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Examination of Witnesses (Questions 20-39)
NATIONAL HEALTH SERVICES
27 FEBRUARY 2008
Q20 Angela Browning: I assume that the department had sight of this Report from the NAO before it was published. Can the NAO confirm that?
Ms Taylor: Yes.
Q21 Angela Browning: In that case, having read that in the Report is that not something you would have raised prior to publication if it had not been accurate?
Mr Nicholson: It is accurate. Neonatal services are not exempt from the activities of the Healthcare Commission. The Commission operates in a particular way around self-audit looking at information and data from the system and then decides itself where to focus its attention. As an example yesterday I visited a neonatal unit which had called in the Healthcare Commission to do an inspection because it was worried about some of the numbers in it, but it is certainly not exempt.
Q22 Angela Browning: Perhaps I can ask the NAO if it can throw some light on the reference to that in the Report.
Ms Taylor: As Sir Bruce says, the Healthcare Commission's focus is on the annual health check in terms of its overall view of the quality of care being provided across the health service. It uses a risk-based approach based on data and to date it has not highlighted that neonatal units are things on which they want to focus. The main point is that they are not looking at quality and consistency of care; nobody is. We found nobody that was auditing or inspecting neonatal units. The Healthcare Commission has recently launched a clinical audit of neonatal units which will provide the first data, but until now no one has looked at neonatal units.
Mr Nicholson: They are doing that because we asked them to do it.
Q23 Angela Browning: That sets the context. It looked as though a very important part of the health service was just falling through the net in terms of a body inspecting and monitoring it. On page 17 in paragraph 1.21 there are comparison of the results as far as concerns England. There is also reference to Scotland. We know from the BLISS report[2] that Scotland does rather better than England. Could you throw some light on whether the department seeks to learn some lessons from the Scottish experience?
Mr Nicholson: Sir Bruce can talk in more detail about the statistical base. The work we have done on this indicates that particularly when one talks of Scotland and Wales these are relatively small numbers compared with England as a whole; they represent one tenth of England. Therefore, one gets significant changes on a year-to-year basis. The statistical analysis we have done looking back at this particular issue seems to indicate that Scotland and England are broadly the same, so we do not believe there is a big difference between Scotland and England. There does however appear to be a difference in Wales; there is, if you like, a better record. We have looked at that issue in some detail and from the analysis we have carried out it appears that in Wales they do not have as many low weight babies.
Professor Sir Bruce Keogh: As you rightly say, there appears to be some difference between different regions of the United Kingdom. The neonatal mortality rate for 2005 in England was 3.5%; in Wales it was 3%, for the reasons to which Mr Nicholson has alluded, and Northern Ireland was 4.7%. Therefore, the average across that group is 3.5% which I believe compares very well with places like the United States at 4.5%. We know that the neonatal mortality rate is affected by a number of variables. If we go along the lines outlined by the International Federation of Gynaecology and Obstetrics and we exclude very, very tiny babies—less than 500 grams—the neonatal mortality rate for England is 2.8% versus Scotland at 3%. If we exclude some of the other major malformations which are a major cause of death and are not influenced by neonatal intensive care and babies under 1,500 grams we see again that England and Scotland are neck and neck at 0.9% and 1%. I suspect that the initial figures are relatively superficial and bear further scrutiny.
Q24 Angela Browning: In one of his opening questions the Chairman made reference to transporting babies. Homerton Hospital is in an urban network and therefore the distances are perhaps not as great as they would be in some of the more rural regional networks. In my own area of the South West I believe that babies in Devon and Cornwall go to Bristol which is quite a journey for sick babies. From the report we have had from BLISS, it appears that Scotland has gone ahead in terms of what it provides for transporting sick babies. I refer not just to the structure it has put in place but its investment and training in nurses, paramedics and medical staff. It seems to have made a lot of progress. I just wonder whether you agree, given the fact there has to be transportation within these networks, that investment in that sort of structure and level of trained staff for the transportation of babies would make a difference.
Mr Nicholson: You are absolutely right. The Report draws attention to this particular area in a significant way. Having reflected on the Report, we decided to set up a small task force nationally to move the thing forward, not to think up lots of new policies because we know what needs to be done; the issue is just getting it done. That is why I have tasked Sir Bruce to lead a task force to do that. One of the first things that task force will do is get into the whole issue of transport. I said earlier that we certainly have plans for all but three of the networks to have 24/7 transport in the way you describe with proper training and staffing underneath it. We are not sure about the other three and we shall pursue them as a matter of course. We need to move on that and it is a priority for us next year.
Q25 Angela Browning: That is very encouraging. Perhaps I may ask you to think outside the box. One matter that struck me yesterday at the Homerton Hospital was how difficult it was for parents to be with their babies. Obviously, there are practical problems; there are other children to look after and so on. There is also the cost of transport for a mother who has just given birth, may not have her own transport and is perhaps reliant on a rather difficult public transport system. I know there are schemes to help people who cannot afford regular hospital visits, but in this case it seems to me that though it may not necessarily be your departmental brief while you are looking at it you may want to consider how to assist parents, particularly those who cannot afford transport costs, to gain easier access to transport so they can be with their babies. I may be wrong, but one of the things that struck me yesterday was that I saw only one mother.
Mr Nicholson: We have a responsibility to the parents as well as the baby, so we will take up your suggestions and let the task force look at it to see what we can do.
Chairman: There is now a division in the House—there may be two—so we must take a short break. We shall return as soon as we can.
The Committee suspended from 4.15 pm to 4.34 pm for divisions in the House
Q26 Angela Browning: I realise that PCTs manage their own budgets and so on, but one of the things that came to light at the Homerton—I suspect it would apply in many of the urban-based neonatal units in particular—was the difficulty experienced by hospitals in communicating with the parents of some of these babies for whom English is not their first language. We saw in one case yesterday that the parents had no English at all. I know that this comes from within the overall budget and it would apply to all levels of patient care, but given the extensive conversations that need to be had not just about sick babies but ensuring that parents fully understand what is required when the baby goes home I ask you to take a look at that. Clearly, it is quite a stretch for the hospital's resources particularly if it is within an area where there is a very large ethnic community and such translation services are needed quite frequently.
Professor Christine Beasley: I agree that it is a very important service for all relatives but particularly for mothers, fathers and families in these circumstances. Certainly, many neonatal units that have that sort of community seek to provide appropriate interpretation facilities and we would expect to see that as part of the package of support for parents. Obviously, it varies from hospital to hospital. I have seen some very good examples around the country of people using proper local interpretation services to help mothers understand what is a very difficult, complex matter even when English is one's first language. You are absolutely right to say that that is a service we would expect to see to support mothers in that very vulnerable position.
Q27 Angela Browning: It is not just a matter of providing the service; it is the impact it has on the rest of the budget because clearly it is something that is part of the general hospital budget and is not related just to this unit.
Professor Christine Beasley: That is absolutely right and it needs to be seen in the round because clearly hospitals which have that issue in their neonatal units have it across the piece; it is rarely in one area and is part of a whole interpretation service, not just a specific one.
Q28 Chairman: The Chief Executive of Homerton mentioned this particular point to us yesterday. She was saying that it was not taken into account in her funding.
Professor Christine Beasley: For neonatal services?
Q29 Chairman: The difficulty in dealing with translation and that sort of thing.
Professor Christine Beasley: These are very useful things that we can pick up as we begin to look at what next we need to do in the task force areas. I think we will pick that up.
Q30 Angela Browning: If you are sending home a baby that will be on oxygen a level of expertise is required for the staff to feel confident that the parents have fully understood what is required and what to do and what not to do and there is a cost associated with that.
Professor Christine Beasley: There is. This goes wider than just the interpretation service. Many units now broaden their staff mix so they have different sorts of staff who can go out and help support people in the community to assist them in this very area. There are nursery nurses and other support staff who can help people when they are first at home.
Q31 Mr Mitchell: I see that the department's public service agreement target for infant mortality was to reduce by at least 10% the gap in mortality between the routine, which is a manual group, and the population as a whole. When was that target set? I want to get the timescale because you have not met it, have you? The department considered that implementing the recommendation of the 2003 review might have had an impact on the infant mortality gap through the reduction of deaths due to immaturity-related conditions, but by 2007 that gap had widened to 18%.
Professor Sir Bruce Keogh: One of the things we know about the gap is that it is due to a lot of factors which influence the parents prior even to the conception or birth of the child. There had been a positive trend in that in the three years between 2002 to 2004 it was 19%; in the next three-year period it went down to 18%; and in the next three years, 2004 to 2006, it had dropped to 17%. I was not aware that it had crept up to 18%, but the general trend has been good.
Q32 Mr Mitchell: But why has it widened in this particular instance? When the reforms were implemented it was hoped that the gap would be reduced and it has not been. Why?
Mr Nicholson: There has been progress in relation to those particular socio-economic groups. The point is that the improvement in the other socio-economic groups has been even greater and faster, so that is the reason. We have placed a huge amount of emphasis on getting this right, but the rest of the population has got significantly better.
Dr Shribman: I have just referred to my documents. It was in 2002 that the target was set to be achieved by 2010. Mindful of the trend in the data to which Sir Bruce has referred, the department reviewed how we were progressing with infant mortality last year and has recently issued a practical guide for local PCTs and health communities to tackle it.
Q33 Mr Mitchell: If it has widened it figures that you will not meet your target which is to narrow the gap by 10% by 2010?
Dr Shribman: The review was to try to accelerate progress towards it. We are not there but you are right that it is a worrying trend.
Q34 Mr Mitchell: But the prospect is that it will not be met?
Dr Shribman: I believe that is correct, yes.
Q35 Mr Mitchell: How far is this an issue of class or ethnicity in the sense that people do not speak English, are not integrated into the system or they hope that things will be all right and do not get plugged into the maternity services? Is it the case that they tend to produce these kinds of problems?
Professor Sir Bruce Keogh: Yes. There are a number of socio-economic and demographic influences. For example, between the top and bottom of the socio-economic scale there is a two-fold increase in neonatal mortality, and there are also some differences between ethnic groups.
Q36 Mr Mitchell: Is class and ethnicity an explanation of the differences shown in table 6 on page 18? If I live in Surrey or Sussex, which I always think of as upper-class areas, or indeed in Essex which is not a high-class county, the neonatal death rate is much lower than if I live in the south west Midlands. Is that mainly a factor of class?
Professor Sir Bruce Keogh: I think there are class, lifestyle, genetic and economic factors. Those kinds of patterns spread into other areas of healthcare as well.
Q37 Mr Mitchell: Part of the answer is education and getting people into the system?
Professor Sir Bruce Keogh: Indeed.
Dr Shribman: You are absolutely right that these are key factors, but improving access to services is also very important which is why in maternity services we are particularly keen to encourage people to book early and have set in train measures to ensure that they book by the twelfth week of pregnancy so there is the maximum opportunity for these services to give them the benefit of help to tackle some of the problems with which they may present. For example, one thinks of smoking in pregnancy or access to services where they are more vulnerable. Therefore, helping people to access the system early is an important part of our strategy to tackle health inequalities.
Q38 Mr Mitchell: As I understand it, the North—Yorkshire and Humberside—does not have a network. Is that correct?
Professor Christine Beasley: It is only the northern region that has a less well established formal network given the absence of a structure, manager and so on.
Q39 Mr Mitchell: But you are happy with the structures that are there?
Professor Christine Beasley: They network together but we want them to have a formal network and they want to have one.
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