority to improve your data collection?

(Ms Pacanowski) Something that is actually standardised across the country.

(Professor Regan) Could we not emulate exactly what happened in Scotland. They have been collected data - relatively simple data - for 20 years. They have a web-site which publishes monthly accounts of perinatal outcomes and is highly effective. My understanding, since I know Professor Steer - who I think has been advising you on the Maternity Care Project - is that there are significant reservations about the complexity of what is being commissioned by the NHS Executive. For example, it is probably not going to be able to pick up still births and late miscarriages which are an essential - enormous - component of our perinatal mortality rate. Without that sort of basic information I do not see how we, as health care providers, are going to be able to dovetail what is required by our maternity system. I would suggest that rather than re-invent the wheel at vast expense and with great complexity, we actually take on board the success of the system in Scotland.

So a relatively simple system that actually works.

(Professor Regan) A single form. I think it is called SMRO2 and it basically collects this data and has done for the last 20 years. Scotland, I think, is an example to us all.

Do each of you units produce an annual report?

(Professor Regan) We do via the SMMIS system so the SMMIS system - although we have been criticising because it needs significant updating - is available to every maternity unit bar, I think, two in the north-west Thames region. It is possible to analyse the outcomes by hospital. It is an incredibly labourious process and most of it has to be hand-picked in the sense that an individual will have to extract items of data and then correct it because of inadequacies in not just the collection but in the storage of the data and missing fields. It is possible to get an annual report, but it is not the most accurate and myself and Lynn, for example (who is head of Midwifery) could not go and actually plan strategy on the basis of that annual report at the present time.

Which is what you ought to be able to do.

(Professor Regan) Which is what we want to do.

(Ms Pacanowski) It is hugely frustrating because we input a lot of data - all maternity units input a lot of data - but we cannot actually compare a lot of criteria from the past and from the present because it is not accessible. Either we have an answer that asks the question or you just cannot draw the data out. Not being able to analyse what gets put in, you cannot actually make improvements because you cannot say, "This would help" because you cannot prove it.

Thank you for that. You have given us a lot of problems to raise.

(Ms Rogers) Can I just add in terms of whatever system, the importance of ensuring that all systems are available in the community setting where most of maternity care is provided and at GP's surgeries so that midwives working in the surgeries can access the appropriate information that may be entered from the hospital setting. That is currently one of our difficulties. A lot of midwives' time is spent on trying to get information.

Do you have compatibility with GP's at the moment?

(Ms Rogers) No. In some cases, but generally no.

Sandra Gidley

I am going to ask some questions about the Caesarean section rates. I think the first question, following on what you said about the accuracy of your data, is do you actually think that your Caesarean rate is higher or lower than the 29.8 per cent which we have been given as a figure for you.

(Ms Pacanowski) I do not know what period that was, but for 2002 ours was 27 per cent.

So it could be a different year that we are looking at.

(Ms Pacanowski) Actually, I think possibly your figures include the Lindo unit. We have a private maternity unit within St Mary's, the Lindo Maternity Unit. This is another situation where data gets misinformed. Sometimes the data includes their statistics.

Why should they be different?

(Professor Regan) Because the Caesarean section rate in the private sector is significantly higher than in the NHS.

Is that women's choice?

(Professor Regan) Yes, I think it is partly women's choice, it is partly different modes of practice as well. Over the last year, on the NHS labour ward - we have done the figures by hand - the Caesarean section rate was 27 per cent.

Even if we take the figure as 27 per cent, the Sentinel Audit said that at least six per cent were unnecessary. I think that was on the average of 21 or 22. What have you actually done as a hospital to try to decrease the rate of Caesareans because by any standards your rate does seem exceptionally high?

(Professor Regan) I think there are two factors. First of all it is very evident to us that when we have a high vacancy rate in terms of midwifery staff the Caesarean section rate goes up. Of course, in an ideal world we would have one to one care for women in labour and I would anticipate a significant reduction in Caesarean section rate. By a recruitment drive 18 months ago we have actually managed to improve the rate, although it may still be high, higher than we would wish to see. Interestingly, having set up two community case load teams in the last year, the first year of audit has shown that the Caesarean section rate - both elective and emergency - in the case load team working in the community in very deprived areas - so we are not hand-picking low-risk cases - is only 15 per cent.

Could you explain briefly why you think that difference is apparent?

(Professor Regan) It is continuity of care and one to one care in labour. These women are cared for primarily in the community with hospital input for various screening tests and investigations and reference for any complications or queries, and then when they go into labour they are seen at home by their midwife in this case load team and then brought into hospital. They are delivered by one, two or possibly a third midwife from that team with whom they will already have developed a relationship. That midwife will stay on duty - unless some exceptional circumstance occurs - until the baby is delivered.

So you would go so far as to say that the biggest factor affecting the Caesarean rate is the availability of midwives in your area.

(Professor Regan) In terms of normal pregnancies, undergoing normal deliveries. You must remember as well that one of the reasons that our section rate is higher than some other hospitals is because of the case load we are looking after. We would have in- utero transfers for a variety of complications. We have a large miscarriage service, for example. We have a lot of operative deliveries that are perhaps not commonplace to all units. Certainly, when we are talking about normal pregnancies and normal deliveries, undoubtedly the midwifery input and one to one care is fundamental in achieving a normal outcome.

Do you have any figures to tease out that aspect of the referrals.

(Professor Regan) I can give you plenty of figures but I did not think you want minutiae, but if we say 27 per cent overall in a high tech/high risk unit and 15 per cent section rate produced by a case load team of midwives working in the community and then bringing those women into our labour wards to deliver.

(Ms Eccles) I am here as a user of the maternity services. I chair the Maternity Services Action Committee at St Mary's. One thing that I know that women want and would produce better results in labour is one to one care. Continuity of care as well. Being supported all the time by a midwife, continuity of care, actually having the same midwife who has seen you antenatally and then is supporting you through labour with a relationship of trust that has been evolved through pregnancy towards labour. If that is achievable I think the Caesarean section rate will definitely drop.

Can I just ask something of the Edgware Centre here because obviously you do not do Caesarean sections. Eleven per cent of your patients are transferred. Am I right in thinking that they are a fairly self-selecting group and some women would not be allowed to give birth if they were perceived as being high risk? What follow-up do you have as to how much of that eleven per cent end up with Caesareans?

(Ms Rogers) We have analysed the actual data for the last two years. I do not know if you have seen our evaluation, our report, which was an independent evaluation of the birth centre. Again, what the report shows is that when they did a comparison between women who intended to deliver at the birth centre and women who met the same criteria but delivered in a hospital, the women who delivered in the birth centre had significantly lower rates of Caesarean section than the comparison group. I think that supports the evidence which we have seen, the philosophy of care at the birth centre, the application of evidence based practice and the support offered by midwives are major factors in terms of reducing intervention rates. We do have women who transfer and in terms of the eleven per cent of women that transfer in labour, the reasons for that transfer is that they are not making good progress in labour, maybe they are wanting an epidural and sometimes the baby has opened its bowels (we call it meconium ). So they are the major reasons for transfers in labour.

Do you have any follow up as to how many end up having a Caesarean section?

(Ms Rogers) Yes, we do. In the figures that I have given you in our report, 85 per cent of women who come into labour in the Birth Centre have a normal delivery. Of those that are transferred out, five per cent have a Caesarean section. Of those women - the five per cent who have a Caesarean section - the majority reach the transferring unit and are there for some time before they are ready. They are not arriving there and being wheeled into theatre. Many of them would go on to have their labour augmented or have an epidural. Five per cent of our transfers in the last two years required Caesarean section. It is very positive.

(Ms Barber) I would also say from a midwife's point of view that it is the continuity of care and the one to one care in labour which is the biggest point, namely why the Caesarean section rate is so low. It is that constant support, knowing the women through their pregnancy and giving them one to one care. There is somebody there supporting them.

Yvette Cooper was on record as saying something like 91 per cent of women have one to one care in labour. I have tried to get a definition from the Government as to what one to one care in labour is. To my way of thinking it is not just being there when the baby is born. Could you define what you mean by one to one care in labour.

(Ms Daly) One to one care for me is when you go into the Birth Centre - and I have had two children there - you stay in one room; you do not get trolleyed between labour, theatre and everything else. You stay in one room and virtually the whole time you are in there through your labour, through the delivery itself and then post-delivery, your midwife is with you. Sometimes they also have a midwifery assistant. That is the one to one care. It is not just the presence of the midwife; it is also knowing that you have an expert with you. It is that confidence to know that you are in the presence of an expert who is going to look after you. But they let you get on with your birth; they do not interfere. They try to encourage lower intervention of drugs, pain relief and also equipment intervention. We have fewer episiotomies, we have less tearing (especially in birthing pools, because they are very keen on using birthing pools as well). If you get more women into this kind of model of care I believe you will reduce Caesarean section. I am absolutely convinced of that as a user. It is all that. It is being in the presence of the expert, having that wonderful midwife there; she is there all the time. You are part of the decision making process. If there is a decision to be made it is not done to you. It is not an intimidating environment. You feel very safe because it is like being at home. There are no huge monitors and big beds. It is like being in your own room. It is the whole holistic approach to that. It is very, very safe. It puts women at ease. That is the kind of one to one care. It is not just the midwife being there, which is absolutely fundamental; it is the whole idea of that, going into the room as if you are going home and the whole process progresses as it should without anybody else. I delivered both my babies myself. That is the one to one care. You must look at it from a holistic point of view.

(Ms Barber) I think the woman's lower anxiety levels - because of everything that Selene explained - is one of the main reasons that they manage with a lot less pain relief - just using mainly the birthing pool and breathing techniques and being able to be active during their labour - which then goes on to reduce the intervention rates. Feeling relaxed is a major influence in birth.

Before I ask St Mary's about this, can you tell me how many midwives are based in your unit? Is it easier for you to get midwives?

(Ms Barber) We have seven whole time equivalent midwives who work on the core staff of the birth centre. We provide 24-hour cover but because we are working with three hospital trusts - we collaborate with three Trusts in the local area - women who are in the community would be booked to come to the Birth Centre but are visiting their community midwife and staying out in the community. Those community midwives then come in with these ladies so our staffing works depending on how busy it is.

(Ms Daly) It is also important to say about the staff retention. Although I do understand that it is easier to get staff into a birth centre environment and it is easy to keep them. The morale is very high which I believe is very unusual for the NHS even in midwifery. They must be doing something right.

(Ms Rogers) I would just like to correct myself. I gave a figure of 5.1 per cent of women who required transfer had a Caesarean section. That figure - 5.1 per cent - relates to women who come into labour at the Birth Centre, but I can supply you with the actual per centage of women who are transferred.

I want to ask St Mary's what they meant by one to one. Would you agree with what has been aid already?

(Ms Pacanowski) Yes. That's fine.

(Ms Eccles) Your original question was what has St Mary's done to address the Caesarean section rate. Something we have not covered yet is the issue of electronic fetal monitoring. There are some nice guidelines which show that with low-risk births there is no positive outcome for the admission trace and through the work of the MSLC the protocols at St Mary's have now been changed and it is all being implemented at the moment to stop doing the admission trace because it has been shown to be the first step towards intervention and therefore the first step towards possible Caesarean but with no positive outcome. That is being implemented at the moment.

Dr Taylor

Who makes the decision when a mother has to be moved from your Centre to a consultant unit?

(Ms Barber) The midwife with the mother and her partner as well. We keep them informed constantly throughout labour. Nothing is ever a surprise.

Is it cut and dried, obvious when that has to happen?

(Ms Barber) Yes, but it is not always cut and dried; there are grey areas.

And in those areas?

(Ms Barber) In those grey areas we would transfer. Geographically how far in time and miles are you actually away from the consultant units you transfer to?

(Ms Rogers) Seven miles.

Do any of you - on either side - see a problem with birth centres that are much further away from consultant units?

(Ms Barber) Your guidelines and your practice would reflect how long your transfer time is and also your acceptance criteria.

You mean if you were further away you might have stricter criteria?

(Ms Barber) I think if you are further away you would have a lower tolerance to transfer. There would be a higher rate of transfer.

(Ms Rogers) Which could be a good thing or a bad thing, actually.

As with a consultant unit, there are a number of births that are necessary to keep everybody skilled. I think you have about 250 a year. Is that right?

(Ms Rogers) Four hundred last year.

Is there a minimum number to keep the midwives skilled.

(Ms Rogers) There is not a set number of births that one must do as a midwife to say whether they are competent or not.

Do your staff rotate? Would you at some points work on the consultant unit and sometimes in the birth centre?

(Ms Barber) Only from a refreshing point of view if we were working in a consultant unit. Working at a birth centre utilises the full range of midwifery skills. You are using everything that you have been trained to do. The core staff stay as the core staff at the birth centre and we do not rotate, although there are some rotational posts from the three Trusts that we are working with so that midwives who are not working within the birth centre can have the experience of working at the birth centre. That helps to integrate it into the services.

Is it the other way round? The ones working in the major centres would get de-skilled with the ordinary births.

(Ms Rogers) This is what has been shown by the evidence. Midwives will look at recruitment and retention nationally and we know that we have a shortage of midwives. One of the problems has been - in terms of attracting midwives and midwives staying in the profession - this issue around not being able to practice what they considered midwifery to be. What we have is a lot of demand in our units from midwives wanting to go to the birth centre to practice midwifery. They need to create more environments where midwives can practise the full range of their skills and also make very good use of a very expensive resource, which is midwives. That is what we are finding.

Should one of our recommendations be rotations between the two sorts of unit.

(Ms Barber) Absolutely.

(Ms Pacanowski) Going on from what Catherine was saying about setting up these new guidelines about not doing the admission trace, we are just implementing that at the moment. Because of the way that midwives are used to working, actually that is not the way they are used to working, in a high-tech obstetric led unit. They have almost had to have a refresher course in using those skills and it has been wonderful. They have really enjoyed going back to practising basic normal midwifery. I do not think you need to rotate from one unit to another. We have quite an antiquated labour ward that has recently been refurbished and we have tried to create an area which is like a low-risk area with a birthing pool. If you turn left you go to that bit and if you turn right you go into the more high-tech part. The midwives work across the labour ward and so they actually get experience in both which I think is pretty beneficial.

Sandra Gidley

I am not very familiar with staffing numbers, but I have just been passed a note from one of our advisers which says that Edgware has seven whole-time equivalent core staff on the labour ward for 500 deliveries. Comment, that seems quite high. I know it is difficult to compare the two, but how does that compare with staffing levels at St Mary's, bearing in mind the comments you made earlier about this being one of your problems?

(Ms Pacanowski) This comes up in staffing structure as well. We have been part of a London-wide project looking at setting up midwifery establishments in all 27 units in London and they compared the ratio of midwives to births. They took the birth rate of a Trust - ours is around 3,000 - fed in the establishment of midwives and then worked out the ratio. We have one of the worst ratios, I have to say. It is something like 38:1, 38 births to one midwife. There is a huge variation across London from 28:1 to 41:1.

(Professor Regan) I think we need to add here that the advantage of this new audit system called Birth Rate Plus is that in addition to counting numbers of baby's bottoms that hit beds and the number of midwives who delivered them, it was also factored in the dependency of the case mix in that hospital. For example, if you can imagine in Paddington we have a large number of intra-venous drug abusers, we have a large number of HIV positive patients, and those patients - proportionately - take up a lot more midwifery time and medical time as well. These figures were the first time there had been any attempt to analyse what these midwives were doing and to factoring what was necessary to look after some under-privileged groups and some ethnic minorities.

(Ms Barber) Can I just add that we do not have access to the monitoring that you have been talking about at St Mary's which means that the way we monitor the baby is by listening to the baby's heart rate every 15 minutes. That alone - with all the other things that a midwife is doing when she is caring for a mother in labour - is another reason that you need the one to one care in labour. Within 15 minutes the midwife is going to be present, you need to be present to monitor the mother's labour and hence the statistics with the low Caesarean sections.

(Ms Rogers) I think if our ultimate aim is to reduce the Caesarean section rate and reduce intervention and to truly get evidence based midwifery practice off the ground we are going to have to re-invest in midwifery. Women who come to the birth centre require as much input as women who are drug addicts or whatever in terms of really giving them the level of support and encouragement and facilitation that is required to get the positive outcomes we do have.

I fully take on board all those comments about facilitating and empowerment, but do women actually have enough information about Caesarean sections to actually actively participate in that decision?

(Ms Eccles) Only if they look for it. If they go on to the Dr Foster web-site or something like that. I think at the moment where women decide to give birth, some of them might decide to go on to Dr Foster and look at Caesarean section rates across the country, but I think that is about the only statistic they can get easily. There are other things like instrumental delivery and epidurals. How women make their choices at the moment is they go to look at the birth unit and just at the general environment, and by word of mouth. I think perhaps it would be beneficial for women to have more automatic access to the statistics in order to make informed decisions rather than ad hoc decisions about where and how they are going to give birth.

(Ms Rogers) People who have had previous sections are very late when it comes to making decisions about subsequent mode of delivery and if we want to reduce Caesarean section rates, reduce second Caesarean we really have to start after the woman has had her first section and meet with her, debrief her, really give her information very early in pregnancy in relation to supporting and being more positive about the whole thing. I think we leave it far too late sometimes.

(Ms Eccles) What women do not realise is that the admission trace or an epidural or induction are all very positive steps towards having a Caesarean section. That information really needs to be put across more forcibly than it is at the moment. I think at the moment women seeing having an epidural as having pain relief and therefore having an easier time. What they do not understand is that they have a far higher chance of an instrumental delivery or a Caesarean and I think that information needs to be given.

So you are making the case for more information generally.

(Ms Daly) Absolutely. From my point of view I went to a major hospital first before I found the birth centre and I felt I was coached in how to use pain relief. When I went to the birth centre I was advised about pain relief in far greater detail. I was also given the option of none and that actually might be far more positive for my birth. If I do not have pain relief then I am probably slightly more corpus mentis and therefore I can probably get through my labour more quickly and deliver more quickly. In fact, you will find in statistics that women do, on average, have shorter labours in birth centres than they do in conventional hospitals. If you look from the cost point of view of a birth centre ethos, reduction in drug use, reduction in intervention, shorter labours, reduction of equipment to use, you do not need the monitoring equipment. Postnatally the GP's have said that the women from the birth centre do not go back; there is a potential reduction of costs of postnatal care. Even rooms management in a birth centre: woman X is in room 1 and that is it. You will never have to look in the loo for her because she has one in the bedroom. That is from a business point of vies. Also midwives: you have staff retention, you can get staff back in, there is high morale. I would say for not containing costs you can actually get far better birth experiences, far better outcomes, raised morale of midwives and women as well and, I think, very much PR for the NHS in this particular area. For me it is a compelling business argument to look at this in greater detail.

But you cannot provide some of things unless you have the staff to support the women, so it actually comes back to the same point.

(Professor Regan) Can I make a point there about the electronic fetal monitoring. I am a great supporter of having this midwifery led unit within our labour ward and we are not actually performing electronic fetal monitoring. One of the problems is that if you have a particularly bad day and you have staff shortages, you could find one midwife looking after three labouring women in three different rooms. In that situation one of the only things that that poor midwife will be able to do to facilitate safety of both mother and baby is to leave these monitors on and when she is in room two just hope that her right hear will here the pip, pip, pip in room three and vice versa. I am exaggerating a little bit, but that is an issue. I think that all of the aspirations that I have heard I entirely agree with and want to support going into practice are just going to be pie in the sky until we completely review our midwifery staffing structure. It is not a question of upping it a little big; it is dramatically increasing it if we are wanting to achieve what has been voiced here.

(Ms Barber) I would never have been able to deliver the care that I can give at the birth centre when I worked in the consultant unit.

(Professor Regan) It is extraordinarily difficult to retain good experienced midwives who find themselves regularly in a situation where they are caring for three women and feel that the situation is unsafe. They are going to leave the service and then you have lost this extraordinary resource. However many people you put back into that one job you may never replace the experience.

Since you have had the midwifery led care unit, has that actually made St Mary's a bit more attractive to midwives?

(Ms Pacanowski) We have been fortunate in that our vacancy rate has been quite low, which I think is due to a lot of other initiatives. I think being able to practise in those different ways is attractive to midwives and Lesley was saying about how stressful it can be, you can only take so much and in the end you think, 'I am not practising what I am supposed to be doing'.

(Ms Daly) The model of care here that is being demonstrated here attracts midwives and helps to retain them and increases morale. From a business point of view I am screaming out here: 'Why aren't we looking at it?' I have been saying that for the past three or four years as a supporter of the birth centre. As a support group we do not support women; the women are supporting the birth centre because we think it is so important.

Andy Burnham

From a constituency point of view I have picked up that it is a very difficult challenge getting a midwifery training place in the north west. There is a great shortage and great competition to get a training place.

(Ms Pacanowski) We were having a conversation before we came in about that. The staffing situation is very different around the country. We recruit people from the north, from the midlands, because they train and then there are actually no jobs for them to go to. It is certainly an issue for London.

A constituent of mine had applied something like six times and was about to give up just because they could not get a training place. Desperately keen to get into the profession - change profession from something else - and has finally just got on.

(Ms Pacanowski) Whereabouts was that?

Manchester. Living in the north west, applying to train in Manchester.

(Ms Pacanowski) I think they are training to replace and they do not have big vacancies. Certainly we have recruited midwives who have undergone their training and then cannot get a job because there are not any vacancies.

So the problems differ markedly across the country. Some places it is the lack of training places, other places the jobs cannot be filled.

(Professor Regan) In central London it is retention. It is very difficult to live on a midwife's salary in central London.

There is no chronic shortage of training places in London.

(Ms Rogers) There is an issue round the number of midwives who are training and the number of midwives who are getting on courses and midwives leaving. I have been in midwifery education for ten years and midwives on the courses are leaving because they are frustrated with what the profession has to offer. They come into the profession and aspire to give the model of care that we have talked about and then the reality is that it is very difficult because they work on labour wards where midwives are looking after two or three people, where they are not getting to know the women like they hoped they would get to know the women. I think in London - certainly at the university where I was attached to - we were having difficulties at times in getting enough recruits to the programme in addition to students leaving, having worked for a while and being frustrated by what they saw. Then they are coming to placements like the community or the birth centres or the midwifery led units we have talked about and it has given them hope for the future in staying on. They might have left had they not had that opportunity to see that midwifery does not have to be like it is in some of the large units.

Dr Taylor

In your unit at St Mary's at what level is the decision to perform a Caesarean section carried out? And at what level should it be carried out? Is it consultant level? SpR level?

(Professor Regan) No Caesarean section is performed without the agreement of the consultant on call.

Does that go throughout the country, do you think?

(Professor Regan) I think you need to ask you advisers that. I do not know. I do not have a snapshot of every unit.

Is that what you think should happen? Should it be a consultant decision?

(Professor Regan) I think it should be yes. I think induction of labour should be a consultant decision as well.

Chairman

Who makes the decision on induction?

(Professor Regan) Frequently our midwifery staff will assess the patient and then we will discuss it. But since the responsibility of the failed induction/Caesarean section becomes mine we obviously have a good understanding that -----

Dr Taylor

Obviously it is a team working together, but the responsibility is the consultant's.

(Professor Regan) Yes.

(Ms Rogers) I think nowadays with the expertise of registrars being very different because of training, it is very important that decisions with respect to Caesarean section are made in direct consultation with the consultant rather than being just seen by somebody who talks to the consultant on call in terms of confirming the decision or not. I think that for the future maybe we need to be strengthening that process that consultants are directly involved particularly for Caesarean section. I think there should be direct consultation the woman - given that having a Caesarean section is such an important decision - and the expert, who is the consultant obstetrician, before they make that decision.

Chairman

We have covered quite a lot of issues on staffing. Could you just pull out for us what the major issues are for you on staffing. We are perhaps particularly interested with St Mary's. You have the midwifery led area. Would you say that genuinely was midwifery led care there? I would be interested in your views on that and what are the major challenges. Professor Regan, you were saying that although you have had a relatively low vacancy rate of midwives you have had the experience of one midwife having to run through three rooms which obviously does not sound good. Is there an issue that there are just not enough in the structure?

(Ms Pacanowski) It is the establishment. The number of midwives that we are allowed to employ, when we had this Birth Rate Plus workforce planning tool - which was Department of Health funded and supported - the outcome from that showed a shortage of 40 midwives in our establishment.

Will you be saving some money if you are reducing your Caesarean rate?

(Ms Pacanowski) We would do, yes. If I could go back to the case load teams, I looked at the statistics for the last eight months for the Caesarean section rate for the maternity unit as a whole, which was 27 per cent. I looked at their outcomes and their Caesarean section rate was 15 per cent. The remarkable thing is that they are not looking after women who are low-risk, who would go to the birth centre. They are actually based in an area of the highest social deprivation around Paddington; that is seriously deprived. They have all the usual challenges in terms of perinatal outcomes, and yet because they were able to provide this continuity of carer and were with the women all the way through their labour, I am sure that had a direct impact on the outcome of those women's births.

Do you feel, particularly in the midwifery led end of the unit, that your midwives are really skilled in supporting normal births?

(Ms Pacanowski) The midwives work all round the unit. They work in clinics; they work on the postnatal ward and they work in the labour ward as well, which I think is very good for them. They get experience of everything all the time. When this workforce planning tool showed that we had such a shortage, our strategy is to create more of these case load teams which are community based, have a case load of women which are already showing very good outcomes, reduce Caesarean section rate which will actually save us a lot of money. They also have far fewer epidurals.

Chairman

From a user perspective, would you say it was genuinely midwifery led care?

(Ms Eccles) I think it is probably half way between the two. In some hospitals - like the new Charlotte's unit - they have actually got the midwifery led unit on a different floor to the obstetric bit. I think that more physical sort of barrier probably makes it more of a self-contained unit. I think what St Mary's has done is within the huge constraints of the area that they have to have the labour ward in, they have done a really good job in trying to have a low-risk end and a high-risk end.

What do users want?

(Ms Eccles) I think users want the choice. I think that the Charlotte's set up is more attractive to users than the St Mary's set up.

(Ms Daly) If you think about it, I can understand - again from a business point of view - a hospital is on a very macro level. You have a lot of resources to manage and it is managed as a business. Then out at the end pops a woman and a baby, which is wonderful. But if you turn that on its head and start from what the woman and the baby wants, from what women have told me they want, when you logically work back you would never get to a huge unit. Even in St Mary's which is a huge unit, even there they are saying: 'We want some other different unit which is away from the white coats where midwives can get back to doing what midwives have been trained to do.' That kind of a model gives women a lot more safety and security and a far better birth experience.

(Ms Larkin) I worked two years as a manager for the community midwives and they all work in teams and they got such great job satisfaction. Some midwives have worked there for 20 years. They would not change because they get so much job satisfaction. They are not just looking at one set of clients, they are looking at the whole range of clients. In the delivery suite they are doing both and they are getting such good job satisfaction that they just do not leave.

(Ms Rogers) Because we are here representing the birth centre and as you know the birth centre is some distance from the main unit, I think, in terms of the future provision of maternity services we have to be cognisant of the fact that if a recommendation in terms of models within main hospitals, the difficulty is reducing local choice from local women. Most of the women at our birth centre are local women and are delivered there. You have to provide a range of models for women.

(Professor Regan) I think it is important that your Committee also takes on board that we are talking on staffing structures there has been an enormous change in the staffing structure from the obstetric side. For example, the European Union Working Time Directives - the need for much reduced hours, the limited number of trainees, et cetera - has had a big effect on the way the staffing structure runs in the maternity unit. It has also had a big effect on the amount of supportive care which the midwives can provide.

I did want to pick that up about what cover you have. Do you have the 40-hour consultant cover on delivery suites and 24 anaesthetic cover?

(Professor Regan) We have 40 hours of consultant cover on our labour ward?

Does it feel right?

(Professor Regan) Yes, in the sense that I am sure it is better for patient care and it is better for staff training, but it has come at a cost to other facets of a busy department of obstetrics and gynaecology. In order to meet that demand or necessity other things have had to be put down the priorities list. The demands on consultant time and on SpR on issues like the governor's audit, appraisal, et cetera, they all have to be fitted in in addition to the clinical work.

Andy Burnham

We talked a moment ago about training places. I want to talk to Professor Regan, Ms Pacanowski and Ms Larkin about the kind of courses available for staff to up skill once they are in post and what kind of training you offer. I have in mind things like neo-natal resuscitation courses or management of obstetric emergency. Those kind of things. Is there a continuous programme that you take?

(Professor Regan) There is a rolling programme for both SHO's who are taught separately to the SpR's and in some of the training programmes like neo-natal resuscitation and interpretation of CTG electronic fetal monitoring we have explored a joint model of training and upgrading with the midwives which we found very productive.

Midwives and consultants together, you mean?

(Professor Regan) SpR's and midwives together, being led by a senior midwife and a consultant. There is some in-course training which is a rolling programme which are delivered individually to specialist groups and some of which we get every team member in the unit together and they undergo the training programmes or the updates together.

Is that a change? Was there more demarcation or has it always been that way?

(Professor Regan) That is just our unit which, I think, has a good reputation for working together as opposed to: 'This is a midwife's case' or 'This is a doctor's case'.

(Ms Pacanowski) I think in terms of training as well, that is one of the reasons we have been quite successful in recruiting and retaining staff because we have a generous sort of approach to people who want to do different types of study.

Is it that at a certain stage of their career they can do a certain course, or can they do a course if they have a particularly interest?

(Ms Pacanowski) If they are interested, yes. We have midwives who trained in Shiatsu for instance, as well as midwives who are doing coping with obstetric emergencies. There is a big range of professional development for them.

(Ms Rogers) Midwives have a main supervisor and that supervisor meets with the midwives on at least a yearly basis but much more frequently than that in most cases, and part of that meeting is about identifying learning needs, practice development requirements. As a result of that meeting recommendations would be made in terms of training and provision and access to courses. In terms of training at the birth centre we have the same philosophy that it is inter-disciplinary multi profession education and the midwives at the birth centre attend educational programmes with their colleagues both obstetricians and midwifery colleagues on the host site, which is Barnet. Again, multi-disciplinary education is important not just because of the cost effectiveness, but it is also about developing the necessary collaboration and trust and respect for each other's contribution to maternity services. It is an excellent forum for that.

Is the trend towards giving midwives more responsibility, doing things now that they perhaps did not do in the past? Is that the way it is developing?

(Ms Rogers) Yes.

(Ms Barber) One example of that is the N96 course which is the examination of the new born which, until relatively recently, was undertaken by a paediatrician. Obviously at the birth centre we do not have paediatricians.

It still is in some places, is it not?

(Ms Barber) In the majority of places, yes. But this course is now available to midwives so that they are actually able to undertake the examination of the new born.

(Ms Rogers) You mentioned about SpR's and reduction in doctors' hours and more pressure on the consultants. The backlog effect is that there is more pressure on the midwives. First we have a shortage of midwives and in order to provide services to women and their babies midwives are taking on new responsibilities and that is something we would wholeheartedly embrace as a profession.

Is the hearing test one of those?

(Ms Rogers) The hearing test in our unit is done by specialist people, not by midwives. Last year three per cent of newborns were examined by midwives.

Is there more way to travel along that road then, that midwives can carry on taking more and more responsibility? Where is the boundary?

(Ms Pacanowski) I think you can come to a point when they are overloaded.

Chairman

Are we getting near that point?

(Ms Rogers) I was very fortunate to be part of the national study looking at midwives extending their practice and certainly in the interviews with midwives a more in-depth study needs to be done on it. Where midwives are extending in what they perceive are the core values of midwifery, the new born examination was seen as a natural extension of midwifery responsibilities. But midwives had more concerns about extending into areas which they considered were outside the parameters of what they considered normal midwifery practice.

(Professor Regan) I would like to make a point about retaining experience staff, and I think nationally we are rather poor at utilising our midwifery workforce after they have gone off to have their own children. Coming back to work, particularly in an inner city, can be almost cost-negative not even cost-neutral. I think if this current head midwife has adopted the policy: 'Okay, what would you like to do?' and, as we have, a couple of our very experienced midwives who come back to work for one long day or two long days and nothing else, the answer is: 'You can't do that'. The answer is: 'Yes, do whatever you would like to do.' Flexibility in employment, especially when they have small children, is really important otherwise you lose that resource completely and you lose their capacity to teach as well.

Dr Taylor

Professor Regan, you mentioned the European Working Time Directive. How does that actually impact on your unit with loss of junior doctor time? Can you keep the unit safe?

(Professor Regan) I am sure it is good for those junior doctors in terms of their quality of life. It has had a massive, devastating impact on the sort of standards of care we have been able to provide and how we have been able to maintain minimum standards. For example, because we do not have enough SpR training numbers it is not a question of being able to go out there and recruit more people even if we had limitless resources. Those people are not out there. As a result of reorganisation they just do not exist at this moment in time. In our particular unit, we have had to beg, borrow and steal from our chief executive to get a pot of money and then advertise for what we call 'clinical fellows'. We were advertising for individuals who would come and be part of a team structure. The quid pro quo was that they would help us with the hours issue in covering the labour ward safely and also the emergency gynaecology theatre at the same time if they are dual trained, and what we would give them would a specialist skill, for example a year or 18 months doing specialist fetal maternal scanning or working in the reproductive medicine unit, doing a research project, supervising an MD thesis which might help them in the future. It has been very difficult to appoint to those posts because there are not the people out there. There is a timing problem here. There is going to be an interval until it is possible to redress that even with limitless resource.

How does it actually impact on the training the SpR's receive?

(Professor Regan) They, I think, feel disenfranchised and often very isolated because the hours that they have to work mean it is not longer possible for them to be in the old team structure. For example, the SpR I did a ward round with on Monday morning will be different from the person who goes to theatre with me in the afternoon and will be different from the person who does the post-operative ward round the next day. That may be frustrating for me, it is not very good for the patient, but if we are talking about the trainees - which was your question - it cannot be the happiest way to be trained. I used to know the trainees that were with me very, very well and now I sometimes find it quite difficult to remember who I am trying to bleep.

It is a huge disaster across the whole field of medicine, is it not?

(Professor Regan) Yes, and you will recall that historically what happened was that obstetrics and gynaecology, surgery and anaesthetics were picked off first. I think we are at the front of that vanguard and now general medicine is experiencing similar sorts of problems. There just are not enough people in the system.

Chairman

We have not talked at all about breastfeeding rates. We know that breastfeeding rates are very different across the country. Do your staff have any training and do you know anything about your own breastfeeding rates?

(Ms Larkin) Some months we have 100 per cent of mothers who deliver at the birth centre. I do the figures every month and I know it is usually 96 to 100 per cent. That is going home breast feeding, but one of our midwives follows that up and they are usually feeding for at least three to four months.

At St Mary's?

(Ms Pacanowski) We have quite a good breastfeeding rate, about 70 per cent. This goes right back to collection data at the beginning. I was trying to collect data that was comparable with ten days or two weeks post-delivery and it is just not available, so it is very difficult to compare units.

What would you need to do to get closer to a hundred?

(Professor Regan) Massive infusion of midwives onto the postnatal ward. The postnatal ward is always the poor relation. Whenever there is a shortage of staff that is where they are lost.

(Ms Rogers) I work across the Trust and one of the issues that has come up in one of the other hospital units is this very issue. Eighty per cent of the women come to the unit wanting to breastfeed and in one group we looked at it was less than half who were actually breastfeeding because of the lack of support that was available.

(Ms Daly) In the birth centre if you do have problems you know you can go back and call a midwife up, whatever midwife, it does not have to be the same midwife, and you know you will get support. You cannot always do it yourself; you do not know how to do it. The first time I had to breastfeed I just got some quick techniques and the next day it worked.

Andy Burnham

I suspect breastfeeding rates vary quite a lot across the country. In Warrington it is the exception rather than the norm, the majority were not breastfeeding. What do you think is the biggest driver of changing behaviour? I think the fact that it is cheaper and more convenient, but I do not think that people are getting that message. They seem to fixate on the negatives.

(Ms Pacanowski) I think the message starts when they are nine and ten years old, maybe even earlier. It is what they are used to, what they are exposed to and what is normal for them. By the time they become teenagers they have probably made up their minds what they are going to do.

Is that right? Do you not think it is something they decide during pregnancy?

(Ms Pacanowski) Then there are three big areas which will change their minds about it. One is during the antenatal period when it is addressed all the time. Then on the labour ward where they have that skin to skin contact for a certain period. Then having the support postnatally. If you are really strapped for staff you cannot give that time.

They get frustrated and give up.

(Ms Daly) We do get literature nowadays but it is often the case that people do not read it. That is true in any walk of life. I saw that there was a huge backing of breastfeeding. It is very openly mentioned and you are made fully aware of it. It is very well supported by the midwives. Sometimes it is just verbal praise, telling the mother about the baby being better protected because of the antibodies. That is far better than a leaflet. Word of mouth is much stronger and that is endorsed by the midwives in this particular unit. I think that is one of the reasons why more of the women do it.

(Ms Larkin) I agree with everything that has been said but I would like to say that we do not provide milk for the babies. A lot of units do. We do not have milk on the premises. They have to bring the milk in with them if they want to use it.

Do some units give birth packs out from a chemist that have formula milk. I am pretty sure we had one of those once.

(Ms Pacanowski) I would say that has been outlawed everywhere.

(Ms Rogers) My final point relates to the comment that was made something like at the birth centre we had so many midwives and it seemed a bit much. I have to say, when we look at the ratio of midwives to women it was based on the recommendation of 1:34. That is similar to our colleagues elsewhere.

Chairman: Can I thank you all. You have given us a very good start to this inquiry. We will obviously be bringing this all together in a report which I hope will improve maternity services across the country. Thank you very much.

MRS JENNIFER FAKE, Midwife, MS MARIE PEARCE, Community Midwife, MS KATY WATERS, User Representative, West Hertfordshire NHS Trust, Mr CHRISTOPH LEES, Consultant Obstetrician, MS JANE HURLEY, Senior Midwife, MRS JEN FERRY, Head of Midwifery and Operations Manager for Women's Services, and MS LIVIA MITSON, Patient Representative, The Rosie Hospital Addenbrookes NHS Trust.

Chairman

Welcome. We now have West Hertfordshire NHS Trust and the Rosie Hospital Addenbrookes. Thank you very much for joining us. We are going to go over the same sort of themes but in a slightly different order. Please feel free to interrupt each other if you disagree. We obviously want to get as much information as we can to help us in our inquiry. We are going to start with some of the issues we were raising about Caesarean rates.

Andy Burnham

I am just going to cover the general area about Caesarean section rates and I am interested in the proportion of sections undertaken in the presence of a senior trained specialist and the proportion of emergency sections that are agreed by a consultant. I wonder if you could just give an outline of that.

(Mr Lees) With Caesarean section you have to split them into planned and emergency I suspect you are talking more about the emergency.

Both, actually.

(Mr Lees) Let me just cover elective sections first, planned Caesareans. I can speak for our Trust where we have specific times where Caesareans are done much like a gynaecology list. They are planned and performed at certain points during the week and there is always consultant cover or a consultant present at those Caesareans. In that sense it is a very satisfactory arrangement because a consultant can be present and either a teacher registrar or a senior house officer do the operation themselves if there is a complication. I would say that roughly half Caesareans are elective.

Where do you draw the boundary? That is purely people who, before they come in to the labour suite, have said they want a Caesarean. It is not people who have arrived and then started to think that things are not progressing quickly who then say they want a Caesarean.

(Mr Lees) No, it is typically a Caesarean that is planned at least 24 hours in advance and in many cases weeks.

So any other kind of Caesarean section you would class as an emergency. They would come in expecting a normal birth but then have a Caesarean, that would always be classed as an emergency.

(Mr Lees) Yes. Emergencies are most commonly at some point in labour when there is a problem with the fetal heart rate - we know the baby's heart rate is either too slow or too fast - and we do a Caesarean section, or the labour is not progressing as planned.

Chairman

Who makes the decision in those cases?

(Mr Lees) If we look at daytime staffing of the labour ward we have nearly reached 40-hour consultant cover so there is always a discussion with the consultant about whether a Caesarean section should take place. If there is any concern about the reasons or complexity of the situation a consultant will be present. During the day - nine to five - most of the time a consultant will be present and always consulted about the Caesarean section. If we are talking about 5pm to 9am, normally the senior registrar will contact the consultant and there will be a discussion. Again, if there is a particular concern about the complexity of the case a consultant will attend. Between five o'clock in the evening and nine in the morning consultants are normally at home.

You say normally, but sometimes the senior registrar might decide themselves.

(Mr Lees) If it were a very, very acute situation they would always get a message to the consultant. There might be occasions where it is absolutely necessary to go ahead straight away.

Andy Burnham

So that would depend on the circumstances in which this section began.

(Mr Lees) Yes.

How do you differentiate between the ones which are high emergency and those which are perhaps quite not so urgent?

(Mr Lees) There are many classifications but there is category of immediate Caesarean section which is really quite rare and certainly fewer than five per cent of Caesareans would be immediate. In that situation no delay can be warranted.

That would be when the heart rate had gone above a certain level or there was a cause for great concern.

(Mr Lees) Yes.

You said that half of Caesareans are elective. Is that high? It seems to me that it might be high. If it is, is that a factor of where you are geographically?

(Mr Lees) I do not think it is unduly high. About 35 and 55 per cent of Caesareans in most units are elective, planned. That would be a reasonable usual rate.

That is 50 per cent of a high number of sections.

(Mr Lees) Yes, it is 50 per cent of a reasonably high number.

I think I am right in saying that the section rate is 26 per cent of births. That is quite high, well above the national average and above the recommended level. What do you put that down to?

(Mr Lees) Firstly you are right in saying that. Addenbrookes is a tertiary unit for both neonatology, obstetrics and fetal medicine. I practice both obstetrics and fetal medicine and we have looked careful at our complexity. We have a much higher proportion of woman who are delivering pre-term, who have severe pre-eclampsia, who have babies with abnormalities and problems that have required help in the antenatal period.

You are a teaching hospital, I think.

(Mr Lees) We are not only a teaching hospital but a regional referral centre with a specialist unit. You will find invariably that units that cater for tertiary level activity have a considerably higher Caesarean section rates than a unit which would have a low or medium risk population.

With that in mind, how many avoidable Caesareans do you think you are still doing?

(Mr Lees) I think it is terribly difficult to classify a Caesarean as definitely avoidable because in almost all situations it is often arguable depending on the point that a midwife or an obstetrician would look at it from. I think that one area that we are looking at is the amount of senior and consultant involvement in the decision making for emergency Caesarean sections and by auditing our figures and looking very carefully at the amount of emergency Caesarean sections and the indications for those, it is relatively uncommon that we will come across Caesareans that we are clear should not have been done.

Chairman

Nationally there are six per cent unnecessary Caesareans being done. Are you not looking at that and thinking that you do have that many?

(Mr Lees) From our own experience we have a very clear audit channel for our Caesarean sections and we put them under the microscope at risk management meetings and at our junior doctor meetings. Are you talking about six per cent of all Caesareans?

Yes, across the country.

(Mr Lees) Six per cent of all Caesarean sections is one in twenty Caesareans that will be regarded as unnecessary which is, in the great scheme of things -----

Not a lot?

(Mr Lees) I would say that if you are getting it right 19 out of 20 times and you are getting it wrong one in 20 times, that is not too bad. It can be improved on, but it is not too bad.

Andy Burnham

Does it become self-perpetuating then? Once people have had a first birth by Caesarean it is almost inevitable the second will be. Or there is a very, very high probability of that happening.

(Mr Lees) That is certainly not our experience in that vaginal birth after Caesarean section - VBAC as it is called in America - is something we actively encourage. Probably over half our women who have had one Caesarean section will attempt a normal delivery in their next pregnancy. Over 70 per cent will achieve that. It is slightly different to the South American experience - or perhaps the US experience - where classically if you have one Caesarean section you often end up having a second by default. We know that the risks are quite low for having a vaginal delivery after one Caesarean section and it is something we encourage and many women are very happy to do it with, of course, appropriate monitoring.

Just talking from personal experience, my wife strongly wanted a normal birth after a first Caesarean but was told the opposite of what you have just said. I do not know whether advice differs across the country, but we were told to expect another Caesarean.

(Mr Lees) I must say, I think what you are highlighting is - and this is why I have to be clear and I preface whatever I say with the fact that I speak from our unit and our experience - quite right. We do see women who have been told in other units: 'Once a Caesarean, always a Caesarean'. Certainly that was classic obstetric teaching probably until about 15 or 20 years ago.

When auditing the rate, do you take into account the views of patients once they have come back about how they felt about the decision making process was made?

(Mr Lees) Are you suggesting in normal women who have had Caesareans?

I am not saying that you would question everyone, but where you said before that you audit regularly the rate, do you look carefully at whether -----

(Mr Lees) We look at the indications of the Caesarean and the delay to Caesarean and how it was done. We do not routinely look at outcomes of all women who have had Caesarean sections ask them their experiences afterwards.

Chairman

We have a patient representative here. In terms of your role in this, how much input do you have into the auditing of things like Caesareans and the induction rates?

(Ms Mitson) The Caesarean section rate is discussed at our meetings. In terms of direct patient involvement the Rosie runs the "Birth Afterthoughts" where, if someone has had a particularly traumatic birth and they are upset and wants to talk it through with the midwife they can do. That then does inform decisions and practice. At that level there is patient feedback into the process.

(Mr Lees) Can I just say that there is another level of interaction. Birth Afterthoughts is a very useful forum for these discussions and any woman who want to come to see their consultant after a traumatic time is actively encouraged to do so. We will occasionally see women who do want to discuss and there are open doors for them to discuss these issues with us.

Andy Burnham

I accept one hundred per cent that decisions are made with the best professional advice and people give, what they think in the circumstances, the best advice they can. But do you think those decisions are in any way altered by the context in which health professionals are now practising and the society we live in, a no win no fee society. Do you think that some of those pressures are affecting professional decisions?

(Mr Lees) Yes, I think they undoubtedly are. When I started obstetrics - not that many years ago but at least a decade ago - we would perform procedures that we would simply not perform now not necessarily because we would regard them as dangerous or bad to do but because we know that there are certain things that in a court of law or in a professional setting we would not be supported if we did. There is no doubt, for instance, that assisted vaginal delivery by forceps or ventouse are not done for the same indications that we might have done five or ten years ago. Certainly litigation and the perception of litigation and the perception of malpractice and, to some extent training, is changing the way we practice obstetrics. That is absolutely true.

Does it bear a little more consideration than perhaps it used to.

(Mr Lees) Yes.

Dr Naysmith

In the situations where you now no longer use forceps, presumably you have to use an alternative technique. Is that a more dangerous technique, or a less dangerous technique than the forceps.

(Mr Lees) The default position almost certainly is that if a vaginal delivery that we might have done five or ten years ago by forceps or ventouse is regarded as a little too risky, we would do a Caesarean section. There is no doubt that there is an upward pressure on Caesarean sections from that.

What I am getting at is, is the procedure you have now replaced it with more risky in some other way than the forceps or ventouse?

(Mr Lees) There is no good data on that. We still do not know. No-one has done a prospective study on the baby outcomes after Caesarean section versus baby outcomes after forceps or ventouse. We know that sometimes a Caesarean section is definitely not the easy option. A Caesarean section in certain situations can be much more difficult and much more traumatic than a vaginal delivery.

Andy Burnham

Can I direct the same questions to Mrs Fake. I think your Caesarean rate is considerably lower.

(Mrs Fake) No, our Caesarean section rate is very similar, I think, 25.6.

Chairman

We had Watford at 19.

(Mrs Fake) That just shows you how good statistics are really.

Andy Burnham

So it is exactly the same rate, or very close to.

(Mrs Fake) They are the figures I have been given. The divide between elective and emergency is also similar. I think one of the points I would want to make is that we very much encourage women to try to have a normal delivery after Caesarean section, but actually many woman do want the choice to have a repeat Caesarean section.

Chairman

Should we have that choice?

(Mrs Fake) You talked about information, I think we need to look very clearly at the type of information that we give women because I think we are quite selective in what we tell them. You cannot possibly go through all the risks with them. I think we need to look at that again, the type of information that we give them.

Do you think people do get enough information?

(Ms Waters) I think there is quite a lot of misunderstanding about how intervention starts at quite a seemingly low level with an epidural. In terms of women receiving Caesareans, you say normal births are encouraged but I can think of cases where women have a battle against intervention. Perhaps the midwife is in a hurry to get somewhere else, I think there are problems with agency staff who are not perhaps familiar with various processes and are not as attentive as they could be.

Andy Burnham

Is there not a much greater strain on resources with someone who is determined to have a natural birth come what may? Does that present a lot more problems to the unit if someone is coming in and saying they do not want any intervention of any kind?

(Ms Waters) I can imagine it can be. In the last few days, since being invited here, I collected some birth stories and certainly of the 24 or 26 stories there are people who had to fight against this intervention.

Chairman

Could we have a copy of that, please?

(Ms Waters) Yes, I have actually e-mailed it to you.

Andy Burnham

Are you trying to bring down the Caesarean section rate? Do you think it is too high?

(Mrs Fake) In April 2001 it was. A group of midwives decided to get together to try to introduce a low-risk birthing unit. There are not many integrated midwifery led birthing units in this country. Against much opposition and a lot of fighting we managed to do it with a lot of fund raising. We are on a different floor. It has not affected the Caesarean section rate but we are looking to delivering about 2000 women a year. We have one of the highest water birth rates in the country, if not the highest. But sadly it does not seem to have that much effect, but it has improved our normal vaginal rates. We are about to open a stand-alone midwifery led birthing unit so we will be split on two sites.

If I am picking up the signals correctly, you are saying it is high but not alarmingly high.

(Mrs Fake) It is something we talk about probably on a daily basis. We do audits. We do not evaluate women but I think that is something we should do, look at more patient evaluation to see what their feelings are after the birth.

I think we have talked about the decision making process in relation to when the decision is made and who makes it, but it is quite complicated. There is quite a difficult set of discussions going on and sometimes the patient may see things quite differently to what the professional story would have been of that birth. I do not know whether you would agree with that.

(Mrs Fake) I think the one thing we are absolutely consistent on is giving conflicting advice and I think that is the trouble. I think you will get a different view point from whoever you speak to.

(Ms Pearce) I actively encourage women - unless there is proven reason - to try to try for a vaginal delivery after Caesarean section because it ruins their obstetric career as far as I am concerned. More and more people are having three or four children and to have repeated Caesarean sections is not a good idea. We will actively encourage them. I spend a lot of time in my clinics going through what happened the first time with women and then empowering them to go to the consultants and getting what they want. I know the doctors are doing it and they have to do it, they have to give the negative side, the risks of having a vaginal delivery after a Caesarean section, but they also do give a balanced view by telling them of the risks of having another Caesarean section as well. We have to get away from the elective sections which are putting the rate up more. People in the press make it sound so easy, you can have your section at nine o'clock on a Tuesday morning and have your visitors at three. You have your champagne afterwards and it looks so nice. Some women see it in the press and think that if they can do it and get their figures back in three days then why shouldn't they. I have to say that is not possible, but it is very difficult. The popular press is making it worse.

(Ms Mitson) I think we also have an issue that if someone is pregnant for the first time and they are not aware of childbirth and children, childbirth can actually be really quite scary, whereas a Caesarean section is seen as an operation and it is planned and is under control. You do read about Caesarean section in the media and you are aware of them whereas you are not so aware of encouragement for home births and that kind of thing. You do have some level of pressure from the women themselves and I think that is partially due to the lack of information.

I do not know what the proportion of people who go to the NHS antenatal classes or people who do NCT, but are you saying that they are not good enough? They are not telling people enough about what to expect?

(Ms Mitson) I think in a sense the antenatal classes are almost too late. I went to antenatal classes when I was about six months pregnant and by that stage I was already really quite worried about giving birth. I have friends who are also very worried about giving birth and it affects their decision as to whether to get pregnant or not. In a sense the antenatal classes are too late.

(Mr Lees) I think this is a fascinating choice of information and I would just like the Committee to perhaps pick up on a reference from about two years ago. I think it was a British obstetric journal that surveyed female obstetricians. Most of them decided that if they were going to have a baby they would want to have a Caesarean section rather than a vaginal delivery. I am not saying that in defence of Caesarean sections but these are people who are extremely knowledgeable.

Chairman

It is a bit worrying if they are obstetricians.

(Mr Lees) That is absolutely true, but I think it underlines two things. Firstly that information does not necessarily push you towards normal delivery and secondly that this is an issue about choice as well. If we are going to give choice in pregnancy care then we have to allow people choice.

Andy Burnham

When you are doing your audit, do you look carefully at how patients are communicated with when the advice is given? A recommendation or a 'We think you should' are very, very important when the process is under way and people may not be in a position to counteract a recommendation. I think that communication is absolutely crucial.

(Mr Lees) We cannot actually audit exactly how the information is given. We can certainly look at the seniority of the person giving it which may not give you the same answer.

Can you see what I am getting at?

(Mr Lees) I know exactly what you are getting at.

Chairman: We will pick up some of these issues perhaps when we go on to staffing a bit later, but just on that paper on obstetricians' attitudes, 70 per cent of women obstetricians decided they would have a vaginal delivery, but 92 per cent of men, if they were in a position, would. It is culturally interesting as well because apparently in Holland 99 per cent of obstetricians would go for a vaginal delivery, so clearly there are other things that can influence this, but we need to move on now to data.

Dr Taylor

Data and its collection. In our written evidence we have really had very severe worries expressed about the quality of the collection system for the data. I would really like the comments from West Hertfordshire and from Cambridge about how you collect data at the moment, the quality of your computer systems, or, if you are still on paper, your records. Can we start with West Hertfordshire. What are your comments about the way you collect data?

(Mrs Fake) This is not my forte, I will be honest. We have just gone from SMIS - the St Mary's system - to another system called SEEMIS which is much more sophisticated. However, it is very much in its early stages and data retrieval is proving a little difficult. It is being audited; we are coming up with what we are finding are problems. I would just make one comment that as a unit which is running on a huge vacancy rate, we are trying desperately to look after women, we are trying to give one to one care. If, at the end of looking after that women, you then have to spend a considerable amount of time inputting that information - of course it is vital information and it is where we get all our information from - it is very, very time consuming. I do not know any way round it. We have to have the information, but I do not know if it should be midwives putting the information in.

Our previous witnesses mentioned the Scottish system which seemed to be much simpler and yet adequate. Do you know anything about that?

(Mrs Fake) No, I do not at all. I think the trouble is that because you want so much information, you want to audit everything that you do, you have to put the information in and I think it is probably midwives that have to put it in.

So your main worry is not really the equipment so much as the time to actually record the information.

(Mrs Fake) I think the data retrieval is quite complicated at times.

But the time is not there to do it. How about at the other end of the table?

(Mrs Ferry) We have a system which we have had in place since 1998 and is called PROTOS. That is our maternity system and we also collect information, as other units do, through the HISS system.

PROTOS is one of the three commonly used ones, we gather.

(Mrs Ferry) Yes. PROTOS as a software package has not been without its problems. It is moderately difficult when we have upgrades to do and you are dependent on a system that does not go down, and when it does go down then you are back into paper trails. I can only support and echo what West Hertfordshire were saying about the time it takes for midwives to input to these systems, but I also have to say that midwives have always had to make records whatever. I think there is an expectation that the computer makes things a lot faster. I also think that certainly we have an improved and enhanced performance with our systems upgrades, cabling upgrades, computer upgrades and everything else but people still perceive it as a problem because they still have to do it. It is something that perhaps we need to quantify. I do think we have to look very carefully at what we are using midwives' time for. We share with West Hertfordshire the difficulty of London and the M4 and M11 corridors and the staffing difficulties. It is difficult to have a midwife out being a project midwife all the time to run these computer systems. It is difficult to have midwives inputting to these systems all the time, but if you do not have that clinical overview and that clinical responsibility then your validation becomes very poor.

Is there a fear that you are trying to keep paper records and computer records?

(Mrs Ferry) I think certainly we are doing that at the moment. Our system is installed in the Delivery Unit which is a strange place to start a patient journey that starts out in the community. We currently have a bid in to extend that system out into the community but it is then very difficult when you have a bespoke system to build it forward. I think we all have different systems around the country. We do have PROTOS. A lot of people have PROTOS. But we have a bespoke system so upgrades are very difficult for us.

Will PROTOS link into your PAS system?

(Mrs Ferry) Yes, it will. We have built a neo-natal module to go with it and we are in the process of building with them a fetal module that can link into it. It is expandable. Our problem is finding the project staff and the funding for them to be able to run the computer system rather than using midwives to do that. Midwives, whilst they have the clinical expertise, do not necessarily have either the project or the IT expertise and it is poor use of valuable clinician time.

Can you interface with GP's?

(Mrs Ferry) At the moment no, but we have a bid in with the region at the moment to do that. We would like to be able to do that.

Turning to the new unit at Hemel, what system will that have?

(Ms Pearce) It will have the SEEMIS system I believe.

Which is relatively new, as you say.

(Ms Pearce) Yes.

Do you about the current national data set? Do you know what they are? No? A complete blank. We are getting the same message as before.

(Ms Waters) May I say that in April West Hertfordshire is beginning an audit on normal births and what the users will be asking for is a comparison of normal births between the ADC - which is a midwife led unit within Watford - and normal births within consultant units.

That leads on to rather major issue that has been hinted at. Is there possibly a danger - and this is to everybody - that one is getting excellent care in the midwife led units but because of the stresses on the consultant units, because of the more complicated problems, the loss of junior doctors with the European Working Time Directive, that the standard of care in a way could be more difficult to maintain. We have had pictures from the first birthing centre of really one to one care, one midwife looking after the lady for the whole time which is probably completely impossible in a consultant unit. Is there any feeling that this is right? Better quality in the birthing centres and because of the stresses on the consultant unit the quality is suffering.

(Mrs Ferry) We have had to do things to maintain our quality. Our staffing numbers are considerably on from where they should be. We have had to look very carefully at the skill mixes and we have introduced a new role of maternity care assistant to back-fill where we do not have midwives. We have had to look very critically at how long we keep people in hospital. I think we are fairly committed to the fact that normal healthy women and babies should not be in hospital anyway. We did actually have an abnormally long length of stay; we had the space, we had the staff and we were keeping people in. We have now reversed that because it is not appropriate and also we could not staff it. Your question was directly about delivery units. I think we have to put in contingency plans and strategic measures to ensure that we keep the risk at a minimum whilst the staffing is so difficult. The staffing is compounded on two fronts. We have the difficulty of lack of medical staff coming through into senior posts and for all the discussion about the lack of midwives our region will be training across Norfolk, Suffolk and Cambridgeshire 30 extra nurses and midwives by the next three years. Our staffing at the moment sits at 105 and Birth Rate Plus which is the acknowledged workforce planning tool said that we need 168.8.

You are training 30?

(Ms Pearce) No, that is the whole of Norfolk, Suffolk and Cambridgeshire are training 30 extra nurses and midwives. The training compliment for Cambridge at the moment, that is three units - ourselves, Huntingdon and Peterborough - is 24 midwives per annum. That gives me a training compliment of 12 per annum which, as you can see, is less than 10 per cent of my workforce. I obviously want junior midwives coming in but I also need seniors. But by the time we have had attrition - as you would get at any training school - that is not sufficient to hold our numbers never mind increase them. The difficulty that we are now facing is that our staffing is so low, although I have now got some tacit agreement to increase those numbers and we should now be starting three year direct entry training in September. I am going to have difficulty supporting and mentoring those midwives as they come through training.

Dr Naysmith

I want to pick up on that information we have just had from Mrs Ferry. What was the number of midwives you have?

(Mrs Ferry) My funded establishment is 135.

That is what you should have?

(Mrs Ferry) That is what I am funded for. I have 105 in post and Birth Rate Plus - a national workforce planning tool - has calculated that we need 168.8.

How are you filling the gaps at the moment? Are you using agency staff?

(Mrs Ferry) No, we are not using agency staff. There is not a plethora of agency staff in our part of East Anglia anyway and with the staff that we have we have made a decision not to do that. We have worked very hard at looking critically at our clinical protocols and with the consultants we have looked very hard at how we do inductions when we do inductions, Caesarean sections and those sort of processes have been looked at. We have been looking at the length of stay. We are looking at what has delayed women's discharges out into the community. PROTOS was one of those things that was slowing us down. Getting drugs to the wards if people needed them, getting consultants to see women when they needed them and the paediatric check which was mentioned by the previous people. We have done all those sorts of things to reduce the pressure and focus our staff in appropriate areas.

Are you one of the 15 supervisors of midwives? I just wondered what the 15 supervisors do.

(Mrs Ferry) Supervisors of midwives are not administrators. It is a professional role that is unique to midwifery.

Administrators can be professionals as well.

(Mrs Ferry) They can and indeed are both. Supervisors very often - such as Jen who is also a supervisor - will be clinical midwives purely and will have nothing to do with management structures whatsoever. Supervisors are the guardians of the profession, the advocates for the women.

You say that you were currently working to try to raise the profile of supervision. What does that mean?

(Mrs Ferry) Supervision has been in place for a very long time. Midwifery has always had supervisors since 1902 when the profession started. It is a role that has an increasing relevance when the service is pressured. We are the guardians of professional conduct and professional advocacy and we will maintain against resource pressures, other pressures, what is the right thing for mothers, babies and, indeed, midwives.

Chairman

You have both mentioned that you have a real problem with vacancy rates. Why do you think you have the problem where both Edgware and Paddington both manage to keep a low vacancy rate?

(Mrs Ferry) Funding. Cost of living.

(Ms Pearce) We are just the other side of the M25 so consequently five miles down the road the midwives can go and get inner London weighting. We are only fringe. It makes a great difference to our retention. They can live in our area, which is quite expensive to live in, but they can travel into London and get a lot more pay. We lose a lot of midwives that way.

(Mrs Ferry) We do not get fringe.

(Ms Pearce) Barnet actually gets outer London. Edgware belongs to Barnet and I think Barnet is outer London, so they still get more than out on the fringes.

(Mrs Ferry) I also think there is another factor about why we do not have the staff. I think that midwives choose which area they like to work in and there will be those who prefer to work in a low-tech environment; there will also be those who choose to work in a high-tech environment, but some of the midwifery led units such as Edgware will attract staffing where we do not, although we are planning a midwifery led unit.

Is midwifery the major shortage? Is that the main problem in terms of staffing?

(Mrs Ferry) Yes.

What is the next most important?

(Mrs Ferry) Doctors. I think the shortage in the middle tiers is particularly profound.

Is that right, Mr Lees?

(Mr Lees) Yes, it is absolutely right. From a medical point of view, doctors tend to gravitate towards higher risk areas, bigger hospitals, specialist units so at Addenbrookes we have a certain comfort zone because of that. Even despite that we have real problems and it has become much worse over the last two or three years recruiting at consultant, Spr and SHO level, and this is not going to get better.

What are the other health professionals that make up the maternity care team?

(Mr Lees) Health care assistants, physios, sonographers (who do a very important job scanning and it is difficult to get appropriately trained sonographers).

(Mrs Fake) I think our problems mirror identically the same problems.

I will ask the same question to both of you then, what are you doing about these shortages?

(Mrs Ferry) We are back-filling with all the support staff that we can, ensuring there is maximum cover so that midwives are not answering phones, seeking notes and doing the administrate chores which should be done by other staff. We are putting maternity care assistants in and generally looking at processes to see where we can make things more efficient.

(Ms Waters) In Hertfordshire I really get the feeling that there has been a reliance on two methods of recruitment. One is poaching. I think West Hertfordshire has had recruitment fairs in both Scotland and Ireland. Last summer there was a recruitment fair in St Albans. I think there has been an over-reliance on putting an advert in a magazine. I have photocopies here. They are not geared towards Hertfordshire midwives who have perhaps left within the last 18 months.

That was one of the points I was going to make. There must be in the community a lot of trained midwives and nurses. I know some places are running training schemes for these nurses and midwives.

(Mrs Fake) We are actively recruiting. Last year I think there were a few days - I went to one myself - where we have an open day for return to practice midwives and nurses and there are many, many ways and schemes. They can study in ways that suit their families; they can take whatever time they need to do it. But it is not recruiting the numbers; we are still not retaining them. We did go to Scotland and I think we recruited two midwives from Scotland, mainly because there are no jobs for the girls who train in Scotland. We do very well at interview stage, we can offer numerous courses, we have very close links with the University of Hertfordshire, but we lose them usually at the interview stage because there is the prestige of the London hospitals. If you are coming from Scotland, why would you work for us? We can pay them a certain amount, but if you go in you can have the prestige of a London hospital on your CV and you can have the added financial benefits.

Chairman

How do your vacancy rates compare with other specialities?

(Mrs Fake) I do not think anyone is as bad. We have 42 full-time equivalent vacancies.

Dr Taylor

You are making an argument against foundation hospitals for us. When the consultant unit closed at Hemel what happened to the midwives? Were they automatically mopped up somewhere else? What happened to them?

(Ms Pearce) A lot deserted.

From the profession or out of the area?

(Ms Pearce) Both. We lost very few to the profession. A lot deserted to other hospitals locally because it was more convenient for them. Where we are situated there are four maternity hospitals within a 15 mile radius. For travelling and convenience of their family unit they went to the smaller units. We are trained to be autonomous practitioners. We look after women and give one to one care and in Hemel - the same as Watford - we were doing nearly 3000 deliveries. It was a nice unit. We had good establishment and we could give the type of care we wanted. A lot of midwives were frightened to suddenly put two units into one, nearly 6000 deliveries. We figured we would lose some, so maybe 5500 deliveries. We would lose some of our skills because we would be on a production line and the mothers would be on a production line so we could not give the care we wanted. Quite a few midwives deserted for that. They went to the smaller hospitals locally because they felt they would not be on a production line, where they would be back down to 2500 to 3000 deliveries.

I would just like to ask Katy a question because she is obviously interested in this area. Do you think that pregnant women understand that some places are short staffed and they feel that they get a bad deal because of it or do they actively choose places where they think there is better staffing?

(Ms Waters) I think in terms of choice the ADC is extremely popular for that reason. It is a great success, there is no question about it. People do not chose a home birth where they would also have one to one care. I think there is still fear about home births. I have some adverts here for midwives within West Hertfordshire. You have to remember that midwives within West Hertfordshire who have left, who have resigned, with very low morale, I think these adverts will be extremely irritating to them because they say what a wonderful place West Hertfordshire is. Some people have been treated extremely badly and these are saying what a wonderful place it is. They are not going to be impressed by that.

Mr Amess

I think midwives are wonderful. You have always been undervalued as a profession. Obstetricians are pretty good as well. Can you just tell us something about training and what courses you have organised in your various units.

(Mr Lees) Midwifery or obstetrics or both?

I was thinking about midwifery but tell us about obstetrics as well.

(Mrs Ferry) For midwifery training, as I say, we are doing post-registration training for nurses, and that is an 18 month training programme and we are taking a cohort of six twice a year. That has proved quite difficult to recruit to in the last few years and there has been a move nationally away from this post-registration training to a direct entry course whereby people come directly into midwifery as they would nursing and it is a three year course and they graduate as a midwife at the end of that. That is a course that we have not yet started in Cambridge but hope to do so in September. Post-registration education at Addenbrookes is a very fortunate Trust and we can offer superb post-registration education and support for staff. We have an awful lot in-house. We are fairly creative about getting scholarships and other funding and we can support people through diplomas, degrees, masters courses whatever. We have a lot of in-service training. Each and every midwife does two days a year in-service training. It is a very intensive two days, looking at resuscitation, breastfeeding, CTG's, all the things that we need to do to keep people up-to-date. We are working more and more with the medical staff. We do not have any shared learning space which makes it difficult for us, and we do need to do more on that. We have attracted funding and we do send all of our staff - or they have the opportunity - to go on courses which are advanced life support and obstetrics courses. So far we have put 46 of the midwives through those courses. It is not grade orientated; it is who wants to go and we send as many people as possible. We have started sending people on neonatal life support courses as well, so we have several midwives who have been through that.

That is comprehensive. Anyone else?

(Ms Pearce) We have been doing the three year entry programme for direct entry midwives for quite a few years and it is very successful. We also do the advanced nurses diploma as well. We are hoping to bring a lot more midwives back in once we open Hemel's birthing unit next month. The adverts have done that. We also provide the various courses and quite a few of the midwives are doing the N96 which I mentioned before which is the examination of the newborn which has taken quite a bit of the pressure off the paediatricians, and the GP's have benefited from it because they will not have to go out and do them either.

(Mrs Fake) We also have a rolling programme as well as internal training courses that midwives can dip in and out of, covering difficulties in labour so that midwives are completely up to speed. There are plans to develop that even further and we are going to be working with the Trust resuscitation officer so that we can incorporate part obstetric part higher risk situation. They are very, very successful. We have a highly motivated workforce.

Is there joined-up training? Sometimes I feel that people are slightly precious about their own areas. Perhaps our consultant could answer this one. Are you all working closely together in terms of training?

(Mr Lees) We are working increasingly closely. Many of our multi-disciplinary meetings, the courses we hold, the conferences we organise, midwives come to, obstetricians come to, radiologists come to, GP's come to. That is already happening and has been happening for many years in many units. I do not think that we would consider ourselves precious in that regard. We have heard glossy accounts of what we can offer as add-ons to a career. In obstetrics - as Lesley Regan very eloquently said in the last session - we face a major problem with training our junior doctors and getting them to consultant level, which is why recruitment is becoming disastrous in obstetrics and gynaecology and, even with extended roles for midwives and even if we can get midwife numbers to vaguely what they should be in many of these units, we are going to be very, very short of consultants because people are not entering the training. Many of them reach the end of their training now and probably do not feel they are getting the quality training and experience they had some years ago.

Chairman

Can we go back to the midwife training. You were making it clear that there were not nearly enough in your region being trained. What is stopping more being trained?

(Mrs Ferry) We now have a constrained on us and how many we can support, but primarily funding. Through the workforce development confederations the funding has not been there. The places have not been commissioned.

So they are just not assessing the training needs, or they are assessing them without funding the training needs.

(Mrs Ferry) Essentially what has happened is they have calculated our training requirement on our vacancy factor. If your vacancy factor is the factor of your funded establishment against what you've got in post, it is not as big as what you really need.

What is the position at West Hertfordshire in terms or training? Are you more satisfied in terms of the numbers of people coming through?

(Mrs Fake) We would like far more to come through. I was at the University of Hertfordshire last week interviewing prospective midwives for courses. They seem to attract a lot but again not many turn up for interview.

So the problem is recruitment, not the number of training places.

(Mrs Fake) Yes. I think the number of training places is fine.

Mr Amess

Mr Lees, is there an issue about people wanting to be an obstetrician or a gynaecologist? Is this an issue that perhaps is affecting overall recruitment?

(Mr Lees) I think that is a terribly important question. In the last five years we have seen several media debacles of badly performing doctors' units that have hit the spotlight. There is concern about litigation, about personal professional issues, about disciplinary issues, about the intensity of work when you become a consultant obstetrician. I think 15 or 20 years ago - or even 10 years ago - going into obstetrics and gynaecology, because it was so varied and offered surgery, medicine, scanning, very interesting interaction with people at a very critical point in life (and sometimes death), it is a fascinating speciality. It suffered very badly among the perception of doctors and the public and many of the people who were appropriate to go into the speciality were put off because of the problems inherent in the speciality at the moment.

Dr Naysmith

Can I ask about something I only have a vague knowledge of. I understand that the training for midwives changed a few years ago and there is now direct entry into the profession without first having had to train as a nurse. Is that correct?

(Ms Pearce) That has been going for 15 to 20 years now.

Some people say that that could be responsible for the problems in midwifery?

(Mrs Fake) I trained ten years ago, direct entry.

Has it made any difference? It has obviously improved the status of your profession.

(Mrs Fake) At the moment we recruit the majority of our newly qualified midwives from the direct entry programme. We barely run the post-registration course because sometimes there are not many on it.

(Mrs Ferry) May I come back to something that was said earlier about choice. There was an inference in that discussion that women were choosing to go to the low-tech units. Within Cambridgeshire we are doing about 4500 deliveries and only 3000 of those women live in our area. So a third of our women are choosing to drive past their own units to come to us, despite our staffing problems. I do think that the change in childbirth and the choice of who we have will be exercised both ways.

Chairman: Can I thank you all very much. It is exactly these issues that we want to pick up in this inquiry and we hope some of our recommendations may make things easier for you in the future. Thank you very much.