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TUESDAY 11 MARCH 2003 __________ Members present: Andy Burnham In the absence of the Chairman, Andy Burnham was called to the Chair __________ Memoranda submitted by University Hospital, Nottingham and Derby City General Hospital Examination of Witnesses PROFESSOR DAVID JAMES, Fetomaternal Medicine and Lead Obstetrician, MRS SHONA ASHWORTH, Assistant Director, Nursing and Head of Midwifery, MRS ELAINE PARKER, user representative, MRS SIOBHAN HARGREAVES, user representative, University Hospital, Nottingham, MS SHEENA APPLEBY, Head of Midwifery Services, MS HELEN SHALLOW, Midwife Consultant, and MISS ALISON FOWLEY, Consultant obstetrician, Derby City General Hospital, examined. Andy Burnham
(Mrs Ashworth) I am Shona Ashworth, Assistant Director, Nursing and Head of Midwifery, King's Medical Centre. I manage a division which includes paediatrics, gynae, as well as other areas. (Professor James) I am Professor of Fetomaternal Medicine, which to you is an obstetrician, in the Queen's Medical Centre as well. I deal only with patients with problems in pregnancy. My philosophy is to leave normal pregnancy care to midwives predominantly. I have a special interest in fetal brain development. (Mrs Hargreaves) I am Siobhan Hargreaves, a consumer and mother of four. I have had five births at the Queen's Medical Centre and was a patient of Professor James. (Mrs Parker) I am Elaine Parker, an antenatal teacher for the NCT, working in Nottingham for eleven years, teaching couples classes. I have links with the Queen's Medical Centre. (Ms Appleby) I am Sheena Appleby, Head of Midwifery Services in southern Derbyshire. I look after midwifery and work in primary and secondary care settings. (Ms Shallow) I am a midwife consultant at Derby City and have a remit across acute and primary care, with my focus being on looking at how we are working currently and how we can change our way of working to promote a more woman-focussed service in terms of midwifery-led care. (Miss Fowley) I am Alison Fowley at Derby City General Hospital as well. I am Clinical Director of Obstetrics and Gynaecology. My particular interest has always been in obstetrics and high-risk pregnancy. Dr Taylor (Mrs Ashworth) From the midwifery perspective, it is difficult for us. We keep the basic statistics about normal births, induction rates, etc. They are fairly easy to keep. It is the audit time, to free up one midwife to do data collection on breast feeding every day. That is very difficult. Our computer systems are not very good. We do not have a link with the sister unit, with our colleagues across town, or the community very well, so it is difficult to keep at times. It is usually data collected at book-in or at or around the time of birth and discharge. That is what we are limited to. (Mrs Ashworth) No. If we were going to get correct data - we are often asked from the department for data at a day or two's notice and it is very difficult to have that all to hand. It is more paperwork for us. We have not got a good data system at our hospital. Across the city they have 1.4 whole-time equivalent midwives looking at audit purely. That is where they have chosen to invest. It is very difficult when you have limited resources to decide where you do invest it. (Mrs Ashworth) We do, yes. (Mrs Ashworth) Yes, but we do not keep the birth register like we used to. We do now rely on electronic data for that. (Professor James) There is no doubt that the push of electronic record-keeping is with us. The trouble is that the investment that is needed is enormous, and it is in excess of what is being put in at present. One would not wish to be unpatriotic, but in Scotland they seem to have a much better system, a remarkable system of writing down on bits of paper, and the bits of paper get fed in centrally, which is a novel approach. Andy Burnham (Professor James) Yes. Dr Taylor (Professor James) It works. What is of concern to me is that, while the push to electronic patient records is commendable in principle, the trouble is the rumours I get that it is going to be implemented on a regional basis. There are four US companies that are competing for the contract in these different places. There is no guarantee that if company A gets the contract in the north of England, that company A will be the same company that gets the contract in south-west England or that it will interface with company B. If a woman moves from York to Plymouth, will the record be transferable and usable when she comes? There are huge logistical issues. Dr Taylor: That is a very important point for us to make in the final report. Andy Burnham (Professor James) I agree; you would expect them to be doing so. (Professor James) No, but I do not know that they definitely guarantee to be so. Dr Taylor (Professor James) In Nottingham, the example here - the electronic patient record is being developed nationally, but because of our local difficulties - and Nottingham has invested significantly in trying to bring together the acute trusts and community trusts, to develop our own system - we are looking at some of these in terms of whether we can go forward. We could be investing a vast amount and developing that locally, and it could be at variance with what is being done nationally. Joined-up thinking is what we need. (Miss Fowley) I would second everything my colleagues at Nottingham have said. Our hospital is moving as rapidly as possible towards EPR at the moment. Various staff are being sent off to Florida and Kansas and other places to evaluate the systems, because they are not up and running in the UK at the moment. There are four on the shortlist, and I can see we will choose a system where we will be able to communicate with our nearest neighbour and share trainees and a number of other things. (Miss Fowley) Yes, because this will be a vast amount of money for our own organisation, and we are no further forward than we have been for a number of years. We were one of the early ones that took on a maternity system way back in the mid 1980s, when we acquired the so-called CCL system, which we still have. That is outdated and not very useful. Andy Burnham (Miss Fowley) Absolutely, yes. Dr Taylor (Miss Fowley) Certainly, but we are not aware of anything coming centrally at all. Our unit is busy beavering away, trying to choose a system that will work for us. (Mrs Hargreaves) I do not have any objections at all, so long as it makes the system more efficient. (Professor James) Yes. (Professor James) As Mrs Ashworth said, we have limited statistics. (Miss Fowley) I would agree again - superficially. We can tell you what our caesarean section rates and induction rates are; but if one wanted to find out more, it would be very, very hard. (Ms Shallow) That is what I wanted to come on to. There is one issue about how we collect data, and another issue about standardisation of terminology of the way we set that data up so that we are all looking at similar things. I come from this normal birth focus, and we talk nationally of a normal birth rate of around 60-65 per cent more or less, in various places; but actually the normal birth rate - what is that? This overall figure hides a multitude of interventions and things happening to women that are not highlighted in the statistics, whereas Genepools, Birthrate Plus, identifies category 1, which is births without intervention, and category 2, where the woman has maybe had a tear that needs suturing - and the categories go up until you have a caesarean section and lots of complications. Using a tool like that, we could break down the data, and it would be much clearer to see what was happening. As Alison said, the statistics are very simple and they do not tell the whole story. (Ms Shallow) If you think that is more sophisticated, then yes; but I think a very simple device to break down what we would consider a normal birth, would reveal a very different picture about the interventions that women are exposed to currently in practice. Sandra Gidley (Ms Shallow) There is some consensus. There is a whole national debate about what normal birth is, and we could argue it all afternoon. However, a consensus opinion would be that it is a birth with little or no intervention and it builds up from that premise, as appropriate. We all know that there are many interventions that occur that maybe are not appropriate. Andy Burnham (Miss Fowley) Not in terms of interrogating the computer. One could go back to an individual study of records. Dr Taylor (Ms Appleby) There is a lot of work been done on it, but none of us have actually had it in our own services to utilise. There has been a lot of work done nationally on minimum data set, but we have never practically used it. (Ms Appleby) I have never seen it. (Professor James) Yes. (Ms Appleby) I think we need to be more simplistic in what is normal birth, what is high-risk. We need to define that so that both obstetricians and midwives are able to work together to make changes. You need to define it. It is like breast-feeding - how do you define that, whether they are fully breast-feeding, partly breast-feeding with a bit of formula milk? Nobody has defined it. We have a national breast-feeding target, but what does it mean? It does not say whether it is partially or fully. We have to be very sophisticated about what data we are collecting so that we can interpret it properly. (Ms Appleby) I agree with my colleague here. The Birthrate Plus data - a huge evaluation can be done around different categories, and you can start understanding where intervention is occurring and abnormality is occurring. There is lots of information in there. Andy Burnham (Miss Fowley) We are slightly higher now - it is 21 per cent. (Professor James) I think there are a number of issues. I do not know where you have our rate from. (Professor James) It just reflects the fact that there has been a big focus on caesarean section rates. We have looked carefully, as a consequence, at the national audit, for example, and the audit data that you mentioned, which gives a lot of clarifications and reasons for why they are done. (Professor James) I have no idea. The WHO has a figure of 50 per cent. Everybody says we defend our high rate because of our high-risk population. I do not think, when at our weekly caesarean section meetings we review every emergency caesarean section that is done, that you necessarily have the view that every caesarean section was justified. If it was, and the rate is 27 per cent, that is correct, but if the rate should be lower because you have unnecessary caesarean sections, which we undoubtedly do, then our rates should be lower than 27 per cent. Our current rate of 23-24 per cent is probably higher than it needs to be. Having said that, it is possible to make a drive - being very critical about the reasons why caesarean sections are done. I think there is a conflict here. Certainly, there is a big consumer input. I do not want to steal the thunder of my colleagues, but I was speaking to a barrister the other day and ----- (Professor James) I said: "Look, you have had a non-vaginal delivery before." She said: "It is more convenient for me to have a caesarean section because it fits in with my timescale and I have a right to demand that." I was not going to argue with a barrister. (Professor James) Yes, I think that is one aspect. Another dimension is the fact that our labour suites are staffed with, shall I say, less experienced junior doctors than we used to have. Nobody is going to sue you for doing an emergency caesarean section when one was justified necessarily, but they will sue you if you fail to do a caesarean section when one was justified. Experience counts for a lot in doing an operation. People see, in terms of experience, it is when you choose not to do it rather than the other way round. Jim Dowd (Professor James) I said "less experienced". (Professor James) It is the impact of the situation with training hours. We are required to train our doctors in much shorter periods of time. When I say "training", we would expect to run through our postgraduate training in obstetrics and gynaecology in maybe eight years, and you would become a consultant. Sometimes it would take longer, but it would be somewhere around that. Now, it is five years - maybe seven, if you add in the pre-registrar. If you add to that the European Working Directive, making people work only 54 hours a week, you cannot get the experience of doing caesarean sections, say, from a shorter period of time. (Professor James) Flying hours - exactly the same. Sandra Gidley (Professor James) The majority of cases we are faced with are - obviously, if you have a higher caesarean section, you have a lot of ladies subsequently coming through pregnancy with a caesarean section scar on their uterus. Therefore, a lot of debate and discussion centres on how subsequent delivery should be handled. Numerically, this is the biggest group we have. This is where people are using, understandably, the experience they have had the first time, perhaps, in an emergency caesarean section, saying, "I don't want to go through that again". You have sympathy with that. Where people ask us, we try to inquire into the concerns and risks - or the reasons they are asking for it, if there is no medical reason. Andy Burnham (Professor James) Not have to, but they will be more inclined to request it, whereas if they have had a normal delivery, the barrister is not likely to be a common experience. The majority of people who have had a vaginal delivery would be advised to have a vaginal delivery. (Ms Shallow) From the midwifery perspective, we talk about caesarean section ever increasing, and it is ever increasing. I think it is a downward spiral in terms of intervention. What becomes the norm becomes normalised practice, and it is what clinicians know best. What we are missing here is the aspect of midwifery care within that, or the lack thereof, that then leads to our colleagues to have to bail women out in terms of taking them for a caesarean section. We know that the only single intervention that will improve outcomes is one-to-one for women in active labour. We know that; it is well researched. However, we cannot provide it. Nationally, in most big hospitals, one-to-one care is, in the main, not happening or not achievable. I think it is achievable, or we are going to carry on having this rise in the caesarean section rate. (Ms Shallow) It is, but it is at what point that decision is made because there is a whole journey through labour, and it is a long way through the journey that that decision is made that a woman has to have a caesarean section. Along that journey, the woman is often left on her own, unsupported, or her care is shared by one midwife who is doing her best to look after two or maybe three women in labour, and sometimes maybe more. It is completely unacceptable and unethical that that should be the situation that midwives find themselves in because there are not enough of us. Our establishments may not be able to fund more midwives. It is unacceptable to everybody working in that environment, but most of all it is unacceptable to the women themselves. Sandra Gidley (Ms Shallow) I believe that if midwives had more input - it is not just a matter of throwing more midwives at the service; but it is about looking at how we work and looking at different ways. If a woman is confined to bed for fetal monitoring for no real reason, her pain is worse. She requires an epidural because her pain is excruciating and there is nobody there to support her. If you change that model and encourage women to move around and be in a nicer environment, a more relaxed environment, where somebody is supporting you, then we know that that makes a difference to how that women labours. We know that. We have the evidence. We can practise evidence-based, but we are not able to in the main because of the constraints placed upon us. We are all living under this guise of litigation and fear in defence of practice, but our medical colleagues often have to bail out a situation that is no fault of their own either; but the situation exists, because of the lack of investment. If we invested now, we could save money in the future. Andy Burnham (Mrs Ashworth) I think one is about the population and high risk, which we both are. I think it is a cultural thing. I came to Nottingham three years ago and I would say that childbirth was extremely medicalised - it was the culture and midwives were not challenging ... (Mrs Ashworth) Yes. Now, these are role models for our new midwives who are being taught about normal physiological childbirth and all that that means. They come out and they cannot practise it. We also have not got an integrated service in Nottingham, so they do not experience the follow-through from conception to birth and post-natal, and the experience is flawed from the outset. You have not got people who are going to challenge, and they need to challenge right from the beginning as to education of women about why they should have a caesarean section or may need one; and also about whether they need to be induced - and the induction rate, we know, can influence the caesarean rate. Then pain relief - because we have not got any midwives - epidural nurses - all those things - it is the culture, as we said. (Professor James) There is usually reasonable agreement on the unnecessary ones. Certainly, the issues which have been touched on here - the unnecessary induction of labour, induction of labour for flaky reasons - invalid reasons - I think the repeat caesarean section rate is an issue around failure to understand fully fetal monitoring. I think there are strategies within the two examples, namely failure to progress, which is related to process - and that is where induction of labour can be a big issue; and the other is how we interpret fetal monitoring, and being prepared to do full blood sampling to back it up, and only use it where it is indicated. Interestingly, the electronic fetal monitoring guidelines which came out a little while ago have demonstrated that you can reduce intervention for fetal distress if you apply it properly. (Mrs Parker) Definitely. All the issues that have been mentioned, particularly support, may help reduce that in the long term. Women want a perfect birth. They want a perfect outcome, and if there is any slight risk then they see caesarean section as an easy option to get that birth, without always understanding the consequences of aftercare and subsequent pregnancies. (Mrs Parker) Definitely. If the woman is supported and comforted in labour, and is feeling she is getting the care she needs, that can only help the outcome. (Mrs Hargreaves) Not coming from this background or having any of the statistics at all, all I know is my experience, over the last couple of years, of friends of mine around me. I have never known before people say they had had an elective caesarean until the last couple of years; and the reasons they have given is because of the convenience of arranging childcare and getting back to work, etc., etc. It worries me slightly that it is seen as this. Obviously, if there is no risk to the child - are they fully aware of the implications of major abdominal surgery? (Mrs Hargreaves) I think they should be made fully aware. I am sure they are told about the risk to subsequent pregnancies or what-have-you, but it is not something that can be lightly undertaken because at the end of the day it is major surgery. (Mrs Hargreaves) But people like to know - "next Wednesday, I am going to have a baby". (Mrs Hargreaves) That makes me uncomfortable, that side of it. Looking at the statistics before we came in, something like 10 per cent of caesareans were elective caesareans. That is a pretty high percentage. (Mrs Hargreaves) Yes, I think I would. (Mrs Parker) There is another issue of the forceps rate. A lot of women can be very afraid of having a forceps delivery and prefer to go for a caesarean section rather than risk having a forceps delivery. (Mrs Hargreaves) It is not cheap either. You have got the anaesthetist, the surgeons, tied up, and all the theatre staff. (Miss Fowley) When we look at caesarean section in the way we do, we find ones where we feel something different could have been done. I think that the rate could therefore be somewhat lower. I do not know how low is low. We all talk about our populations. We have an increasing refugee population in Derby, and they have very high morbidity and fatality rates within that population, so that is something that has changed for us. We all know that the whole country is getting fatter, and our obesity rate in Derby is particularly high. I cannot compare it with other places, except to say that there are certain procedures that I used to do when I worked in London and in Birmingham, where I was able to use a much shorter needle than I have to do in Derby! We are hoping to be able to look into that as part of an audit. I would also like to say a word about patients choosing caesarean section. It is very difficult, sitting in the consultation room, with someone saying "I want a caesarean section". You ask them why and you go through the risks and procedures. You try to say it is much better for them generally, for their health and future pregnancies not to. You go into all of this, and many will still be absolutely insistent. (Miss Fowley) You cannot refuse. I suppose you can, but patients tell us these days they have a choice, and so they should have; but it would often come down to insisting ----- (Miss Fowley) I find it very difficult. I spend quite a lot of time with them in clinics where you have a 5-10 minute slot. They may take an hour and still you are left with this problem. (Miss Fowley) Elective can be for not just patient requests; it is proposed for breech presentation or a baby that has a problem. Out of our 21 per cent I think roughly 9-10 per cent are elective and 12 per cent are emergencies. It is only a small proportion of elective who are patient requests. I cannot tell you what that proportion is. Jim Dowd (Miss Fowley) If somebody is requesting it, and there is no medical indication, I try to discourage. (Miss Fowley) I do not think that is fair criticism because I am saying that I try to give them all the evidence. The evidence is that it is safer for the mother to have the baby vaginally. If there are no problems with the baby, then - I do not know what the evidence is exactly, but I think it is - at the end of the day, we are talking about different choice, not a "the doctor knows best" attitude. We are trying to give them the facts and figures, as we know them at the moment. (Ms Appleby) At the same time, you are talking about making a recommendation. You must not lose sight of the fact that the argument around all of this, I believe, is the fact that women need that information. They need the information on which to make the choice. A lot of women's experiences have been so poor in the last ten years that they are scared, and the issue is that they need the support. If we cannot provide that support - having heard our colleague that there is no clinical indication, you can be supportive, with one-to-one care in labour. If we do not break that, then we will never achieve any improvement. Andy Burnham (Ms Appleby) They need it, but they need it with information, and they need a skilled midwifery workforce to look after them, because I think midwives have forgotten the art and science of good midwifery care. (Ms Appleby) Yes. To help our obstetric colleagues, we need both those elements in there. Dr Taylor (Miss Fowley) Consultant level. (Professor James) Yes. Andy Burnham (Mrs Parker) As an antenatal teacher, I have to say that on the whole they do not. The couples who come to my classes generally go to the community and hospital classes, if they are available. Not all hospitals offer couples classes that they can get on to find out the information, so there is sometimes a gap there. That, again, is about resources, and parent classes are not always a priority. (Mrs Parker) I do not know what the numbers are. (Mrs Ashworth) Again, this is a data issue. We provide, from the acute setting, parent-craft, and run quite a lot of parent-craft in Nottingham; but they should be transferred to the community because that is where people live, and they should know the community midwives. It actually becomes the job of the hospital. Then, if it is in an acute setting, again it is the hi-tec. It is reinforced and it is, as Sheena said - in order to offer them an alternative and to allay their fears, you have to be able to offer them the quality care. If you say to a woman, "I am sure you will not have a forceps delivery; it is your second child" and they are left alone, then you can see how ... (Professor James) The other dimension to this is that what might have been - referring to Ms Fowley's comment about refugees - a lot of the parent-craft classes are attended by well-motivated middle-class people; and teenage mothers and ethnic minority mothers - people who cannot even speak English - would perhaps not be so encouraged, or feel it appropriate for them to go. This illustrates the difficulties that midwives have to deal with. They deal with people of all nationalities and they have to change their style and approach for different people. (Professor James) You are quite right. The word "advice" was given up when you asked the question. In the antenatal setting, where we are faced with this discussion, we quite clearly say "we advise you" or "we would advise you against this"; but we know in other medical settings we advise against smoking - people do not believe in taking tablets. I am not sure what they do not believe in - to the patients, choice is exercised in a number of areas of healthcare, but in labour it is totally different. (Professor James) Absolutely. Jim Dowd (Ms Shallow) One of the first issues is midwives working in the kind of environment I described earlier. Inevitably, midwives become disconnected from what it is they came into midwifery to do. They are leaving and will continue to leave the profession. We have a shortage of midwives and it is going down year on year. We have to provide very flexible ways of working that suits the needs of women and suits the needs of midwives. I do not think there is a "one size fits all" model for midwifery, but we need to engage and go back and speak to people. What is good for women is good for midwives; the two mirror each other. The issue of choice for women has to apply to choice for midwives as well to some extent. You could have a variety of different models in one service, as at King's, which has different models, some of which provide a very partnership caseload practice in very deprived areas with extraordinarily good outcomes. We can provide more variety of services instead of this utilitarian approach we have adopted over the years, where there is a "one size fits all" model. I would say there should be more flexibility. (Ms Shallow) I think it is a complex issue. We do need more midwives. We know we are under-established. We have established that but also the way midwives are organised can be looked at and reorganised - so restructuring. I do not think it is a huge investment, but we need to be able to support changes in practice in terms of training needs. If we have a vision, as many of us do, that midwives can work in the community in small group practices, working alongside their GPs but not for their GPs because they do not work for their GPs but are traditionally attached to GPs' practices, which creates big problems - if midwives are to work as partners in care, they need to be afforded the same rights and privileges. We need some investment for premises. Midwifery-led care has got a small cost attached to it, but huge enormous cost-savings, I think, a few years down the line. (Ms Shallow) I think we can demonstrate that very effectively. I would like to add that two weeks ago on Channel 4, a Government representative said, quite clearly: "We need more obstetricians on the delivery suite". I do not know about that because there was nothing said about midwifery and the effect that we know it can have on the calibre and quality of care that women receive. If we are just focussing on birth at the moment, and on the outcomes and the interventions, and the cost of caesarean sections, then we have to look at these things more broadly. (Ms Shallow) I am suggesting it is not necessarily the best investment, and that it has already been alluded to here that we do have concerns about the experience that comes with fast-tracking new consultants that do not have the experience to watch and wait and the experience of the older obstetricians who knew how to attend births without caesarean sections. It is the thing that most younger practitioners know how to do. You cannot blame them - that is their experience. I think that is very concerning because if what a person knows how to do is the forceps and the ventouse and caesarean section, which are entirely appropriate - if that is all that that kind of practitioner knows how to do, and we do not improve midwifery, then we have a serious problem, and that will continue on the downward spiral. Andy Burnham (Ms Appleby) In our service, as I speak today they are interviewing this afternoon, and we will then be full up. Our problem is establishment, not recruitment. We are very close to recruitment issues; it is spreading up the country as it comes from the south, but at the moment we are about right. Our biggest problem is our establishment. As a service we have used the BirthratePlus tool back in 1998, and again in 2001, and it identified a significant shortfall on our establishment, but it also told us if we practised differently, we can make some changes to the decision-making part of BirthratePlus tool. It not only identifies staffing, but probably where we can change practice, and I think we have a much better chance of making a significant difference. When we are asking for more staff in our particular environment under the local development plan, we are in, with the rest of the NHS, who have also got particular needs in particular areas - we are competing with that. In the maternity service, we are in a model that has significant problems, with huge litigation issues. We are constrained by all of that. We have decided we need more establishment. In the bigger picture, we have not had the investment we needed. (Ms Appleby) It will be. We are going to have to deal with that. That will be a particular problem for our service when we are already under-established. We need to provide 24-hour access for women and we are in a dilemma about what we do and what we do not do. We have to make a judgment every day, seven days a week, 24 hours a day. (Professor James) I have already mentioned the European Working Directive. The other thing which we have not heard too much of recently is the national plan. It was claimed it would offer a consultant delivery service, and, as a rough back-of-the-envelope job, that would mean doubling the number of consultants in obstetrics because, obviously, there would need to be a consultant obstetrician on for 24 hours. That would mean they would be off the next day because they would only be allowed to work 48 hours a week in a few years' time, and that accumulates. We have had consultant expansion, that is true; but the two do not tally because by the time we are all required to do 48 hours, we will not have expanded enough to hit that figure. There is also the issue of how experienced other consultants are coming through. We are working more and more on teams and everything is more evidence-based. One would hope that experience does not count for quite as much as it did in years gone by, but nonetheless experience still is an issue. (Mrs Ashworth) I am smiling because - what does continuity of care mean? Is it a shared philosophy of care or is it - if you go back to childbirth, that gave us all kinds of problems. Things like Partners in Care was set up in Nottingham prior to my going there, and that requires a case load and it requires midwives to follow a group of people through - and that is a real commitment from them. Most midwives are now not willing to work those kinds of shifts. They are mothers themselves. It is really difficult to offer continuity. As shifts get very fragmented, the number of carers increases; so the most we can aim for for the majority of the time is a shared philosophy and very clear guidelines and procedures. That is the way we have to go. We have to offer midwifery care where they are with a woman and can take charge of the case. I think that is creating more ownership, and I have seen midwives now wanting to stay a little longer and being less willing to hand over the care. So that brings benefits, but it is difficult with the short shifts or lengthened shifts - and midwives have choices too. (Mrs Ashworth) We do not have the benefit of an integrated community, as I said to you. We are one of two places nationally that do not have an integrated community, so we are not able to meet the peaks and troughs of the service at all because we have got nothing to fall back on. Our establishment is set so we are either okay or we are stretched. There is no continuity from community to hospital so even for the chosen few there are not any that are getting a midwife. I think there is a tiny amount, a very small percentage, that get followed through with a DOMINO type delivery. They only represent about one or two per cent. It is not huge. There are very few that get continuity care. Actually the high risk pregnancies probably get the better continuity care because they are obstetric-led and they come to the hospital, they meet the staff, they stay on the antenatal wards, they get followed through. The low risk women get left behind because the care is fragmented, both in and out of hospital. Even in the postnatal areas, because there is such intensive care following Caesarian sections and transitional care babies that are now off the neonatal units and on the wards, the care that a normal delivery gets with help with breast-feeding and so on is again very fragmented because you have to deal with the most sick person. You may want to help somebody breast-feed or you may want to talk about parenting skills, but if somebody has just come back from theatre or somebody has got really high blood pressure and you are trying to stabilise it, they do take priority. That is with the best efforts because on some shifts we have got two midwives running with support workers on a 35-bedded ward where we have perhaps got up to 40 babies because we have got transitional care as well. It is really stretched at times and we have not got the investment in establishment because we have not got a national target, we have not got the waiting times. It is all emergency care. If you have got waiting times you can get more staff. We have inherited the transitional neonatal push. All that is now on maternity. (Mrs Hargreaves) Throughout all my pregnancies in Nottingham I rarely saw the same midwife twice, even after coming out of hospital. I rarely saw the same midwife the day after the birth. I personally think it would have made an enormous difference to the whole experience to form a relationship with someone, even better if they could have been in the hospital and helped deliver. But even just to have had the same one after the birth, someone that you got to know and trust, would have made a huge difference. Andy Burnham (Mrs Ashworth) I think it is what Sheena said earlier. It is not just more midwives. It is about us actually looking at working differently and using the midwives that we have got differently. Birth Rate Plus has been done but it has just been done at the City Hospital. We are doing it in June and then it is going to be done in the community, so until that has been used we will not know exactly how effective it is. (Ms Shallow) I think we live in a paradox. I think we have been living in a paradox since the Winterton Report and we then had Changing Childbirth which was such a positive document. The work had been done on continuity of carer, continuity of care, and we thought we knew the way forward. I believe that we did, those that wrote and contributed to Changing Childbirth. I think that was the way forward and I think it still is the way forward. When I read the NHS Plan I was quite disappointed to see that midwifery was not mentioned all that much but actually when I read it again and replaced the word "doctor" or "health visitor" or "nurse" with the term "midwife" it followed beautifully in terms of care closer to home, appropriate care, breaking down professional barriers. It all fitted and I think the biggest problem at the moment is that birth is virtually sewn up in acute hospitals and so the Primary Care Trusts, who are now the commissioners, have perhaps forgotten that they are going to be commissioning the services in the future and yet maternity care for them is not really a priority because it has not been a priority for a very long time because the acute services provide it. In our service we have many midwives working in the community but it is almost like the primary care midwives are stuck between a rock and a hard place. Every government report you read, every midwifery journal you read, even in the obstetric press as well in terms of why women are requesting sections and why the rates are going up, point one way and yet we seem to be stuck somewhere where we cannot actually make this big move to a more community based, focused service which is rooted in the community, teams of midwives working in the community and then feeding through to the acute service appropriately and as and when required. That is what we need but we cannot do it on existing budgets within the overall trust because we do not get priority. Nobody is giving it priority. Jim Dowd (Ms Shallow) It needs to be refocused. (Ms Appleby) It also needs accommodation to do it. It is mainly done in GP surgeries but what we need are places where women can gather and receive local care in the community. That is another issue in terms of resource because we need the investment to provide that facility. (Ms Appleby) We are talking about midwifery centres. We talked earlier on about antenatal classes. There are practices in the country that have demonstrated that they can work in the community in the high risk areas focusing on women who have particular needs, not just Mrs AB who is a middle class woman. She has her needs too and they often get cited in an almost derogatory sense but we have practices in the country that show that you can improve outcomes for very high risk women with very high breast-feeding rates, high home birth rates, marvellous outcomes. Why are we not looking at this and saying, "How can we replicate this one way or another throughout the country?" It is the way forward; I totally believe that. (Professor James) Once again it is evidence based guidelines. For example, in Nottingham now at Queen's, in the first contact with professional staff our present estimate is that 55 per cent of our ladies are midwifery-led care. They do not get booked under a consultant; they have midwifery-led care. Admittedly, a portion of those may have to transfer across during the pregnancy because problems arise out of the blue or indeed in the late stages of labour, but the philosophy we are trying to roll out is with agreed multi-disciplinary guidelines you can identify risk. A point I would put in here as a high risk specialist is that marginalising numerically is nowhere near as important as the majority of pregnancies that we look after. The concern that is there from the confidential inquiry on stillbirths and deaths in infancy is interestingly that the foetal risk in apparently low risk pregnancies is higher now than the risk of foetal death in high risk pregnancies because we have focused very much on high risk pregnancies and we monitor them very well. For example, in Nottingham, if you look at the single normally formed foetal death rate, it is half in the high risk pregnancies what it is in the low risk pregnancies. In the low risk pregnancies it is still only five per thousand but the point is that we perhaps need also to explore from a risk point of view ways of looking for risk in the foetus more than we do at the moment. (Professor James) About two to 2.5 per cent. (Professor James) Correct, in the low risk category. There is risk there. We identify risk predominantly on whether the mother has a risk. We are getting into technical areas which I do not want to go into, but I think there are areas of antenatal care and screening that we need to be careful about and look at. Certainly high risk we focus on very well and we do reasonably well, but it is the low risk, appropriately apportioning intervention, that we need to look at. (Mrs Ashworth) If you look at the report that you were referring to, it does actually state that the most high risk of low risk women are the socially deprived that do not attend in early pregnancy, so that is probably where that category is missed, if you like, early on, because they would perhaps be deemed high risk because they are taking drugs, etc, or just through personal neglect. They may come into a high risk category but they do not present until much later in the pregnancy. (Ms Shallow) It might be that if there were more midwifery centres with drop-in services they would. (Mrs Ashworth) More local services, so you can focus on where the need is. (Professor James) As I say, in our population we think that at the outset of the pregnancy 55 per cent is too low in midwifery care. It should be higher than that. I think it could be as much as two-thirds at least. The other thing which is very reluctant to be implemented is that once a lady is suspected of having a risk factor during the pregnancy, including in labour, and that risk has been eliminated, it is a false alarm, that suspicion has not been realised, there is a failure of obstetricians to let go again and to let the midwifery care take over again. Once a lady has been referred there is a natural reluctance to pass her over to midwifery care. Jim Dowd: Doctors are notorious control freaks, of course. Andy Burnham: Unlike politicians! Jim Dowd (Mrs Parker) My children are quite a bit older but I can certainly say that postnatally there were staffing issues, so support for breast-feeding was not always available when my baby needed feeding and that I think is still a difficulty because I get those reports from the couples coming home and they say, "Can you come round and help because we have not been able to get the help we needed in hospital?" That is purely to do with staffing. The help they have had has been very good but it is not always available. That does have an effect when parents are coming home (Mrs Hargreaves) There was a marked difference for me in my first child. Quite rightly so, there was a lot of help given for breast-feeding, etc, but the focus is on the first-time mums. It was significant how much less there was in the subsequent deliveries. I think the attitude is that you know what you are doing, get on with it but, as every mother knows, every child is completely different and you do sometimes need that support even if you have been there before. That is obviously a staff issue. The emphasis is on first-time mums. (Mrs Parker) Can I also say that the community midwifery service is also stretched and although at one time a midwife would come and visit a woman for ten days after delivery, that is not always happening now. Sometimes it is just a phone call and many new mums have got nothing to compare it to, so they say they are fine and accept the phone call when really they could have done with a visit. That is very sad. A lot of support is needed in those early days for all sorts of issues around a new baby. (Mrs Hargreaves) In terms of control over the birth situation, to be honest, I was quite happy to leave that to the professionals. I did for my first one have a birth plan, the ideal situation, but as soon as I was in there I just left it to the professionals to advise me what to do and I took their advice. John Austin (Mrs Ashworth) We are currently part of an evaluation between Queen's and Sheffield Hospital because Sheffield initiated it much earlier than we did. We are doing a formal evaluation. We have not got that data available at the minute. We did talk about data collection and our data system does not currently allow us to do the real detail for midwife-led care. As Professor James says, it may start out as midwifery care but it has not got on to the computer as to at what stage they were transferred either for an opinion or take-over of care, whether that was transferred back and whether that affected the outcome, whether it was an inappropriate referral. They are real details that we do struggle with because they become paperchase exercises. There is an evaluation going on to look at what the outcomes are. (Professor James) The actual application of this is an example of application of evidence-based medicine. There is a net analysis of randomised drug trials showing that obstetricians do not need to get involved in low risk pregnancy care, and so we do not. (Ms Appleby) It has been supported because of the commitment of the midwives in there and I think sometimes we struggle to provide that service and sometimes they really have to come in because we cannot cope. It depends on what is going on at the time and what the activity levels are, but at the same time we have got acute staff shortages in the acute unit as well. It is about that interface and we are looking to change the way we work that. (Ms Appleby) Home births in terms of referral costs are much lower. Andy Burnham (Ms Appleby) Yes. (Ms Appleby) It is midwife time that they need. John Austin (Ms Appleby) Of course. There is more specific work that needs to be done and we want to do that and, although five per cent was last year's figure, I have a funny feeling it will probably be slightly lower this time. Certainly it is higher than colleagues elsewhere in the region. We sustain it because we believe that it is something women ask for and as far as possible we need to be able to provide it but it does put severe pressure on midwives. Jim Dowd (Ms Appleby) That is a resource question. If you want to ask me how many midwives I would like, I would like another 40. In reality, in terms of the bigger picture for the NHS, that is like asking for ----- We try and temper it with the fact that we need to change the way we work. We have got a bid in for more midwives for next year but we as professionals acknowledge that we need to reconsider the way we organise ourselves. We still maintain the home birth service, we are still moving to more robust implementation of midwife-led care and we are still working with our consultant colleagues in terms of providing quality high risk care to women who need that input as well. We are almost between a rock and a hard place when it comes to those demands when our base establishment is so poor. It is poor in terms of Birth Rate Plus. I cannot emphasise enough that we need more midwives in our establishment and we seem to be able to recruit them. (Miss Fowley) I think it is reasonable to say that we have done as much as we can moving acute midwives to community, community midwives to acute, when there is a crisis. We have been very creative as far as possible to try and put people where they are needed at any one moment in time, but we do have a particular establishment which has been well identified in Birth Rate Plus. Sheena mentioned that we have put in for some more midwives this year but we will not get them because there is no money available, so we are not going to move forward in that way. We have to try and do what we can with what we have at the moment. We do try very hard to look at all different ways of running our service. Our midwife-led care at the moment is probably only running at 20 per cent and one of the reasons for that is that our community midwives, because they have been stretched with high case loads, have not quite felt able to take that responsibility forward. We have been trying very hard for a long period of time to get it going. It has taken a while to get to the 20 per cent level and it was the main reason for considering the appointment of Helen here as midwife consultant to support and lead the care of normal pregnancy. There are all sorts of issues around staffing. Going back, it is not just the midwifery side of things; we do have a crisis with obstetricians because with the various junior doctors' hours with the new Working Time Directive we do not have enough bodies to cover the service properly 24 hours a day and even if you do manage to drop the Caesarian section rate and the forceps rate and all those other rates, you do not know when these problems are going to appear and you still have to have bodies around to be able to deal with them. We really do have problems on that front too, not just numbers but again coupled with the things that people have already said: the experience, the training. It is all very worrying. John Austin (Ms Appleby) In that particular unit I think it is three to four per cent which is quite low and compared to the rest of the Trust it is very low in terms of nursing. We do not have a lot of midwives going in and out of the service. When they come they tend to stay. We have a reasonable turnover but compared to colleagues elsewhere I think it is quite low. (Ms Appleby) We are a class of Nottingham University in terms of midwifery training and there is an element of that curriculum that does promote the notion of multi-disciplinary training. That is a concept that exists. From the midwifery point of view I think we do very well with our university and the university works very closely with us in terms of delivering the curriculum but also the experience in the workplace and a lot of the tutors work with the midwives in the clinical areas. We produce midwives who are certainly fit for purpose. There is an issue about what their perceptions are about being a midwife. When they hit the service the way it is at the moment their training is not concurrent with the real experience of fairly high interventions and all that. Therefore I think they become demoralised, not just in our service. It is a national issue and that is an issue that we are having to wrestle with at the moment. (Ms Appleby) Yes, of course it is. It depends on how that philosophy of care is defined and how those midwives or those professionals work within that philosophy and what it is that they endeavour to deliver to the local population. (Ms Appleby) Absolutely key, yes. (Ms Shallow) You will find in training that there is a well known paradox between training and practice, the theory/practice gap, because midwives are trained to support women through the whole pregnancy and birthing experience and yet they find very frequently that the care that they are then by necessity having to provide is extremely fragmented, so there is a dissonance there. I think we are at the point of looking at training being fit for purpose. If we say that the reality gap is very big then we have to ask ourselves, do we change the training or do we change what is happening in practice? I would argue very strongly that we change what is happening in practice and do not change the training because the training is at the heart of midwifery; it is what it is all about. (Mrs Ashworth) I agree. I think the education departments are as stretched as we are because we have asked them to try to narrow this theory to practice gap by bringing the educators back into practice. We have got a fantastic relationship with Nottingham University and they are working now on the labour ward areas to try and make their expectations much more real, but they are really stretched. Although, like Sheena, we are able to retain staff by jiggling hours and accommodating all their needs, the students are talking with their feet. They are leaving, they are not completing training. Then we have got wastage because we have got people waiting to get on to the training who could perhaps have been there and have stayed and others leaving because they have decided that it is the wrong career choice. They are not able to practise as midwives. They are overstretched; they are not able to give quality care and you often see newly trained midwives crying because they feel devastated that they know that the care that they are giving to women on the wards in their view is substandard. I try to say to them, "Is the care you are giving safe?", because ultimately you have got to be safe, but it is the quality on top of that. Andy Burnham (Mrs Ashworth) Yes, it is, because we have not got the staff to meet the peaks and troughs. What you tend to do is that you pull always from the ward areas, so the wards are depleted of experienced staff and then you have got a newly qualified midwife who is quite fearful on the wards and not able to prioritise and feels that this is not what they want to do for the rest of their career and it is far less stressful in some areas of nursing, especially the ones who have come post-register. (Mrs Ashworth) No. (Ms Shallow) That is exactly the problem: how to break the cycle. We want our midwives in primary care to do so much more in order to ensure that women do not come into hospital unnecessarily in the first place and do not fill up the labour ward when they do not need to be there at that particular time. It is a cyclical thing but until we can provide more midwives to reduce the enormous case loads that some of them have they cannot entertain taking on more duties because they can only just about manage with what they are doing. It is a vicious circle. Sandra Gidley (Professor James) No. There are two questions there. No is the answer to the second one. We are not involved in formal training. At undergraduate level the medical schools have different practices on how many normal deliveries you are supposed to attend and so on, but for education purposes they have limited value because they are usually on-the-fingers-of-one-hand experiences. We do not attend normally. I am not answering the question you have asked but one thing I wanted to mention in response to Mr Austin's question was that, given the previous comments about concern about the abilities of our junior doctors, what the Royal College of Obstetricians is moving forward on is the idea of competency training, in other words, not just saying you have passed this exam but can you do this thing. The challenge is to try and work out whether you can with the new appointees assess what their real level of competency is and what they are able to do, and I think that may be a much more helpful and practical way forward. Andy Burnham: Could I at that point of roughly half an hour over time thank you on behalf of the Committee for what has been an extremely valuable session. The fact that we have run over so much shows that we do value and appreciate the information you have given us. Hopefully our report will pick up possibly changing the issues you have been touching on. John Austin: If anything comes out of your evaluation perhaps you would let us know. Andy Burnham: That would be very useful. Thanks. MR DAVID REDFORD, Consultant Obstetrician, MS CATHERINE SMITH, Professional Development Midwife, MS SUSAN BRESLIN, Women's Services Manager, and MS JULIE BALL, user representative, Royal Shrewsbury Hospital, and MR JOHN WATTS, Consultant Obstetrician and Clinical Director, MRS TONI MARTIN, Head, Midwifery, and MRS DAVIDIKA MORRIS, user representative, Maternity Services Liaison Committee, Worcestershire Royal Hospital, examined. Andy Burnham (Mr Redford) I am David Redford, Obstetrician Gynaecologist, Clinical Director of Women's Services in Shropshire based at the Royal Shrewsbury Hospital. My major interest has also been in the high risk or complicated pregnancies. (Ms Ball) I am Julie Ball and I am here as the user representative. I have three children, all of whom I had at Shrewsbury. I am also on the Labour Ward Forum as a user representative. (Ms Breslin) I am Susan Breslin, Manager of Women's Services in Shropshire. (Ms Smith) I am Cathy Smith, Practice Development Midwife for Shropshire based at Shrewsbury and with a particular interest in case load midwifery. (Mr Watts) I am John Watts, Clinical Director at Worcester for the Worcestershire Trust and also Consultant Obstetrician and Gynaecologist at Worcester. (Ms Martin) Toni Martin, Head of Midwifery for the three units in Worcestershire. (Mrs Morris) Davidika Morris. I am the user representative from Worcester and I am also on the Maternity Services Liaison Committee. Andy Burnham: Thank you very much. Can I say, particularly to the Worcestershire contingent, that your local MP is not snubbing you. He is lobbying for the continuation of some of your services at some of your hospital sites. He will be joining us at some point during this session. Sandra Gidley (Mr Redford) Our rate is audited mainly through our regular monthly audit meetings of various events, both good and bad, happening to our obstetric patients. I was very interested that you said our rate was significantly better. It is significantly lower than the average but ----- (Mr Redford) We have asked ourselves that a lot because it is a very low rate around the country and I do not think there is one single reason for it. I would highlight three points that I think are important. First, the structure of our organisation of maternity care, the fact that we still have low risk units in country terms run by midwives with input from GPs means that a lot of women never hit the consultant unit at all during their pregnancies, about a third of them. Secondly, the culture of our organisation is that we have low intervention rates and once that is known we attract both midwives and obstetricians who like to practise in that way, so to a certain extent it strengths that position. The third factor is almost a statistical quirk because the Caesarian section rate this year is very largely determined by what it was last year in that the largest single contributor numerical-wise to the number of Caesarian sections is repeat Caesarian sections from previous years. (Mr Redford) I think there is a bit of a puzzle. Again, we do a certain amount of auditing of the reasons for induction. Again, I think there is an issue of definitions in terms of exactly what constitutes induction and I think the evidence is conflicting. For instance, the evidence about prolonged pregnancy, which is one of the major groups of induction, says that it is both appropriate and indicated and also that it reduces subsequent intervention rates. (Ms Smith) Twelve per cent. (Mr Watts) I thought you might start with that. I think you need to appreciate the slightly different geography that we have. Worcestershire has three hospitals with regard to delivery and maternity care. We have Kidderminster, which is a low risk midwifery-led unit, and then we have Redditch which also has a consultant-led unit. The Caesarian section rate there is about 22, 23 per cent. Ours at Worcester itself is currently about 27 to 28 per cent. I have only been with the Trust over the last three years. It is interesting that, according to my colleagues, they felt that the Caesarian section rate has only increased over the last five years, two years before I came. That coincided with the amalgamation of Kidderminster and Worcester. I think we were one of the first units where there was 40-hour presence of consultants on the labour ward during the week, which is one of the guidelines which our college has been striving to get all units to achieve. The midwives are convinced that it has coincided with the consultants being present on the labour ward for 40 hours a week. That is something which we are looking into. One of the things that we did look into was that, contrary to David at Shrewsbury, we did have a very high induction rate and we have in fact reduced that now, so we are hoping that by reducing our induction rate we are going to see a reduction in the Caesarian sections. However, I think we are into a bit of a spiral because once you have got a high Caesarian section rate there will be a lot of patients coming back who have had a previous Caesarian section and if somebody has had a previous Caesarian section you probably would not get a group of obstetricians to agree how to manage them, so we are in a difficult situation but we are trying to make amends. Andy Burnham (Mr Watts) No. It obviously depends on what the reason for the primary Caesarian was. If you had a woman where you could prove that there was some form of cephalo-pelvic disproportion, in other words, there was no way the baby could be delivered vaginally, then she would automatically be offered a Caesarian section the second time round. For somebody who, for instance, had a Caesarian section for foetal distress or quite possibly the first baby with a breech presentation, then we would automatically advise that patient that she ought to attempt to have a vaginal delivery. Sandra Gidley (Mr Watts) The consultants each audit their own patients. I am sorry that we came on to Caesarian sections before the maternity information because we do not have a maternity information system, so we have great difficulty in auditing any of our work. All our deliveries are kept on a ledger on the labour ward. All we know in fact is who the patient was, when she was delivered, what type of delivery she had. If somebody needs to do an audit or if we need to produce some statistics, it means one of us, either one of the midwives or one of the consultants, ploughing through the delivery book. If you are trying to look at why you are having a high Caesarian section rate, if you are trying to do a retrospective audit of that, it means you pull in all the notes for the last 12 months to try and identify common reasons. (Mr Watts) Yes, we do. (Mr Watts) I would have thought a fair proportion of the emergency Caesarian sections, either for failure to progress or for Caesarian section in the second stage of labour, could possibly have been avoided. (Ms Martin) No. John and I have discussed this. There is a certain feeling that you need skilled consultants or skilled medical practitioners on the labour ward, as you do need skilled midwives, but there is also a definite feeling that you are more likely to have interventions, even with a relatively normal, ongoing labour, which will then create its own spiral leading to more interventions unless you have a very strong, skilled midwifery workforce to say, "No, this is a midwifery-led lady who requires only midwifery-led care". It is not necessarily an element of bullying; I would not say it is anything like that. It is simply that we have reached a stage in one of the three units in Worcestershire where the Caesarian section rate is high, the midwifery staffing is perhaps, as you have heard from the people earlier, not always appropriate, the skills of the midwives become much more obstetric-led rather than midwifery-led, and it leads to a lack of confidence, so you end up with this continuing spiral. I do think you need active, skilled medical presence on a labour ward but you equally need active midwifery skilled midwives on the labour ward to counterbalance that. Andy Burnham (Ms Martin) I would say not that often. (Ms Martin) Oh yes, of course it does, but it is not in a difficult environment because it is a very good working relationship. Oddly enough, you would probably get more disagreement in one of the other sides where there is not as good a working relationship. Worcester has a very good working relationship between medical and midwifery colleagues. If you have not got a confident midwife she is less likely to object. Sandra Gidley (Ms Martin) Oh yes, we have tackled it on various levels. We have concentrated quite a lot of time and thought on this - it comes down to money at the end of the day - and have asked supervisors to audit every single record and every single emergency Caesarian section for quite a period of time. Looking at inappropriate midwifery interventions, or ones that we considered inappropriate, and there is of course a training issue, we found that the money for that runs out so that it slides a little bit further down for this to carry on. It is very intensive to have a strong midwifery presence on the labour ward urging normality. It is an expensive resource and Trusts do not always find that to be appropriate. (Ms Martin) Absolutely. It has been said already that a low intervention rate brings lower costs. (Ms Smith) I agree with what has already been said. It makes a lot of sense to keep women that have low risk factors out of consultant clinics. I would not say it is so much the consultants that are keen to intervene, but obviously the junior trainees are always going to err on the side of caution, so they are always going to bring a mother back to the next consultant clinic, hoping that it might be a senior colleague or a consultant that then will give an opinion. Women with very few risk factors can find themselves coming back several times to a consultant clinic for no good reason, and that hinders the continuity that we are trying to achieve. We do have a policy in Shropshire that we try not to get women into the consultant system unless they have a need. It is something that we are currently looking at ourselves. We do not think we have got it right in Shropshire yet. Quite often the first port of call for a woman who is pregnant will be her GP and then we will decide whether to refer to midwives or a consultant. More often than not they will refer to a consultant clinic. What we are trying to do is put in a process as midwives and consultants and say, "This woman does not have a high risk factor and therefore should be referred to a midwifery colleague", and in that way not embark on that cycle and journey of intervention. (Ms Smith) Yes. The choice is always going to be difficult. Women tell us that they do not want to offend their GPs, that they know the GP is going to be there all the way through their child's life probably. They are going to be going back to them, so if the GP says, "I think you should go to the consultant clinic", the majority of women will go along. A midwife phoned me last night saying, "What can I do? This woman has clearly said she does not want to go to the consultant clinic but she does not want to upset the GP." Midwives have a vital role in helping them make those choices. Coming back to the 40-hour a week cover for obstetricians, I have to say that we have had the 40-hour a week cover in Shropshire for a while. (Mr Redford) That came in in the Royal Shrewsbury in 1997 and it may work very slightly differently than Worcester, but that was one of the models we followed, but I do not think it made the same difference to our Caesarian section rate. (Mr Redford) One of the key recommendations of a Royal College of Obstetricians gynaecologists' report Towards Safer Childbirth was that, instead of consultants often being in a gynaecology clinic and an operating theatre doing all sorts of things but being on call for the labour ward, there should be a consultant for at least the 40 hours, nine to five Monday to Friday, with no other commitments and providing some continuity. Only a minority of maternity hospitals have been able to achieve that, but Worcester and Shrewsbury are two that have. (Mr Redford) We have not noticed a change in our rate because of that. (Ms Breslin) It is both really. We follow the NICE guidelines for induction of labour. (Ms Breslin) It was very similar. The commonest reason for induction in Shropshire is post-dates, ladies that have gone over their due date. They just seem to have a long gestation in Shropshire. When they are post-dates and they are seeing their midwife, they become a higher risk case because they have gone post-dates, and she can simply book them in to the consultant unit for induction of labour without having to go through a clinic and so on if they want to be induced and, to be fair, most of them are ready to be induced when they have gone post-dates; or their GP may refer them to the consultant clinic and they will then refer them for induction of labour to the consultant unit. We do have a high induction rate but it is an appropriate one, I think, because the outcomes are still quite good. They do not end in Caesarian section because they have been induced. (Ms Ball) Going back to your booking and the GP, I think the consultants certainly seem to shift them back to the GP units very quickly if you do get as far as the first appointment with the consultant and you are low risk. The feedback that I am getting is very much that the people that are going through as high risk are the ones that need that input. (Ms Ball) Yes. (Mrs Morris) My experience is a high risk person and so I was referred to a consultant and there I stayed. I do not know about any other way so it is difficult for me to comment. (Mr Watts) We have a similar situation as Shrewsbury with regard to booking. The majority of patients are booked in the community by the midwives and either themselves or the GPs would decide whether they felt they were low risk and can be kept as midwifery-led. Patients who are referred up to the hospital for consultant opinion may well be higher risk and then continue on, but what we have found is that some patients are continuing to be classified as high risk when they are not. This is part of the education we have to do with some of the consultants on our patch, that they need not necessarily keep those patients under their care within the setting of the hospital. The GP has sent them off for an opinion and quite often I send the patients back. It is a similar situation to Shrewsbury. (Mr Watts) The actual decision is made by the consultant. That consultant may be present on the labour ward at the time or he may not be. If it is after five o'clock or maybe in the middle of the night, the consultant may be at home, so you have to make a decision perhaps over the phone relying on the judgement of your middle-grade staff. If they ring you up and tell you that there is a severe foetal distress then you are not going to argue with them over the phone and say, "Wait until I come in to make a decision". You have to be guided by what the middle-grade staff tell you. (Mr Watts) No. (Mr Watts) I think that is fair comment. But then you are getting to a consultant perhaps being on the labour ward 24 hours a day and I think you heard from the other group that if we go down that road then you are going to need three or four times the number of consultants. Andy Burnham (Mr Watts) There is no drive. We do not encourage Caesarian sections. (Mr Watts) It is difficult to put it down to litigation. It is always flagged up as a reason but personally that does not come into my mind if I have got a patient in labour, whether I should deliver her vaginally or by Caesarian section. That is the last thing on my mind, so I think that is a bit of a red herring. It may be a factor with some of the junior staff in making their decisions because perhaps they have not got as much confidence or experience as I have. (Mr Watts) That is something that we would like to look at. It is something that we have looked at partially but, as I was trying to explain earlier, we have not got access to that data to find out why the Caesarian sections are being performed. I would like to take a month off and pull all the notes for the last three months to look at all the Caesarian sections that we have performed, but that is not physically possible. If we had access to a proper data system that is something that we might be able to achieve and I might be able to come back to you in six or 12 months' time and say, "This is the reason why we have got the problem". Until we get that maternity information system in place and we are collecting appropriate data, I cannot tell you. (Ms Martin) From the midwifery perspective that would compare with the previous groups when they said that it was a lack of one-to-one midwifery support. A lot of surveys have been done looking at when women want midwives and do they want to know them prior to the birth, and the majority of women tend to say that it does not matter as much as somebody being with them. It is great if they are known and that is the ideal, if they know the woman. (Ms Martin) It was a completely different service at that time. (Ms Martin) Oh yes, but it was a different working life. You have to be careful when you compare women today who are active working mothers with the fifties and sixties. As the other speakers said, if you try to talk a woman out of a Caesarian section, - and it is very small numbers of women and I do not think they should be used as scapegoats, those who are requesting Caesarian sections; they are a small percentage overall; it is made up of lots of things - and in our area we have tried with the National Childbirth Trust having classes specifically run by the NCT so we cannot say there is prejudice from midwives to try to talk women out of automatic request for Caesarian sections after a previous Caesarian section, and it is disheartening because we cannot promise them one-to-one midwifery support, somebody with them who will reduce the pain away, reduce the intervention rates. That in my view is the main driver behind Caesarian sections. The labour wards are so busy and the midwives are running around giving partial care to women. (Mrs Martin) Potentially training. It is the advent of a litigious culture because, again, midwives will practise more defensively, yes, but you cannot blame that alone. It is with the advance of technology that you can see a problem arising, and midwives stop relying on their old skills of hearing, listening, watching, waiting. (Mrs Martin) I am not too sure but I think I would be right in saying possibly the 1970s onwards with the advent of technology. I would not be too sure that you would be able to say categorically. Andy Burnham: Thank you. Richard, I explained your absence. Dr Taylor (Mrs Martin) Absolutely, and unfortunately this type of unit is considered to be prohibitively expensive because the staffing ratios are built for safety as well as for good midwifery care. (Mrs Martin) It is about the natural average. (Mr Watts) It is about the national average at 27 per cent. (Mrs Martin) That is intra-partum. That can vary from not at all urgent to really urgent and the really urgent are a very, very small percentage. (Mrs Martin) We heard that that was the national transfer rate. (Mr Redford) I think there is a very high rate of transfer from a low risk to high risk setting in labour around the country in birthing centres. (Mr Watts) I believe this is a regional thing. They have looked at setting it up within Worcester - and I must admit I am not very computer literate - but for some reason or other they cannot seem to connect this system up between our computer software and systems and those in the NHS. There is some blockage between the NHS and Worcester. They are looking at it as to whether or not we can actually use it. It will be a start. You would be able collect some data. (Mr Watts) A nationwide, compatible system would be far better. (Mrs Martin) It takes a considerable amount of time. Simply collecting the data, which is a paper exercise, you try to devolve not to the midwives if at all possible, if it is purely number crunching. It is the analysis of that data that takes the midwives' time and we simply do not have sufficient time for that. (Mr Watts) We just have not got enough information recorded at a particular time. I am sure that given the appropriate time and given the appropriate resources if we pulled out all the notes for the last 12 months on emergency sections, I would probably be able to come up with a common denominator as to what the problem is. I just do not have the time. Andy Burnham (Mr Watts) Oh yes, it should have been. I am glad you raised that. My colleagues have been striving for ten years to get a system at Worcester. It has not been dealt with properly by the Trust. Dr Taylor (Mrs Martin) Most units have some sort of system; they will not talk to each other and they collect different sorts of data. (Mr Redford) We do not have an electronic data collection system. It is not a new problem. I remember when I was first in Shropshire in 1984 spending a day with a senior midwife going to Newcastle to look at the system and the computer, and things do not seem to have moved on in maternity information services. One of the reasons maternity is poorly served is that we have quite good systems for the gynaecological side of our work but because we have a block contract for maternity and we do not get paid for each individual patient we deal with, there has not been the same perception of the need to have accurate data collection. We have the problem of small units around the county and indeed we deal with patients from Wales who have been booked into a small unit there and who come across the border for some of their care. Having a system that will cope with that is a very big challenge indeed but we desperately need it. Dr Taylor (Ms Breslin) We have numbers for babies which started last year, as you know, and we register a baby's birth on the computer and it gets back its new NHS number. We have slightly modified that to give us local information, not a great deal but nevertheless it gives us a little more. All our statistics are manually collected and collated and presented, and they all come through me, so I know! John Austin (Ms Breslin) I have a calculator. I know exactly what the deliveries are, I know when they are going awry, I know they are presented to all the staff every month on whether the section rate is up, whether the forceps rate is up, when unit deliveries are down. I can feel the difference in Shropshire month-by-month so it is constantly monitored and if there is a problem it will be handed over to audit to look at it formally. We use registers, as we have since the day I started, but the registers have been expanded and expanded. We have presented as much information in these registers as possible and while the information we collect is quite excessive and we collect a lot of information, it is very one-dimensional. When you want something that is more complex then you have to go back to those registers. The information is there but you have to then count it. That is how we have always done the statistics. Andy Burnham (Ms Breslin) The trust had a plan for computerisation. As a trust it wanted to go department by department so it all fitted together and it was a cohesive computerised system where all the departments would feed in and we were always last and they have never quite got round to maternity services yet, so we are still waiting. John Austin (Mr Watts) We have a problem with retention. (Mrs Martin) It is one of size. In midwifery in the smaller units it is quite the opposite and we do not have a problem with retention, in the middle-sized units we do not have a huge problem with recruitment and only nominally with retention, but in the larger units, the busier ones, with the high caesarian rates and the high stress, we have a problem not of recruitment but retention. Not a huge one, I have to say, but that is because we offer a flexible type of working to midwives to keep them, quite honestly. (Mrs Martin) It certainly will. It has had an impact because of the shift patterns. Some midwives choose to work a very long day so they do not have to work so often, which will of course stop. (Mrs Martin) The vast majority of midwives are part time - the vast majority - which means the continuity of care is difficult. The vast majority are young with children who, again, will not want to stay late if the work is not satisfying. (Mrs Martin) It is very important. (Mrs Martin) With some difficulty, but you try. It is more difficult on the labour ward because you do not have teams of midwives. When we had a lot of team midwifery we met every training and childbirth recommendation but that was considered too expensive on one of the sites, which was a shame. Continuity of care on community has become more - and we have an integrated community service - difficult with midwives wanting more time and to have more flexible working but you have to match the needs of the working woman as well as the needs of the woman who is pregnant. (Mrs Martin) I have a vague recollection. (Mr Watts) I remember the days when GPs were involved in intra-partum care. For some reason more and more GPs are not providing that service any more. Some of them are only just providing ante-natal care. (Mr Redford) I do not think we could go back to those good old days. We have got to find better new days later. Dr Taylor: Am I allowed a comment? As a student I had to stitch up episiotomies unsupervised. I hate to think of the damage I did, it was appalling. John Austin: Careful or there will be a reference to the GMC. Dr Taylor (Ms Smith) Yes, women in Shropshire will all have a named midwife. We have an integrated service, as you already know, in Shropshire so the community midwife will be the named midwife for that mother and she will know how to contact her pretty much any time of the day or night. She will not be the midwife who goes in to deliver her in the majority of cases. If the mother delivers in one of the low risk units in the county it may well be a midwife she has met before but she certainly has a named midwife at all times. (Ms Breslin) We have a policy on booking criteria for low risk units. You simply match the lady against the criteria and if she fits she is able to choose that as her option. If she does not fit we recommend a referral to the consultant for his opinion. If he overrides the booking criteria because he does not think it is particularly significant then she is referred back for GP/midwife care. We even experimented with giving the women the criteria rather like a magazine test "Are you a red hot lover? Tick these answers." She went through the list of booking criteria and booked herself or saw where she would best fit and she would be more involved in that choice. (Ms Smith) At the end of the day whatever she chooses is what she will have. (Mr Watts) There are guidelines which most units tend to follow for low risk or high risk. You only classify somebody as low risk after they have had a normal delivery. John Austin: I know you were semi joking there but I am sure you feel it is important to involve the woman in that decision. Sandra Gidley (Ms Breslin) No, most of the women who want to make the decisions, who want to be involved in the decision making tend to prefer the lower risk side of things and the fact that it is such a big county you are talking miles of travelling as well. If they are going to be booked in Shrewsbury and live in Ludlow they have been on the road an hour and a half before they get to us. There is a big appeal in being delivered on your doorstep because your family is there and you probably know the midwife anyway because they are of that community. It is a very, very pleasant way to have a baby and a lot of them do choose that when you give them that option. Of course, they can have a home birth if they wish or they can be delivered on the consultant unit, if that is their wish. We have a lot of people who deliver on the consultant unit but then transfer back to the low risk unit for the post-natal care. Lots of women choose to do that. Andy Burnham (Mrs Martin) With one of the PCTs - Wyre Forest - we are in greater discussion but they are a far more established PCT. The ones in Worcester are very new and it is quite hard to engage them in something that is not a waiting list initiative or a money-based issue. In time I think they will become far more involved and be much greater drivers. (Ms Breslin) I think we have got a particularly good set-up in Shropshire and we have worked hard to get it so. It did not drop down from heaven. This started in 1974 and we have been working to perfect what we have had since 1974. (Ms Breslin) Because of the geography and what we inherited and how we worked to change it and keep it so and Mr Redford is absolutely right, we have recruited people who are like minded. If you want to keep something going and you believe in it you do not want to employ people who do not believe in what you believe in. You tend to recruit like-minded people. When I interview midwives who have not trained in Shropshire, although most of mine have trained in Shropshire, some of them have never seen a baby born in breech, they have never been with twins who have delivered vaginally. I am employing them as midwives to work on my unit; what am I to do with them? They almost need retraining to be able to work in Shropshire. They have never seen a breech and they cannot believe that women are delivering vaginally, and their first thought is, "It must be a caesarian. Why are we doing this?" We have to show them how we look after women in labour and show them how it can be a perfectly straightforward delivery and I think the consultants have a similar problem with the middle grade who come to us who trained elsewhere whose first recourse at the first blip is caesarian, get the baby out. (Ms Breslin) I am not even sure it is litigation, it is just an unwillingness to persevere with a difficult labour. (Ms Breslin) I do not know. If you are the person who is on duty and you have got a girl whose labour is going to last another eight hours and you do a caesarian now and you will be home for your tea --- (Mr Watts) I disagree with that, I am sure that does not happen. To go back to a couple of points as regards training issues and continuity of care and the Working Time Directive, I think the previous group mentioned, and I am sure David will agree with me, as regards the training of our juniors at the moment, the number of hours that they work and the number of years that they do now before they become qualified to become consultants are reduced, so they do not see as much as we used to do in the days when I was training and we get several of our juniors coming to us who have never ever seen a normal vaginal breech delivery, and the likelihood is they probably will not. (Mrs Martin) They will opt for a caesarian section. (Mrs Martin) It compounds the problem. John Austin (Mr Watts) Between midwifery --- (Mr Watts) There is no reason why some of the training which the midwives get and some of the training doctors get should specially be normal births. (Mr Watts) No. (Mr Watts) They should get it, yes. (Mrs Martin) It is completely different training. There is no point in a budding obstetrician looking after one woman in labour and delivering one woman. That is not going to influence his practice in any way other than he has seen it. I would think that we do not have joint training other than CNST requirements, the skill drills, and that is very good because it is team working. If you are going to look at training midwives and potential obstetricians together you need to completely re-look at why you are training and who you are training because they are very different skills, completely different skills at the end, and a lot of it should be about respect for each other's professions as well and each other's skills. (Mrs Martin) I think it is, first of all, the belief of the person who is being trained that there is such a thing as informed consent and the patient/the woman can make a decision for herself. Unbiased information is rarely truly given. You increase the time you spend with the woman significantly if you give true, unbiased, wide-choice information. (Mrs Martin) It is difficult because I have not been trained as an obstetrician but I would imagine so because a midwife spends three years --- (Mr Watts) I did not take it as such. (Mrs Martin) Perhaps Sue you might feel the same, it is at the local unit level - the skill drills and team working with trained people. You are probably talking about that level rather than student midwives and medical students. We do not have joint training for those but we have joint training for medical colleagues and midwifery colleagues at local level. (Mr Watts) At local level on the labour ward. Andy Burnham (Mrs Martin) We have a shortage. I do not know if you do, Sue. (Ms Smith) One of the problems is the establishment of midwives that we have in Shropshire. That is linked to the number of midwifery places from the local university, so we feel it would be wrong of us to ask for training places for midwives if we know that we cannot employ them. We feel, particularly now when they enter training as a midwife not a nurse then a midwife, that if there is not a job within the county they have got to move county once they have trained as a midwife, so the moral obligation is not to ask for too many places that we know we are not going to be able to recruit from. That is our biggest problem in Shropshire - the low establishment of midwives. We have not traditionally had a recruitment problem, we hit a blip 12 months ago which was the first time we had come across it. Up to that time we had a waiting list for those who wanted to be midwives. (Ms Smith) No, we did worry about this problem when we had direct entry into training if they had not been in the NHS at all, whereas when nurses came to train as midwives knew what the culture was like. The majority of training was worked around trimesters and they did not have to work weekends and nights and they then qualify and it is a huge shock so, yes, we have an issue with that and with some of the training. (Ms Smith) Very little control. In fact, the university very recently said that we should not be interviewing students because it is university selection and it does not need to be done on an interview basis. We negotiated to retain that to at least be able to go along and ask why is it you want to be midwife? (Ms Smith) Yes, on the selection of people so that it is not just a degree course for qualification and that they eventually want to become midwives and work the hours and give the continuity that the job requires. (Mrs Martin) If I could just add something. Our experience is quite the opposite. We have a very good working relationship with our local university. We have increased training places. Of course you have to guarantee you can give them the jobs so you do take a bit of risk but I am sure we will. We have a huge input into the content of the curriculum and how we negotiated extra training places was by getting rid of that trimester feel to it so students are there all the time and we do not get blocks of students. It has worked very well. That is our local university. Andy Burnham: With the autonomy of universities it is very much up to them what they do and it might differ from one part of the country to another. John Austin (Mrs Martin) I think so. (Ms Smith) Yes, that is one of the reasons they are not required to work weekends and nights - because the majority of them have jobs at weekends. (Ms Smith) Yes. (Ms Smith) We do have that worry. In Shropshire 80 per cent of our midwifery workforce are part-time workers. That is not because they are all married with children. It is part of a trend where the younger midwives are not coping with a full-time job and are preferring, for various reasons, to opt for part-time working, possibly to do some agency work and other jobs, but the reason that they give mainly is because of the stress of the job through insufficient midwives. Andy Burnham (Mrs Morris) I personally think they are very important. I did not do any ante-natal classes in Worcester. I had my first child somewhere else and the ante-natal classes were not at suitable times for me. I feel that they are very important and they give parents the knowledge to make more informed choices, I guess, and help them in making decisions during their pregnancy and labour. (Mrs Martin) Yes. There is also an issue with starting levels, I guess. Antenatal classes are less important than delivering babies because the babies have to be delivered. (Mrs Martin) The midwives do the antenatal classes so where there are shortages of staff the antenatal classes are less important than delivering babies. (Ms Ball) As far as feedback that I get the antenatal classes are invaluable. In Shropshire we actually do classes at the outlying units as well so whether or not you talk to that unit, perhaps you under the care of the hospital, you can go to them, so they are very available for the clients. The NTT also do back-up classes as well, so it is two-fold. The classes are important in that it allows people to know what the choices are. They go to, say, one of the outlying units, for example Bridgenorth, for the class and that gives them the ability to have a look around, to get the feel of the place, get to know the midwife and maybe decide that they want to deliver there. It is a knock-on effect as well on the care that they are going to get. (Ms Ball) The feedback I get is generally very good. The biggest thing really is the information that they get during labour, the support that they get during labour and then the help and support that they get postnatally. (Ms Ball) Yes. (Mrs Morris) Generally pleased with the care, I think, but, again, not always having a midwife present with them during labour is a big issue. (Mr Redford) I am very sorry. I know that you have heard from previous witnesses about great concerns about training of obstetricians and the numbers and calibre coming through and I have two very small points about that. The practical issue for me is having six doctors in the middle tier doing a lot of the key work at night, the advice is in a year and half's time with the European Union Working Time Directive I will need eight and I really do not know where those two are going to come from at the same time that every other trust is looking for two more. The second very small point is recruitment into obstetrics as a profession. In a recent study looking at the intentions of medical graduates one year after qualification, obstetrics and gynaecology showed a 50 per cent halving of the medical graduates thinking of doing OG compared with ten years ago and that is a very real worry. (Mr Redford) That is a big question. I guess yes is the short answer. (Mr Redford) The danger is that you have to rely more and more on agencies and you get into a blackmailing situation where you are paying £40 or £50 an hour for a diminishing pool of doctors who are not fully committed to a job in one hospital and you end up spending enormous sums of money just to keep your service running. (Mr Watts) I agree. With regard to continuity of care, we have had to move over to a shift system for doctors and also our SHOs and they are working true shift patterns. From the point of view of continuity for care for the patient it is very poor. Even the doctors themselves are critical of the number of hours they are now working because they appreciate now that they are not going to get the proper training that they require within that period of time. (Ms Smith) And that will impact on the way midwives work because we are looking for better continuity for midwives following the mothers through. (Ms Smith) Yes. Sandra Gidley (Mr Redford) Yes, because there is a very finite limit to how much night work in obstetrics you can stop doing whereas there is more potential in other specialties. Equally, because the speed of reaction has to be very quick you have to have your staff on the site working and that is the European criterion for saying you are working rather than just available. Andy Burnham: Okay. Can I thank you all for a very valuable session. We hope to produce a report in the not too dim and distant future, after Easter. I think it is also fair to say that the issues that we have touched on both in this session and in the one before will be closely covered and hopefully we can pick up on some of the evidence you have raised. Thank you. |