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2 May 2007 : Column 490WH—continued
“There would be an increase in the burden of responsibility on midwives and ambulance crews. Legal claims”—
the comments of the hon. Member for Stroud are relevant here—
“following incidents where there was harm to the mother or baby might be very costly to settle.
Babies born in need of immediate resuscitation would incur a transit time of approximately one hour. The idea that paediatric cover could be provided safely from Oxford in these circumstances is false and dangerous.”
“We submit the opinion of Professor James Drife who wrote in the BMJ...about the shortfalls of midwife led units...It accords with recent publications by NICE on the safety of such units”
“We are not reassured and maintain that a midwife led unit with a delivery rate of 450+ per annum, which is 25 miles away from the nearest obstetrician and paediatrician, is not safe. Through no fault of the midwives working in such a unit, GPs would have to consider the wisdom of recommending mothers to this service, numbers would drop further and the service soon become non viable”.
“A midwife led maternity unit, possibly lacking the confidence of local GPs, may well wither. Kidderminster had to close its unit due to excessive neonatal mortality (6 avoidable deaths in under 2 years). Increasing concern about such units is being expressed by RCOG and NICE.”
RCOG is the Royal College of Obstetricians and Gynaecologists. The GPs’ submission continues:
The existing serious congestion at peak times and lack of parking facilities at the JRH site will be worsened by 1,000 to 1,600 extra deliveries per year. All emergency surgery and major gynaecology currently managed in North Oxfordshire will need to be absorbed by the JRH as will all paediatric cases requiring overnight assessment or admission.”
“We conclude that the current proposals...will result in services which are unsafe and unsustainable into the future”
“are not in the best interest of our patients who will be faced with serious obstacles in both accessing services and visiting sick children or relatives. The most vulnerable will be hardest hit.”
They believe that the proposals
“will increase demands on the ambulance services and its crews and on already overstretched departments at the JRH...will have consequences both in medico-legal and human terms that are far reaching and expensive...adhere to an outmoded model of centralisation that ignores more modern trends to bring services closer to patients...ignore the clear recommendations of the Davidson Inquiry and the prerequisites of the agreement to merge into a single trust”
“are overly influenced by a small group of medical specialists in Oxford who have plans for centralisation that ignore the expressed and documented needs of this community.”
“These proposals offer neither a better deal for children nor security for a range of other services vital to our local community”.
Those views were in a document signed by 85 local family GPs from north Oxfordshire, south Northamptonshire and south Warwickshire. As a consequence, not surprisingly, the trust took its proposals off the table and set up two clinically led working parties on paediatrics and children’s services to see whether they could find an approach that GPs would find acceptable. They are still deliberating.
I have one concern and one question to put to the Minister in that respect. I can see no justification for keeping the membership of the working parties confidential. I understand why they might want to deliberate in private; however, I walk into the Court of Appeal every day, where the lords justices of appeal deliberate in private, but I know who they are and they are accountable. It cannot be right, as a matter of public policy, that clinicians should decide whether their participation in the working parties should be made a matter of public record. It undermines confidence in the system and the process if my constituents are told that they cannot know the membership of the bodies that will determine the future of services at their general hospital.
At the end of the process the working parties will, I imagine, make proposals, which will vary to some extent from those that were originally on the table. GPs will have to decide whether they think the amendments make the changes safe. They consider the existing proposals unsafe and inhumane. Unless there is overwhelming support from GPs for the changes, given their total opposition to the changes to date and given that the Horton will no longer have consultant-led midwifery services, I want to ask that, if in those circumstances the matter is referred to the Department, the Secretary of State look favourably on the idea of the proposals being considered by the independent reconfiguration panel.
I share the concern that was put to me by a GP, who said that he and his colleagues felt constantly worn down by academic professional pressure to accept as the least worst option something that they were not happy with but thought they would end up with. GPs have been put in an intolerable position in all of this, and I still have a very unhappy impression of the situation. We want to continue to have a general hospital in Banbury that provides the full range of services of a general hospital, including consultant-led midwifery.
Taking away the consultant-led unit from the huge catchment area that has had such a unit for as long as anyone can remember because there is a midwife-led unit down the road, or another consultant-led unit an hour away, does not enhance choice, but undermines it. It means that there is a worse service, and nothing that the Minister or anyone else does will persuade my constituents that a service that they see as worse than the present one is an improvement to the NHS. If the Minister believes otherwise, he is welcome to come to Banbury at any time and meet people from the “Keep the Horton General” campaign, which has been ably led by George Parish, a local Labour councillor. I do not believe that it is possible to get that message across because people realise when their services are being downgraded, and services are being downgraded in Banbury.
3.30 pm
Martin Horwood (Cheltenham) (LD): I join others in congratulating my hon. Friend the Member for St. Ives (Andrew George) on securing this debate. Given the subject, it is slightly bizarre that it is being conducted entirely among male MPs. That is yet another example of why Parliament needs more women. As my hon. Friend pointed out, it is appropriate that the debate is taking place during midwifery week, which celebrates the role of midwives and enables us all to congratulate them on the role that they so often play in making childbirth a healthy, happy and fulfilling experience for all concerned.
This year in particular, midwifery week is drawing attention to the fact that childbirth is not only a physical experience, but a social and emotional one. The hon. Member for Enfield, Southgate (Mr. Burrowes), who spoke about his personal experiences, illustrated that well. That means that where childbirth takes place and the nature of the experience are just as important as the physical outcome of the process, or at least important alongside the physical outcome. An increasingly important part of the philosophy of patient care is paying attention not only to the physical needs of patients but to their wants.
The Government’s national director for patients and the public, Harry Cayton, who is a brilliant man with whom I have had the pleasure of working, said that
“it is essential that we put the needs and preferences of patients and service users at the centre of all we do.”
In this respect, it is right that the words that emerge from Government policy are more often than not words with which we can agree. The trouble is that the practice is often very different, as hon. Members have pointed out.
Let us review the evidence on the policy itself. Going back as far as 2003, positive policy statements were made. “Keeping the NHS Local—A New Direction of Travel”, which was published in February 2003, contained the general aim of retaining good local services. It clearly stated:
“The mindset that ‘biggest is best’ that has underpinned many of the changes in the NHS in the last few decades, needs to change. The continued concentration of acute hospital services without sustaining local access to acute care runs the danger of making services increasingly remote from many local communities.”
I would certainly agree with that. The document pointed out clearly, as the hon. Member for Banbury (Tony Baldry) has done, that we should not be concentrating services in certain regional or other centres at the cost of providing a lesser service somewhere else. It said that the focus should be
“on redesign not relocate. Redesign can offer a high quality alternative to relocating services, extending the range of options for developing new configurations that meet local needs and expectations”.
Again, the emphasis was on what local people want. I have experienced a campaign in which 10,000 people marched through the streets of Cheltenham trying to get not just what they needed, but what they wanted. Many hon. Members have had similar experiences.
The document also specifically addressed maternity services, stating:
“The challenge facing maternity services is the need to identify EWTD-compliant models of care in the middle ground between large consultant obstetric units and midwife-led units.”
That was one of the clouds already looming on the horizon, because the European working time directive was clearly going to pose a challenge to the delivery of the existing model of maternity care. The Government were rightly thinking about how to respond, but in that 2003 document they were not thinking in terms of the large-scale centralisation of services, let alone of reductions in the number of midwives or of midwife training places. They were talking about developing the middle ground between very large units, of which we have an increasing number in this country, and midwife-led units. That sounds great: it sounds just like Cheltenham general hospital’s St. Paul’s wing. Its 2,500 deliveries a year makes it quite big for the rest of Europe, but in the middle to small end of delivery units in this country, where the trend is increasingly towards giant maternity units.
Other policy documents have been published. In July 2004, the wonderfully named “The Configuring Hospitals Evidence File: Part One” was published. One of the sections was specifically on maternity, where it was stated:
“Recent research shows that childbirth in such centres”
“is as safe as in consultant-led units, provided that a) admission is restricted to low-risk women or b) if the midwife unit is not located near a consultant unit, there are efficient escalation protocols for transferring the woman to an acute hospital.”
Other hon. Members have alluded to the need for proper escalation protocols, but that should reassure those hon. Members who were expressing concerns about the risks inherent in midwife-led units, as the hon. Member for Banbury seemed to be doing at times. I hope that the reviews that we know about will conclude that, when properly managed, and with proper escalation protocols, midwife-led units can be a safe and positive alternative. Certainly, the National Childbirth Trust believes that they offer the best outcome for those in low-risk categories, and often offer better continuity of care for women.
In 2005, the latest Labour manifesto was published. It contained the very positive statement:
“By 2009 all women will have choice over where and how they have their baby and what pain relief to use. We want every
woman to be supported by the same midwife throughout her pregnancy. Support will be linked closely to other services that will be provided in Children’s Centres.”
I congratulate the Government on the approach based on children’s centres and on the use of Sure Start to support antenatal classes; those are positive things. I also support the words in that statement. As we have all said, choice is important and the way in which it is delivered is important. There is no reference in any of those documents to reduction in the number of midwives or to the centralisation of services.
Andrew George: Does my hon. Friend acknowledge that in many parts of the country antenatal classes are declining or closing? That is having a direct impact on the welfare of mothers, particularly as they need to build up social networks of other parents post-natally. That is important for their mental welfare after their child is born.
Martin Horwood: I am grateful to my hon. Friend for saving me time, because I was going to point that out later. Antenatal classes, by their nature, also help to reduce complications, so they are even a cost-saving device as well.
As I was saying, there is no reference in any of those documents to a reduction in the number of midwives or to the centralisation of services. The clear of thrust of stated policy was in the opposite direction, towards localism and more choice. That was reinforced in a health White Paper that supported the concept of care closer to home and more choice in maternity.
In February, Sheila Shribman, the Government’s maternity tsar, set out the choices that women should have:
“a home birth supported by a midwife, or...birth in a local facility under the care of a midwife such as a designated midwifery unit”
or—this was carefully phrased—
“birth supported by a local maternity care team that includes a consultant obstetrician. For some women, this type of care may be the only safe option.”
This is where we start to get to the nub of the problem with the concept of choice, because once the number of consultant-led units in an area is restricted, as we have heard is happening in Oxfordshire and may happen in Gloucestershire, there is the risk that for many women for whom such care is the only safe option, there is much less choice.
There were subtle differences in the phraseology used in “Maternity Matters”, which was published last month, because the parallel statement in that Green Paper was
“birth supported by a maternity team in a hospital.”
The word “local” was conveniently dropped. It continued:
“For some women, this type of care will be the safest option”.
That is not what Sheila Shribman said. She said clearly, and more realistically, that for some women such care may be the “only safe option”. The impression of choice is being given, but the reality is different when maternity units start to close.
I shall illustrate that with an example that might be close to a Minister’s heart. I gather that the Prime Minister might be moving house soon and that he may
have a little more time to spend with his family. He will find that within nine miles of his new home in Connaught square, there will be 19 obstetrician-led maternity units. By contrast, the residents of Clyde crescent, which is one of the poorest areas in my constituency, will, if the planned changes go through, have a choice of just one obstetrician-led maternity unit within 20 miles—twice that distance. Their journey distance will change from just over a mile to Cheltenham general hospital to more than nine miles to Gloucestershire Royal hospital along the congested A40 into an unfamiliar city.
Mr. Ivan Lewis: The hon. Gentleman keeps referring to a reduction in the number of midwives. Will he correct the record because that is entirely inaccurate?
How on earth can we pore over locally based geographic decision making from an office in Richmond house in Whitehall, Westminster and make the right judgments and the right calls, locality by locality in this country? Why mislead people into believing that that is possible or desirable?
Mrs. Janet Dean (in the Chair): Order. I draw the attention of the hon. Member for Cheltenham to the time.
Martin Horwood: Thank you, Mrs. Dean. I shall draw my remarks to a close by quoting the Royal College of Midwives, which makes it clear that the number of midwives is falling and not rising—[Interruption.] The Minister does not believe me, but in 1997, there were the equivalent of 18,000 full-time midwives. By 2006 that had risen to 18,862, but it has now fallen. That is so whether measured by full-time equivalents, head count numbers or even training places. In a recent survey, two thirds of heads of maternity reported that their unit was understaffed, and more than one in five reported that their midwifery staffing establishment had been cut. The general secretary of the royal college says:
“With this situation women are not going to get the choices they’ve been promised. Some areas are struggling to provide even basic services. Vulnerable and disadvantaged women who need the most intensive support will suffer the most."
3.42 pm
Mr. John Baron (Billericay) (Con): I, too, congratulate the hon. Member for St. Ives (Andrew George) on introducing the debate and other hon. Members on contributing to it. The topic is important. It is vital that NHS services are both safe and accessible, and we thank midwives throughout the country for all that they do, often in difficult circumstances.
As we know, this is midwifery week. It was organised by the Royal College of Midwives, which does an excellent job of representing its members and highlighting the important issues for discussion.
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