Examination of Witnesses (Questions 80-99)
NATIONAL HEALTH SERVICES
27 FEBRUARY 2008
Q80 Mr Dunne: The majority? My discussions with obstetricians suggest that the majority of premature labours do not result in a premature birth and many mothers who exhibit signs of premature labour do not go on to the delivery phase and may or may not subsequently deliver prematurely.
Dr Shribman: Certainly, for anybody who looked as though they might be going into labour at a pre-term stage—I am not an obstetrician but am familiar with the background to it—you would do what you could to stop that proceeding if there were steps you could take in each individual clinical case because, as we have heard, a premature delivery is undesirable in general because of the risks associated with prematurity and low birth weight. Sometimes it is desirable to deliver a baby early because the risks of the baby remaining in the womb are too great and therefore one chooses to deliver a baby early for clinical reasons.
Q81 Mr Dunne: Indeed, but it would be most desirable for both the mother and the health of the baby not to have a premature birth if it can be avoided?
Dr Shribman: Yes.
Q82 Mr Dunne: The anecdotal evidence from those to whom I have spoken suggests that in my area of Shropshire approximately one in five women who present with premature labour end up having a premature delivery. Is that something you would dispute? If there are any statistics on this it may be helpful to have them.
Dr Shribman: I can certainly go back to the experts and provide more detail on those obstetric issues. I guess the question here is: what is true labour? When a woman presents she may have symptoms that are believed to be labour but turn out not to be. I think a critical issue is whether a woman is truly going into labour or has some symptoms that it is believed indicate that is the case.
Q83 Mr Dunne: I believe this is very important. My understanding is that one of the consequences of focusing on level 3 intensive centres of excellence is pressure on staffing and beds as we have heard from other Members earlier. If we drive the population of women who present with the possibility of premature birth, which is very small, into these intensive centres and a large proportion of them—I am told it is the majority, but you will come back to us and say whether or not it is true—do not require intensive care at that point those costs are being absorbed unnecessarily in many cases by those centres.
Dr Shribman: We need to be very clear about the definition. Technically, the definition of prematurity is before 36 weeks of gestation, that is, any baby born earlier than four weeks early. It is only the very small pre-term babies that we would look to have born in level 3 units.
Q84 Mr Dunne: I think that we are talking only about level 3 under 28 weeks. That is the information to which I am referring.
Dr Shribman: Indeed, but the definition of premature labour would include prematurity under 36 weeks, so it is a question of which population we are covering. The vast numbers arise in that larger group and we would not seek to transfer those.
Q85 Mr Dunne: To avoid confusion, I am not talking about any babies over 28 weeks.
Dr Shribman: You are talking about premature labour below 28 weeks, not the technical definition of it.
Q86 Mr Dunne: Mr Nicholson, I do not know whether or not you want to comment on this, but it seems to be very important in providing the appropriate level of care in appropriate places that there is some clarity about the clinical need for intensive services in the way the networks are being established at the moment. I come to this from a parochial perspective. Having looked at the NAO Report with some care, I have gone back to my area which you know well. Unfortunately, as is clear from table 6 on page 18 to which Dr Pugh referred the area I represent and where I live, Midlands South, is the second worst in terms of mortality. But these figures mask some good performance and some less good performance. If one turns to the appendix on page 40 there is a little more clarity. For example, if we take Midlands North—it is one I know well—it is the second worst performer in terms of mortality and the worst performer in terms of babies transferred out of the network for clinical reasons, yet we have lower than average vacancies for nursing and so it is not a staffing issue that causes it but something else. If one goes to the CMEC website, in particular the West Midlands neonatal register, it is clear that the mortality rate in the acute hospitals that provide level 2 services at the moment, the Royal Shrewsbury Hospital and the Princess Royal Hospital Telford, have a 93% survival rate for both 2005 and 2006 based on a very similar number of cases to the two level 3 facilities at Stoke and Wolverhampton which have between a 59% and 72% survival rate for both 2005 and 2006. The populations are broadly comparable. If we are trying to improve mortality rates across the country should we compel the better performing and smaller level 2 units which have better staffing capacity, professional expertise and outcomes to be conjoined with a network where performance is much less good?
Mr Nicholson: That raises a whole series of issues. In a sense you put your finger on a dilemma that is identified in the document itself which talks about some places commissioning level 2 and 3 separately from other bits of the service and the argument is that all of the service should be commissioned together. The danger of doing that is, as you say, that you shift acuity right up the system so you end up using more level 3 than perhaps you would expect. That is a danger in the system and why the protocols have to be absolutely right throughout the system. We have seen the development of what other people describe as level 2-plus, that is, those places that have a really good record and have worked really hard at it and can take babies that perhaps in the past might have been seen as level 3 because of the experience, knowledge and understanding of their staff and the way they have developed. I believe that is something the task force should take on board to consider the issue between what might be described as level 2-plus and level 3. That is absolutely right.
Q87 Mr Dunne: I am encouraged to hear you say that. If that is an outcome of this inquiry then we will have made great progress. Having delved into the numbers, I am fearful that we are at risk of dumbing down as a result of trying to create a network that is convenient from an administrative point of view. We do not want to lose clinical excellence where we have it. One of the concerns of practitioners is that because of the infrastructure being established nationally there is a risk to funding of level 2-plus facilities. Can you comment on whether if you to pursue this line of inquiry internally you will also consider maintaining resources for level 2-plus facilities?
Mr Nicholson: This is part of the discussion about the tariff in addition to what you pay and how you pay it.
Dr Shribman: To comment on the clinical issues, not specifically the tariff, we strive for clinical excellence at all levels. I could not agree more that that is absolutely essential. There is a very large amount of work to do at the level 2 end of the spectrum because there are a large number of babies in the 28-week-plus category, not to mention the ill term babies who require full care as well. It is not simply an issue of the under 28-weekers who are very important; there are other issues as well. We want our level 2 units to perform very well in their own right.
Mr Nicholson: We do not envisage one outcome of this being a massive increase in level 3 at the expense of levels 1 and 2. That would be a perverse way of working. We are very keen to make sure that does not happen.
Q88 Mr Dunne: The question of distance has been raised by a number of colleagues. If one looks at the map on page 14, three sections of the United Kingdom that are not included: Wales and Scotland and Northern Ireland. Many of the mothers who require neonatal care in Shropshire come from Mid-Wales. I do not know whether I can claim that is a greater distance than would apply around Merseyside or the South West but it is very considerable and the stress on parents having to travel potentially large distances to go in this case to Wolverhampton and Stoke right on the eastern extremity from Mid-Wales where there is effectively no public transport is very considerable. If you have outstanding level 2-plus capacity I think that is another argument for maintaining some of it round the region. Do you share that concern?
Mr Nicholson: I think we have to take all of this on board and the issue of distance is vital.
Q89 Mr Dunne: Can you comment on the impact next year of the EU Working Time Directive in exacerbating existing staffing problems you have within nursing provision?
Mr Nicholson: Particularly on nursing or in general?
Q90 Mr Dunne: You have an apparent shortage of permanent staff in servicing these networks and it will get worse when the directive comes in, will it not?
Professor Christine Beasley: Inevitably, when the directive comes into force it will tend to impact on medical rather than nursing staff, but, as you rightly say, it has a knock-on effect on nursing staff. That is one reason, not the only one, we have asked PCTs in terms of the operating framework to look at both their services and their workforce for a range of reasons. They will need to take into account also the new Working Time Directive in terms of how they staff units. It hits mainly on the medical staff but it has a knock-on effect particularly between doctors and nurses who work so closely together.
Q91 Nigel Griffiths: Do you accept that the financial management of the unit level needs to be improved?
Mr Nicholson: Yes.
Q92 Nigel Griffiths: Why have they got into a position where some PCTs include pharmaceuticals in their costs and others do not?
Mr Nicholson: We are continually trying to improve the way in which we allocate costs and understand the way those costs shift in the NHS—I have to say from a very low base—over the past few years. It just takes time to get organisations in place. If it does not matter to them and they get funded no matter how their costs are organised the chances are that they will not take as much care over it as they need to. Now that they know the tariff will be established and real money will move round the system based on the analysis they are making people are paying much more care and attention to this particular area. For most parts of the country up to two or three years ago essentially there was a big block of money given for these services and that did not vary depending on activity, but it will do so in future. I think we can be assured that people are paying attention to make it happen, but I acknowledge that we are not there yet.
Q93 Nigel Griffiths: Will you be able to look at data at, say, spending on pharmaceuticals across the 180 neonatal units and then decide whether pharmaceuticals might be making a difference? I see in paragraph 4.8 that a number of the items are included in some but not others. How on earth do you get to grips with what of all the elements makes for good care, apart from the obvious one of caring doctors, specialists and nurses?
Mr Nicholson: I guess we will focus on the big issues in relation to the inputs here. We will have good data on the staffing element, that is, the number of doctors and nurses. I guess that in the medium term the detail around pharmaceuticals, until we have got electronic prescribing up and running across the NHS, will not be a major issue in the way we benchmark, but it is only a relatively small amount of the expenditure.
Q94 Nigel Griffiths: You mentioned nurses. Nurses' salaries are included in all the estimates and one would expect that to be picked up, but medical salaries are not.
Mr Nicholson: Medical staff should be and the electronic staff record will enable us to do that in a much clearer way.
Q95 Nigel Griffiths: Does that mean you will be able to pick that up for the 180 units?
Mr Nicholson: There is benchmark information that we will be able to pick up.
Q96 Nigel Griffiths: Do your guidelines or whatever instructions you communicate to the financial directors or those responsible reflect this?
Mr Nicholson: Yes; it is in the accounting manual we send out.
Q97 Nigel Griffiths: Does it mean that when the NAO found that 9% of units had to operate above 100% levels that would be picked up by the system and addressed?
Mr Nicholson: It is picked up now. The issue is whether it is addressed is the role of the network. Very often it is a short-term issue that has moved it in this particular direction. It may be that the balance between levels 1, 2 and 3 is not right or that transport is not working appropriately. Part of our job is to strengthen the networks because we now know that it is action which is the important thing.
Q98 Nigel Griffiths: How do you intervene to assist them with this at the moment, or how do you intend to do so?
Mr Nicholson: The task force has already started its work. It will look essentially at each network to see what arrangements are in place both to deal with this but also to deal with the consequences of it. Nationally we shall be monitoring quite closely the out-of-network transfers that take place and take action through the normal performance management system.
Q99 Nigel Griffiths: What happens now to the almost one in 10 units that operate above the 100% occupancy rate? What do you do? Does anyone care?
Mr Nicholson: Of course people care but that does not always mean there are more children on the unit for which it has physical capacity.
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