Children’s Cardiac Surgery (Glenfield)

Baroness Burt of Solihull Excerpts

Monday 22nd October 2012 Westminster Hall

[Sir Edward Garnier]

I am grateful to my hon. Friend for that intervention. His support demonstrates that the issue is not only for Leicestershire, but one that affects patients from right across the east midlands and, I would suggest, from well beyond the east midlands.

Before my hon. Friend the Minister feels a little surrounded, may I thank her for being here to respond to the debate? I also congratulate her, although she must be bored of hearing congratulations, on this first step in what will be a long and successful ministerial career; I say that not as a question but as a statement of fact, and on that basis I am sure that we have won the case. I have no doubt that her response to this debate will act as an accelerant to her progress and provide great hope to those of us who want to see the Glenfield hospital’s ability to save lives continue.

Let me read out part of a letter from some members of staff at the Glenfield hospital:

“As members of the East Midlands Congenital Heart Centre team, we feel that we have a responsibility to our patients to ensure that we make clear our intentions with regards to the implementation of the recommendation of the safe and sustainable review. We are not in a position to leave our homes and families, to move to Birmingham to work. As a team of (predominantly) women, we are (predominantly) second wage earners, with husbands, children and homes. The toll of this review on both our work and home lives has been immense. It has created uncertainty and confusion, as well as intense anxiety. The repeated mantra of the review team that it will all be ok ‘with the help of the EMCHC team’ is meaningless in that we have not even been consulted. Unfortunately, we have been placed in a position where to refuse to relocate is openly criticized as being obstructive by the review. This is not the case. Our patients remain our priority within our working life, yet we have a responsibility to our families which, when push comes to shove, will over ride this.”

They go on:

“This letter is in no way representing a threat. It is an open expression of our concerns, over another assumption made by the review team, and which places us in a position where we are forced to choose between our patients and our families. We are a group of dedicated professionals, who have worked hard to achieve the excellence that we have done. Our patients deserve the best, and we fear that the recommendations will not give them that, and we will be unable to be there to support them.”

In my view, that letter speaks for them all—from doctors through to cleaners—and I hope that the Secretary of State will not forget the work that employees of the national health service do at the Glenfield unit when he comes to decide how best to proceed.

It is proposed that the number of cardiac centres in England be reduced from 11 to seven, and thus they will all be working at full capacity. Can the Minister ensure that in the event of a superbug outbreak, for example, as happened at the Belfast neonatal unit this year, or of a fire, as happened at Birmingham hospital in 2010 and in Leicester in 2011, or of any other catastrophic event in one of the cardiac units under consideration, that the remaining six will be able to cope with the pressure without endangering the lives of the critically ill children and babies in their care?

Glenfield already takes patients not just from Leicestershire, but from across the east midlands, as my hon. Friend the Member for Newark (Patrick Mercer) said. It also receives patients from Birmingham, Southampton, Northern Ireland and elsewhere in the United Kingdom—and even from Scandinavia and mainland Europe.

The Safe and Sustainable cardiac review for children in England has been under way for more than three and a half years. It proposes that the Glenfield unit be closed and its patients and neonatal and paediatric ECMO services be transferred to Birmingham. The Minister and the Secretary of State are, we now know, to revisit the medical and economic evidence that the review board has considered, but I look to them to make a different, better and more logical decision, based on the evidence that is there for all to see.

Four available options emerged from the review, and they were predicated not so much on the cost of providing children’s cardiac services—albeit that cost must play a significant part—as on their sustainability. I will not, for reasons of time, list the options or their components, but option A suggested that there should be seven surgical centres: at Glenfield, at Freeman hospital in Newcastle, at Alder Hey children’s hospital in Liverpool, at Birmingham children’s hospital, at Bristol royal hospital and at the two centres in London, each with four surgeons looking after a minimum of 400 children every year.

Following the public consultation between 1 March and 1 July this year, option A received the greatest support. The consultation was the largest ever public consultation within the national health service, with more than 75,000 respondents; nevertheless, that number is much smaller than the number of people who signed the e-petition that provoked this debate. Option A was supported by six of the 10 health regions in England. It is, at £22 million, the least expensive option—the next cheapest costs £44 million—and it has the added advantage of ensuring shorter travelling distances for families.

None of the four options is perfect or ideal, but the option that includes Glenfield satisfies many of the objective criteria that one would expect of a good solution—not least in respect of Glenfield’s nationally commissioned ECMO services. Given today’s letter from the Secretary of State, it is in that regard that our attention now needs to focus. Glenfield provides both cardiac and respiratory ECMO. Its national ECMO centre has been in operation since 1991, and it treats babies, children and adults from across the country and abroad.

ECMO is an invasive life-support system, which can be used on patients with severe respiratory or cardiac failure. It consists of removing blood from a patient, taking steps to prevent clots from forming in the blood, adding oxygen to the blood and pumping it artificially to support the lungs. There is an increased chance of survival of half as much again when a patient is treated in an ECMO centre rather than in a conventional intensive care unit. The Glenfield ECMO unit has the best results in the world, has more expertise and success than any other ECMO unit in the country and is the only such unit in the country to provide mobile ECMO. We have four national centres for ECMO, and the ideal scenario would be to maintain ECMO services in their current locations.

There is the fact that Glenfield’s ECMO unit was applauded by the national health service during the H1N1 crisis and that Glenfield’s ECMO survival rates are 20% higher than the United Kingdom average. Kenneth Palmer, director of the ECMO unit of the Karolinska university hospital in Stockholm and an international expert on ECMO treatment, wrote to my right hon. Friend the Member for South Cambridgeshire, the former Health Secretary, on 7 July, on learning about the proposal to shut the Glenfield unit:

“You will take over 20 years of experience from one of the world’s...best ECMO units and throw it away...to rebuild it in another place...You cannot move a unit, you can just destroy it and rebuild it with many years of decreasing survival rates and increasing morbidity”.

Mr Jim Fortenberry, paediatrician-in-chief of children’s health care in Atlanta, Georgia, also wrote to my right hon. Friend on 6 July:

“Glenfield has one of the finest ECMO programmes in the world and was the source of the recent CESAR trial, a landmark study that helped sort out the benefits of adult ECMO...The impact on care of attempting to move out this program in toto to another location would be devastating. ECMO is not merely the equipment, but the incredible collective expertise and institutional memory of its entire team”.

Glenfield has, over the years, built up a team of more than 80 ECMO specialists.

Dr Thomas Müller, ECMO co-ordinator at the university medical centre in Regensburg, Germany, wrote to my right hon. Friend on 9 July:

“Glenfield Hospital has won an excellent reputation for their expertise in paediatric and adult ECMO treatment and is deemed to be one of the world’s leading centres. The knowledge and experience of the staff in Glenfield probably is unmirrored in Europe and the US. To my knowledge, Glenfield treats the largest number of patients with severe cardiac and respiratory failure with ECMO worldwide...centres with less expertise certainly will experience a higher mortality. Therefore, in the interest of best patient care the decision to close down the most experienced centre of the UK is difficult to comprehend for somebody from abroad.”

Dr Leslie Hamilton, a cardiothoracic surgeon at the Freeman hospital in Newcastle, has also acknowledged that there is a risk in moving ECMO services from Glenfield.

Glenfield performs about 100 ECMO procedures a year, which accounts for 80% of the neonatal and paediatric activity in England and Wales. As I have mentioned, Glenfield also takes patients from other countries, including Scotland, Sweden, Finland and Ireland. The mortality rate at Glenfield is 20%, compared with 34% in the rest of the United Kingdom. Two additional surgeons have expressed an interest in going to work there. The centre is a popular place to work and can be made more “sustainable”—to use the jargon—with more surgeons and space.

In advancing the case for Glenfield, I do not need to denigrate the facilities and expertise of other hospitals. I see the right hon. Member for Newcastle upon Tyne East (Mr Brown) in the Chamber along with my hon. Friend the Member for Solihull (Lorely Burt), who no doubt represents the interests of the Birmingham children’s hospital. In advancing the case for the retention of the internationally acclaimed ECMO centre in Glenfield, I do not need to undermine the good work and dedication of cardiac and thoracic specialists elsewhere. I do not want to do that, and I would not have the time, even if I thought it a proper or sensible thing to do. It just so happens that Birmingham children’s hospital regularly refers patients to Glenfield. Why? Because unlike Birmingham, which conducts only cardiac ECMO, Glenfield does both cardiac and respiratory ECMO.

[Lorely Burt (Solihull) (LD)]

I fully endorse my hon. and learned Friend’s comments about Glenfield. Indeed, one of my youngest constituents, Yvie Beards, would probably not be here today were it not for Glenfield. However, does my hon. and learned Friend not agree that the type of expertise that we have in Leicester should be replicated in other parts of the United Kingdom? Although the Birmingham children’s hospital has one of the best child treatment centres, it could also contribute to that same level of care for children and others in the west midlands.

[Sir Edward Garnier]

I am sure that my hon. Friend is right, but we do not replicate what goes on in Glenfield by closing down Glenfield. If she and I are right about this, we need more Glenfields, not one fewer. We certainly do not need Glenfield itself to be closed.

Glenfield has this year opened a paediatric intensive care unit—a PICU—which will also become unviable as a result of losing paediatric cardiac surgery. Currently, 71% of those in the PICU are cardiac patients, so closing it down will no doubt affect the non-cardiac patients whom the unit treats. The loss of the ECMO service would also make the adult ECMO unit unviable. As of 18 October, option A is supported, on the e-petition, by about 103,000 signatories.

The Guardian, not necessarily a newspaper that a Conservative Member of Parliament leaps to quote from, pointed out on 28 April 2010:

“There has been a wealth of clinical evidence for many years that specialist clinical services, such as stroke, trauma and heart surgery, should be concentrated in fewer centres… Survival and recovery rates would improve markedly with many lives saved.”

The ECMO unit at Glenfield works: it helps children survive and, as we just learned from the Prestatyn case, it helps adults survive. The medical evidence shows that the ECMO unit works, and now it is up to the Secretary of State to understand that and let both the unit and the children it treats survive.

Oral Answers to Questions

Baroness Burt of Solihull Excerpts

Tuesday 21st February 2012 Commons Chamber

[Mr Burns]

Very briefly, Mr Speaker, I can say to the hon. Lady that a number of the organisations that she mentions are trade unions that do not represent the views of GPs up and down the country who are actually engaged in implementing the modernisation by commissioning care for their patients.

[Lorely Burt (Solihull) (LD)]

12. What steps he is taking to improve the standard of dementia care in hospitals.

[The Minister of State, Department of Health (Paul Burstow)]

As many as four out of 10 people in hospital have dementia, and people with dementia stay longer in hospital. We know that there is much room for improvement. That is why we have set a new national goal for hospitals actively to identify people with dementia.

[Lorely Burt]

According to the Royal College of Psychiatrists’ report on dementia care in hospitals, only one in three staff said that they felt that their training and development in dementia was sufficient. What action is the Minister taking better to equip staff to be able to take care of dementia patients in future?

[Paul Burstow]

I am grateful to my hon. Friend. Training is certainly one of the issues highlighted by the audit. We are taking a number of steps. We are working with the Royal College of Nursing, which has developed an online dementia information resource; we have been working with Skills for Care and Skills for Health to provide a series of training workshops for staff; we have been working with Oxford Deanery to trial a new approach to dementia education and training for GPs; and we are funding another audit to make sure that we keep track of the improvements that we expect to see across the NHS.

NHS (Private Sector)

Baroness Burt of Solihull Excerpts

Monday 16th January 2012 Commons Chamber

[Frank Dobson (Holborn and St Pancras) (Lab)]

I agree with a substantial number of the points made by the hon. Member for Southport (John Pugh). The Government claim that their proposals are just an incremental extension of the Labour Government’s involvement of the private sector, bringing private patients into NHS hospitals. In fact, they are nothing of the sort; they are dramatically different in nature and scale. To justify them, the Government grossly exaggerate the contribution the private sector has made.

I am sorry that the right hon. Member for Charnwood (Mr Dorrell) has left the Chamber, as in 1997 when I took over from him as Secretary of State for Health, the NHS was carrying out 5.7 million operations. By the time Labour left office, the figure was 9.7 million—4 million more than when he was in charge. Of those 9.7 million operations a year, 9.5 million were being carried out in NHS hospitals and the private sector was doing 200,000, or 2.1% of the total. So much for its massive contribution to improving the service for ordinary people.

The private sector cherry-picked operations and patients, yet now we have the proposition that things will be franchised out; it was to be to “any willing provider,” but now it is to “any qualified provider.” Recent events suggest that it will be to any willing profiteer—to people who are good at the sales pitch and say that they can keep costs down and are superior to the NHS. They will be the people who use the cheapest breast implants and when things go wrong expect the national health service to bail out the patients they have harmed. They are a bit like the bankers: they are in favour of competition and a free market, but when things go wrong, they say, “Will the taxpayer please bail us out?” That is what we are seeing.

We also see in the proposals that the NHS hospitals should in future be able to undertake up to half the work on private patients. The right hon. Member for Charnwood talked about increased revenue. This year sees the 200th anniversary of the birth of Charles Dickens. He had a character called Mr Micawber, and he would have noticed that it is not the revenue that counts, but the revenue against the cost of providing the service. If the cost of providing the service to private patients is greater than the revenue that comes in from private patients, we are running at a loss and the NHS is subsidising them.

I say that about the Royal Free hospital, which does a very good job in serving my constituency. It just so happens that I have its figures, because I asked for them. In the last year for which figures are available, the Royal Free hospital took in £17.3 million in revenue from private patients. According to the figures it gave me, the cost of providing those services was £15.6 million—an apparent gain of £1.7 million. However, it went on to say that “costs are estimated” and

“not all costs are split between private and NHS patients in this way”.

The costs are not clear. It might look as though the income is clear, but I then asked what the private patient debt is from those people.

[Lorely Burt (Solihull) (LD)]

Will the right hon. Gentleman give way?

[Frank Dobson]

No, I do not have time and others want to speak.

The answer is that, over the past five years, private patient debt has never been lower than £6.4 million, against an income of £17 million. They are not exactly subsidising NHS patients out of the private sector income at the Royal Free, because they do not have enough income to subsidise them.

I recall years ago, when I was shadow Health Minister, running a campaign on this issue. The Tory Government said that they would change the rules and introduce a system, backed up by the National Audit Office, as it is now called—then, it was the Comptroller and Auditor General’s office—that ensured that any private sector contribution produced a surplus. No such arrangements were put in place, and I challenge the Minister to identify what the position is with all those private patients in NHS hospitals. How many are running a surplus and how many are running at a loss?

Manufacturing

Baroness Burt of Solihull Excerpts

Thursday 24th November 2011 Commons Chamber

[Guy Opperman]

I will give way again.

[Lorely Burt (Solihull) (LD)]

The hon. Gentleman has obviously excited a lot of interest with his suggestion. Will he consider the American model of community banks, which have stood the test of time and served their communities?

[Guy Opperman]

My hon. Friend anticipates my next move, which is to say that such matters are already road-tested in other jurisdictions in other countries. Sadly, the FSA is reluctant to change its regulatory system. I have heard other examples of its failing to meet individuals who want to provide local financing—something that would be immensely good for local communities and could provide a flexible approach. Instead of being stuck with a loan from Barclays, for example, people would have a much lower flexible interest rate and adopt a much more interesting way to recuperate their finances at a later stage when the company was in profit. Banking would be local. We all know what happens when we are approached by a constituent when a business is in trouble. The decisions in relation to such financing are made not in Hexham or Newcastle or even in the north-east, but in a place such as Nottingham or Leatherhead or, ultimately, in London. That must change.

--- Later in debate ---

[Gordon Birtwistle]

I am grateful to the Minister for that assurance and I hope that that continues.

When I started in manufacturing some 53 years ago, manufacturing was 40% of the country’s gross domestic product and a balance of payments surplus was delivered every month. What on earth would the Chancellor think of having a constant balance of payments surplus now rather than the negative position we have? As manufacturing was so big, lots of apprenticeships were available through local companies that delivered the products that the country needed. The unemployment rate for young people was very low. When I left school, I applied for many apprenticeships throughout Lancashire. Most young people with whom I went to school achieved an apprenticeship in some industry or other. The vast majority of people in those days did not go to university; many people would have liked to have gone, but they could not, so they spent their time being apprentices and learning skills in the old-fashioned way by making things and having a trade.

I do not want to make this political, but I have to point out that under the last Labour Government, manufacturing fell from 22% to 11%. Even Mrs Thatcher did not achieve such a drop—she only managed to get it from 25% to 21%. Manufacturing has a number of variables to overcome. They include how the industry is perceived by young people, the lack of skills, and the lack of investment and of research and development. One of the biggest challenges to manufacturers in my constituency is finding enough skilled workers to carry out the incredibly technical jobs that are available. More must be done to change the image of industry to make it attractive to young people. I know that those who undertake skilled apprenticeships will end up with great jobs working on interesting projects, earning decent salaries and probably with a job for life.

A lot of damage has been done over the past 10 years to the image of manufacturing and vocational courses. A priority for the Government and for our successful and well-known manufacturers is changing the perception of manufacturing, especially among the young. We have become a country relying on a fragile financial sector and on the service industries. If young people were asked what they thought manufacturing was, they would probably respond that it is dirty and grimy. That is not the case. We need to show young people that there is more to manufacturing—that it is about maths and science, about design and innovation, about robots and computers. Manufacturing and technology in the food industry, for example, are phenomenal. There are so many different areas in the manufacturing sector and they are all innovative and exciting sectors to work in.

Controlling the supply side of our skills deficit is but part of the problem. As important is ensuring that both new entrants and existing employees in manufacturing are sufficiently upskilled to meet the demands of British employers. The preparation work needs to begin in schools. We know, for example, that pupils who take three separate science subjects at GCSE are more likely to study science, technology, engineering and maths later in their educational careers. If we can tackle the problem at source, and improve the rigour of the subjects and the number of pupils studying them, it will have a cumulative impact on the calibre of graduates entering the job market.

[Lorely Burt]

Does my hon. Friend agree that a great way to get youngsters more excited and involved is to have closer collaboration between employers and schools, so that children can see what it is they aspire to do, and therefore choose to take the subjects to which he refers?

[Gordon Birtwistle]

I totally agree with my hon. Friend and I will come on to an initiative in my constituency related to that suggestion.

In my constituency we have Burnley college, a joint FE-HE campus working with local firms to train highly skilled youngsters to be ready for the world of work. We are also getting a university technical college that will bring young people into the industrial life. Burnley college has made huge leaps in changing the perception of manufacturing locally among young people, and if the model the college uses were introduced across the UK, it would go a huge way towards really changing the perception of manufacturing at a national level. More schools and colleges need to start joining up with local businesses to provide youngsters with the knowledge and experience that will help them in the world of work. Too many children do not have any experience of working, or of the personal and other skills required. I will continue to encourage the Government to introduce impartial careers advice from the age of 11. Indeed, we should start careers advice long before young people go to secondary school.

Oral Answers to Questions

Baroness Burt of Solihull Excerpts

Tuesday 18th October 2011 Commons Chamber

[Anne Milton]

I draw the hon. Lady’s attention to the fact that the Health and Social Care Bill proposes for the first time a duty on the Secretary of State to have regard to health inequalities, which, I repeat, widened under the previous Government. I also point out to her that the letter to peers signed by Professor Marmot and others welcomed the emphasis on establishing a closer working relationship between public health and local government. I suggest that the hon. Lady gets out more, because she would hear from public health doctors and local authorities on the ground who welcome these changes.

[Lorely Burt (Solihull) (LD)]

5. What steps he is taking to reduce the burden on NHS hospitals of (a) PFI repayments and (b) debt.

[The Minister of State, Department of Health (Mr Simon Burns)]

A study conducted by the Treasury has identified savings opportunities of up to 5% on annual payments in NHS PFI schemes. The Cabinet’s Efficiency and Reform Group is rolling out a programme of work to secure savings of up to £1.5 billion across the 495 PFI contracts in the public sector in England.

[Lorely Burt]

Contrary to the earlier complacent comments of the Opposition spokesman, some national health trusts are paying up to 20% of their revenue to PFI contracts. What steps can we take to ensure that the payments are reduced and that the same terrible financial situation never happens again?

[Mr Burns]

I am grateful to the hon. Lady. I, too, recognise the small number of organisations that are reporting financial challenges. The Department is continuing to work with strategic health authorities to ensure that those organisations have robust plans in place for financial recovery, while ensuring the quality of services for patients.

Maternity Services

Baroness Burt of Solihull Excerpts

Tuesday 1st February 2011 Westminster Hall

[Ms Gisela Stuart (Birmingham, Edgbaston) (Lab)]

I wanted to have today’s debate on maternity services for three reasons. One is the confidential inquiry into intrapartum-related death, conducted by the Perinatal Institute in Birmingham in October 2010. Incidentally, its director is one of my constituents, which, of course, adds to the quality of the report.

Secondly, I vividly remember an article in The Sun during the election campaign in 2010, in which the right hon. Member for Witney (Mr Cameron) clearly promised 3,000 extra midwives. The third reason is last night’s debate on the Government’s health reforms. The three are unfortunately related.

I will begin with the report. An enormous amount of good work is being done in maternity services and provision, and the Birmingham women’s hospital in my constituency provides excellent care. The west midlands should not feel that it is being singled out. It was simply the first area that took a good, honest look at what is happening and, therefore, has produced figures from which the rest of the country can learn. The west midlands is an area of huge diversity, both in income and ethnic background. Roughly speaking, it has 70,000 deliveries a year, which account for 10% of live births in England and Wales. It also has about 10% of babies who die from intrapartum-related causes—that is, events surrounding labour and child birth.

In 2006, the chief medical officer highlighted the fact that one of his areas of particular concern was intrapartum-related death. In a national report in the 1990s, that was continually highlighted as requiring more attention, but the figures did not show any particular improvement. For that reason, the Perinatal Institute decided to look at that area. We know that in politics to be described as “brave” sometimes means “foolhardy”. However, in this case the institute was brave to look at the figures honestly. It looked at 25 cases that caused concern. The full report is available on the institute’s website. It found that of those 25 cases, in four there was substandard care and different management would have made no difference to the outcome.

[Lorely Burt (Solihull) (LD)]

As another west midlands MP—the Heart of England trust covers my constituency—I wonder whether the hon. Lady has noticed any problems with care of parents after neonatal death. I have the charity Stillbirth and Neonatal Death Society, SANDS, in my constituency—as I expect she has—and it is most concerned about the quality of care for parents following the death of a baby.

[Ms Stuart]

I have come across SANDS. The Heart of England trust did some work, which I will consider later, whereby it looked at midwives’ case load and found it to be far higher than required. Incidents are spread across an area and each of us probably sees only one or two cases occasionally. The real problem comes when we look across the city and the west midlands. We should pay tribute to SANDS and its work and to the bereavement nurses it has now put in hospitals. They are in east Birmingham and in my patch. However, that is not good enough.

Coming back to the 25 cases, in four cases of substandard care, different management would not have made a difference. In five cases, it might have made a difference to the outcome, but in 16 cases, different management would reasonably have been expected to make a difference to the outcome. In other words, 84% of the deaths were considered potentially avoidable. The overall conclusion that the report reached looking at the west midlands was that many deaths were avoidable and need to be avoided. That is why we need to discuss this report and decide what to do about that.

This is not a particular west midlands problem; it is just that the west midlands has been the first to take an honest look.

--- Later in debate ---

[Ms Stuart]

I am sure the Minister will be grateful for that helpful intervention. However, have we not been told that the NHS is ring-fenced? That is how I understand it. Therefore, the financial argument really does not hold.

I would like to analyse what the Prime Minister said a little more. He went on:

“It doesn’t have to be like this…First, we’re going to create new maternity networks…Second, we are going to make our midwives’ lives a lot easier. They are crucial to making a mum’s experience of birth as good as it can possibly be, but today they are overworked and demoralised. So we will increase the number of midwives by 3,000. This is the maternity care parents want: more local and more personal. And under a Conservative Government, it is what they’ll get.”

[Lorely Burt]

As the Prime Minister said, the aspiration should be for more local and more personalised services. However, in my local hospital at Solihull, the full maternity service has unfortunately been downgraded as a fait accompli, and instead of 2,700 births a year, we are led to expect only 300. Does the hon. Lady agree that that hardly offers the choice, localism and personal service that we should seek to achieve anywhere in the country?

[Ms Stuart]

I will respond to that point before returning to my favourite subject of the Prime Minister’s promises. The hon. Lady is right: there is always a huge tension between local and more centralised delivery. My first Adjournment debate in this Chamber as a junior Minister was about the closure of the William Courtauld maternity unit in Braintree in Essex. It had about 300 deliveries, and there was always a tension about whether services should be offered there or in Colchester. We need both. However, when campaigning to keep local maternity units, we should note that the Royal College of Nursing looked at changes in maternity care. It stated that, apart from the rise in numbers, there are more older mothers with higher rates of complications, and there is a higher rate of multiple births and more obese women who are less fit for pregnancy. More women survive serious childhood illness and go on to have children, and they need extra care during pregnancy and childbirth. There are also increasing rates of intervention.

Therefore, apart from social and ethnic diversity, some births are becoming increasingly complicated. If the hon. Lady were to go to the Birmingham women’s hospital, where women who have had heart transplants give birth, she would see that a safe delivery might require not only the expertise of the women’s hospital, but that of the Queen Elizabeth hospital next door. There is always a natural tension between localism and the best care. The real answer is that we need both.