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11 am

Mr. Kerry Pollard (St. Albans) (Lab): I am grateful for the opportunity to debate the very important subject of maternity services. I shall focus in particular on the role of midwives.

I have seven children, five of whom were born at home with the help and support of our local midwife, so my family are big fans of midwives. I was recently honoured by being appointed as a fellow of the Royal College of Midwives. That is an honour that I greatly prize, although perhaps it should have been awarded to my wife.

The Select Committee on Health has taken a keen interest in midwifery. It has made several important pronouncements that it considers helpful to potential mothers and to the health service generally, which have the full support of the Royal College of Midwives. The Select Committee believes that midwifery is still too medicalised and based in the acute sector, and that it needs to be brought into a community setting. My family experience fully supports that contention, and a low-risk birthing unit at St. Albans city hospital, like the one at Edgeware, would be an ideal way of delivering that.

The Select Committee also suggested making midwives, instead of GPs, the first point of contact. That would establish at the beginning of the pregnancy the important relationship between the mother-to-be and the midwife. It would also remove an additional burden from the GP, and would recognise the midwife as a professional in her own right. It has the added benefit of making midwifery a much more attractive career option.

A big problem with midwifery, as with other caring professions, is the shortage of qualified practitioners. The Select Committee has noted that, and the Secretary of State for Health has singled it out as an issue of concern for the Government. The average age of midwives is going up. As midwives retire, they are not being replaced by younger midwives. The average entrant to midwifery tends to be older: often a mother returning to work after having children of her own. Strategies need to be developed to attract more people into midwifery. I look forward to hearing any thoughts that my hon. Friend the Minister has in that regard.

I want to focus on our local situation, in which we have a first-rate team of midwives. Two years ago, our special care baby unit had to be shut down due to lack of staff—not because of funding problems as used to be the case in years gone by. There was an inability to recruit, so the unit was transferred to an expanded unit in nearby Watford hospital. Many of us worked hard to re-establish the closed unit, and none worked harder than my hon. Friend the Member for Hemel Hempstead (Mr. McWalter). I am pleased to say that about nine months later we had the privilege of welcoming Dame Karlene Davis, general secretary of the Royal College of Midwives, to open a brand new, low-risk birthing unit, which is now operating well.

I would like to see an equivalent unit opened in our own St. Albans city hospital to complement our other excellent units, such as the minor injuries unit run by

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Sister Rita Dunkerley, the day surgery unit run by Sister Eileen Kent and all the other services run for our local community by dedicated professionals. Our local primary care trust is doing sterling work, and it is my hope that before too long it can make a foundation status bid for St. Albans city hospital, which can then be run by local people for the benefit of local people—a winning combination.

We were grateful for a recent visit from my hon. Friend the Minister to St. Albans city hospital. He was fact finding and getting to know his new regional responsibilities. He was well received, and all the staff were grateful for his visit. Only two weeks ago, the Secretary of State for Health also visited St. Albans city hospital. He met many members of our team of professional health workers—consultants, sisters, nurses and ancillary workers—and he spent more time talking to them than doing anything else. He also toured our hospital and chatted to Sean, who was having a splinter removed from under his thumbnail in our minor injuries unit.

While he was with us, the Secretary of State opened a brand new orthopaedic operating theatre. We now have five fully functioning theatres, with supporting wards, that are able to perform many more routine operations, thus reducing waiting lists and leaving the acute hospitals to carry out more complex operations. A figure approaching £1 million has been spent on those new facilities. That is in addition to a new hydrotherapy pool and other rehabilitation facilities for those recovering from strokes. Facilities are much improved, and more are to follow.

Recently, a full consultation exercise was undertaken by the strategic health authority on the future of our acute services throughout Hertfordshire and Bedfordshire. I am pleased to say that there was a big majority in favour of option two: the provision of a new acute hospital to serve south-west Hertfordshire, which would be situated adjacent to my constituency. I am also pleased to report to my hon. Friend that every PCT in the two counties except one voted for option two. I hope that the Secretary of State for Health will approve option two, so that I can look forward—in a few years time—to his opening our new hospital linked to a medical school at the nearby university of Hertfordshire.

11.5 am

The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman) : I congratulate my hon. Friend the Member for St. Albans (Mr. Pollard) on securing this debate, and on the work that he has done on behalf of midwives and maternity services. I had not appreciated that he was a fellow of the Royal College of Midwives, which is a considerable honour given by an impressive organisation. On hearing that he has seven children, I wondered whether it was given as a loyalty bonus to one of its best customers.

We all know that midwives are key members of the maternity service team, and that they play an important role in the provision of high-quality maternity care in the national health service. They are key to ensuring that women and their families receive appropriate

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information to help them to make choices during their pregnancy and childbirth. Midwives are rising to the challenges that we have set to tackle health inequalities, and to modernise NHS maternity services. I would like to express my personal gratitude to them for the wonderful work that they do.

In recent years, there has been an increase in the number of midwives working in the national health service, and we hope to encourage 500 midwives to return to practice during 2003–04. So far this year, 173 midwives have returned or are returning to the NHS.

My hon. Friend raised some concerns about the recruitment and retention of midwives. I frankly acknowledge that progress in increasing the number of midwives has been slower than we had hoped. By no stretch of the imagination am I ignoring that. Indeed, just a couple of weeks ago, Sarah Mullally, chief nursing officer, hosted a summit with key stakeholders, including representatives from the Royal College of Midwives, NHS managers, midwives themselves, obstetricians and users of maternity services. The purpose of the summit was to explore the main barriers to increasing midwife numbers in the NHS, and to identify what needs to be done to tackle that.

I attended the summit, and I made it clear that progress was not acceptable and that radical and ambitious thinking was needed. I also threatened them by saying that if the proposals that came out of the summit did not work, I would keep calling them back until they came up with plans that would work. In the event, the team developed a package of measures that will help considerably. I am grateful to those who took part in discussions for their assistance and commitment to continuing to work with the Department of Health and the Government to ensure that we get more midwives into the NHS, and keep them there. I am particularly pleased to tell my hon. Friend that the Royal College of Midwives has given its commitment to work with us directly to take the action required.

The summit produced a six-point action plan. I am grateful to my hon. Friend for securing today's debate because it gives me the first opportunity to place the action plan in the public domain. First, the summit identified the issue of leadership. We know that good midwifery leadership is crucial to our being able to modernise maternity services and midwifery care, and to ensuring that midwifery in the NHS is an attractive option. We have asked the leadership centre to ensure that there are appropriate leadership programmes for all midwives, and that appropriate succession planning is in place.

Secondly, we want to examine the geographical variations. We know that areas around the country find it difficult to recruit and retain midwives, but we also know that there are trusts within those work force hot spots with fewer difficulties. We will take action to share good practice, explore further what attracts midwives to those units and learn from organisations where work force issues have been resolved.

Thirdly, we must raise the profile of midwifery. The action plan includes a national recruitment campaign and a conference to highlight the midwifery profession and the contribution of midwives to the NHS. We will also use the commitment and leadership of the Royal College of Midwives to market the midwifery

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profession, and we will try to harness the input of every midwife in the NHS to ensure that their skills and expertise are recognised by those contemplating training or returning to the NHS.

Fourthly, we must do more to improve midwives' working lives. At the summit, we heard about the importance that midwives place on how, where and when they practise. We heard that some feel frustrated by the constraints of organisational structures, and that that leads them to leave. Midwives want flexibility, and they want to provide models of care that meet the needs of women and families, but in a way that meets their own needs for job satisfaction and family life. We will work with NHS trusts to ensure that all aspects of improving working lives are encompassed and implemented in maternity services, and we will issue a good practice guide for maternity services by spring next year.

Fifthly, we must do more to encourage a return to the practice of midwifery. We heard from midwives at the summit that returning to midwifery practice was often a tortuous and off-putting process. To increase and maximise the potential for return to the midwifery profession, we will work with work force development confederations and NHS trusts to streamline the process for midwife returners.

Sixthly, we must address education and training issues. The number of training places for midwives has increased: there are 450 more places than in 1996–97, which is an increase of 28 per cent. However, students attending the summit told us of their financial difficulties, and about the problems that they face during their clinical placements. They want their education programmes to prepare them to practise midwifery in the NHS, and they want role models to nurture and support them. We will work with representatives of higher education institutes and the Nursing and Midwifery Council to ensure that education programmes and clinical experience are appropriate and meet the needs of future midwives, and that student midwives are confident and competent to take up their role in the NHS.

Those six action points emerged from the summit, but they are in addition to actions already taken. For example, we allocated almost £1 million to focus on recruitment and retention and return to midwifery practice. The money is being used to fund a package of initiatives, including a full-time post to lead on recruitment, retention and return to practice for midwives. Also, an allocation of £750,000 was made to work force development confederations in 2003–04 to fund 500 return-to-practice places.

We have also worked in collaboration with the Royal College of Midwives and the Open university to develop a distance learning pack to assist those midwives who may find it difficult to access full-time courses to return to practice. The first midwives to use it are currently returning to the NHS.

To ensure that we really understand what prevents midwives from returning to work, we are funding a research project on why midwives stay in the NHS and why they return. It is being carried out by Dr. Mavis Kirkham, a well-respected midwife researcher. That will provide follow-up data to her previous work, "Why Midwives Leave", and will give us an insight into what

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keeps midwives in the NHS. We are confident that there will be transferable practices that can be applied across the NHS.

Of course, pay is an important issue, and I was encouraged by the strong support of the Royal College of Midwives for "Agenda for Change". We are testing the new pay system in 12 early implementer sites to ensure that it delivers the intended benefits for staff and patients. Those sites began to implement "Agenda for Change" in June 2003. What is learned in the early implementation phase will be used to inform the national roll-out, which is planned for October 2004.

My hon. Friend also raised issues relating to the training of midwives. Health care professional students, including midwives, are crucial to the future of the health service, and I recognise the challenges that they face while undertaking demanding programmes of education and training. We want, and students are entitled to expect, a system that ensures that as many students as possible qualify and go on to work in the service, as well as one that provides the widest possible access to the health care professions.

Following devolution, it was acknowledged that there were differences in student support arrangements across the United Kingdom. For students, including student midwives, undertaking health professional training at colleges in England, the Department of Health keeps the support arrangements provided by the NHS bursary scheme under review. That ensures that the scheme continues to support the Government's plans for the expansion of the health professional work force and the modernisation of the service.

Mr. David Drew (Stroud) (Lab/Co-op): I congratulate my hon. Friend the Member for St. Albans (Mr. Pollard) on securing the debate. Does my hon. Friend the Minister accept that one of the problems with midwives' training is that there is now an obvious shortage of midwife-led units, because many have been closed down? I am pleased that this Government have ended that process. We have a midwife-led unit in Stroud, which was recently described in a book written by two of my friends, Tracy Spiers and Diane Harris. That book shows the love that the community has for that unit.

We have been bedevilled by the many reviews looking into the maternity-led unit's efficiency, and its role within the modern health service. It is almost a case of death by review. Will my hon. Friend the Minister assure me that we now value such institutions? Can we end the continual review cycle that saps the energy of all who love that place?

Dr. Ladyman : I am happy to give my hon. Friend that assurance. I have visited several midwife-led units, including the one to which my hon. Friend the Member for St. Albans referred. I found the standard of care and the atmosphere of calm and professionalism that pervades those places inspiring. If I were ever to have a baby, I would want to go to a midwife-led unit, so I understand why such units would be the first choice of many women.

There have been differences of opinion. There are obstetricians across the country who do not think that midwife-led units other than those co-located with

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obstetrician-led units are safe. However, midwife-led units are increasingly being developed away from such centres, and they are proving safe and effective, so long as proper careful decision-making is made in the run-up to labour. As long as women are being given the proper information, and know whether there is any particular risk from their birth, they can make the right choice about whether they want to go to a midwife or obstetrician-led unit.

I strongly support the development of more midwife-led units. We allocated £100 million of capital to the development and refurbishment of maternity services across the country. I am pleased to say that in quite a few places people chose to use that £100 million for the development of those maternity-led services. I certainly want more such units to be developed where local services identify that there is a benefit to be gained from them.

We have increased the support provided through the NHS bursary scheme, both by the basic bursary and other elements of the package. Bursary rates have increased every year since 1998, and by 10.4 per cent.—well above inflation—since September 2001. Moreover, NHS-funded students are eligible for a tuition fee contribution, worth £1,125 for this academic year, without means-testing.

The Government believe that, overall, the NHS bursary scheme, supported by the further improvements that we have made, continues to provide effective support for students, as evidenced by the increasing numbers of students embarking on health professional training programmes, including midwifery. However, we are keeping the matter under review.

I now come to maternity services, and I thank my hon. Friend the Member for St. Albans for describing his aspirations for a midwife-led unit in his constituency. I am sure that he would not expect me to comment on that specifically, because it is a matter for the local health organisations. I am sure that his views are well known. I have now expressed my support for such midwife-led units and, from my visit to the midwife-led unit in Hemel Hempstead, I know that the high-quality care provided there, and the benefits to the users who deliver there, will be well known in the local health community. The lessons will be learned by those who will make decisions about whether a midwife-led unit should be built in my hon. Friend's constituency.

Like my hon. Friend, I want health communities throughout the country to give consideration to this model of care. Midwife-led care should be considered as one of a range of options available to women when they are choosing where to give birth. Having a range of care allows people a meaningful choice. As my hon. Friend knows, choice is central to our plans to reform health services across the country. Today we published a document called "Building on the Best; Choice, Responsiveness and Equity in the NHS", which sets out the main themes emerging from the consultation that we conducted during the autumn. The consultation reached 110,000 people—the biggest response since the NHS plan.

Clear and consistent themes emerged from the consultation. Patients want to be more involved in decisions about their health care. They want more and

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better information to help them to make decisions and choices about their care and treatment, they want services to be shaped around their needs, instead of being expected to fit the system, and they want choice to be genuinely available to everyone. Those themes are just as important in maternity services. We will be asking local services to publicise details of how women can access midwives directly, as my hon. Friend requested in his speech. We will promote the use of birth plans, which record women's preferences for the birth of their child. We will also ensure that the response to the consultation, including the task group recommendations for maternity services, are taken into account in the development of the national service framework for children, which we plan to publish in 2004.

The children's NSF, including the section on maternity services, will be a key statement on the way in which we expect maternity services to develop in future. I look forward to discussing the children's NSF with my hon. Friend and the Royal College of Midwives when it is published—and I particularly look forward to his, and its, support in implementing it.

Mr. Drew : I thank my hon. Friend for his generosity in giving way. He mentioned earlier the view of some consultant obstetricians. Would he also accept that it is vital that we continue to engage with general practitioners, because more often than not they are the person whom a pregnant woman would contact for professional advice? The GP's role is to offer a degree of choice, at least, when that is sensible. It is sometimes put to me that GPs tend to be rather conservative in their recommendations to women about where they should have their children. Perhaps that is not necessarily the best way of putting things.

Dr. Ladyman : My hon. Friend is right. We must ensure that GPs are fully aware of the options available to women, and can give them proper counsel and advice. As I have just announced, we will try to make it possible for women to go directly to midwives in future, if that is what they want, and to get advice from a midwife's perspective. However, my hon. Friend is right. I suspect that pregnant women will, more often than not, contact their GP first. If we are to ensure that there is a comprehensive, high-quality information service, without which choice is just a figment of the imagination, and make it available, we must make sure that all the professionals women can contact, including GPs and midwives, have a full range of quality information and the time to provide the support and advice that women need to make choices.

In addition to setting that out in the national service framework for maternity services, and setting the standards that we want to achieve in maternity, other work will be going on at the same time—including the National Institute for Clinical Excellence guidelines, which are in development. We already have a number of clinical guidelines from NICE on antenatal care, induction of labour and the use of electronic foetal monitoring. We are awaiting further guidelines on caesarian sections, which will be published next year. I have no doubt that those will lead to a further improvement in clinical care in the NHS for women during pregnancy. These guidelines will complement the

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national standards that will be set out in the national service framework. It is still intended that the national service framework for children will be published in spring 2004.

Just over 600,000 babies are born in the UK each year. The NHS spends around £1 billion a year on maternity services. That area of the NHS has not been afraid to modernise and respond to the needs of users. Improvements are needed in many areas, but maternity services represent one of the success stories of the NHS. That is due in no small part to the contribution made by midwives. Over the past 50 years childbirth has become much safer for both mother and baby. The latest confidential inquiries into maternal deaths report covering the years 1997–99 found that the overall maternal mortality rate was down. There were 11.4 deaths per 100,000 maternities, which is a decrease from the 12.2 per 100,000 maternities in the previous report.

There have been similar improvements for babies. The perinatal mortality rate—still births and deaths within seven days of birth—was just under 40 per 1,000 births during the period 1946–50, and has reduced to fewer than eight per 1,000 births in 2001. There is clear evidence that pregnancy is far safer today that it has ever been, and much of that improvement is due to the excellent care provided in the NHS. There is also a much greater range of choice in maternity services. As I announced today, the Government intend to extend that range of choice even further with the help of midwives and professionals throughout the NHS.

We can all be proud of the maternity care that is provided for women in this country. It is a prime example of partnership between the midwives and doctors who provide the service and the women and their families who use it. The Government will continue to keep maternity services high on our agenda, and will ensure that we have the right number of skilled personnel to maintain a high quality service.

Once again I congratulate my hon. Friend on his endeavours in this area, and I look forward to further opportunities to debate these matters with him in the coming months.

11.27 am

Sitting suspended until Two o'clock.

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