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Lord Winston: My Lords, before the noble Baroness finishes, will she clarify her remark that mistakes are common? Professional mistakes are not at all common in midwifery, but there is a perception—often in the courts, quite unjustifiably—that they are because of monitoring that gives imprecise information. It is unwise to say that mistakes are common. As a practising doctor in this field, I believe that it is untrue.
Baroness Thomas of Walliswood: My Lords, I bow to the noble Lord's superior knowledge. I was referring to a type of mistake made in a particular case and quoting a letter sent to me by a pressure group. I am sorry if I gave a mistaken impression: I am certainly not suggesting that mistakes are common in obstetric care in general or trying to justify the large claims made by lawyers on behalf of their clients.
8.16 p.m.
Baroness Noakes: My Lords, I add my congratulations to my noble friend Lady Cumberlege for initiating this important debate and for drawing in so many expert speakers. It has been an excellent debate.
We know that the topic is important, as it touches the lives of almost 600,000 women who give birth each year, and the lives of their families. As other noble
Lords have said, it is also apt that the debate should be led by my noble friend, who has been closely associated with the development of maternity services over the past decade. The report entitled Changing Childbirth is much better known as the Cumberlege report. That report was revolutionary in proposing women-centred care.Simple principles underpinned that, including choice for women, continuity of care and control of women over their care. When the Audit Commission examined maternity services in 1997, its report, entitled First Class Delivery, found that the policies of the Cumberlege report were not being achieved. It said,
- "there is a wide variation in the sort of service offered that cannot be attributed to women's own choices".
A key issue is what the Government have achieved since 1997. It is far from clear that we can confidently say that in 2003 maternity services live out those principles of choice, continuity in care and control. The Minister has said, on more than one occasion in your Lordships' House, that the principles of Changing Childbirth—the Cumberlege report—are now embedded in maternity services. That is a complacent view and not one that is shared by professionals or users. Indeed, the noble Lord, Lord Patel, said earlier that maternity services are in a mess.
I start with home births. They are not desired by all women, but a substantial number want home delivery—we do not know how many. The statistics for home births are at around 2 per cent, but that does not tell anything like the full story. The Association for Improvements in Maternity Services has reported many instances of women being pushed into hospital delivery, usually at a very late stage in pregnancy, because they are told that no midwife will be available to support a home delivery. Those women have been denied real choice and have lost control of their birth arrangements. Some parts of the country achieve home birth rates of 12 per cent, or occasionally even more. One can deduce from that that unmet demand is at least 10 per cent. It is clear that in home births, choice and control for women is simply not happening.
We have heard from many people this evening that pregnancy and childbirth are not illnesses: they are part of normal human life. Yet maternity services have developed around a different concept. I mean no disrespect to the medical profession, and in particular to obstetricians, when I say that the medicalisation of pregnancy and childbirth is part of today's problems.
Of course we are proud of the low level of our maternal, neonatal and perinatal mortality rates, which are so much lower than when many of your Lordships were children. However, as an article in the British Medical Journal last April pointed out, these improvements are attributable to many causes. The article said:
- "it cannot be assumed that access to obstetric care . . . has invariably had beneficial effects".
Several noble Lords have already referred to caesarean rates, which are frighteningly high and still rising. They are well above the WHO's bench-mark level. The variations around the country that we have also heard about are even more worrying. Every unnecessary caesarean carries with it a raft of potential problems for both mother and child. My noble friend Lady Cumberlege and the noble Baroness, Lady McFarlane, both referred to the Audit Commission's estimate back in 1997 that for every 1 per cent of unnecessary caesareans, there is a cost to the NHS of around £5 million. Rolling that forward to today's prices, it is probably nearer £7 million. I have heard no recognition from the Government that this is a serious problem for which practical and urgent solutions are necessary.
Caesarean sections are not the only issue. There are other aspects of increased medicalisation, including instrumental deliveries and rates of anaesthesia and of episiotomies. As my noble friend Lady Cumberlege pointed out, some interventions tend to lead to more interventions, which makes the problem worse. It is clear that the rate of normal births is declining. That is not what women want or deserve.
What problems lie behind these features of modern maternity services? The Royal College of Obstetricians and Gynaecologists will say that there are not enough senior obstetricians available and that this will get worse as the Working Time Directive takes hold. We have heard from my noble friend Lady Perry of the related problems for obstetricians.
That may well be part of the problem, but a much more serious problem is that from the perspective of the Royal College of Midwives. Many noble Lords have referred to the severe shortage of midwives. The noble Lord, Lord Chan, referred to the 2002 survey by the Royal College of Midwives, which shows the highest vacancy rate against funded establishment that the college has recorded since it started its surveys. It also shows great disparities around the country. We know that some areas of London operate at near crisis level. Perhaps more importantly, in the survey, 70 per cent reported that their funded establishments were too low to meet the demands of today's maternity services.
The midwifery shortages identified by so many noble Lords are very important because they reduce the prospects for continuity of care, which many noble Lords have explained is a crucial part of achieving normal births and high levels of patient satisfaction. We need more midwives if we are to improve the prospect of real choices being available to women—choices such as home births, but also births in other settings.
The shortages in midwifery are imposing massive burdens on remaining midwifery staff. That leads to the inevitable loss of staff morale and causes further midwives to choose to leave the profession. We cannot afford that. We will need more midwives if there are to be more community-based maternity services and more midwife-led maternity units. It is through those routes, backed up by appropriate acute services and
service delivery protocols, that maternity services will be able to start to deliver the policy aims of women-centred services.The Minister will be aware that community-based and midwife-led maternity services are "win-win" services. Studies have shown their popularity with women. More than that, studies show that they cost less and have outcomes at least no worse than acute-based services. Will he say what proportion of maternity services are currently midwife-led in England and, similarly, what proportion are community-based? Does he agree that those aspects of maternity care should be given priority in funding service delivery? Is he satisfied that primary care trusts give adequate priority to them in drawing up their commissioning plans? Is he satisfied that PCTs adequately consult users of maternity services when they draw up their plans? I hope that he will not be complacent on the matter, and will be able to set out what proactive steps the Government will take.
Many of the problems keep coming back to the shortage of midwives. The Minister will say that the Government have the target of a further 2,000 midwives by 2005. Early last year, a Health Minister in another place said that there would be an extra 500 in place by the end of 2002. Will the noble Lord say how many midwives there are currently and how many there were in 1997—not just in terms of head count, but in terms of whole-time equivalents? What matters is not the number of midwives, but the amount of time cumulatively that they can contribute to maternity services. In particular, the problem with targeting returners is that they often come back into part-time work, so simply adding heads will not solve the problems. The figure that I have for whole-time equivalents is 18,050 at the end of 1997, and again in 2001. Will the Minister confirm those figures? Will he say whether there is any increase at all in that in 2002?
In May 2001, the Secretary of State for Health promised a national service framework for children and maternity services including, to use his phrase, "a gold standard" of a dedicated midwife 100 per cent of the time in labour, and choices for all women including home birth. That framework was promised by the end of 2002, but has not yet seen the light of day. As we have heard, Scotland and Northern Ireland are already ahead of us. Will the Minister say when the framework will appear? Will he confirm that it will include the two matters that I have just mentioned, which were 100 per cent dedicated midwife cover, and more choice including home birth? Will that framework promote normality in childbirth in the hope of offsetting the trends that have happened in our maternity services recently? I look forward to the Minister's reply.
8.28 p.m.
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, I congratulate the noble Baroness, Lady Cumberlege, on securing the debate. It is some time since we had one on maternity services, and the debate
has been helpful and has raised a number of very important matters on which we need to make progress. As other noble Lords have mentioned, she played the key role in Changing Childbirth. She knows that, when the report was published, I gave it warm and wholehearted support. The Government, of course, remain committed to the principle of establishing a high-quality woman-centred maternity service.I was looking for some optimistic signs in the speech of the noble Baroness, Lady Cumberlege, but she was rather bleak about some of the outcomes that she thought had been achieved since her report was published. One can identify considerable signs of progress, although they are not as consistent throughout the NHS as she and I would have wished. However, that is progress none the less. I thought that the noble Baroness, Lady Perry, was very cheery in that respect.
There are examples of fundamental changes. Information and communication to women have improved considerably over the past decade; there is more discussion with women about aspects of their pregnancy care; there is more emphasis on women seeing a smaller number of midwives; and many women carry their own notes. I am not in the least complacent; we need to confront some difficult issues. However, we should not underestimate some of the progress that has been achieved.
On strategic leadership—the fundamental issue of what strategy we have and how we are going to take it forward—the key decision has been mentioned by various noble Lords; that is, the announcement of the children's national service framework in February 2001, including maternity services. In the new architecture of the NHS the setting of national standards through the national service frameworks is just about the most effective way of ensuring consistency of service provision and quality in what is, as the noble Baroness, Lady Perry, suggested, a devolved healthcare system.
We have debated the balance between devolution and central direction. It is interesting that the Audit Commission report, which was mentioned by the noble Baroness, Lady Noakes, found in 1997 that, despite the impetus that the noble Baroness, Lady Cumberlege, gave to the Changing Childbirth report, there was very patchy implementation. I am convinced that if we wish to achieve the right balance between wishing to have national standards, which is absolutely right, and giving room for the service to breathe at local level, the development of the NSF is undoubtedly the way forward. The aim is to set national standards of care and to look at how maternity services can be more flexible, accessible and appropriate. It will also pick up the issue of the commissioning of maternity services and the points raised by the noble Lord, Lord Chan, about establishing the network of maternity services, whether that involves primary, secondary or tertiary care. He rightly pointed to the need for an integrated approach.
We have formed a maternity external working group to advise on the development of the NSF. Appropriately, it is co-chaired by Heather Mellows, the junior vice-president of the Royal College of Obstetricians and Gynaecologists, and by Meryl Thomas, who is vice-president of the Royal College of Midwives. The work of that advisory group is being taken forward through five sub-groups. In a sense, the pathway of those sub-groups covers the point made by the noble Baroness, Lady Thomas, about what she wished to be covered, starting with pre-birth and involving birth.
I accept the points about home births. My understanding is that the figures have risen from 1 per cent in the 1980s to about 3 per cent, according to the latest data for 2000–01. I recognise that many more women would have wanted a home birth but that circumstances made that difficult. Undoubtedly, the NSF will need to look at that. It will need to consider post-birth and baby support.
The points raised about inequalities will also be covered in the national service framework. The noble Earl, Lord Listowel, was right about breast-feeding. The statistics are overwhelming in indicating a huge variation between the different social and ethnic groups in this country. That matter has to be addressed. I shall come later to the issue of caesarean rates, but, as the noble Lord, Lord Chan, suggested, those rates also indicate that some of the same issues arise.
The NSF will also look at the question of user involvement, which I recognise as extremely important. Indeed, as part of the work of preparing and developing the NSF, today my department held a discussion with midwives and users about the experience and relevance of the maternity services liaison committee. I was able to visit the committee for about an hour and to listen to some feedback. Some very interesting ideas were put forward with regard to good practice and the effectiveness of some maternity services liaison committees. Reports of committees feeling that they did not have sufficient support to make an impact were also mentioned.
There is no doubt that the ability of the national service framework to allow us to set national standards and frameworks for the future will be critically important. We shall want them to explore some of the areas to which the noble Lord, Lord Northbourne, referred. The noble Lord made some interesting remarks about how one dealt with particularly vulnerable parents—often young parents. I believe that the initiatives that we have taken in Sure Start plus show some of the ways forward, but we shall need to pick up the points raised by the noble Lord.
We want to explore all the areas which we know are important to women: a safe birth which is as normal as possible; a choice of place of birth, with home birth as a realistic option; appropriate support for women in labour and the feasibility of one-to-one care; improving the support and advice that women need when they are making decisions about how they are going to feed their babies—I very much accept the
need to ensure that the benefits of breast milk are widely known—and the provision of appropriate information, presented in a variety of formats, to assist women and their families to make those decisions.The noble Baroness, Lady Noakes, is always asking me when we are going to publish reports. The first module of the national service framework covering children in hospital will be published shortly. The other modules will follow. I cannot give a precise date for the maternity service module, but obviously I hope that it will be as soon as possible. However, clearly it will take time to ensure that it is as thorough as we would all like it to be.
A number of noble Lords, including the noble Lord, Lord Patel, asked about one-to-one care by midwives. We have already said that that is our aim. The gold standard should be that every woman has access to one-to-one care. It is intended that the children's national service framework will set out how best we can achieve that gold standard and that it will give a timetable for doing so.
The evidence that we have from the midwifery practice audit report for 2000–01 of the English National Board for Nursing, Midwifery and Health Visiting is that the percentage of units not able to provide one-to-one midwifery care to each woman in labour reduced from 28 per cent in 1999 to 22 per cent in 2000; in other words, 78 per cent provide one-to-one care to all women in labour. However, we shall look for further guidance on that from the national service framework.
The national service framework will consider the examples of good practice mentioned in tonight's debate. The noble Earl, Lord Listowel, asked about the Albany practice. Of course, we shall be very interested to know of the experience of that practice and of other examples of good practice.
Before I deal with a number of specific issues which have been raised, I say to the noble Lords, Lord Chan and Lord Patel, that I recognise very clearly the issue of litigation. It goes somewhat wider than the maternity services module of the children's national service framework. But anyone looking at experience in the NHS at the moment has to be concerned about the cost of litigation, and, even more so, whether it leads to defensive medical practice. We are looking seriously at what we need to do to ensure that we move away from some of the current difficulties.
Despite a litany of gloom tonight there are encouraging signs of improvement. I am surprised that no noble Lord mentioned the £100 million capital allocation we have made to over 200 maternity units to modernise the environment. The money that has gone to the service has ranged from large to small sums, but it has all helped to improve the environment.
Good as that is, there is no question that unless we have enough midwives we are not going to get very far. All noble Lords have raised this question. There is no doubt that a great deal of work has to be done to get recruitment and retention up to the standard that we wish to see. We are offering more places for students to train as midwives. I say to the noble Baroness, Lady
Perry, that compared with 1997 there are 226 more training places available. As regards the number of midwives, there has been an increase since 1997 of about 700, although the figures quoted by the noble Baroness, Lady Noakes, are also correct. That shows that we have to increase the effort in co-ordinating a recruitment, retention and return to practice strategy.As regards the question raised by the noble Baroness, Lady Noakes, that funding establishments are too few, we are supporting the use of what is described as birthrate plus, which is an excellent workforce planning tool. Many trusts are now using it. I hope that that will lead them to a more realistic assessment of the number of midwives required.
But if we recruit and train enough of them, we have to retain them. The noble Baroness, Lady Cumberlege, and the noble Baroness, Lady McFarlane, discussed why it is that midwives leave the profession. I say clearly that we do not want midwives to feel that they are either de-skilled or unable to provide the care that they wish in all settings. I echo the wishes of noble Lords for midwives to have professional autonomy, to feel confident in their skills and to be in a position to promote normal birth. I am sure that that is the key to answering the question posed by the noble Baroness, Lady Cumberlege, as to how we should promote normal births. I am convinced that the key is in the autonomy and support that midwives are given, supported by appropriate midwifery leadership in management and with the continued appointment of consultant midwives with responsibility for giving clinical support.
I agree that the more women receive care from a midwife they know the better the care. The issue of one-to-one midwifery is tied up with the recruitment of more midwives into the National Health Service.
The noble Baroness, Lady Perry, applauded the appointment of consultant midwives and then regretted that that meant they were diverted from management and teaching tasks. We have 32 consultant midwives and they are doing excellent work. I believe that our ability to reward high calibre people to stay in practice is excellent. We need more than 32 consultant midwives. As regards teaching, I am very exercised about that, not for midwifery but for clinicians and nurses. It is an issue that we continue to discuss. Between the Department of Health and the Department for Education and Skills a number of new strategies have been launched. But in light of what the noble Baroness has said, I shall ensure that the midwifery teaching issue is picked up.
On management, I could not agree more with the need to ensure that we have strong midwifery management. We know that we have to do more to help heads of midwifery make as big an impact as they can within their local organisations. The Leadership Centre is exercised in ensuring that we do that. In relation to addressing the group of people that I met today within the national service framework, I have said to my officials that we need to think clearly about
how we can help heads of midwifery make more impact when it comes to the trusts' boards making the right decisions for the development of services.That issue is a common one between two governments. I do not believe that we have yet found a way of carrying that out as effectively as possible. I am absolutely sure that having good, strong head-midwifery leadership within each NHS trust is absolutely critical to achieving the right qualities at the local level.
I turn to medical workforce issues. I know that there are concerns in that area. The number of consultant obstetricians and gynaecologists in post has increased by 21 per cent over the past five years, but currently with the college we are exploring expanding the number of consultants.
The European working time directive has been mentioned by the noble Baroness, Lady Cumberlege, and other noble Lords. It is a major challenge. There is no question about that. We produced a circular on implementing the directive only eight or nine days ago. We have a programme of pilot projects in NHS trusts to develop and to test innovative solutions. There is no doubt that that will pose significant challenges on the National Health Service.
That brings us to the issue of configuration. We know that a combination of service and workforce development is having a major impact on the configuration of maternity services. Pressures such as the drive for improved safety, more efficient use of resources, better medical training and the directive have often tended towards greater concentration of services on to a smaller number of sites. But those pressures have to be balanced against local access to services and—particularly in maternity—promotion of normal pregnancies and births without unnecessary intervention.
I have no doubt whatever that we have to achieve the correct balance. I say that as someone who a year or so ago had to deal with the issue of the Hemel Hempstead maternity service, where we were faced with agonising decisions. There is no doubt that we must achieve effective configuration to gain the correct balance. We cannot allow a headway drive into centralisation to undermine so many of the units that are currently in place.
I was asked about the Maternity and Neonatal Workforce Group and when the report will be published. It will be published shortly and it will be taken forward. In the department we are also developing a configuring hospitals project which is picking up those issues, not just in relation to maternity services but in relation to the broader issue of configuration. It will also look at the particular focus of the challenges facing smaller hospitals and at creative options to ensure that the headlong rush into centralisation is not always inevitable.
Of course, I recognise the value of birthing centres and the value of midwifery-led units. I hope that the national service framework will enable us to explore those options and to encourage them further in the future.
On Malmesbury and Devizes, I am assured by the PCT that it aims to modernise services and that no decisions will be made without public consultation. I shall keep an eye on that matter in the light of the comments that have been raised today.
I cannot finish without turning to the issue of medical intervention and caesarean section rates. I accept that the noble Baroness, Lady Noakes, is right to say that the medical interventions taking place do not just cover caesarean sections. The reasons for their increase are complex. Over the past 20 years, technical advances have enabled obstetricians and midwives to identify complications at a much earlier stage, so that appropriate interventions that improve clinical outcomes can take place.
If noble Lords are asking me to say whether I am concerned about the current rates, I am and always have been concerned about them. I have made no secret of that. None of us can say that all caesarean sections are unnecessary. Sometimes they are very necessary. I am also aware of the variations between different parts of the country. However, the absolute evidence needed to draw hard conclusions is not available. That is why we have commissioned the Royal College of Obstetricians & Gynaecologists to undertake the largest ever national sentinel audit.
The initial result of that audit has provided valuable data. The noble Baroness, Lady Thomas, raised the question of choice. That audit showed that 7 per cent of caesarean sections are performed at the request of women. This is a very difficult issue. I do not pretend to have any easy answers to it.
The issue of choice has been raised. It is important, but decisions have to be made by well-informed women with the appropriate unbiased information and in the light of the best clinical evidence available. All interventions must be based on sound evidence. I agree with the points made by the noble Baroness, Lady Greengross, on the matter. That is why we have asked the National Institute for Clinical Excellence to develop guidelines for some of the most used interventions, including caesarean sections.
The noble Baroness, Lady Cumberlege, invited me to set targets for reductions in caesarean rates. She usually tells me that I set too many targets for the health service. I understand why she should want me to do this.
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