Examination of Witnesses (Questions 60-79)
NATIONAL HEALTH SERVICES
27 FEBRUARY 2008
Q60 Dr Pugh: Therefore, patients in Cheshire are likely to go north rather than towards the Manchester region where there is an ample supply of very experienced and good hospitals?
Dr Shribman: No. Patients need to go where they are clinically most appropriately cared for. Patients cross boundaries and therefore people need to work together where that is required. A typical example of moving across networks would be perhaps neonatal surgery where, in the case of the North West, you may need to access the services at either Alder Hey in Liverpool, if that is the specific clinical need, or Manchester. It depends on the baby. We need to see clear referral pathways across the networks and network managers get together to discuss any issues there may be about those.
Q61 Dr Pugh: My constituency is Southport. There is no maternity hospital in Southport. There is a trust there but it involves the transfer of people to Ormskirk. They live in network 6 but when they go to hospital they are in network 2. Does that create any problems for them?
Mr Nicholson: Sadly, my knowledge of that particular part of the country is not as good as it might be.
Q62 Dr Pugh: But you can see the difficulty in designing a network?
Mr Nicholson: Wherever you draw the lines I am afraid these issues will arise. In those circumstances I would expect the admission and transfer protocols to be consistent between one network and another.
Q63 Dr Pugh: Supra-network protocols?
Mr Nicholson: Absolutely, because that reflects the reality of the clinical and patient experience and relationships.
Q64 Dr Pugh: Referring to page 36 and the situation in Cheshire & Merseyside, it says that there is no level 3 unit (plus surgery). Alder Hey is within that network, is it not? Does it not provide surgery?
Mr Nicholson: I am sure it does.
Q65 Alan Williams: What about the other end of the story? What are the associated risk factors? What is being done to avoid premature birth? Paragraph 4 identifies causes. Having identified the risk groups, is there any initiative taking place to try to prevent those groups suffering this misfortune?
Mr Nicholson: Absolutely.
Dr Shribman: You touch on an extremely important point. If we were able to reduce premature births and tackle low birth weight it would help enormously. We have already this afternoon talked about a number of factors in terms of vulnerable women and pregnancies, but with about 43,000 babies being born prematurely every year it is clear that research in this area is very important. There is much that we do not understand about this. I understand that about £4 million a year has been devoted to this area, but there are four new research projects to do with premature birth costing over £1 million due to start shortly. There is a call for further research over the next five years, so it is a very important area that we need to tackle in terms of a clearer understanding.
Q66 Alan Williams: I can understand that it is very nebulous. Is it possible to analyse and take effective action earlier? Would that be a high cost?
Dr Shribman: It would certainly be very cost-effective for the country if we were able to reduce these deliveries. In terms of factors that we now know are important, I referred to people accessing services early. We encourage mothers to book early with their midwife or GP, which is very important. We can then offer interventions to help them with other risk factors such as smoking cessation because we know that smoking and pregnancy has adverse effects. We can tackle the things we already know, but we do not yet know all of the answers. I certainly wish we did.
Q67 Alan Williams: I can understand the incredible complexity and difficulty and that prompts further investigation. It has been said that you use the mortality rate as a guiding statistic. How far do you through clinical audit and so on use predisposition to such things as disabilities, either physical or mental, for premature births?
Dr Shribman: Obviously, that is a very important factor in terms of outcome because we need to look at outcome more widely than mortality, and morbidity, particularly disability, is important as you draw to our attention. It is for that reason that the neonatal audit commissioned through the Healthcare Commission not only looks at a number of parameters but towards the end of this year will collect data on the outcome of these babies at two years. That is a very important factor that needs to be taken into account in terms of looking at how well we are doing in the broader picture and in terms of individual units.
Q68 Alan Williams: I gather that most of the recommendations of the 2003 review have been achieved only in part. Why is that five years on?
Mr Nicholson: Changing any kind of clinical service is complex; it is not a straightforward journey where one tells people what to do and they do it. One must work with clinical staff and organisations to take things forward and identify when one can fund particular priorities and do things. We have seen that over the past few years. Whilst I agree with you that we have not done absolutely everything we set out to do we have set up and staffed the networks and increased the number of cots. We have increased the number of staff and completely reorganised the transport services. We are well on the way to getting better data about the system. We now understand better our costs. We believe that demonstrably we have saved lives, but there is more to do. I have come to the conclusion that if we just left it to the system to operate in the way it is we would not get to the end of the strategy soon enough. That is why we have decided to set up the task force under Sir Bruce which is not there to develop a whole set of new policies and clever ideas; it is about ensuring we do what we know works. That must be the national focus to take forward over the next 12 months or so. We need real action to finish off the strategy.
Q69 Alan Williams: Sir Bruce, have you identified the key reasons why certain elements of the recommendations have not been fulfilled, or is it too early to say?
Professor Sir Bruce Keogh: It is too premature at this stage, but we shall be looking at them very closely.
Q70 Alan Williams: PCTs are expected to Commission neonatal services and yet there is no common way to calculate the cost of running them, so how do the purchasers know which unit represents the best use of public money?
Mr Nicholson: Absolutely. It is true that we are on a journey of understanding all of this and we are getting our financial situation in the right shape. We plan to have a national tariff for neonatal services.
Q71 Alan Williams: How soon?
Mr Nicholson: We estimate that it will be within the next couple of years.[3]
Q72 Alan Williams: Will it take that long?
Mr Nicholson: It will take that long because it is an incredibly complicated thing to do on a national basis because of all the potential local arrangements one has. For the year starting 2008-09 each of the specialist Commissioning groups which have overall responsibility for making all of this happen is currently baselining and setting out clearly what the costs and expectations are against the amount of money it invests in 2008-09, which will be a much narrower band than we have seen in the past and will show significant progress.
Q73 Alan Williams: You prioritise things for maximum gain?
Mr Nicholson: Yes.
Q74 Alan Williams: Would it be asking too much to request a more detailed note so it can go into our Report?
Mr Nicholson: You mean a note about the neonatal tariff and how it is operating?[4]
Q75 Alan Williams: Yes.
Mr Nicholson: Yes.
Q76 Mr Dunne: From your responses to this Committee and the Report can I take it that one of the primary objectives in establishing networks was to reduce mortality from premature birth?
Mr Nicholson: Yes.
Q77 Mr Dunne: Dr Shribman, is it the case as I presume that all premature births stem from a premature labour?
Dr Shribman: Yes.
Q78 Mr Dunne: Approximately what proportion of premature labours results in premature birth?
Dr Shribman: In terms of labours that then proceed to a delivery? Some people go into labour and then do not deliver, so I cannot give you that data now.[5]
Q79 Mr Dunne: But do you have a rough rule of thumb? Can any of your colleagues help you?
Dr Shribman: The majority of premature labours result in a premature birth.
3 Note by witness: On further consideration, however, I do not think that that a tariff for neonatal critical care within a couple of years is likely. Back
4 Ev 16-17 Back
5 Ev 17 Back
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