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Westminster Hall

Tuesday 9 May 2006

[Mr. Martin Caton in the Chair]

NHS Maternity Services

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Michael Foster.]

9.30 am

Sir Nicholas Winterton (Macclesfield) (Con): I am delighted to have obtained this debate on maternity services. Perhaps I should first declare a non-pecuniary interest, in that I am an honorary vice-president ofthe Royal College of Midwives. It awarded me that position, which I am honoured to hold, after theSelect Committee on Health, which I chaired in the early 1990s, produced what I would describe as a groundbreaking report on maternity services.

My purpose in calling for this debate is fourfold. First, I want to mention the “Making it Better, Making it Real” consultation on health care services for children, young people, parents and babies in Greater Manchester, east Cheshire, High Peak and Rossendale. However, I want to make particular reference to in-patient services at East Cheshire NHS trust’s Macclesfield district general hospital. Secondly, I want to draw attention to the continuing staff shortages affecting maternity units, of which I know the Minister is aware. Those shortages are exacerbated by the current funding deficits in the health service. Thirdly, I want to question this Government’s commitment to making good their manifesto pledges on maternity services. Finally, I want to propose the implementation of measures designed to arrest the current shortage of midwives and deliver high-quality maternity services for all women.

However, I begin by focusing at constituency level and on the consultation on the reconfiguration of service provision. Some may consider the recruitment of staff to small units a problem that affects the quality of and generates risks to continued service provision. In addition, questions have been raised about the financial viability of smaller units. I say to the Minister that those issues do not exist at the East Cheshire NHS trust, where a vibrant facility is continually providing high-quality care within the income calculated under payment by results—a policy introduced by the Government.

The services provided by the East Cheshire NHS trust are needed by the population of eastern Cheshire, which, by the way, includes the constituency represented by my hon. Friend the Member for Congleton (Ann Winterton). The trust also serves the population of High Peak, the Buxton area, and north-west Staffordshire, represented by the towns of Leek and Biddulph.

The maternity and children’s services at the Macclesfield district general hospital are sustainable, affordable, efficient, safe, highly regarded and recommended, and those facts are known to the strategic health authority. Those facilities are integral to the delivery of district general hospital services on the Macclesfield hospital site. They are responding to increased demand, and are providing a local service to a geographically large and isolated
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part of Cheshire, Derbyshire and north Staffordshire. I remind the Minister that the Government believe that services should be provided to people as locally as possible.

Both children’s and maternity services have sustainable models for the delivery of the European working time directive. The proposed model for paediatric services is innovative and approved by national and local training organisations. I emphasise to the Minister that services such as paediatrics, obstetrics and maternity have no vacancies at Macclesfield district general hospital and are rarely closed to admissions. If they are closed, it is never due to lack of staffing, but due to excess demand. Does that mean that there is a danger that such in-patient services will be removed to a hospital much further from the community that they serve? I hope not.

The service is sustainable under the new financial rules. Financial analysis across all specialties shows that income for obstetrics and paediatrics under payment by results covers expenditure. The payment by results rules expect the non-activity-driven paediatric services—that is, the community-based services—to be paid for at cost by the commissioners. The service does not requireany capital development to provide future services.The hospital and community service is provided by the integrated paediatric consultant team, reducing the infrastructure costs involved with separate teams.

All services have undergone a Commission for Healthcare Audit and Inspection review. Regular visits from the training organisations have resulted in praise for the service and an increased demand to manage more junior doctors—not fewer—at Macclesfield district general hospital. The most recent quote from the Mersey deanery, following the annual assessment visit last October, stated: “Best hospital so far”. That recommendation came from a teaching hospital. The demand on services has increased against a background of a changing age profile, about which we all know. Women are choosing to deliver their babies at the East Cheshire NHS trust. Parents and, yes, general practitioners are choosing to bring ill children to that trust.

Only last week, a mother of three from the Buxton area, whose family are patients at Macclesfield district general hospital, spoke at a public meeting of herfear that her son, who has asthma, would lose open access to the children’s ward. When she was 38 weeks pregnant, she transferred from Stepping Hill hospital, Stockport, to Macclesfield district general hospital because, “Bigger hospitals forget about people; we need smaller units.” Stepping Hill is the hospital to which people would be directed if the in-patient services were transferred from Macclesfield district general hospital. That is an example of the people who use the service speaking, and that is what is critical about the consultation, which ends in a day or two’s time and which I hope will be noted by the Government.

Some 96 per cent. of those questioned in the 2004 national young people’s patient survey rated the overall care at Macclesfield district general hospital as excellent, very good or good. Of that 96 per cent., 33 per cent. said that it was excellent. That is a high degree of approval.

Ann Winterton (Congleton) (Con): Will my hon. Friend further confirm that mothers who live in the
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large rural area that surrounds Macclesfield—in west Derbyshire, north Staffordshire and particularly inmy constituency of Congleton—do not wish to lose facilities at Macclesfield district general hospital, which is a mere 10 miles from where they live, to Stepping Hill hospital, Leighton hospital or University Hospital of North Staffordshire?

Visiting those three hospitals would involve long journeys for those mothers. The arrangements for parking are difficult—and anyway, many such parents have no transport of their own. Should people in rural areas have a worse service than those in urban areas?

Sir Nicholas Winterton: My hon. Friend raises important issues, some of which I shall touch on in a moment.She refers particularly to transport. Transport from the Congleton area—and from Macclesfield, for that matter—to Leighton hospital is not only fairly limited in its frequency, but expensive and inconvenient. How would the House like to see a mother perhaps with two other young children going from Macclesfield, Congleton or many of the rural villages that surround those towns all the way to Stepping Hill in Stockport, or to Leighton hospital near Crewe? My hon. Friend raises important issues, and I intend to come on to one or two of them later.

Eastern Cheshire primary care trust’s demographic assumptions indicate a reduction in the number of children between the ages of nought to five of about10 to 15 per cent. Over the past four years there has been a reduction in the number of children born but an increased demand on the services of Macclesfield district general hospital. The influences on the level of demand are, of course, wider than the total number and relate to morbidity, expectation of the users and the services available. East Cheshire NHS trust is working with the Eastern Cheshire primary care trust to develop appropriate in-patient and community services.

To pick up on what my hon. Friend the Member for Congleton said, the impact of the removal of in-patient children’s services and consultant-led births would be disproportionate in a hospital the size of Macclesfield district general hospital. The immediate impact would be to remove all children’s planned and emergency surgery, which would result in the removal of all adult ear, nose and throat provision, because 44 per cent. of ENT provision at the hospital is for children. Another department would therefore be made vulnerable and would inevitably close.

Gynaecology emergencies would be redirected to surrounding hospitals. It has been estimated that midwife-led births are appropriate for approximately 350 women, representing only 18 per cent. of deliveries. The loss of activity would have a significant adverse impact on the financial viability of the remaining services provided by the Macclesfield district general hospital.

The loss of income is assessed at about £8 million. I know that money is important to the Minister, but although the loss of income is assessed at £8 million, expenditure reductions are anticipated to be onlyabout £5 million. That creates a 4 per cent. additional
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recurrent financial pressure on the East Cheshire NHS trust if paediatric, maternity and obstetric in-patient services are removed. The risk to recruitment and retention of all other specialties would be high indeed. That has been highlighted to me by one of the consultants at the hospital, Dr. Mark Nicol, who is an accident and emergency consultant and lead clinician in strategy at the district general hospital.

Services are provided to the whole of eastern Cheshire; the High Peak, in particular Buxton; and the north Staffordshire area—the townships of Leek and Biddulph. Some women from Stockport choose to give birth at Macclesfield district general hospital because it is a delightful hospital with a super reputation.

I now come again to a matter raised by my hon. Friend. Public transport in a rural area, such as Macclesfield, Buxton and north Staffordshire, is in short supply. I refer in particular to my hon. Friend’s constituency. There are no direct bus routes from Congleton, or Knutsford for that matter, to Stepping Hill in Stockport. The last bus from Stockport to Macclesfield is at 5.10 pm. I remind the Minister that one in six people in rural areas do not possess a car; how are they going to get to the hospital? The Minister might say that the ambulance servicewill take them, but it is already inadequate and does not meet any of its attendance targets now, let alone with the huge additional burden that would be imposed on it if in-patient facilities were removed from Macclesfield to other hospitals.

The paediatrics and maternity service is staffed by seven full-time equivalent consultants, and the team covers acute and community paediatrics. There are close links with the Eastern Cheshire primary care trust, which provides services such as school nursing, child health surveillance, immunisation and vaccination.

Sadly, in the consultation, Macclesfield district general hospital appears in option D, which is not the preferred option. So far, however, option D has been supported by 70,000 people who have signed a petition and 25,000 people who have completed and sent in cards to the authorities. It is supported by people in east Derbyshire and north Staffordshire, by all the consultants and clinicians at the district general hospital and by all the general practitioners. It is supported by Macclesfield borough council, Congleton borough council, Cheshire county council and the Macclesfield branch of the Royal College of Midwives. That shows the support for Macclesfield district general hospital and the in-patient services that it provides, and if the consultation is to be meaningful, to be taken seriously and to be trusted, the overwhelming evidence in support of option D will, I hope, carry weight with the authorities.

I now move on to maternity services more generally. Sadly, the maternity care that women and their families receive continues to be adversely affected by a long-standing shortage of midwives in large parts of the country. I pay tribute to the Royal College of Midwives, which, from time to time, provides information to Members and to me, as one of its honorary vice-presidents. In 2005, the number of NHS midwives fell for the first time in five years. On 30 September 2005, the head count stood at 24,808 midwives, down by 36 on the previous year—yes, that is only a small number, but it is down. Although there is better news on full-time equivalents—the
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Government’s preferred work force measure—the figure edged up by only 95 in the same period. Between 1997 and 2005, the number of full-time equivalent midwives in the NHS in England rose by 896, from 18,053 to 18,949—a rise of just 5 per cent. over eight years. As the Minister will be aware, that compares somewhat poorly with full-time equivalent figures for the overall nursing, midwifery and health visitor work force, which increased by 23 per cent. over the same period.

Sadly, the midwifery work force is ageing. Analysis conducted by the Health and Social Care Information Centre reveals that the average age of a midwife increased from 33 in 1997 to 40 in 2004, that the age profile for midwives is much older than that for all NHS staff and that nearly half the midwifery work force in some strategic health authorities is in the 46-69 age group. In addition to the NHS work force statistics, the Royal College of Midwives produces an annual staffing survey. The most recent figures—as at 1 July 2005—show that 78 per cent. of maternity units had vacant midwifery posts. That is the situation nationally, although not, I am pleased to say, in Macclesfield. Some 59 per cent. of vacancies were unfilled for more than three months. Vacancies represented 5 per cent. of the establishment, rising to 9 per cent. in south-east England and 12 per cent. in London.

Although Government vacancy statistics for midwifery are lower than the RCM’s figures, there is good reason to suggest that the Government have understated the extent of the shortage of midwives. In an answer to a parliamentary question asked by the hon. Member for Northavon (Steve Webb), the then Under-Secretary of State for Health, the hon. Member for Birmingham, Hodge Hill (Mr. Byrne), stated that the Government counted only vacancies

Even so, if a midwife leaves her job, the vacancy is not a vacancy unless it has lasted for three months and the trust is genuinely trying to replace her. A declining number of midwives could be left to staff a unit, but according to the Government there would not officially be any vacancies in that unit.

I move to the issue of work force pressures. Midwives are the primary carers for women experiencing normal pregnancies and births. That essential role has beena constant since legislation for the regulation of midwifery was introduced in 1902. The pivotal role of midwives was highlighted by the Health Committee in its report in the early 1990s in which we emphasised the importance of the continuity of care; of an identified midwife dealing with a pregnant woman throughout her pregnancy and delivery.

Over the years, midwives have adapted to the changing NHS environment. As the Minister knows, every midwife is responsible for maintaining her existing skills and ensuring that she becomes competent in any new skills required for practice. In short, midwives have been required to adapt and extend their role, and increase their work load in response to a series of policy and socio-economic drivers. The national service framework for children, young people and maternity services compels every NHS trust to meet certain commitments regarding minimum levels and standards of care in maternity
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services. I repeat, from personal knowledge, that the district general hospital in Macclesfield well meets all those standards.

The Government’s manifesto promises:

It goes on to say:

That was one of the major recommendations of the Health Committee report on maternity services.

Childbirth has become an increasingly interventionist and medicalised practice. Increased intervention in childbirth increases the demands placed on the midwifery work force. The length of post-natal stays has increased in line with rising intervention rates, and that places an additional call on midwifery time. Moreover, the additional requirements resulting from increased intervention rates come at a time when the overall number of births is also on the rise. There was a 5 per cent. increase in the number of births in England in 2003-04 compared with the previous year. That places yet more demands on midwives, as does the increase in the number of women experiencing childbirth both later and earlier in their lives.

The proportion of pregnant women who are teenagers or women aged 40 years and over is growing. Between 1991 and 2003, the number of women in Englandaged 40 or over conceiving almost doubled from 11,497 to 20,128. In the same period, conceptions in women under 20 also rose. Older and younger women who are pregnant tend to be at greater medical and social risk than pregnant women aged 20-39. Consequently, their care needs tend to be more complex and intensive.

I return to an issue that I mentioned at the beginning—NHS funding deficits. The current funding difficulties in the NHS in England have exacerbated midwifery shortages and the various pressures on the midwifery work force. The Royal College of Midwives has undertaken what it would describe as a snapshot survey of heads of midwifery in England, in order to assess the impact of funding deficits on midwifery services. According to the RCM survey, more than one in three managers reported that their maternity services budget had been cut—that is serious—and morethan one in four that their training services budget had been cut.

More than one in four respondents reported that their midwifery staffing establishment had been reduced. Half of all trusts had been operating a recruitment freeze. One in four managers reported that their trust had been replacing senior midwives with more junior colleagues, and a similar number said that support staff had been substituting for midwives. I am sure that the Minister will take that information very seriously. One in four respondents report that they have reduced the number of home visits by midwives. At a time of urgent need for more midwives, not fewer, the RCM has received reports that a number of strategic health authorities are set to cut the number of midwifery training places. Again, that bodes badly for the future.

Of particular concern is mounting evidence that post-registration midwifery training will no longer be financially supported and that, for example, the 18-month conversion
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programme in Oxford for nurses wishing to train as midwives will be stopped “for this year only”. The arguments for cutting 18-month training places are clearly financial and the move is a short-term knee-jerk reaction that will have long-term ramifications for the midwifery profession.

It is also a matter of grave concern that a number of birth centres throughout the country have closed or are under the threat of closure. Birth centres can play a significant part in increasing choice for women during pregnancy and childbirth and in ensuring that maternity services are delivered in what we would all describe as a more home-like setting. Closing birth centres will therefore make it harder to implement the Government’s own policies on maternity services.

Although midwives have embraced changes in accordance with Government policy, such as shifting services closer to where people live and providing more diverse services, the funding deficits, allied to continuing staff shortages, are making it harder for midwives to implement those policies in practice. That much has already been acknowledged by the Government, and I give them credit for that. In recent oral evidence on NHS charges given to the Health Committee, the right hon. Member for Liverpool, Wavertree (Jane Kennedy), who sadly resigned recently as a Minister, had to concede that staffing shortages affected delivery of quality maternity care, saying that

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