Westminster Hall
Wednesday 30 January 2008
[Hywel Williams in the Chair]
Maternity Services
Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Dave Watts.]
9.30 am
Harry Cohen (Leyton and Wanstead) (Lab): I thank Mr. Speaker for granting me this debate on maternity services. I have been planning it for a while, but it is well timed, given the publication of the Healthcare Commission review last Friday.
Along with our colleague, the hon. Member for Macclesfield (Sir Nicholas Winterton), I am an honorary vice-president of the Royal College of Midwives, and very proud to be so. I pay tribute to the college and to midwives. They are professional and effective in the cause of first-rate maternity provision in this country. They are one of the major reasons why giving birth has become safer for mothers and their babies.
I also want to pay tribute to the management and midwives at Whipps Cross hospital in my constituency. It has improved and, in a way, has bucked the trend in London. I shall say a bit more about that later.
Giving birth is a major, life-enhancing experience in a woman’s life—and in her partner’s. It should be a happy experience, not a traumatic one, and high-quality national health service maternity services that are consistent across the country are essential for that.
The Minister was recently the guest of honour at a Royal College of Midwives event to honour those who did a lot of innovating. She will have seen the brilliance and enthusiasm that midwives bring to improving their profession and their service. As a former nurse, she has been on the NHS front line, and she is aware, more than most, that the front line is vital to delivering quality treatment. So it is with midwives for mothers and babies. I hope that she will excuse the pun, but I know that she is keen to have the best service on the NHS front line. However, that requires action.
The Healthcare Commission’s report shows a service that is patchy. It is good in many areas, but inadequate in too many. The trend is in doubt: some factors seem to indicate a worsening. I know that that is not the Government’s intention, but they must act promptly to ensure that the needed improvement happens all over the country.
I shall come back to the commission’s report, but let me quickly give examples of how the press reported the situation: four in 10 maternity units give poor or below average care; nine out of 10 are not meeting the National Institute for Health and Clinical Excellence screening guidelines for maternity; one in five of the 148 trusts surveyed failed to carry out scans, discharged too quickly or did not follow up with post-natal visits; one third of trusts do not have a consultant on the ward for at least 40 hours a week, which is considered the norm; in one quarter of trusts, three times as many babies were readmitted for
jaundice or dehydration than in the best trusts—that is a serious disparity; the maternity care in 31 NHS trusts fell below the approved standard. Those were reports in the press, and they are, of course, a matter of concern.
MPs are concerned. An early-day motion was put down by a Liberal Democrat colleague, the hon. Member for Bath (Mr. Foster), in mid-November. It already had 119 signatures yesterday, and the turnout for this debate indicates that many MPs are concerned about maternity services.
Andrew George (St. Ives) (LD): On the Healthcare Commission’s report, is the hon. Gentleman aware that the Royal Cornwall Hospitals NHS Trust, which had a very good result in the report, has a maternity unit, the Princess Alexandra suite, where the roof often caves in despite the good and professional standards and dedication of its staff? In fact, the unit itself is structurally unsound, and people often say that they are surprised that it had such a good report, given the capital challenges that the service faces.
Harry Cohen: I hear that point. Those structural matters must be addressed. It is crucial that the strategic health authority makes provision for and sorts out the problem.
Some key factors are putting the service under intense strain. The Government have guaranteed that by the end of next year, England’s NHS will deliver a world-class maternity service, but with less than 24 months to go, action is needed now. The emerging baby boom is placing additional demand on a service that already has to cope with an inadequate and shrinking budget and insufficiency of the midwifery work force. In addition, there is a declining number of student midwives, which means a failure to produce the next generation of midwives—that is a concern. If action is not taken now, it is difficult to see how the Government can avoid failure to honour their guarantees. That would be deeply depressing to midwives and a let-down for women.
The Government gave guarantees in the past two elections. In 2001, the Labour manifesto stated:
“By modernising all maternity units, increasing the number of midwives and giving women greater choice over childbirth, we will ensure that women receive the highest quality maternity care.”
In the last election, the manifesto stated:
“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.”
A good document was published by the Department of Health in April last year. “Maternity Matters” included guarantees that by the end of next year, all women would enjoy the choice of how to access maternity care, they would be able to go directly to a midwife or via a doctor, they would have a choice of antenatal care, they would be able to choose between midwifery care or care led by both doctors and midwives, they would have a choice of place of birth, depending on their medical history and circumstances—they and their partners would be able to choose between home birth, giving birth in a midwifery unit or in a hospital with midwives and doctors—and they would be able to choose how and where to access post-natal care. The Royal College of
Midwives congratulated the Government on that document, and it still does. It says that it wants to work constructively with the Government to achieve those objectives, which are important.
However, let us look at what happened with the health care report. It was the single most comprehensive assessment ever made of maternity services in England. It was based on evidence gathered throughout 2007, and it found significant variations in the provision and quality of maternity care provided by the NHS. Thirty-eight trusts secured the top ranking, or best performing; 47 achieved the second highest ranking, or better performing; 32 trusts—22 per cent. of trusts—attained the third best ranking, or fair; and 31 trusts finished with the bottom ranking, or least well performing.
In London, the worst performing region, 19 out of 27 trusts—70 per cent. of London trusts—got the worst ranking. Like me, the Minister is a London MP. I do not think she is happy that London is behind the rest of the country. She will want London trusts to reach the best standard. That is a matter of concern that the commission’s report brings to our attention.
Mr. Eric Martlew (Carlisle) (Lab): I agree with what my hon. Friend is saying. Does he, like me, welcome the Healthcare Commission’s report, because of which we actually know what the situation is now? However, the problem is that we do not know what we are comparing it with, because this sort of survey was never done before. The real answer will tell us whether it has improved next time.
Harry Cohen: I hear my hon. Friend’s point. That will be a factor, but I do not think that it is the only factor, because the report clearly shows a service that is under strain and that a significant number of trusts, including in the capital, appear to be underperforming and are below the approved standard. The Healthcare Commission review stands on its own in the present as well as being a factor for the future.
I shall run through some important points made by the Healthcare Commission in its press papers. It says that:
“those trusts that were least well performing should as a matter of urgency take steps to improve and we shall be checking that they do so.”
“The review raises real concerns about performance in London. There are a number of factors that may have influenced these results, such as lower staffing levels and the mobility and mix of the population. But London trusts need to rise to these challenges.”
In fact, the Healthcare Commission has said that it will do a more detailed assessment of what needs to be done this year, but says that
“very low staffing levels may be associated with poor overall performance”.
That certainly seems to be so in some London trusts. It said that
“antenatal and postnatal care tended to be consistently poorer”
“the quality of care around the time of birth was mixed.”
It says that there needs to be
“greater continuity where women are getting different aspects of their care from different trusts.”
The Healthcare Commission mentions mental health issues in respect of pregnant women, which is important, because depression and suicide are associated with pregnancy. It states:
“All trusts ask women about their mental health at a woman’s first antenatal appointment, however only 55% conduct all the mental health checks identified in NICE guidance...42% of trusts said that they did not have access to a specialist mental health service.”
That aspect needs to be addressed.
“64% of trusts are providing women with a named midwife”,
“34% of trusts are providing a named midwife sometimes”
“2% of trusts are not providing a named midwife at all”.
That is a serious criticism. All trusts should provide a named midwife.
In respect of the London factor, on bookings, the Healthcare Commission says that most trusts took
“1.5 weeks or less from the time between a woman making contact and having her first booking appointment.”
However, in some London trusts it took “4.1 weeks or more”. I put it to the Minister that that is not acceptable.
The last point that I want to quote from the Healthcare Commission report is on breastfeeding. Initiation rates are “58% or less” in some trusts, whereas in the higher performing trusts the rates are “78% or more”, because of the quality of the advice. We know how important breastfeeding is for the health—and the future health—of the child. Those are serious flaws that the Healthcare Commission has outlined.
The report also outlines some challenges facing NHS maternity services: the emerging baby boom, cutbacks to the budget, shrinking midwifery numbers and student midwife numbers. I want to deal briefly with each one in turn. On the baby boom, the birth rate in England between 2001 and 2006—the latest year for which figures are available—rose from 563,744 to 635,679, a 13 per cent. increase. The number of births in London increased by 16 per cent. in those five years. Addressing the Labour conference last year, the Secretary of State for Health said:
“We have initially planned an extra 1,000 midwives by 2009. If birth rates continue to rise, we will need to train more.”
Well, they are continuing to rise. I should like to know what the Minister’s reaction is to that. I would also like to know whether that figure of 1,000 is a head count or refers to full-time equivalents, because if it is just a head count it will not do the job. The Royal College of Midwives estimates that some 5,000 extra midwives are needed if it is to meet the targets on one-to-one care that the Government have been talking about.
On a new projection, there would be 652,000 births in 2006-07 and 673,000 by 2009-10. If those official predictions are correct, the number of births in England will have increased by more than 100,000 in less than a decade. The BBC has talked about that in terms of migrant labour, but I think that that is just
a factor. The BBC estimates that that increase will add a £200 million bill on to NHS costs in terms of maternity services. The Government are putting in £122 million. Putting those two figures side by side shows that more needs to be done in that respect. Migrant and immigrant labour is vital for the NHS and for many other industries as well, but that factor must be taken into account if we are to meet our aims in terms of maternity services.
The budget has been reduced. There was a cut of £55 million in NHS cash spent on maternity services in 2006-07, which is equivalent to £87 less per birth than in the previous year. In 1997-98, maternity services received 3.1 per cent. of the NHS budget, but by 2006-07 that had fallen to 2 per cent., so those are getting a lesser proportion. If the figure had remained at the higher proportion of 3.1 per cent., maternity services would have received, on average, £1,274 more per birth than they actually received. There have been reductions in the budget. That has to stop. In fact, it must go the other way if we are to achieve the target.
The work force issue is important. There is general party political consensus that we need more midwives; I could quote all parties saying that that needs to be so. However, I want to make a point about what the experts say. The various royal colleges in this field talk about a level of one midwife per 28 women—a ratio of 1:28. Let me give the figures for the increase in births per full-time equivalent midwife in 2006, compared with 2001: in the north-east the number of births is 29, which is an increase of 16 per cent.; in the north-west it is 27, up 8 per cent.; in Yorkshire and the Humber it is 33, up 10 per cent.; it stands at 40 in the east midlands, which is an increase of 25 per cent.; in the west midlands it is 32, up by 10 per cent.; in the east of England it is 38, down 5 per cent.; the figure in London is 36, down by 3 per cent.; in the south-east it is unchanged at 37; in south-central it is 43, up 19 per cent.; and in the south-west it is 31, up 15 per cent. The trend is mainly in the wrong direction and well above the 1:28 ratio that the experts say is needed. That is not good.
In 2004-05, 2,374 NHS midwife training places were commissioned in England. That fell to 2,200 a year later, and fell again to 1,990 in 2006-07. Does the Minister have the latest figures, and do they show a fall? There is a serious problem for future generations, partly because the Government reduced the bursary for midwives—the amount that they receive in training. A big push is needed for more midwives in training, or there will be an even bigger problem.
I am running out time, because plenty of hon. Members want to speak, but I want to draw attention to a few points. UNICEF has introduced a baby friendly initiative and says that in trusts where it is in operation breastfeeding has increased by about 10 per cent., but it is not in operation in the majority of trusts, and it should be.
The Royal College of Obstetricians and Gynaecologists agrees that 5,000 more midwives are needed, but says that more obstetricians are also needed on the wards to provide a consultancy service. It points to the huge litigation costs in maternity services, which are second only to those in general surgery. When something goes wrong, the costs may be in the millions, and the RCOG makes the good point that if there were a better overall service, it would save on some of those litigation costs. I
do not have time to give the figures, but the point is relevant and worth making.
More proactive intervention is needed from Ministers and NHS management to address the situation and to achieve our manifesto commitments and aims. There should be more resources. I welcome the £122 million, but that is the figure that will be reached in three years. What will happen this year and next year, and what are the figures for those years? The figure should be higher if we are to have the necessary increase in the number of midwives and student midwives, higher consultant cover, and more choice, as we were promised.
The poorest performing trusts, particularly in London, must be forced to improve their maternity services up to the standard of best practice. The guarantees were clear, and are still being made, but time is running out. I urge Ministers to will the means and to require the relevant authorities to fulfil them. That is what our top-rate midwives and, more importantly, mothers and their babies richly deserve.
Hywel Williams (in the Chair): Order. I intend to start the winding-up speeches at 10.30. A number of hon. Members have indicated their intention to speak, so I appeal to them to be suitably brief.
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