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2 May 2007 : Column 477WH—continued
Maternity and Midwifery Services
2.30 pm
Andrew George (St. Ives) (LD): I am particularly pleased to have secured this debate this week because it is the international week of the midwife, which, I am sure the Minister knows, culminates in the international day of the midwife on Saturday 5 May.
Being a reasonable chap, I will start with some sugar for the Minister before the pill arrives. I congratulate the Government on their record on investment in the NHS, which is most welcome. [Interruption.] As I think the Minister has just acknowledged, the Liberal Democrats have supported that investment and some, although not all, of the activities of his Department during the past 10 years. I am sure that to a far greater extent today than 10 years ago many consultants and GPs are happy with their personal circumstances, with the rewards that they have received and the conditions of service under which they operate. One would expect such investment to result in an improvement in outcomes and I am pleased that the Government have a record of some improvements, although not perhaps to the level that many of us would have liked. None the less, there has been an improvement in outcomes. I hope that the congratulations I have given to the Minister will dissuade him from filling too much of his response congratulating himself and the Government.
I have spoken to the makers of “Panorama” and, as the Minister is no doubt aware, they will be broadcasting a programme tomorrow evening that will demonstrate that there are matters of concern within maternity and midwifery services—obstetrics—across the country. I will refer to the national context, but I have spoken to and am well aware of the issues facing those involved in front-line maternity and midwifery services in Cornwall and the Isles of Scilly, as that is the patch that I represent. The “Panorama” programme shows some worrying and, one assumes, not necessarily exceptional cases from St. Mary’s hospital in Manchester and a hospital in Barnet that demonstrate the consequences of having an overstretched service that is supported by an insufficient number of midwives and insufficient resources for front-line patient care. In addition, the Minister needs to address some serious questions about safety.
On a more general point, the culture of good and wise Government requires transparency, clarity and a capacity to see the benefits of robust scrutiny as a contribution to service improvement and good governance itself. I shall be constructive in my comments, but I have recently asked the Minister and his colleagues a number of written questions about midwifery and maternity services, and many of the answers that his Department has provided reflect a climate of cynicism. Those responses would provoke even a normally calm person such as myself into raising stakes and using hyperbole and colourful adjectives that could otherwise have been avoided. That is not true only of the Department of Health; the climate is similar in other Departments. I will give examples of some of the literal interpretations and minimalist responses that I have received from Ministers in a moment.
Tony Baldry (Banbury) (Con): There is not only a climate of cynicism, but a climate of secrecy. Would it surprise the hon. Gentleman to know that the Oxford Radcliffe Hospitals NHS Trust is refusing to publish the names of the clinical working parties that are determining the future of maternity and children’s services in my constituency and the Horton general hospital? Can the hon. Gentleman think of any possible justification for the names of those on a working party that is determining the future of hospital services not being a matter of public record?
Andrew George: I cannot. No doubt the Minister will have heard that intervention; he will have an opportunity to reflect on it and consult his colleagues before he responds to the debate. Perhaps the hon. Gentleman will receive an answer or explanation of why he has not been given that information.
I will give an example of the type of response that I have received by referring to a written question tabled on Wednesday 7 March, which received an answer on 23 March. The question was
“To ask the Secretary of State for Health (1) how many maternity-related compensation claims there were in each year since 1995; (2) how much her Department paid in compensation to patients in each year since 1995; and what proportion of such payments were for maternity-related claims.”—[Official Report, 23 March 2007; Vol. 458, c. 1196W.]
In response, the Government provided a table of claims and payments made on the basis of the date that the claim refers to. Therefore, it provides us not only with an impression that obstetric and maternity-related claims are reducing over time, but that the total number of claims is as well. We all know that many claims are still waiting to be resolved after the initial occurrence—for 20 years, in some cases. It would have been helpful if the Government had presented that information in the correct context.
Another question asked on 7 March was responded to on 23 March. The question related to hospital births:
“To ask the Secretary of State for Health, what the (a) minimum and (b) average period was that (i) primagravida”—
and (ii) all other mothers spent in hospital after delivery in each year since 1995.” —[Official Report, 23 March 2007; Vol. 458, c. 1189W.]
The answer provided by the Minister of State, Department of Health, the hon. Member for Leigh (Andy Burnham), was:
“information is not available in the form requested and it is not obtainable without disproportionate cost.”
Given one of the basic tenets of the Government’s health reforms is to keep copious records and capture hospital episode statistics, why would that information not be available and why would the Government not know how long a patient spends in hospital? Frankly, I find it beyond comprehension that the Government have provided me with such a response when it is clear that they have based their business case for health care reforms and payment by results on the application of tariffs that relate to the amount of time that patients spend in hospital.
The deliberate diversionary avoidance tactics used in many of the answers that I have received do not aid the process of constructive engagement with the issue.
That does not set us off very well, so I urge the Minister to look again at the nature of the responses provided by his Department.
Mr. David Drew (Stroud) (Lab/Co-op): Does the hon. Gentleman accept that one of the advantages of payment by results—there are disadvantages—is that it can clarify how smaller maternity units can prove their business case, which is to be welcomed? I remember evidence from Torbay seen by the all-party group on maternity that showed clearly that a smaller unit is viable. Does he agree that that, at least, should be welcomed?
Andrew George: The hon. Gentleman makes a reasonable point, although an entirely different one from mine. Certainly, smaller units do not have the same high level of complex interventions—including obstetrics, clinical and anaesthetics—as tertiary centres. Certain accounting mechanisms can demonstrate a cost-effective service for relatively low-risk—one hopes—patients.
We welcome the policy statement on the future of maternity services set out in “Maternity Matters”, published on 3 April. Having spoken to those in the profession, I think that it has been universally welcomed as a statement on how the Government intend to improve services by 2009. One hopes that the Government can achieve a first-class NHS maternity service in that period.
Philip Davies (Shipley) (Con): I congratulate the hon. Gentleman on securing this debate. Although I am sure that the aims set out in “Maternity Matters” are welcomed by everyone, does he agree that too few people are training as midwives in the first place and that those who qualify often cannot find jobs? Although we can all support the aspirations in “Maternity Matters”, they are highly unlikely to come into practice.
Andrew George: I was about to come on to the hon. Gentleman’s point about dealing with the core services that the Government need to provide safely now.
Having investigated the problem with training posts, I think that the picture is mixed and variable. Evidence from some parts of the country suggests that midwife graduates have had difficulty getting jobs, particularly last year, when many posts were frozen owing to budget difficulties in many trusts. I hope that the Minister is listening to the general point: adequate work force planning is needed to maintain experienced midwives, who are crucial to the provision of a safe service, and to ensure that the training available—training in this country is excellent—is adequate and provides the required midwives.
Although it is desirable to improve services so that patients have the luxury of genuine choice, it is important that core services are in place first. That is the theme of my comments to the Minister today. The Royal College of Midwives provided a useful analysis of the policy statement in “Maternity Matters”. As I am sure that he knows, it has undertaken a rigorous analysis of the numbers of midwives required on the basis of actuarial predictions of births, which very often underestimate what actually happens. However, those predictions showed that England needs the equivalent of at least 22,000 midwives. The latest figures that I have show that we are some 3,000 full-time equivalent midwives short of that figure.
The Parliamentary Under-Secretary of State for Health (Mr. Ivan Lewis): I congratulate the hon. Gentleman on his balanced and responsible argument. I welcome the RCM’s extremely fair assessment of “Maternity Matters”, but is he aware that, only a few weeks ago, its position was that there was a shortage of 10,000 midwives? Week after week, that figure was being repeated in the media. He just acknowledged that its assessment now—I shall explain in my speech our position on work force development—is that only 3,000 midwives are needed. Is it not curious that it went from 10,000 to 3,000, and yet still we see the former figure used in press reports week after week?
Andrew George: I am dealing with the situation as I see it now and with the briefing that the RCM provided me with. I shall not attempt to referee a spat between the Minister and the RCM over estimates that might have been made. Having looked at the basis on which the RCM’s calculation was made, I consider it to be a conservative—with a very small “c”—estimate. I think that the figure of 22,000 is an underestimate and that the RCM took a very conservative line. As I interpret the assessment, it is saying that we need at least that many.
I wish to draw out another point demonstrated in chapter 4 of the document, regarding roles and responsibilities—it has fallen open nicely at the right page. Acres of space on responsibilities are given to foundation, delivery, acute, ambulance and primary care trusts. A significant number of bullet points list those with responsibilities: general practices, local authorities, mental health trusts, maternity service liaison committees and so on—right down to 16th place and the smallest sentence of all, on the roles and responsibilities of the Department of Health.
According to the document, the Department’s responsibility is to develop
“national policy and guidance to support and enable local implementation”.
That is interesting. It demonstrates a culture of pushing away responsibility from the Government. In fact, that is in line with parliamentary answers that I have received in recent weeks. On 22 March, I received an answer providing a table on obstetrics and gynaecology figures. It was good to see that, between 1995 and 2005, the number of midwives increased from 3,406 to 4,580—a significant increase, owing largely to the working time directive.
According to the same answer, between 1995 and 2005, the number of registered midwives increased from 18,034 to 18,949, although I understand that the figure has gone down since. However, the figures fail to recognise a relative plateauing—proportionately there are fewer midwives in comparison with the overall NHS work force. Over those 10 years, the role of midwives has increased tremendously. They are now responsible for clinical governance, child protection and public health roles, dealing with, for example, teenage pregnancy, smoking, infant feeding, antenatal screening and the provision of information on choice and continuity of care. They are the overall professional leads for mothers. All those roles come on top of their role in the past, but that is not reflected in the figures.
On 22 March, I received answers to another four questions about average case loads, particularly of community midwives, and about other related matters. Once again, I had the following answer:
“This information is not collected centrally and we have not carried out an assessment of, or provided advice about, the size of case loads. It is for primary care trusts in partnership with local stakeholders to commission midwifery services in order to meet local needs.”—[Official Report, 22 March 2007; Vol. 458, c. 1141W.]
How can the Government publish a document such as “Maternity Matters”, which talks bravely about choices available at grass-roots level, when they do not collect the data and do not make an assessment of the case loads that community midwives are supposed to take on?
The Minister gave a similar answer when I asked what estimates the Department had made of the numbers of midwives needed by the NHS now and in the next five years. He said:
“It is for local planners with support from the workforce review team to determine their future requirement for midwives to meet local service needs.”—[Official Report, 14 March 2007; Vol. 458, c. 441W.]
How can the promises be made in a document such as “Maternity Matters” when it is clear that the Department takes no responsibility for making any estimate of the needs in the service?
Similarly, when I asked what factors were taken into account in estimating the average case load of community midwives, the Minister answered:
“Decisions about the size of community midwives’ case loads are made locally. It is for primary care trusts...in partnership with local stakeholders to commission services”.—[Official Report, 20 March 2007; Vol. 458, c. 863W.]
It is the same answer. How can the Government make the brave guarantees, the statements and the recommendations in a document such as “Maternity Matters” if they are clearly making no assessment and are not even providing any advice?
Andrew George: Yes, I will happily give way to the Minister.
Mr. Lewis: I thank the hon. Gentleman for giving way again. Can he explain how he squares his ambition for a command-and-control direction of the health service from Richmond house with his party’s rhetoric about localism, devolution and responsibilities being placed at the front line of people in local communities and in local public services? How can he square the rhetoric in his speech on that issue and his party’s underlying philosophy and policies on local devolution and freedom to make decisions related to local need?
Andrew George:
The Minister’s statement exposes the problem. The written questions to which I have referred are about information and assessment. Yes, I agree that we should all aspire to achieve minimum levels of guarantee nationally. I see no difficulty at all with a Government taking a view that we should have aspirations to a minimum level of expectation of care at the front line. However, we would have democratically elected authorities delivering that on
the front line, rather than those appointed by the Secretary of State to do her bidding, yet the Minister is now saying, “No. Once they are out in the field, on the front line, making decisions, it is their responsibility.” She and he take no responsibility. What is worse—this is the point of exposing the barrenness of those written answers—they make no assessment and they provide no information. There is no monitoring of the situation at all if that is what the Government are saying.
The Minister’s party believes in a more centrally controlled system, it seems. At least, they appoint the trust members to run—
Andrew George: Well, whether it is directly or indirectly, they are certainly not elected by the local populace to represent local people in the community and to defend local services. This is clearly an area of strong argument between the Minister and me. I query the capacity of the Government to talk about a choice agenda in 2009, when it appears that they make no assessment. They are not monitoring; they are not collecting the information that is clearly crucial to them in even talking about rolling out the services in the future.
The primary focus of this debate should be the role of the midwife. [Interruption.] I am trying to explain the main issue to the Minister. At least he understands that the Royal College of Midwives, which he is clearly listening to—at least, I hope that he is—has come up with a recommendation to the effect that 3,000 full-time equivalent additional midwives are required. There is serious pressure on the service.
The “Panorama” programme tomorrow evening will clearly show that in one case—I do not think that it is exceptional; certainly the anecdotes that I hear from front-line staff bear this out—one qualified midwife was responsible for 24 antenatal and post-natal mothers on an acute ward. There are occasions when that happens. The programme will also show that there are serious equipment shortages with regard to CTGs—cardiotocographs.
I hope that the Minister pays attention to the consequences of the resource constraints with which midwives are operating on the front line. Those out in the community tell me that they have been given new computer systems, but they argue that the Government and the consultants whom they use to roll out the information technology programmes need to consult the front line before rolling them out. They are finding that, even though they put all the information into the IT systems, they have to keep paper records, because they cannot get the information out again.
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