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TUESDAY 25 MARCH 2003 __________ Members present: Julia Drown, in the Chair __________ Memoranda submitted by St James's University Hospital, Leeds and Goole Midwifery Centre Examination of Witnesses PROFESSOR JAMES WALKER, Obstetrician, MRS ANN GEDDES, Head of Midwifery, MS CAROL BURNS, User Representative, St James's University Hospital, Leeds; MS KAREN FOX, Team Leader, MS GILL SMETHURST, Clinical Co-ordinator for Midwifery and Gynaecology, Scunthorpe General Hospital and MS PHILIPPA McENROE, User Representative, Goole Midwifery Centre, examined. Chairman: Welcome to you all. Thank you very much for joining us. This is the third of four sessions that we are having with different units from across the country as part of our Inquiry into the different services that women are experiencing across the country, what that means for women services and what lessons that can be learned from that for maternity services - obviously picking up some of the work the Health Service Committee did with the Winterton report, following on from some of the work we did there. We do appreciate you coming, and coming from some distance. to help us with our Inquiry. We are going to be covering data collection, caesarean rates, induction rates and so on, staff structures and the provision of training. So we will go at it in that order, starting off with Richard Taylor on the data collection issue. Dr Taylor
(Professor Walker) Leeds has two hospitals, which comprise the Trust, and both hospitals are slightly different in the computer facility they have. Both are out-of-date and need to be replaced. The main problem with all computer systems I have experience of in maternity services is that they are put into place by administrators who want administrative data, they have not been put in place by people wanting clinical data. So from our point of view it can give us information about the number of people that deliver and certain basic information, but does not give us any clinical information that we can use for audits or care comparisons. We are looking at replacing the computer equipment but the usual resource problems that come into improving computers and buying computers come into play. So there is a system in place, it gives us basic information but it is not nearly as good as we would like it to be and there is a resource implication on trying to get what we want. (Professor Walker) The two systems do not particularly need to talk to each other because they are in separate hospitals. The problem is that there are problems in our delivery computer systems talking to hospital computer systems like pathology results or things like that. That is true in many hospitals. (Professor Walker) About ten years old in St James's. (Professor Walker) Yes. (Professor Walker) We can do some on the computer - basic information; if you want to look at caesarian sections you can get information about who they are. You then need to retrieve case records to get any further information about the individual or we use things like the delivery suite book, but it is going to case records for the final audit. (Professor Walker) What we need is to try and aim for a common data set that we collect around the country. Whether we use exactly the same computer systems is probably less important, as long as they can communicate and can be adapted accordingly. I think each individual unit has different needs, so the one-size-fits-all may not be the best way forward, as long as there is a degree of uniformity across the board. (Professor Walker) We have been working on a common data set for the last 30 years. This is not a new concept, it is a revisited concept. (Professor Walker) It goes in certain directions and then it falls back again depending on the enthusiasm of the people doing it. (Professor Walker) Yes. If it is recommended that it has to be done, then it has to be done. If it is recommended as a good idea then it will be put down the pecking order of things implemented. (Professor Walker) I believe so. Earlier in my career I worked in Scotland where we do have a common data set and it is actually hugely beneficial. (Professor Walker) It is simple and works, but Scotland is a smaller place. Therefore, it is an easier concept to manage a country which is the size of an area. Yes, it is possible and it can be done. (Ms Smethurst) We have been computerised but we are now unable to retrieve any of the data from the computer. (Ms Smethurst) Yes. (Ms Smethurst) We had a maternity information system set up for us and the chap who set it up left and nobody else knows how to get anything from it. The very sad thing is that we are still inputting on to it. (Ms Smethurst) Yes. We have a new maternity information service, hopefully, later on this year across the Trust, which is in three sites, which we will be using. In Goole specifically, we still decided to keep paper records of everything when the maternity information system came in about five years ago, so, thankfully, we still do have good statistics, but they are on paper. It is a register that we keep. (Ms Smethurst) We do not think so, no. Chairman: Why are you still using the computer? Do we need to move swiftly on? Mr Hinchliffe (Ms Smethurst) They are all more or less the same - Hull, Doncaster, York, Scunthorpe, Pontefract. (Ms Smethurst) They would probably choose - if it was a consultant unit - Scunthorpe because then they can have their scans in Goole and there are some pathology services as well. (Mrs Geddes) It is a very good question. Women have the right to choose and some women will require caesarean sections for some very good reasons - others perhaps not so good. I feel our role is to give the information that is required in a non-judgmental way and help them to make that decision. In a unit such as ours, where we have tertiary pre-natal referrals and tertiary referrals for foetal medicine issues, some of these women will go on to have caesarean sections both for their own safety and for the safety of the baby. (Mrs Geddes) I think you have to look in context at the mother - the condition of the mother and the condition of the baby. Not every woman will require a caesarean section but there are some who, for very good reasons, will. Yes, break down the geography of that, but the women's individual needs and her health needs are important as well. Chairman (Mrs Geddes) Probably not. (Professor Walker) If I can come in, if you look at rates across the country you can see differences which you can relate to hard things, like age differences, health differences, and the fact that tertiary units are different to even district general hospitals, and so on, but you cannot explain all the figures for the differences that way. Other differences relate to the attitude within the environment of the women themselves, the midwives and obstetricians. This can be seen not only in our country but in Dublin, where the three different hospitals have huge differences in section rates, and that is because of a philosophy that comes from within the hospital. Also, to some extent, women choose which hospital fits their philosophy, so there are multiple reasons for it. It is not a simple thing that we are a tertiary centre or simply that we encourage or discourage caesarean section; it is a multi-pictorial thing. (Professor Walker) No, I do not think all the differences across the country relate to women's choice; I think women's choice is important but women's informed choice is important. They need to know what the benefits and risks of a caesarean section are. There are complications both in the short and long term which not all people are aware of or are discussed with women before they make the choice. So, yes, you should be concerned, but I think it may not be as major a concern as you might make it. It is of concern why there are differences and if there are ways that we can smooth these differences. If we can reduce it where it is not necessary, that will be of benefit. Mr Hinchliffe (Ms McEnroe) Yes, it is. With my second child I particularly wanted to have a home birth and so I was really looking for low intervention rates in which hospital I chose, so I did choose to go to Scunthorpe if the case arose, and it did do, and that is where I went. (Ms Burns) I think it is very complicated issue. I think I would agree with Professor Walker. We actually had a user meeting in Leeds not so long ago when we had the report of the first stages of the sentinel audit that was done by the Royal College, and in the room users disagreed about caesareans and what their options should be. So I think for some users it is very clear that choice is paramount, as long as the medical conditions are appropriate and it is not an emergency. I think they are very keen to be part of a discussion where it is an informed choice about what the risks might be. That is obviously for situations where you can predict, where perhaps a baby is breech or something like that, if it is in the course of labour. The other thing that users, perhaps, are concerned about is if they do feel that there is a philosophy around when induction takes place, which then might lead to more caesareans, although the evidence in the audit is not particularly showing that. So I think at our meeting what came out was that all the audit information was showing how complicated it was and there was not one reason why - as we had thought before - intervention would increase the caesarean rate. (Professor Walker) I do not think we have tried any conscious effort to put over our philosophy. I think we do, as a unit, believe that vaginal breech delivery is something which we would support and encourage, and so on. We probably find more often that the women do not want to go ahead with these things rather than us telling them that they cannot. So I think there may be differences in that way. Also there are differences in the women who we look after compared with, particularly, it would appear to be, further south in the country, where people come with a different philosophy to the hospital. It is a combination of things; it is not just a philosophy we are directing, to some extent we will also follow the feelings of the what the women who come to us want. It is a mutual thing. (Professor Walker) Yes. I actually chaired the caesarean audit to the national audit, and that came out of similar audits we developed in Scotland before I came south. So it is a philosophy that I have always had. We do not have the computer system that allows us to review it on a regular basis, but we do have ad hoc analysis of emergency sections, why they are done, how they are done and what decisions are made, etc. So we do do that and then try and put in guidelines for practice and then re-order it. Dr Taylor (Professor Walker) There appears to be, to a degree. It is not a divide, like a wall, at some point such as Watford or something. There is a difference of a few percentage points, for instance. The National Sentinel Caesarean Section Audit showed that more women in the south were requesting caesarean sections than in the north, but you are talking about a 1 or 2 per cent difference, you are not talking about huge differences. These things all help to influence. If there are more people requesting, then the hospital themselves will develop a philosophy that changes slightly. Everyone influences everyone else. It is not one particular group which is pushing it; I think there are multiple reasons why philosophy changes. Andy Burnham (Professor Walker) I think all people within maternity services are aware of litigation at the current time because there are increasing amounts of it. The question you ask is one which is always asked and one which we ask ourselves; the problem is it is very difficult to find evidence that might support that. What evidence there is, certainly from the United States, is not particularly supported that decision-making is necessarily driven by litigation concerns, but common-sense would say it has to have some influence on it. There are other factors as well: the operation itself is now safer than it was 20 years ago, and I certainly know from my own practice that 20 years ago we strove far more not to carry out caesarean sections because of the risks to the mother. The risk to the mother is now less, therefore your threshold changes purely because the balance of risks and benefits has changed. Litigation must come into that equation. (Professor Walker) Yes, we do, but what is interesting about the evidence is that when you ask women whether they were involved in the decision-making, women who have an emergency caesarean section always say they were involved in the decision-making more than women who have an elective section, for instance. I find that quite bizarre. What they really mean is that someone comes up to them and says "If we do not deliver your baby it is going to die", they say "I agree" and that is involvement in the decision-making. The problem we have got is that in an emergency situation there is often a stress both from the staff and from the women themselves, but communication is actually very bad at that time. I think that no matter how hard you try, I do not think you can have a sensible, unbiased conversation. I agree with you and with what Ann was saying earlier, that what we should be doing is giving people information to make the decision for themselves. In an emergency situation that is very difficult. In an elective situation there is far more time; people can go away and think about and come back and ask for more information, and so on. (Professor Walker) That is a great question which we have debated endlessly for years. An elective really should mean that it is a decision you have elected to do, which you do not need to do. Whereas normally we describe an elective as being a cold section, meaning someone who wants it on Tuesday morning, an emergency is thought of as being someone for whom a decision is being made at the time in the hospital and the decision to deliver has to be made now. That can be "We need to deliver you within the next hour" rather than in the next five minutes, but the terminology of elective and emergency is actually very hazy. (Mrs Geddes) I think, in common parlance, for women, an elective is something that you decide before you go into labour. Elective is something where your consultant says to you "There are some issues as to why", whereas an emergency is something that happens. (Mrs Geddes) For users I think it means one thing. I think the issue about elective, when is it necessary and are we choosing a caesarean for reasons other than medical, has to be clear. Chairman (Ms Smethurst) We provide one-to-one care in labour, and so I could not really comment on that. (Ms Smethurst) I do not think you could predict that, no, because it would depend on other factors as well, as to whether the women was at high-risk or low-risk and other things that would make them need a caesarean section. I am sure support in labour on a one-to-one basis is extremely important but whether it has a huge effect on caesarean rates, I would not like to say. (Mrs Geddes) There is a lot of evidence to support that it can. One of the difficulties that we face in a big unit is that some days you could have 25 midwives on the delivery suite and there still would not be enough. The challenge is to control the work flow, which can often be quite difficult. (Professor Walker) I think, as I said earlier, I think the environment where you work affects both how you practice and, also, to some extent, the women. You cannot separate this. I think there are obvious differences in the way people practice from the north of the country to the south of the country and from Scotland into the north of England and from the north of England down. There is also a different philosophy. I found that obstetrics has a far higher consultant input, say, in Scotland to the north of England, compared with if you go further south as well, of the level of importance that is put on the process, I suppose, from a medical point of view. There are differences in philosophy. It is very difficult to take out one thing and say "That is the reason why there are differences". There are so many influential factors. (Professor Walker) Women's choice is something which came from a different direction than was intended, from the point of view of caesarean section. Choice in medical practice does occur all over the place. If you look at trends in things like tonsillectomy, for instance, there is a lot of parent choice and demand which influences whether these operations are done or not, not purely on medical grounds. I do not think obstetrics is the only area where patient choice or women's choice influences it; there are other areas of fashion that go in and out. So that it is not purely that, but it is an important factor. The reason it has become more important is the fact that the operation has become safer, so therefore the aspect of choice becomes more of a real thing. Twenty years ago the choice was not there. (Professor Walker) Yes. Mr Hinchliffe (Professor Walker) The first one is an audit decision. In our practice we have a regular audit programme and there is a consultant in charge of the obstetric audit who will make decisions on what audit is done at any given time. Then people, usually junior members of staff, are involved in getting that audit together and putting it together. We then sit and listen to the audit, and policy decisions made as a result of that audit are then decided by the consultant body. If it is a decision relating to midwifery as well then they are involved in these guidelines. As far as decision-making about induction and caesarean section are concerned, that varies in lots of various ways. Induction, to some extent, probably primarily follows a hospital policy; so they may say "Well, routinely induce at term plus ten or term plus twelve, unless there is a reason to intervene before or the women does not want an induction". So that could be laid down. So decision-making could be made by relatively junior members of staff along these guidelines. If someone has a medical problem then the decision to induce will tend to be at consultant level. At caesarean section decision-making, it is a very difficult one to try and decide who made a decision. The consultant may have been notified that it is being done, but in general a good registrar will have sold the story well to the consultant on why it is required, so the consultant really will over-rule that. The other thing is, if it is an emergency, if the consultant is not there, then it is potentially putting that mother and baby at risk for ten or fifteen minutes for the consultant to get there - if it is a dire emergency. That goes towards the argument for having consultants present on labour wards, so that decision-making can be made by the most appropriate and senior person at the time. (Ms Burns) I think there is some evidence to show that the experience of the person who makes the decision is significant, and your experience of what is a difficult labour is going to have an impact. The whole push for consultant cover - although there are difficulties about the funding of that - is significant for users. (Professor Walker) I think there are hospitals throughout the country that have good practice and there are hospitals throughout the country who have better practice than we do, in some areas. I think one way of improving maternity services would be to share good practice, so that we do not reinvent the wheel all the time. I think the importance of this form of audit is that it is done in a non-judgmental, informative way. One of the problems in a lot of hospitals is that review of practice is done in a judgmental way, of blame. As soon as blame comes into it - "You should not have done this" or "This was wrong" - then people stop buying into the audit. It needs to be done in a regular, no-blame, way so that the information can be fed back to people so that they can learn from the information that is collected. It needs to be repeated, just to make sure that if we do implement change we are doing good - we actually might be making things worse. (Ms McEnroe) I think it is given to you if it is relevant to your situation and you are part of making the decision then. I do not feel it is taken out of your hands, I think you do have a say in the decision that you are making. The information is there if you ask for it. (Ms McEnroe) Yes. (Ms McEnroe) If you are having a normal pregnancy and it did not arise, then I do not think you would need to know. (Ms McEnroe) I went to parent craft classes for my first child and I think it was covered, but until the time of your actual birth then you do not know how things are going to go. (Ms McEnroe) Everything was covered in relation to caesarean. It was all covered, yes. (Ms Burns) My personal experience is a lot longer than 15 years, so I am talking about users that I am in contact with. On the basic issue of information, it is one of the commonest criticisms that comes back in feedback - and we have had a full-time worker on our project doing involvement work, particularly with hard-to-reach groups - that they did not get enough information when they wanted it and when they needed it. They felt that this issue of being fully informed was sometimes hard to achieve, really. Although I agree with some, I think it is a very fine balance. I think some users would say "Well, I do not want to know about caesarean section because that is if something goes wrong and I do not want that when I am three months' pregnant". I think it is very complicated and there is a balance between the individual women's needs and providing the information. In Leeds we have explored a variety of things, including a video which people can access in bits when they need it. There are information packs that people get. Even so, we still get a lot of feedback. I think that interaction, particularly because most of our bookings are done in the community with community midwives, and relationship between the midwife is crucial, really. I am not sure that people do get the information that they need, overall, when they need it. If English is not your first language then I think we have got huge issues of communication and resources to support that, and I think we are struggling. Although we do have a very good project in Leeds which tries to address that, I think there are still huge issues. Dr Naysmith (Mrs Geddes) We do not have any difficulty in Leeds in recruiting staff. We are very lucky that we have a feed-in institution from Leeds University who train 40 midwives a year. We do have a retention problem because people tend to come and stay and not move on; therefore, the opportunities for promotion are few and far between. What we have been trying to do is look at retention issues, about how we can encourage people to stay by developing new skills and extending the midwife's role. (Mrs Geddes) No. (Mrs Geddes) It is difficult. Obviously, when people have had a few years in the profession they are looking for promotion - because we all do that, do we not - to further their career. (Mrs Geddes) That is right. (Mrs Geddes) We are okay, in terms of the staff that we have. The difficulty is getting sufficient numbers and sufficient funding. (Mrs Geddes) That is right. I am aware of that, and I am very lucky compared with other places in the country. Andy Burnham (Mrs Geddes) There is more demand than there are places available at Leeds University. We work very closely with Leeds University in terms of our recruitment and there are always more recruits for the programme than there are places. (Mrs Geddes) They could be providing more but that comes with the funding stream, of course. Dr Naysmith (Mrs Geddes) No, because we are very flexible in how we allow our shifts to work. We obviously have to comply with the Working Time Directive but I have midwives who work one night a week, two nights a week, three days a week, etc. We very carefully plan it because we understand the parameters of the Working Time Directive. We have done a lot of work to make sure we comply. It is very difficult to expect a midwife to be looking after a woman 12 or 14 hours later, because she is not going to be sharp, she is not going to be of any benefit to that woman. So we have done a lot of work to make sure our shifts are flexible. (Ms Smethurst) I would say the same. We do not have a recruitment problem in our area. We have students from Hull University and those courses are over-subscribed as well. Dr Naysmith: Why do you think it is that in the South they have so many problems in recruiting people? Mr Hinchliffe: Yorkshire is a much nicer place to live! Dr Naysmith (Ms Smethurst) No. (Ms Smethurst) In Goole we work very well with the GPs in that they have very little input into the maternity services. They were quite happy to reduce their input some years ago, and we have good communications with them. They let us know if we need to know and we let them know, but they do not actually see the women any more. (Ms McEnroe) Yes, I am. When you are dealing with the midwives there is no real need to see your GP. (Ms Smethurst) I think the GPs support the midwifery services by their absence, if you like. That gives the women confidence. (Ms Fox) GPs are not always aware of the choices available to the women, either. Things change. We keep up with the changes, the GPs have enough on without keeping up with changes in maternity services. So it is much easier for us to keep up with the maternity service because it is a very small part of a GP's case load. They will refer the woman to us or the woman is self-referred to us and then we will give them the information on what their choices are. (Mrs Geddes) Very similar. We work very closely with the Primary Care Trusts and the Primary Care Teams locally at the surgery to involve the midwife in the decision. Obviously, the patient is going to be a pregnant women but she is going to need other primary care services. So the communication, particularly in some of the more difficult areas, is very, very important. Chairman (Mrs Geddes) We provide a home birth service in Leeds. (Mrs Geddes) We deliver just over 8,000 deliveries in the city and we had 70 home births last year, so it is just less than 1 per cent. We work very hard through our maternity services liaison committee to clarify the role of professionals at home births, because we found that women were experiencing a lot of conflict, in that they went to the GP, where they would never allow you to have a home birth, whereas the midwife would support that. We worked very hard to produce a document which clarified each person's role, including women who were requesting a home birth. That has gone a long way to actually breaking down a lot of these barriers. (Mrs Geddes) We have many GPs who would not support it. (Ms Burns) I think that would be where the move from GPs having very little involvement is actually significant, because they can influence the decision about home birth. We have certainly been talking in Leeds about how we can improve the information that we give to women. For example, you can change your GP while you are pregnant to one who supports a home birth. The first contact that women have, even though the midwife is very involved, may traditionally be with their doctor, and so get the message that home birth is not supported. Although I do not think there is a huge group of women who want home births, we suspect there are more than are having them at the moment, and that there is some work we can do. (Ms Fox) The GPs just refer to us. If a woman goes to a GP and says "I want to have my baby at home" they will just say "Go and talk to the midwife", which is the way we want it. (Ms Fox) We do not have any problem with any of my GPs, no. (Ms Smethurst) But we do not expect anything from them either for a huge part of the care. We would never call on a GP in an emergency, and I think that over the years they have come to understand that. When we first started promoting home births more, about three years ago, I think some of the GPs were worried that they were going to get called to deal with things that they could not deal with. Over time, they are now confident that we are not going to call on them. (Ms Smethurst) Yes. (Ms Smethurst) Last year we had 16 per cent of women delivering in the community - that is both at home and in the midwife unit. Dr Naysmith (Ms Smethurst) There is in a small service like ours, because there are only seven midwives each carrying a caseload, so the women know who their midwife is; they see her at every contact and if they ring they ask to speak to her. We cannot guarantee that in labour it would be that named midwife but it would be two of the seven midwives who will attend in labour. Post-natally, we aim that the main midwife plans with the women the post-natal visits, so that it is the same one going. We did do team midwifery for a while but women in our area - we surveyed them - did not want a team of midwives, they wanted continuity antenatally and post-natally. (Ms Smethurst) Yes. (Mrs Geddes) We try very hard to maintain continuity for women. We are very open with women that we cannot always guarantee that during delivery because it very much depends on how long the delivery goes on for. We are very conscious of the fact that we need a midwife to be sharp, not over-tired and able to give good care to the women there, but we would do that in conjunction with the woman. Many of the midwives will stay on after their shift, or at home, to deliver a woman if the delivery is imminent, but if it is hours and hours away it is not good for anybody. We tell women about this and we try to make sure, particularly for home confinements, that they will have one of four women to help that delivery. Dr Taylor: I have a question on the Working Time Directive, specifically to Professor Walker, because other people have told us that it is a killer from the medical point of view. Chairman: We will come back to that. Dr Naysmith (Ms Smethurst) Last year there were 30 at home and 24 at the unit, but the unit was closed for six months last year because we were having a birthing pool installed and we had some problems with it. So that was the figure for six months last year. (Professor Walker) In our unit, which has a range of women from low-risk women to high-risk women delivering, what we try and do is have that graduated involvement, depending on the risk of the woman. Women who are low-risk are seen largely in the community by midwives, they come in in labour and they are looked after by midwives and, therefore, managed as far as possible as low-risk women looked after by their midwives. Medical staff can be asked to review or be involved without the need of them being removed from the midwife. I am a great believer, personally, that if a woman starts having problems that is when she needs her midwife most, in fact, and the idea of her being removed from a low-risk to a high-risk environment is wrong. There should be some sort of graduated system that medical staff can be involved as little or as much as is required, but midwives need to be involved continuously all the way through. We try and get that balance. (Ms Fox) Yes. When the patient first comes to us we access the medical records that we might have and have access to the GP's medical records. Talking with the women we can decide between us whether the pregnancy is going to be classed as low-risk or high-risk. If it is low-risk she will stay purely with the care of the midwife; if it is classified as high-risk, or if anything changes through the pregnancy and it is felt that medical intervention may be needed, then we refer to the consultant, Mr Young, who comes out to Goole, but they still continue with the same named midwife but they will also see the consultant at the same time. Because the consultant clinic is run from a midwifery centre in Goole Hospital it is midwives that run it with the consultant. We are very closely involved there. (Professor Walker) It is not just the problem of the hours of work, there are multiple factors affecting the staffing from a junior level. There are the hours of work but there are also the new training requirements that take them away from clinical practice on a regular basis. It is interesting if you look at the numbers of juniors now compared with ten years ago, there is not much difference, it is the fact of what they are doing now which is different, and they are able to do less of the hands-on clinical work they did previously, which makes it very difficult to have the same cover that we used to have at junior level. The problem from a consultant point of view is that it is difficult for them to take up that load because we have not had the consultant expansion. The difference is across the two sites in Leeds. On one site we have 40-hour cover in our labour ward because we have the consultants who have been appointed to actually do that, but the other side of the city does not have it because we do not have the consultant staff there. By having consultants present on a labour ward you can help to reduce the problems of lack of junior staff. Mr Hinchliffe (Ms Smethurst) It was 30 births at home out of 434. (Mrs Geddes) Eight thousand. (Ms Smethurst) One of the things that restricts midwives working in the community at the moment is prescribing, prescribing routine things, and that is got round in various ways, and there is extended prescribing, but I think it could be made a lot simpler for certain restricted things - antacids and things like that. (Mrs Geddes) I think there is a role for a different type of professional. To try to put it into context, we had 70 home births in Leeds last year. We have 70 community midwives who work in the community in Leeds. That is, on average, one per midwife per year. The skill of the midwife is changing because of the lack of home confinements, but there still is a need for that there, and I think there is a real opportunity for a new practitioner - whatever you want to call it - to support these women who request that service. Andy Burnham (Mrs Geddes) It is a very good question, and it is one I have never been able to get to the bottom of. I believe there are women who request home births who fall down on the hurdles that they ----- (Mrs Geddes) Yes, I would consider it is. Dr Taylor (Ms Fox) Yes, because we were a lot busier the year before. (Ms Fox) Yes. Chairman: You might want to send us your data for the year before. (Ms Smethurst) As well as that, there are two midwives at every birth, so as well as the midwife who is attending the woman, you have also got another midwife there who is getting the experience of being with a woman in labour and seeing things; so you can double that really. We also do quite a lot of intra-partum care for women who then go on to deliver in consultant units - women in labour who do not want to go into hospital too early. (Ms Smethurst) That is from Goole Hospital. The ambulance site is at Goole Hospital from the Health and Home Unit, but not for home births, no. (Ms Smethurst) For home births? (Ms Smethurst) Yes. The ambulance station is on site. (Ms Smethurst) No. Chairman (Ms Smethurst) I would just ask they why. (Ms Fox) They should develop the skills. We did; we all started from the same level, so they should develop them the same. I think Leeds would agree with that. (Mrs Geddes) Definitely. Dr Taylor (Professor Walker) Although we have tried to move towards multi-disciplinary training, we have not really managed that to the extent that we would like to for various reasons. It is partly because medical students but also junior doctors have to train in a wider range of things than just obstetrics alone. We try and have as many combined postgraduate meetings as we can, but we have not achieved a great deal of joint training or communal training, although we have tried that. It is separate at the moment. (Professor Walker) Yes, we have postgraduate meetings with the midwives and junior doctors and other doctors. The main problem with that is getting release of the midwives, in the same way that we have now managed to get the release of the doctor. That has been legislated for in relation to doctors, but not for the midwives, and so they have less ability to get to them. (Ms Fox) There are three sites of the Trust, because it now covers Goole, Scunthorpe and Grimsby; so there are training days organised across all three sites. You can apply to attend any one you feel you want to attend. There are mandatory training days for things like emergency obstetric procedures and CGT training. Then we organise that in Goole, so instead of seven of us going on a training day in Scunthorpe, there will be one person from Scunthorpe coming to Goole to do the training. It is much more cost-effective. (Ms Fox) Not usually. Usually, it is just midwifery staff. Chairman: Thank you all very much for coming; you have given us a very different picture to that given to us by some of our other witnesses, and it is very useful to see the different experiences for you as staff, but also for the woman and the babies in your areas. Memoranda submitted by St Mary's Hospital for Women and Children, Manchester, and Trafford General Hospital Examination of Witnesses
MS KAREN CONNOLLY, Head of Midwifery, DR TRACY JOHNSTON, Clinical Director for Obstetrics, MRS ALEX SILVERSTONE, User Representative, St Mary's Hospital for Women and Children, Manchester, MS ROSEMARY CONNOR, Head of Midwifery and Service Manager, MR ANTONY NYSENBAUM, Clinical Director, Obstetrics and Gynaecology and MS CLARE HODGSON, User Representative, Trafford General Hospital, examined. Chairman: We will be going through a similar format with yourselves. We want to cover as many areas as possible but also get into other areas. I am particularly conscious that we did not deal with breast feeding in the last session, so we have to try and sneak that in at some point. Richard will start with data collection. Dr Taylor (Ms Connolly) We have a comprehensive maternity services information system which was originated in 1987 for one particular consultant; and then it was implemented across the maternity unit in 1997. It collects specific data from the outset of booking, right through to the postnatal period. We do get our annual statistics from that system, and all deliveries are put into the computer and outcomes; so we can get annual reports and monthly statistics. We also have the patient administration system, which collects the episodes of women who come through the service. Only in the last 12 months have the two talked to each other, but only in a minimal way just for the demographic details. We are still having some teething problems, so we are trying to get combined data. (Ms Connor) Yes. (Ms Connor) I could not say how old the PAS system was because it has been there as long as I have been there, for the last twenty years; but the updated version of the computer system for maternity information was updated in 2001, but prior to that in 1997. (Ms Connor) Yes. I have not been involved directly but I would support that because at the moment it is very difficult to compare data from different units if it has been collected in different ways. For example, in recording things like a "born before arrival birth" everybody has different definitions. When you try and compare them you find that they are slightly different, so we do need agreed data. (Ms Connor) Not very often, I would say. We have a midwife who is responsible for that overall system, and she talks with the company that are based in London. If we do have any problems, we have a help line that staff can ring throughout the day, and also internal systems at night. (Ms Connor) We keep birth registers and individual medical records, but we do not duplicate. (Mr Nysenbaum) We have paper records of the birth register that our senior labour ward midwives use to create data - and that has probably been running for ever. We have a computer system that was created internally a couple of years ago as a module of PAS, and it enables us to collect data and to print out maternity discharge summaries, but as yet it has not allowed us to access all the data that we are putting in. We have a shortage of people in the computer department, and prioritisation I am afraid is very low. The first information we extracted off it successfully was yesterday, when I waved the sledgehammer of the Commons Select Committee at the computer department, and they managed to print off how many inductions we had last year. So there is a wealth of information, but we have no means at all of accessing it. (Mr Nysenbaum) Yes, and the funding to pay for it. We have the expertise there. (Mr Nysenbaum) I am not sure whether it is a good thing or a bad thing, but it certainly has the information on it, and it appears to be fairly straightforward to access it, if you know how to use it. Certainly within half an hour of asking for some information, it was e-mailed to me. It is clearly there, and it is accessible. I think that every unit must collect the same data, though. It seems absurd that we have hundreds of different systems running. (Mr Nysenbaum) Yes, which we created for our own use. (Mr Nysenbaum) Yes, absolutely - and it is purely cost that meant we had to develop our own because we could not afford to buy other commercial systems. (Mr Nysenbaum) It is access to it as well. It is housed - I cannot access it from my own PC, for example; we have to go through the computer department to get it; but they assure me that it is possible if someone can work on it sufficiently to enable us to access it; so I think it will be possible. (Mr Nysenbaum) No, no, it does not talk tome. It does not talk to anyone at all, except for the Chief Executive periodically. Dr Taylor: It is absolutely scandalous - amazing. Chairman (Mr Nysenbaum) Yes. There is a wealth of information there. Mr Hinchcliffe: We had a discussion with the witnesses in the first session, but I would like to know why there are such marked differences. We know the differences between your own rates: St Mary's is 16.6 per cent and Trafford is nearly 26 per cent, the national average being 21.5 per cent. I am not aware of the geography involved here. How would you explain the marked differences in the rates within Manchester between the two? Chairman (Dr Johnston) The caesarean section rate for St Mary's last year was 18 per cent not 19 per cent. Mr Hinchcliffe (Dr Johnston) The section rate for St Mary's last year was 18 per cent, and unfortunately year on year we have seen a 1 per cent increase in our section rate. Four years ago it was 15 per cent. That is something we obviously take very seriously. St Mary's serves a central Manchester population that has a high social deprivation index. (Dr Johnston) In central Manchester. It is a city centre hospital. As I say, we have a very socially deprived population but we are a tertiary unit and only 50 per cent of our workload is from our own district residents, so 50 per cent of the work we do comes from our local DGH population, and the other 50 per cent of our work is tertiary work and work that comes from outwith our own area. If you look at the caesarean section rates for other tertiary units, they are very high, and they will always justify that by saying, "it is because we are a tertiary unit; we have got a high-risk obstetric caseload". We have got a high-risk obstetric caseload as well. If you split it into elective caesarean sections - and I listened to the argument about women's choice and maternal request caesarean sections - they would all be elective caesarean sections. Our elective caesarean section rate has been stable at 6 per cent for the past few years; that has not gone up and it is an increase in our emergency sections that is contributing to the rise. That is where we are trying to target work to try and bring that back down again. As far as maternal choice is concerned, choice is only choice if it is informed choice. We do get a lot of women requesting elective caesarean section, and with each of these women we sit and talk to them and find out what it is they are frightened of; and the vast majority of them are scared about something with labour and delivery. With good investment antenatally, with obstetric staff and midwifery staff, I would say that over three-quarters of these women will change their minds and then go for a vaginal delivery afterwards, and be very, very satisfied with that. That requires a lot of time. That would take me two hours of clinic sometimes to talk to somebody about that, but I see that as important - as a consultant, that is what I am there for. The other reason I think that we have got such a low section rate for such a busy high-risk unit is that we have a massive consultant presence on the labour ward. We have got 40 hours of dedicated consultant cover. That does not include annual leave. If colleagues are on annual leave, we then have to cancel other sessions. For example, I would cancel a scan list if I was going to be on the labour ward; so you are not trying to be in two places at once and you are genuinely on the labour ward. Caesarean sections do not happen in our unit without discussing with the consultant first, unless it is something like a cord prolapse and it is a case that you need to get on with it. But they would still phone us from theatre, and say, "I have got a cord prolapse; we are in theatre and we are carrying on". There is not a decision for section made without consultant input, and to say that a registrar can sell it to you over the phone - it is not that uncommon to take a woman out the anaesthetic and say, "I am sorry, you do not have an indication for section there". You talk to the woman and you can reverse the decision. That is not ideal, but I think it is better than putting a woman through an unnecessary caesarean section. (Dr Johnston) It depends. I am sure that in many units there is less effort made. If a woman says, "I want a caesarean section" some people say, "Okay, that is fine; if that is what you want, we will do it." If you go through and talk to them about the risks of caesarean section compared to normal delivery, and present them with the evidence as it stands, find out what it is they are frightened of, get their midwife involved and all the support they need for that - as I say, three-quarters of these women will change their mind. The vast majority of them are very happy afterwards that they changed their mind, even if they end up with a section - they are still happy that they have given it a go. There are still women who will say, "that is fine; you have given me all the information; I have thought about it and taken it on board, but I want a section" . Your hands are tied, but that is fine - the woman's choice is there and you can support that. Andy Burnham (Dr Johnston) Yes, and bear in mind that in our unit we have got dedicated obstetricians. We are not gynaecologists that send most of our time doing gynaecology, but calling the labour ward because we have to and that is part of our job description. We have got dedicated obstetricians that run the obstetric service, and we do not do gynaecology - and that is unusual; you will only get that in tertiary units; you are not going to get that in DGHs. Because of that, our whole philosophy is geared towards midwifery and obstetric care. It is not so much that we will not do caesarean sections at any cost, but it is very much a case of promoting normality, minimising unnecessary intervention, but taking the women with us and making sure that they are involved in the decisions that are made. (Dr Johnston) I do not think it is the no win/no fee and I do not think it is the litigation side of things. I think everybody is hard pressed to find two hours in a clinic to counsel somebody about a maternal request for caesarean section. It is difficult. People do not have that time. Units still do not have dedicated consultant cover in the labour ward, and if you leave the decision-making to junior members of staff, particularly the juniors we have got coming through now that do not have the experience that we had as juniors, because you spent hours and hours on the labour ward - you are not allowed to do that now. (Dr Johnston) Yes, I think that is a factor. If you do not have the expertise and you are not confident in your decision-making, you will err on - you know if you deliver that baby by section now, it will be fine and it is all over, and you can go to bed and that is fine. If you have the expertise to say, "no, it is not a completely normal CTG but I am happy with it and we will push on" - if you have the confidence, because you have got the clinical skills there, then you will do that. (Dr Johnston) It is very difficult to pick a figure out. I would like to say that 15 per cent, the way we were before, is good, but I think you need to be able to justify every intervention. That justification may be through maternal choice, but whatever it is you need to have sound evidence to justify why that intervention was performed - and the rates will vary depending on the case mix and population. Dr Naysmith (Dr Johnston) We are a tertiary unit. We have got the regional sub-specialty for fetal and maternal medicine within St Mary's. We have got the university department of obstetrics within St Mary's, and that obviously attracts the sort of people that want to do obstetrics. The vast majority of people are trained in both obstetrics and gynaecology, and as you get on gynaecology is by far and away easier because you are not phoned during the night; you are not in the labour ward twice during the night when you are on call. There is also not the private practice. (Dr Johnston) Yes, I think they are genuine, yes. Dr Taylor (Dr Johnston) In university departments you will have obstetrics and gynaecology there, but you will find that there is more and more sub-specialisation. In my unit, we have got seven obstetricians but there are eleven or twelve gynaecologists that do the oncology and urodynamics, that do not do any obstetrics; so in a tertiary unit you have the ability to be able to sub-specialise like that because you have the staffing to support it. If you work in a DGH where there are only five consultants, you cannot split because you would end up with two doing obstetrics and being on call every second night. (Dr Johnston) In terms of? (Dr Johnston) Yes, I think in most of the tertiary units you will find there are some dedicated obstetricians - not all people. We still have a couple of folk that do obstetrics and gynaecology They are very much in the minority. Certainly, in terms of on-call, you are either an obstetrician or a gynaecologist, so you have a bent one way or the other. Mr Hinchcliffe (Mr Nysenbaum) The current figures are 24 per cent, so we peaked at 26 per cent and we are heading downwards now. The population profile in Trafford is probably better than that at St Mary's in relation to social deprivation. We have got a couple of pockets of severe deprivation, but it is mostly fairly well off in comparison. It is almost exclusively Caucasian. If you look at the caesarean section rates around the north-west, the big difference is between the ethnic mix of patients delivering. Those with a high number of ethnic minorities have a much lower caesarean section rate; so if you look at the two hospitals closest to us, one has a section rate higher than ours at 27 or 28 per cent, so they are dealing with a very local type of population. That may or may not be a factor, but it is certainly very noticeable in the north-west. We have traditionally had colleagues with high levels of intervention, and we would find it extremely difficult to drift it down again. We have had two major interventionists for some years, and by means of audit we have been able to identify that and we are beginning to get on top of it. That is one of the causes. Because we have had a high caesarean section rate, we have a high number of women coming back having had a previous caesarean section; and they need to have careful discussion about mode of delivery. As Tracy said, if you spend time with them, most of them will opt for aiming for a normal birth - successfully. It does take time, and it takes a wish to direct them in that direction. Andy Burnham (Mr Nysenbaum) The vast majority of women that have had a caesarean section - it is safe for them to aim for a vaginal birth the next time round. Between probably 50 and 80 or 90 per cent will opt for a normal birth next time round; but someone who had a bad experience, however carefully you talk to them, will not wish to end up that way again. Some women may have an absolute reason for recommending it. (Mr Nysenbaum) Not at all, no. Even in the States, where they started it off, people are often recommended to attempt a normal birth the second or even third time round. That is certainly part of the philosophy we try to engender, but it does not necessarily cover all obstetricians in any given unit. We are a small unit with four obstetrician and gynaecologist consultants; we both do both things, and people have a different commitment to how much effort they put into each. (Mr Nysenbaum) It varies quite a lot between obstetricians, not necessarily younger or older. Mr Hinchcliffe (Mr Nysenbaum) No. (Dr Johnston) I do not think there is. I have male colleagues that have exactly the same philosophy as their female colleagues. Chairman (Mr Nysenbaum) Very much. It is an issue of background and what you consider to be correct. Not all obstetricians around the country have the same views as others, and that does direct what happens a great deal. Dr Taylor (Mr Nysenbaum) No. (Mr Nysenbaum) Yes, unquestionably. (Mr Nysenbaum) We were delivering 800 a year when I went to Trafford in 1986, and now we are delivering almost double that. While a lot of units round the country have seen their births decline, ours continued to remain static. They rose, and hopefully they are not plateauing and may well go up again. The difficulties we are going to have will be issues of staffing. That will be a very serious issue over the next year and a half. (Dr Johnston) That is an issue in our area now. (Mr Nysenbaum) It is a national issue. Viability for births - unquestionably. We are surrounded by large units, and patients continue to choose to come to our unit for whatever reason. You can hear from Clare why they come to us. I think we are viable. Mr Hinchcliffe (Ms Hodgson) I personally did not have any experience of caesarean or a caesarean being suggested, but it was covered in the antenatal classes. Obviously, had it arisen, I would have been consulted about it. I am quite confident that the options would have been gone through with me in some detail. (Ms Hodgson) I am not really sure actually. (Ms Hodgson) No, it is not something I have been able to get a handle on really, not having known very many people who have had caesarean sections. (Mrs Silverstone) I work in the unit as well with the women, and I think a lot of it is that they have easy access to consultants, and the consultants do sit with them and talk to them. They explain it. They do not talk them out of it. There is definitely informed choice. In labour, I have noticed very much in St Mary's, because there is virtually 24-hour consultant cover, that the staff are not fighting to phone the consultants up in the night. That is a very, very important thing. If you presented with somebody in labour and you are not sure, if you feel confident to phone the consultant, that must be positive down the levels. It is explained to the woman and the patients, and they are listening to them. If she is very worried - she might have had a very traumatic experience the time before with a caesarean - they will listen to her and will continue to listen - it is not just that one point at the beginning; when she goes back again she is listened to and supported. (Mrs Silverstone) Yes. I think this is much more important, what goes on in the unit - continual support and counselling from registrars, in-house officers and the midwives themselves. Andy Burnham (Mrs Silverstone) Yes. (Mrs Silverstone) Yes. Chairman (Ms Connor) I think a lot of the decision-making about caesarean sections depends on the experience and confidence of the obstetrician dealing with the case. We do not have the same consultant cover that St Mary's has, and I think it is extremely difficult when you have got a crisis. Our elective caesarean section rate, which is what Tracy was talking about, in clinic when you are talking to people - ours is 8 per cent but it is not vastly different. The main difference in ours is the emergency caesarean section rate, and that of course is a decision taken when the woman is in labour. That decision is taken by the obstetrician that is on duty at the time, obviously in consultation with our consultants; but if you have junior staff or inexperienced staff, or people who are not even very confident - and we were talking before about the difference in consultant decisions - it takes a lot of confidence to stand back and say, "no, we will do a fetal blood sampling and wait and see how it goes". If people do not have that confidence, then they are much more likely to go to section in the first instance. (Ms Connor) I think that is true. (Ms Connor) There are many cases where there is no question that it is an emergency situation, where there is a cord prolapse or you have a persistent bradycardia or something - you would go to caesarean section. That is what the NICE guidelines are saying and that is exactly what you do. But there are some cases where it is a grey area, where it can be managed more expertly by somebody who has experience and confidence, and they can guide the more junior members of staff and midwives to manage that case. It may well end up at caesarean section at the end of it, but caesarean section would not be the first option. (Ms Connor) It is very hard to retrieve from that situation if a more senior person comes in, if that discussion has taken place. It is that sort of situation that might well be handled differently by a more experienced obstetrician who would have a different slant on it, and would inspire confidence not only in the patient but in the rest of the staff to monitor the situation. A percentage of those would end up delivering vaginally. Mr Hinchcliffe (Mr Nysenbaum) We audit. (Mr Nysenbaum) Yes, we audit in two different ways. We have had for probably a few years a regular meeting when we look at the emergency caesarean sections of the previous week, where one of the obstetricians - the labour ward lead will go through them with the middle-grade junior doctors and midwives, and discuss how appropriate they are. We do formal audits where we pull 50/100 notes, and break down the reasons and look at them very carefully. Each time we have done a formal audit, it has been noticed that our rate of emergency caesarean section falls, starting the day after the formal audit has been produced. We know where we are going wrong; it is the ability to change that that can be very, very difficult. We have relatively junior, middle-grade doctors. Most people say that they are junior and they do lack in confidence. As James Walker said earlier, it is getting more and more noticeable as time goes by. (Mr Nysenbaum) The difference would have been extremely striking. Twenty-four years ago, I was on a labour ward, and within three months I was competent at looking after the labour ward, delivering babies by caesarean section, and with obstetric forceps in those days. By the end of six months I had vast experience, due to the number of hours that we worked - which may or may no have been good. Now, to get equivalent experience, it will take an SPR probably two or three years to get as much knowledge as I would have acquired within six months of working. It is very, very different indeed. The experience you gain by hands-on contact is very difficult to acquire now. I think that it will get progressively more troublesome. That is a problem that we are stuck with, and it is getting worse, and significantly so. Chairman (Dr Johnston) We induce for medical indications only. We do not really have a philosophy of social induction unless there are very pressing situations for that. If there is a medical indication for induction in a tertiary unit - and there are often medical reasons for induction - either antenatal fetal compromise or a maternal disease - but as far as the post dates induction, no-one is induced before 10 + 10. That is in tablets of stone: you do not do that, and at 10 + 10 everybody is given a choice. They are presented with the evidence that exists; they have a cervical assessment done to try and assess how easy the induction process would be. There is a service put in place that if they opt to continue with the pregnancy with antenatal fetal surveillance, and they are reviewed regularly at the hospital, and if they change their minds and say, "I have had enough; I am now 14 days over and I am still not going anywhere" - "we will bring you in". Again, it is informed choice. It is not a case of, "right, you are ten days over; you must come in". It is a case of sitting down and giving the options: "This is what your cervix is like. An induction process will be easy or it will take two or three days and you have got a 50 per cent risk of a section." You can leave that a few days and see if that improves, and quite a lot of women will say: "That is fine. As long as you are monitoring it, it will be fine and I will carry on." Again, it is informed choice. (Dr Johnston) Yes, there are NICE guidelines ----- (Dr Johnston) Yes. (Ms Connor) We are actually coming down from 26 per cent for our section rate, and it is now down to 24 per cent. One of the big issues when we tried to tackle our caesarean section rate was that we had a very high induction rate. Once you start intervening, you are much more likely to end up with caesarean sections, so we did address it. Again, we had clinicians who were very interventionist. We have had to address that now. We have revisited our induction policy in line with NICE, and we are seeing a falling in induction rate. (Mr Nysenbaum) We have altered it as well on a number of occasions. Each time we have altered it, we have found that the level dropped by 5 per cent immediately and then creeps up again. We adhere closely to the guidelines, but we have a number of clinicians that fly by the seat of their pants and believe they know that the patient needs to be induced, and it is very difficult to determine what a consultant colleague is going to do. (Mr Nysenbaum) I have labour ward sessions, which I am there fore; so I do an elective caesarean section which means I can train juniors while I am there. I do very, very little in the way of delivery other than that. We all have a policy of coming in, probably very freely and very readily, given the relatively junior nature of our middle-grade staff. It is fair to say that we all do a reasonable amount. Mr Hinchcliffe (Ms Connor) Husbands influence their wives. (Ms Connor) I think if labour seems to be prolonged and the husband sees his wife is in distress, he will be agitated, and I think that is where the presence of a midwife and a full explanation is reassuring to both of the couple. (Dr Johnston) It varies very much on the couple and it depends on the dynamics of that relationship. Ethnic background has obviously got an influence in that as well. We have certainly run across the problem - we have a big Somali refugee population local to us, and we had someone divorce his wife in theatre because she ended up with a section. They traditionally have very large families; a caesarean section in a first pregnancy is a major problem for them. So you can get them going very much against caesarean section, but by the same token if there has been a bad experience the previous time that the partner has witnessed and has been very concerned for the safety of his wife and his unborn child, they might try and push things towards caesarean section. Again, it is taking them on board with the counselling. We can only do that if the partner attends with the woman. If they are there, then, yes, they are very much involved in the counselling process. At the end of the day, that couple has to make the decision; we are not going to come down in favour of one or the other. They go off and sort it out. Andy Burnham (Ms Connor) I think you are right. If they are well informed, even if - I know we do parent craft education, but if they are well informed that they should not need to have a caesarean section unless something untoward happens, they are much more likely then to question it. I think we have to make sure that they are educated enough to know that it is not a norm, that it should only happen in exceptional circumstances; and if it is looking as though it is going to happen, that they should be challenging it, not just going along with it because it is the route of least resistance. (Dr Johnston) I still think the consultants have a major role to play here because if you are the midwife and you deviate from the norm and get the registrar in and they are trying to manage things, they are the ones that are potentially saying, "I think you need a section". Then, for the consultant to come in and say, "well, actually, take a step back and look at this" - a fresh set of eyes, more expertise - "you do not need a section". I think couples find that very reassuring, that a more senior doctor has come in and is looking at the whole picture again. It is a different voice from the one they have been hearing all night. They turn round and say: "I have looked at this. You are doing fine. You can do this. We do not need to intervene just now. Carry on." A lot of them take a lot of faith in that, but if the consultant is not there and does not come in, then it is very difficult for the registrar to go back and say "I phoned him and although I said I thought you needed a section, they said that you do not so we are not going to section you now". It is not the same as going in and talking to them. Chairman (Ms Connor) I listed to the previous debate about staffing. It seems to me that in Scotland there are no midwifery vacancies, and as it percolates through England it gets worse the further south it goes. For us, it has never really been a problem until just recently - perhaps in the last six months. We are now running with an 8 per cent vacancy rate, which is high for us. Trafford is a big district geographically, so a lot of our resources are community based. I did put in the information I sent to you that we deliver 1,500 women, but we actually give antenatal and postnatal care to 2,500 women, because roughly 1,000 deliver either in Wythenshawe and 150 in St Mary's. We give the antenatal and postnatal care, but the births are being counted somewhere else. We need to put a lot of resource into our community to provide that care. As a result, the maternity unit is relatively small, with only 50 per cent of the staff. I am sure it is very different for St Mary's. For us, the number of staff on duty, and an 8 per cent vacancy rate, is a big issue. Normally, we have recruited very well because it is a suburban area and our midwives live locally. As they were saying in St James's, we do not get a lot of levers, so promotion is an issue. Just recently, we have had difficulty in recruiting. (Ms Connor) We have not had difficulty in recruiting - I lie; we have had difficulty retaining. We have recruited and then our junior midwives have moved on. We take students from Manchester University. There seems to be a fair amount of drop-out of student midwives, and I am not sure what the reason is. We are talking to Manchester University about that. I feel that because it is a small unit it is a busy unit and it is quite stressful for junior staff, and they have to be adequately supported. (Ms Connolly) In the last 18 months we have had an issue with retention and turnover of midwives, so our current vacancy rate is over 10 per cent as it stands. Up until 18 months ago we were always able to recruit. We still had a turnover which is quite normal for a tertiary unit: staff move in, have experience and then move on; but in the last 18 months now we cannot fill the vacancies. We have currently got vacant posts for 50 midwives. We had Birthrate Plus that came in and identified that we had between 13 and 21 midwives less than we should have for our current caseloads, let along what would need if we implemented the changes that are in the document as far as midwifery-led care goes. So this is the first time we have felt pressure. The spiral down effect of having not enough staff and the stress on the staff that are there - we are playing constant catch-up. At the moment we have 20 midwives going through our new development programme that we started 12 months ago, in June; but we have never had 20 midwives at one time going through this process. Andy Burnham (Ms Connolly) It is said there has been an increase in places, but to my knowledge the actual number of places available is exactly the same as it was previously, and the number of midwives that have reached retirement age or have moved out of midwifery because of the pressures that everybody is aware of, means that there is still this catch-up. We know there is going to be this generation that are retiring, and the impact of the Government putting in new training places is not yet felt. My numbers for students are exactly the same as they were four years ago. (Ms Connor) Can I just say that ours have gone up. There is a worry about the more students you have because you do reach saturation point. Students take time by the midwives to teach, and that is in itself an extra demand on the midwives when we are short of staff. Ours have gone up. We have asked for more midwives and they have given us more places, and we have a lot of our students out in the community, because it is a big community; but in itself it is another stress on midwives. John Austin (Ms Connor) I suspect it is a fair representation across the country, but I am not very sure. It is not something that has been apparent to me in Manchester except for the last 12 months. (Ms Connor) No, as students. (Ms Connor) It is hard to say. (Ms Connolly) I think it is the bursary that has a big impact because students that are training just cannot afford to live on a bursary. They may be more mature students where they come from previous jobs and have received a wage, and to go into a bursary has a big impact on their own home life. (Ms Connolly) I think when they are more mature and they have received a wage previously, and then they go to a bursary ... (Ms Connor) That is if they are diploma they get the bursary. If they are a degree student, they are only on grants, like every other student. Again, if we are looking at the married population with children, as Karen said, they may have been working previously and they cannot afford to go into that situation or go into debt. It is the diploma students that get the bursary. Dr Taylor (Ms Connor) Before the changes in the NHS boundaries in 1974, or whenever it was, part of Trafford was historically linked with Wythenshawe, south Manchester area. The towns of Altrincham, Timperley and Sale historically used Wythenshawe as their district general hospital. Then the boundaries changed and they became part of Trafford, so our community midwives are employed by the Trafford district, so they worked out of GP surgeries in Trafford. Obviously, the vast majority of antenatal care and postnatal care is given in the community, so that is picked up by Trafford midwives. But they still have the option of going to Wythenshawe for their delivery, and if Wythenshawe is a mile down the road and we are seven miles to the north, they opt to go to Wythenshawe. (Ms Connor) The Trafford women who deliver at St Mary's live in the north of the district, which is the other side of the district. They are on the Manchester city boundary usually, and they go there, again I suspect just because it is more convenient for them to go there. (Mr Nysenbaum) We will find it probably impossible to maintain medical cover once we are reduced to the European Working Hours Directives unless we are able to employ more middle-grade doctors, which is quite difficult to justify, given the amount of work we do. We would not be able to provide cover, and therefore we would no longer be viable. That is at the middle- grade level. At the moment, we have five middle-grade posts; we have two specialist registrars; we have two trust grade doctors who are sort of registrars, and one senior SHO. We cannot always recruit to those; we have usually got one vacancy. It is extremely unlikely that viability would continue on the basis of the Working Hours Directives. There is no easy way round that. (Ms Connor) It is less difficult. Midwives work for seven and a half hours, so we have done a lot of changing shift patterns and we work flexibly. It is not really an issue. (Dr Johnston) I would say it is going to be a problem for midwives as well because we are compliant with New Deal at the moment for our SHOs and registrars, and that obviously involves a greater consultant input anyway, so we are busier than we used to be just because of shortage of hands sometimes. When you look at being EU Working Time compliant, you have to look at what roles medical staff are performing; and if you have less of them around, they should only be doing roles that are essential for medical staff to do; so you are then going to have to expand the role of midwives. That is something that we are looking at. If you expanded the role of midwife without a big increase in the number of midwives, you need to take things from them; and we are looking very much at the role of the healthcare support worker and trying to expand what they do, so that you free up midwives to do midwifery duties, who can do more of the stuff that doctors are doing that midwives are capable of doing, and therefore trying to concentrate the role of fewer medical staff. That goes all the way up; it is not just junior staff. Once it is EU Working Time compliance for consultants, there is going to be a major problem. That, in a tertiary unit, will be compounded even further because if you look at a job plan for somebody that is doing night work in the delivery unit, being resident on call, which in a tertiary unit is what the College is recommending, you can only do three clinical sessions a week, being available to work one and a half days a week. In one of our units we have three sub-specialists in fetal maternal medicine that provide a service to the whole region. We will de-skill if we are not maintaining the day-time work that we do. We have got university consultants that need to fulfil university commitments. So for us, in St Mary's, to be EU Working Time compliant, at consultant level we are going to need eleven extra consultants to be able to do that, and they are just not there. They have not been trained. If you ask medical students now if they want to do obstetrics and gynaecology, a lot of them say "no" because they know it is a high intensity specialty. If you say to them, "you are going to have to be resident on-call" which is one of the very few specialties where, as a senior doctor, you are going to have to live in and be hands-on during the night in your specialty, even more of them are saying "no". The ones that start off saying they want to do it then change their minds, when they realise what their working life is going to be like. So there is going to be a big recruitment problem there. To say that it will not affect midwives, I think it will because their role is going to have to expand and therefore the numbers are going to have to expand. I think that maintaining lots of small units, which is what we have got in Manchester at the moment, is not going to be viable because you are not going to have the staff to do it. We have got a unit down the road from us that is part of a four-unit trust that in two weeks' time - we found out about this last week - cannot provide paediatric cover - so it is not just obstetrics; you have got to look at neonatal cover. They cannot do it, so in two weeks' time they are going to a midwifery-led service, with no provision for the women that cannot deliver there - in the other units round about. I know that we are going to have to take some of them, and we are already overstretched staffing-wise. It is a big horrible mess, I am afraid. (Dr Johnston) I think they are saying that because we just cannot deliver it. There are not the doctors there to be able to deliver EU Working Time compliance obstetrics, or in neonates. Dr Naysmith (Dr Johnston) There is no doubt that the working lives of junior hospital doctors is better. Their lives are much better because they are no longer doing 108 hours a week in the hospital. Their working lives are better: there is no doubt about that. But you have to look at where your service provision comes from, and it is how you train them in half the number of hours. (Ms Connolly) From the midwifery point of view, we are implementing family-friendly policies all the time, which is trying to attract women into the service; but at the same time, because more midwives are becoming part-time and doing less hours, with the lack of midwives being trained it is having a big impact on the service. It is great for women and working lives, but it is not actually helping with the provision of maternity services. Dr Taylor (Ms Hodgson) Well, I had one particular midwife. I went in very quickly pre-labour and then I went into labour a couple of hours after I had actually gone into the unit and the same midwife actually stayed with me for most of the night and was going to outstay her shift, but unfortunately could not stop any longer because of her own children. The point at which I got to the delivery suite, another midwife came in and she stayed with me for the rest of the labour and I was very happy and confident that there had been continuity. (Ms Hodgson) Yes. (Mrs Silverstone) I think they do try and have continuity, but if the labour is going on for quite a long time, it is quite hard, but they are very specific and the next midwife comes along to explain to the woman her feelings and they explain the situation and I think the women feel confident with the next midwife coming along. It is difficult to do total continuity if it is a long labour, but usually the midwives do say, "When I come on duty, I will find out what you had", and I think that is that nice little bit at the end and she feels cared for. (Ms Connolly) In 1998 we actually implemented what we call "collaborative care" where we moved a lot of the antenatal clinic out of the hospital and into the community and had agreed protocols with the GPs and we had discussions about the women's choice. The impact that had is that midwives will provide continuity antenatally and postnatally, but we did not have sufficient midwives to provide that care intrapartum and our community midwives had caseloads of 120, so we cannot meet the demands, and even though we give the women a choice, we are not able to actually put the choices in place. (Ms Connor) Well, that is absolutely true and one of the things about canvassing for part-timers, and we offer long shifts, is that again with the Working Time Directive, there have to be rest periods, so that again works counter to continuity. When we audited our women, the priority for them was continuity antenatally and postnatally and as long as they have got the right person with the right attitude to look after them in labour, then generally that is an acceptable compromise. (Ms Connolly) All the time. (Ms Connor) We have never had to do it. My own staff do extra hours. Dr Naysmith (Dr Johnston) In the context that I have a four-year-old, a two-year-old, a six-month-old baby and a husband who works in Birmingham, I am juggling, but yes, I do a night a week on the labour ward and I do every fifth weekend, Saturday and Sunday, on call in the labour ward and if I am needed during the night, I am there. I am in at half past eight in the morning and I leave at half past five because I have got childcare issues and I cannot come in earlier or leave later unless I have other arrangements made, but I still do every Thursday night on call and every fifth weekend on call, and that is onerous, there is no doubt about it. That is hard work. (Dr Johnston) And I am not alone. My consultant colleagues are the same. In the unit that I work in, we all feel the same way and we all pull our weight and do the same thing. I fully understand that there are some units where they say they have got colleagues who go off and do their own thing, but we do not. We have very much a unit philosophy and we all follow the same ethos. (Dr Johnston) Now there are not so many. In fact we do not have anyone who is over 55. (Dr Johnston) No. (Mr Nysenbaum) Well, I think that is probably what is going to happen as time goes by and actually it is going to be the only way we can provide maternity care within the hospital environment if that is what we are going to end up doing over the next 50 years. I think large DGHs will also begin to separate out a bit in the way they provide care as well as major tertiary hospitals, so I think it is inevitable. (Mr Nysenbaum) I think the issue is simply going to be to have enough doctors to provide care and to have enough midwives to provide care and it is probably only going to be possible, I suspect, in larger units and probably as is happening now with midwifery care units that are looking after women that have a very low likelihood of needing intervention, but I think that can be incorporated within larger units as well. Whether we need to have people who are solely foetal medicine specialists or not or whether we continue to have general obstetricians and gynaecologists providing that care, I think that is perfectly reasonable as well, and a larger unit could have both of them and it does not solely have to be obstetricians. John Austin (Dr Johnston) Training is absolutely fundamental to all of it and it does not matter what your level of staff is and it goes from the healthcare support worker right up to continuing training for consultants which is something that is often missed out, that consultants need to be continuously trained and to be able to maintain their skills. Everybody talks about training the midwives and the junior doctors, but you have got to talk about making sure that your consultants' skills are maintained as well. (Dr Johnston) We have some GPs in Manchester who still want to be involved in intrapartum care and they have direct access to the delivery unit and they do GP deliveries where they will come in with the community midwife and they will do deliveries and we are happy to encourage that, so we have some, not a huge number, but we have some GPs in the area who still wish to be involved. I think the life of the GP is very difficult these days and I do not think it should be mandatory for them to do something that they do not really want to do. If they are interested and they want to be involved, fine, support them in that, but if they do not want to be, do not make them. Midwives are more than capable of doing everything the GP can do and more, so GPs are not essential to the workforce, but if they want that, and a lot of women appreciate it, then yes, support them in that choice. (Ms Connor) I agree with that completely. I think Trafford GPs are not any longer involved in active obstetrics, but they provide prescriptions and various things and I would say that we do need some based in Trafford and it is interesting hearing the previous people because if I was in trouble with a home birth, I would not want a GP. We have paramedics and the neonatal consultant unit and that is the way we went years ago and most GPs are very happy with that and we are very happy. In fact it works very well and if women want a home birth, they get a home birth and it is immaterial whether the GP actually approves of it or not. Chairman (Ms Connor) Well, 1.6 per cent, but we do an awful lot of domicile(?) births as well. John Austin (Ms Connolly) At St Mary's there is a wealth of training available, but there is a lack of staff to enable them to access the training. There is a willingness among professionals, for example, a consultant will work and train the midwife in an area of speciality and the midwives are more than willing to be able to access training, but we do not have the means to do that. We put training programmes in place, whether it be, for example, for management training, customer care training and we have put sessions in place to train midwives on HIV which are multi-disciplinary sessions, but it is accessing that training and also funding the training because although the Government have again given the money for continued professional development, we do not necessarily see it in the form it is needed on the shopfloor. (Ms Connolly) All the time, yes. Whatever funds I have available to me, and most of it is charitable-source funding, then I give that over to the midwives, but it is so competitive for them to access that that we are constantly trying to find what is the most fair way of actually distributing the money all the time. (Ms Connor) My own do it almost all in their own time. Chairman (Ms Connolly) Our breastfeeding rates are currently 50 per cent and it has remained at that level ---- (Ms Connolly) At discharge and it has remained at that level now for just over four years and the reason that there is no increase is because again we need more dedicated support for the women not just while they are in hospital, but also when they are discharged from hospital. (Ms Connolly) Yes. We have just been fortunate in that we have received funding from the Neighbourhood Renewal Fund which is to help midwives support breastfeeding and artificial feeding of babies and also clinical support workers and those midwives now will work across the community and the hospitals, so it will be interesting in twelve months' time to see the difference in the rates. (Ms Connor) Our breastfeeding rate on discharge is 44 per cent and again it has been fairly static. I have just appointed an infant feeding co-ordinator, not funded out of my generic workforce, again to try to improve breastfeeding rates. (Ms Connor) Yes. Chairman: Well, can I thank you very much for helping us. It all adds to our experience and we hope that the work we do will help you in time to deliver a better service for the women and babies you serve. Thank you very much for joining us. |