Maternity Services

Baroness Stuart of Edgbaston 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.

[Andrew George (St Ives) (LD)]

I raised the issue of the Perinatal Institute in Birmingham in a debate I led on maternity and midwifery on 2 May 2007. I spoke to Professor Jason Gadosi before and after that debate. What he said then, nearly four years ago, was precisely what he appears to be saying now: there has been a failure fully to monitor and interrogate what went on and to draw conclusions that might better inform the improved care, and avoid the perinatal mortality levels that still exist.

[Ms Stuart]

That leads me to my next point. We have clearly not come up with systems in the NHS that allow us to learn properly from mistakes when things go wrong. I fully accept that we have the NHS Litigation Authority, and that the NHS insures itself. We try to deal with negligence effectively and efficiently. However, there is still a mentality of institutions, when something goes wrong, closing in on themselves. I wonder whether we should look at the way the aviation industry deals with accidents. Fault is not allocated; the facts are looked at, and the real outcome is what to do as a result of the problem. Rather than understanding the errors that have gone further and further, we should consider what is to be done as a result.

Going through newspaper cuttings, I found one over Christmas about Good Hope hospital. There was a very unfortunate incident when a lady who had miscarried was left for four hours in sight of other patients. She complained to the hospital, which simply apologised and said it hoped to do better. Hoping to do better simply has not done us any good, if that experience is anything to go by.

It is not clear to me who has responsibility for this matter. In the current structure we have PCTs and strategic health authorities, where at least theoretically we could allocate responsibility. In the new NHS, who will do that? I will return to that point.

We need national maternity data sets that are much more standardised and allow us to make us comparisons across the country. That is not a question of money. Given that we are told that the NHS is one area that is ring-fenced, there is much we can do within existing provision.

I now come to the promise that the right hon. Member for Witney made during the election campaign. We all know what happens during elections; not keeping election promises is not particularly new. However, let us look at what he said in January 2010. Maternity and childbirth is an immensely emotive subject. It is not an illness; it is one of the most joyful events in life. In the majority of cases, a healthy baby is born and we try to keep the medics out of the process as much as possible. When politicians go into election campaigns and talk about maternity services—particularly when they do so in The Sun—it is a pretty toxic mix. The right hon. Member for Witney went to a maternity unit and said:

“Having a baby might be the most natural thing in the world.”

Fine, I agree with him. He continued:

“Every parent wants…to give birth in a relaxed local setting, where they get the personal attention they need. So, why isn’t that happening? It’s because after a decade of constant reorganisation, Labour are giving us bigger and bigger baby factories where mums can feel neglected and midwives are stretched to breaking point.”

[Daniel Kawczynski (Shrewsbury and Atcham) (Con)]

Will the hon. Lady give way?

[Ms Stuart]

I assume that the hon. Gentleman comes in on the bigger and better baby factories.

[Daniel Kawczynski]

The hon. Lady surely understands that after 13 years, the previous Administration had still not managed to achieve some of its long-term goals and aspirations. She almost indicates that the promises made by the Prime Minister should have been met seven or eight months into a new Administration. Given the state of the public finances, she must acknowledge that it will not be as easy to deliver on those promises as quickly as she—or I—would like.

[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.

[Andrew George]

The hon. Lady makes a balanced case. However, the previous Government also promised thousands more midwives and failed to deliver on that. Is there is a general cross-party agreement that the choice of a home birth should be available, where that is a precautionary safe option and as far as it is possible to predict what is likely to happen during birth? Under such circumstances, two midwives are needed on site. In the “baby factories” that were mentioned earlier, the efficiencies that can be achieved are greater. If more home births are to be serviced and supported, even more midwives will be required.

[Ms Stuart]

They will indeed. I may risk alienating my own party a little here. Home birth is one of those nice, idyllic and romantic ideas, but, frankly, when I had my children I would rather have had a small cottage hospital with a safe delivery, where I left for home after 24 hours, knowing that if I needed care it was on hand. Home births are probably not as romantic as people think they are.

Let us return to whether the Prime Minister meant what he said. He spoke of an increase in the number of midwives of 3,000. When the Royal College of Nursing challenged the Government, an unnamed Conservative spokesman said:

“There must of course be enough midwives to meet the demands arising from the number of births. The commitment to 3,000 midwives made in Opposition was dependent on the birth rate increasing as it has done in the recent past. It was not in the coalition agreement because predictions now suggest the birth rate will be stable over the next few years.”

Let us analyse the words

“enough midwives to meet the demands”.

We all agree with that. However, if one looks at the planning tool, Birthrate Plus, which estimates how many midwives are needed, and calculates the number nationwide, when that promise was made, according to that tool, there was already a shortage of 4,765 midwives. Even the promise of 3,000 fell short and far more midwives were needed.

The spokesman said that the commitment made in opposition depended on the birth rate increasing. However, nothing was said about that in the article in The Sun. Furthermore, if we look at the only figures that were available at the time the promise was made, they did not suggest any such thing—indeed, they suggested the opposite. The promise is not in the coalition agreement, but the newest figures were not available until long after that agreement. Therefore, there is no proper excuse. It is not about money, and the birth rates that were predicted were not happening. The figures were not available, and I would like to hear why that promise was not in the coalition agreement. It does not stack up.

I can conclude only that when the Prime Minister made that statement, he did not mean it. It is callous to do such things. Maternity and childbirth are sensitive issues, and if something specific is promised during an election campaign, that promise should be kept. I shall return to maternity networks later.

I am not alone in this view—I am not making it up. In November last year, the country’s leading midwife, Cathy Warwick, accused the Prime Minister and the Health Secretary of risking the safety of mothers and babies by backtracking on their pledges to hire more NHS midwives. She said that she was

“extremely disappointed...Both coalition parties supported a commitment to more midwives, now they have apparently changed their minds, and yet the economic situation was well-known before the election.”

Not only was the economic situation well known, but NHS funding is ring-fenced. The money argument does not stack up. She went on to say that she had encountered a “deafening silence” from the Government when she asked whether they intended to honour the pledge. That is a broken promise.

Let us look at where we should go from here. If the record shows that figures on maternity have not improved for 20 years, we need to make some progress. There is a strong association between deprivation and stillbirth as well as infant mortality. The index of multiple deprivation for the west midlands between 1997 and 2007 gives an overall score of 29.9. In Sutton Four Oaks—Sutton Coldfield, the royal borough, still has not quite come to terms with being part of Birmingham—the score was 10.5. Washwood Heath, which I think has the highest unemployment in the country, has a score of 65.1. In my constituency, the area of Bartley Green has a score of 40.3, while in Harborne it is 24.7. However, after the slight boundary reviews that remove the Welsh House Farm estate from Harborne, I expect that figure to be higher. There is a real link between deprivation and stillbirths and infant mortality. Those areas need far greater numbers of midwives to deal with the case load.

That highlights the fact that reducing perinatal and infant mortality is part of public health. That cannot be addressed just at GP level, and it requires a far wider view. As we still do not have national standards for collecting data, we are not even able to say to pregnant women how well the service is doing. That is why the Prime Minister’s promises matter. If we want to create the big society, and if we are all in this together, we need to strengthen commissioning, which needs to go far wider than the current structure. The current commissioning is weak, and from what I heard last night, it will only weaken further. We do not even know how well we are doing, and we are now talking about GP-led commissioning—leaving it to the professionals.

In yesterday’s edition of The Times, the Prime Minister said, “The NHS will sicken unless we modernise”. For the moment, I will leave the use of English—“the NHS will sicken”—to others to comment on. The Prime Minister goes on to say that he wants to debunk five myths. He says:

“The fifth and final myth is the most important: the suggestion that patient care will suffer. The opposite is true. Our changes draw on some simple logic: that professionals, not managers or politicians, are best placed to understand the needs of patients. Couple that professional freedom for doctors and nurses with choice and transparency for the patient, and you get a mix that will expose poor performance and drive standards up.”

Will it really? What if the professionals are not doing a proper job? If we do not have the nationwide data that allow us to tell them whether they are doing a good job, it is not only the professionals who are not aware of whether they are doing a good job by comparison. The patient will not know that, either, and they will take the care that they get. How many of us have had feedback relating to hospitals in which the hospital’s performance was based on whether people thought that the food was any good? Although that is important, it tells us little about clinical standards. I am sure that the parents of those babies who died where better care would have made a difference would not have been aware of that, because what are the comparisons?

[Andrew George]

I do not want us to repeat yesterday’s debate on the Health and Social Care Bill. I took part in that debate, and my position on that Bill is reasonably well known. However, on the substance of the case that the hon. Lady is advancing, I fear that if we are going to be trading promises made by the previous Government on maternity care that were not delivered and similar promises made by a party leader that may or may not be delivered, we will not get what I hoped that we would get from this debate, which is a recognition that midwifery is under-resourced and that we should all be working together to acknowledge that we are putting a lot at risk. That includes the fact that we have high levels of litigation. If the bill of £1.4 billion that was apparently expended last year in meeting the costs of litigation in obstetrics were brought down, one could invest in the very services where such high levels of litigation arise.

[Ms Stuart]

The hon. Gentleman is absolutely right. That is why I have said that one of the things that we need to move to is much more serious consideration of no-fault investigations where something has gone wrong.

I return to the point that areas of higher deprivation that have high infant mortality rates require much higher numbers of midwives than areas of lower deprivation. There is no getting away from that. I am rather sad that the Perinatal Institute’s report on community midwives is not ready for publication yet, but I will not be surprised if it finds that the case load of the majority of community midwives is too high and that they regularly work more hours than they are contracted to do. There are no national standards on the accepted case load for a midwife, but professional opinion is that the figure is about 110. The Heart of Birmingham Teaching primary care trust has found that case loads are about 150.

The question is what the right figure is in areas of deprivation. Strictly speaking, Bellevue is in the Edgbaston constituency, but it borders Ladywood. A two-year study there looked at case loads of 60 to 70. The sample was too small, but there is a link between deprivation and infant mortality, and deprived areas therefore require higher levels of midwife input than other areas, which cannot be picked up by GP commissioning. In the case of the west midlands, it certainly requires a Birmingham-wide view, if not a west midlands-wide approach to commissioning, because it is a public health function as much as anything else.

[Andrew George]

The hon. Lady is being extremely patient in allowing me to intervene. I want to support the point that she is making. The anecdotal information that I have been picking up from midwives is that a high number are, at the pinnacle of their career, retiring as a result of stress, because of the pressure placed on them. There are unreasonable expectations of them in the case load that they are expected to undertake. Those are some of the best people, who are able to contribute the most to their local community and to the health service, yet we are losing them from the service as a result of poor staff management and the fact that they are expected to work under tremendous stress.

[Ms Stuart]

Indeed. If we look at the findings of the work force assessment conducted by the Royal College of Midwives, we see that the hon. Gentleman is absolutely right. The issue is not only that we are short of midwives, but that many midwives leave early or are coming up to retirement, which is really worrying. There is no doubt that we need to strengthen the work force.

I want to bring all the strands together. We are told that the new health service will give the patient the say, and we are trusting the professionals to know better than the politicians and the managers. My argument is that, in some areas, the professionals themselves clearly do not know how well they are doing, and it is about time that they did—when they find out, they need to put in place mechanisms to put things right. Unless we have standardised maternity data that allow us to make comparisons across the country, the professionals, even if they are willing to do so, will not be able to respond.

The third point is that patient choice sounds really good, but in some areas of deprivation—we have them in Birmingham—the question of choice is something from fantasy land. People just want decent services. To say to them that they are driving up choice is an absolutely ridiculous aspiration. Even if all the other things were to happen, midwives on the ground are so utterly overworked that they would have very little time to drive forward the improvements that would be made.

I can see that the Prime Minister’s vision of the new NHS will work perfectly well in Sutton Coldfield and in parts of Solihull, but not all of it. However, it will not work well in our big cities, where we need far stronger, coherent commissioning. I have four questions that I want the Minister to answer. First, the report from the west midlands is exceedingly important. What steps will she take to ensure not only that there is data gathering but that the lessons will continue to be learned not only in the west midlands, but throughout the rest of the country? I am referring to standardised data gathering and standardised analysis, so that we can get a true picture of how well the service is doing and so that we reach a position in which, when we ask how well we are doing, the professionals can answer that.

On my second question, I am fully aware that it takes x years to train nurses, midwives, doctors and consultants, and we have to start down the path of training them at some stage. Will the Minister therefore tell us whether the promise of 3,000 midwives was contingent on birth rates? If it was, can we say that it is no longer on the table? If it is on the table, what steps are being taken to start training and recruiting those midwives, on top of retaining the current ones?

My third question is about the Prime Minister’s second promise in the article in The Sun, which related to maternity networks. What are they? Where are they? Will the Minister spell that out precisely? She looks rather surprised, but when I expressed my surprise about these new maternity networks and wondered exactly what they were, the professionals came to me and said, “It would be really helpful if the Minister could spell out during the debate precisely what these networks are and where they are.” If I am being accused of ignorance, I plead that I am not alone in my ignorance.

My final question is the one that ultimately troubles me most. We are breaking up the units in the health service and moving down to GP commissioning—I have to say that I have far less faith in the universal wisdom of GPs, as opposed to other medical professionals—so how will everything hang together? There are pretty good GP groups in south Birmingham, and they will probably make the new arrangements work, as will some of the groups in other parts. However, in the areas with the highest deprivation and need, where people will be least able to exercise choice or make their demands known, I simply cannot see GP commissioning delivering for people on the ground.

Whose responsibility will it be to ensure equity in maternity care across regions? At one stage, there were thoughts that maternity commissioning should still be a national service, like the specialist commissioning services, but I gather that that is no longer the case. A fair number of MPs from Birmingham and the west midlands are present, so will the Minister explain which body will ensure in those areas that the findings in the Perinatal Institute’s report and the consequent actions are brought together and rolled out so that we receive better care?

--- Later in debate ---

[Ms Gisela Stuart]

An important thing we have learned in the past 15 to 20 years is that when it comes to extremely complex and difficult clinical cases, a hospital must perform a particular function a minimum number of times if it is to be at its clinical best. Some of the hon. Gentleman’s constituents will end up in Birmingham. He questions why Birmingham has received investment, but it is because we provide national centres of excellence. Some of the mothers from his area will come to the women’s hospital because their case is so complex that only the women’s hospital can deal with it. There can be only two or three centres in the country able to provide that clinical excellence. There is always that tension between the local and the centralised.

The hon. Gentleman is unhappy about the reconfiguration, but does he have an objective assessment of how good, clinically, his area’s maternity services are? He may feel good about them, but does he have a professional assessment of whether they could be better?

[Daniel Kawczynski]

That is a very good question. The chief executive of the trust and the PCT and many others believe that there must be a reconfiguration and specialisation at both hospitals. The argument is that without it, we shall lose services, which will go out of the county. We shall not get our NHS trust foundation status and services will be moved out even further away. That is the gun being pointed at my head—not to rock the boat too much on this issue, because there is the possibility of services moving away. I understand that. I feel that the maternity services at the Royal Shrewsbury hospital are good. When my daughter was born there I found the services tremendous. Speaking emotionally, obviously I want them to stay in Shrewsbury. I understand that we must have the reconfiguration debate and that the professionals and clinicians must make the decision, and that is why I shall write to local GPs and consultants to gauge their views. I shall keep the Minister informed.

I congratulate the hon. Member for Birmingham, Edgbaston on raising an important issue, and look forward to hearing what the Minister has to say.

--- Later in debate ---

[Emily Thornberry (Islington South and Finsbury) (Lab)]

I want to make three points about the provision of maternity services. The first is about the provision of extra midwives, the second is on the question of Sure Start and the third is about health visitors.

It seems to me that maternity and antenatal services are provided not only at birth; they are also post-natal services, and new mothers rely upon them strongly. I had two babies under a Conservative Government and one under a Labour Government. At none of those births did I believe that there was sufficient investment in maternity services. That situation continues.

During the last three years of the previous Labour Government there was a massive increase in investment in maternity services, and a new strategy was put in place. Unfortunately—perhaps fortunately—that coincided with a great increase in the birth rate. There was increased investment in maternity services; for example, the number of midwives rose in 2007 by 624, in 2008 by 571 and in 2009 by 787. However, that coincided with one of the largest rises in the birth rate. Being able to keep up with the increase was a problem.

We passed the baton on to this Government. They must build on our achievements and not let us down. We need to continue working on maternity services. Through an article in The Sun, the public heard loud and clear that the Prime Minister was promising 3,000 extra midwives. The fact of the matter is that 3,000 extra midwives would in any event not make up for the shortfall in their number. Even if the Government were to provide 3,000 extra midwives, we would still need at least another 1,700. The problem is that, having made that pledge and promise, the Government seem to be going back on it.

A spokesman gave this pledge on behalf of the Government:

“There must of course be enough midwives to meet the demands arising from the number of births.”

The Royal College of Midwives agrees; it calculated the national England-wide shortage of midwives in 2009 to be 4,756. If, as the nameless Conservative spokesman says, we should have enough midwives to meet demand, we need more than 3,000. The spokesman then said:

“The commitment to 3,000 midwives made in Opposition was dependent on the birth rate increasing as it has done in the recent past.”

My hon. Friend the Member for Birmingham, Edgbaston (Ms Stuart) asked—she put it so beautifully—what was his starting point? What did he mean? The whole piece was written in the present tense. Midwives are stretched to breaking point. They are overworked and demoralised, but the increase in the number of midwives was contingent on a continuing rise in the number of births.

The spokesman’s next excuse was this:

“It was not in the coalition agreement because predictions now suggest the birth rate will be stable over the next few years.”

The veracity of that statement does not stand up to proper analysis. There has not been a prediction since the Prime Minister made his pledge, so we do not know what the difference would be. If improvements are made, we need to continue to build on them. I suggest that the Government are letting everyone down.

[Ms Gisela Stuart]

I have some figures on the future of the midwifery work force. The Department of Health document “Midwifery 2020: Delivering expectations” states:

“The midwifery workforce across the UK is ageing with 40%-45% of the midwifery workforce reaching the current retirement age in the next ten years.”

In other words, even if we stand still, we will undermine midwifery as a result of the fall in the work force.

[Emily Thornberry]

I respectfully agree with my hon. Friend. In a moment, I shall be speaking about another part of the work force, health visitors. They suffer exactly the same problem. The majority of the work force is over 55. It is important to retain such valuable and experienced people—they are mostly women—but we cannot increase their number if we continue to lose existing staff at the current rate.

According to the Library, the number of births in the UK was projected to fall in 2009-10, in 2010-11 and in 2011-12. If the Prime Minister’s pledge was based on the latest birth projections, perhaps he expects to cut the number of midwives. That is clearly nonsense. We need to consider what is needed and ensure that it is fulfilled.

My hon. Friend the Member for Birmingham, Edgbaston made a devastating analysis of the difficulties that will be caused by the changes the Government propose. How can we make forward projections and how are we to manage the national health service if we give NHS commissioning to doctors? They will simply consider the needs of the local area and not our national needs.

In passing, may I briefly touch on the important issue of Sure Start? During the election, the Prime Minister claimed that Labour was scaremongering when we said that there would be difficulties in relation to Sure Start. He said:

“Yes, we back Sure Start. It’s a disgrace that Gordon Brown has been trying to frighten people about this.”

The Under-Secretary of State for Work and Pensions, the hon. Member for Basingstoke (Maria Miller), then the shadow Minister for the family, said:

“It’s unforgiveable that Labour has used the tactics of creating fear and anxiety amongst families and Sure Start staff”.

[Mr Roger Gale in the Chair]

The Minister of State, Department for Education, the hon. Member for Brent Central (Sarah Teather), has said:

“Sure Start is at the heart of our vision for early intervention”

If that is true, why did the charities 4Children and the Daycare Trust find out that 250 centres, which serve 60,000 families, are certain either to close or be earmarked for closure? There are 3,578 children’s centres in England, 3,100 of which have been told that their budgets will be cut this year. About 2,000 services will be cutting their services as a result. The findings are based on responses from almost 1,000 Sure Start managers to a questionnaire sent out by 4Children and the Daycare Trust.

It is hugely important for a new mother to be able to find a friend, get guidance and go to a children’s centre. Nevertheless, centres offering such services are being cut. The other friend that mothers need is the health visitor. Again, when the Prime Minister was in opposition, he made a big thing about increasing the number of health visitors:

“The substantial increase in the number of health visitors will mean that families get more support—from properly trained professionals. Health visitors will be able to spend time with families, have the opportunity to spot parenting issues, and build the trusted relationships needed to help with them. For instance, if they feel a mother is not bonding with her baby, and recognise the cause as post-natal depression, they might gently recommend that she visit her GP, or steer her towards a local counsellor.”

He was absolutely right; no one can disagree with that. However, when I met London health visitors from the Community Practitioners and Health Visitors Association earlier this year, they told me that there was a huge problem in recruiting new health visitors. They were losing a lot of older, experienced staff through early retirement. Nearly a third of health visitors in London are over 55 and they have dangerous work loads. In some cases, there are more than 1,000 children per five health visitors. That is four times higher than Lord Laming—the writer of the Baby P and the Victoria Climbié reports—recommended. His recommendation is for health visitors to have a quarter of their current work load.

In an area such as London, which is very demanding, current work loads are dangerous. We need more health visitors. The Government recognise that a health visitor should have no more than 250 children under five and no more than 100 in highly vulnerable areas, as was recommended by Lord Laming and the Community Practitioners and Health Visitors Association. Will the Government consider that recommendation when they look again at how many health visitors are needed?

When I asked the Under-Secretary of State for Health, the hon. Member for Guildford (Anne Milton), whether the Government would take responsibility for recruiting and training the extra 4,200 health visitors promised, the answer I received was odd. She said that she will learn from the decisions on the case loads and they will be “locally determined”. In the same answer, she says that the Department is shortly to publish plans to

“conduct a demographic and geographical analysis to establish location and population need and match with trainees and training places; and ensure positive correlation between work force growth and population need.”—[Official Report, 27 January 2011; Vol. 522, c. 460W.]

On the one hand, the Government say they will look nationally and decide what the need is, and on the other they say that it will be left to localities to decide. We really cannot have it both ways. What we have is a lack of health visitors.

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[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

May I say what a pleasure it is to be under your chairmanship, Mr Gale? I congratulate the hon. Member for Birmingham, Edgbaston (Ms Stuart) on securing this debate. She was right to emphasise the good work that goes on in our maternity services and to praise the staff for the care that they give to women and their families. Pregnancy is an exciting, but sometimes bewildering, time for us all. I have had four children in four different hospitals in four different parts of the country. As is the case for many women, the care that I received had a significant impact not only on me but on the care that I was able to give my children at the time.

The hon. Lady raised three issues. She referred to the excellent work of Professor Gardosi, an article from The Sun—much reference has been made to The Sun—and the debate yesterday on the health Bill. The hon. Member for Solihull (Lorely Burt), who is no longer in her place, also mentioned the excellent work of the Stillbirth and Neonatal Death Society. Let me also take the opportunity to praise that organisation for its work in this difficult area. It would be an honour for me to be at the opening of the Forget-Me-Not suite at the Royal Surrey county hospital in my constituency.

My hon. Friend the Member for Shrewsbury and Atcham (Daniel Kawczynski) made an important intervention. As he said, the birth rate rose by 19% between 2001 and 2009, and the midwifery work force rose by only 9% in that period. Listening to Opposition Members this morning, one wonders where the Government have been for the past 13 years. In that period, significant amounts of money were going into the NHS. So, as my hon. Friend asked, what exactly did the previous Government do in that time?

I want to mention some of the other points that my hon. Friend made. His dedicated service to his constituents is legendary and this morning he spoke with his usual passion. He has already raised his concerns about reconfigurations of services and I know that he will listen to what GPs, midwives and, most importantly, women and their families have to say about those reconfigurations. I know that he will use every tool at his disposal to ensure that his constituents’ views are heard loud and clear.

My hon. Friend the Member for Montgomeryshire (Glyn Davies) also reiterated his concerns about reconfigurations. I must say, Mr Gale, that he should relax about parliamentary procedures, which confuse even the most experienced Members at times. As a new Member, you often feel that it is just you who is confused. But fear not—people who have been in the House for 20 years or more can also get confused by procedure.

I was very heartened to hear of my hon. Friend’s positive tale of his wife’s four home births. Clearly, they were successful and happy experiences, which were doubtless helped enormously by the excellent support of a midwife on the spot. He rightly raised the difficult issue of cross-border care and it is critical that we get that care right. Arbitrary lines do not wash with the public, and I am sure that people will listen to his contributions on this subject when the reconfigurations are considered. The first duty of maternity services is to provide safe, high quality care for mothers and babies. Women should rightly expect to receive consistently excellent maternity services, no matter what time of day they have their baby or where they are treated.

I did not have any home births, but I am very aware—this is slightly contrary to the hon. Member for Birmingham, Edgbaston—of what an important choice having a home birth is for many women. Personally, I am a little more nervous. I quite enjoyed my stay in hospital after each of my babies arrived; I put that down to the fact that I always feel the need to do housework if I am at home, so a hospital stay gave me a few days off. However, having a home birth is an important choice and I know that many women gain enormously from the opportunity to have a baby in their own home, and our aims reflect that. We have made provision of maternity services that are focused on improving outcomes for women and for their babies, along with improving women’s experience of care, an absolute priority for the NHS. The Government set out our long-term vision for the future of health care in our White Paper and there was an extensive debate in the House on many of those issues yesterday.

By focusing on health outcomes and delivering maternity services through provider networks, we want to deliver high quality maternity services. Networks will bring together all the maternity services that a mother might need, linking local hospitals, GPs, charities, secondary and tertiary services, and, indeed, community groups, so that they can share information, expertise and services. Commissioners and providers will drive that process forward. Maternity networks will extend choice for women by encouraging providers to work together, offering expectant mothers and their families a broader choice of maternity services and allowing women to move seamlessly between the services that they want or need.

[Ms Gisela Stuart]

I am trying to understand these networks. How many will there be? I am concerned about the fragmentation of maternity services. Will there be one network in the west midlands, or will Birmingham have one network? Will there be 25 networks? How big are the networks?

[Anne Milton]

The important thing for central Government, and it is what we are doing, is to move away from being centrally very prescriptive. If I were to guess, I would say that networks will be on a regional level, but their size will depend on various things. Delivering maternity services in Birmingham is very different from delivering maternity services in Cornwall. We need a network that can offer all the services that women and their families need while not being too big and thus unresponsive to local need.

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[Ms Stuart]

This issue is quite important. When we created primary care trusts, there was a kind of vision that they would each serve a population of around 250,000. That was a framework, but there were still some very small PCTs. Are we looking at a maternity network that would serve a million people, as in Birmingham, or a network that would serve 3.6 million people, as in the west midlands as a whole?

[Anne Milton]

The hon. Lady is already falling into difficulties. She wants central Government to prescribe what works on the ground. If one looks at the proposals for GP pathfinder consortia, one sees that the proposed consortia vary in size enormously. That is because local people on the ground know what size of consortium will work for them. We will see more details emerging as the health Bill goes through Parliament and as the consortia get going. What matters is to be locally responsive. The hon. Lady mentioned accountability; having the right accountabilities in the system is important. What also matters is using the commissioners in particular to drive up quality.

Our focus on public health is also critical to maternal outcomes. Healthier women have healthier babies and for the first time we will ring-fence public health money. The hon. Lady was right to mention inequalities. Increased rates of stillbirth are associated with deprivation. I must say that, despite the previous Government having what was doubtless the best will in the world, during the 13 years that they were in power, health inequalities widened. I do not think that that was because they were utterly incompetent; it was partly because it is extremely difficult to do something about inequalities. However, I believe that our focus on public health and our ring-fencing of public health money will have a significant impact.

--- Later in debate ---

[Anne Milton]

There is no rowing back. We have always made it clear that the number of midwives will be in proportion to the birth rate. In fairness to the previous Government, they made concerted attempts, although much too late, to increase the number of midwives in training, and, as I have said, we have 2,500-odd in training now. We will continue to ensure that we have the right staff mix and the right number of midwives to ensure that women have safe births.

[Ms Gisela Stuart]

On that very point, I would be very happy for the Minister to write to me, stating that the Prime Minister himself said that that promise of 3,000 was contingent on the birth rate.

[Anne Milton]

I will happily discuss that further with the hon. Lady if she would like me to.

Significant progress has been made, and what matters is that the number of midwives that we have in place—the skills mix—provides good, safe outcomes for women and their babies. The NHS commissioning board will provide commissioning guidance and we are, of course, keen for it to support GP commissioning consortia in their commissioning of services. The Government will specify outcome indicators that demonstrate high quality and improving care, but it would not be appropriate for us to dictate models of care or how resources, including staff, are used. Instead, we will look for local leadership, from health and well-being boards for example, which will develop the joint strategic needs assessments and health and well-being strategies to inform commissioning, ensuring that trends in the birth rate and the growth in the number of more complex cases are taken into account by the local service. The complexity of a case is becoming more important than ever in determining the care and the number of staff needed to deliver babies safely, and its consideration will allow individual maternity services to adapt to the different pressures faced in different communities.

The hon. Member for Birmingham, Edgbaston rightly made important points about the deaths of the 25 babies in the west midlands between April 2008 and March 2009, and said that the report sadly states that 84% of those deaths were potentially avoidable. That is totally unacceptable, and I must admit that it comes as a shock to me, as it probably did to the hon. Lady, that we are still not good at using serious untoward incidents, and indeed the deaths of children and babies, to learn and to improve our practice. I met Professor Jason Gardosi, director of the west midlands Perinatal Institute and author of the report, to discuss the issue in more detail, and we have a lot of work to do to ensure that we learn from such tragic incidents. When I talk to women who have lost babies, they say that, more than anything, they want this not to happen again and lessons to be learnt from their experience.

The report outlines steps that could improve the safety of services, and we are looking at a number of ways in which they can be addressed. The NHS in the west midlands now has clear plans for improving standards of care and reducing preventable deaths, and it is important that those plans are implemented, including the urgent introduction of a system whereby maternity units and commissioners can learn from and respond effectively to adverse incidents, and a standardised regional perinatal death reporting system across all its maternity units. Interestingly, as a result of that, the west midlands in many ways now leads the way in this field.

Nationally, the National Patient Safety Agency has launched an intrapartum toolkit, which is valuable in helping maternity units improve safety. Sharing best practice is terribly important and we do not do it enough in the NHS. I hope that the new outcomes framework will act as a catalyst for driving up quality across all NHS services by measuring what is important: clinical outcomes. Such outcomes make a real difference to people’s experiences of services and to their health and well-being, and can sometimes save the lives of mothers and babies.

It would be unfair to say that there have been no improvements in the past few years; there have been improvements in antenatal care. The Care Quality Commission survey of women’s experiences of maternity services published in December 2010 found that 92% of women rated their maternity care as good or better. We should be proud of that, but it is the 8% sitting on the edge and those babies who die that are completely unacceptable, and we need to do much more.

The hon. Member for Birmingham, Edgbaston talked eloquently about the association between deprivation and poor outcomes, and rightly said that commissioning is weak. She described Professor Gardosi’s report as damning, but the previous Government presided over the years covered by the study. What exactly did her Government do? Where were they? Why were inequalities in health not reduced? What happened to the health visitor numbers? Why is commissioning so weak? It is the weakness of commissioners that has failed to drive up standards, and the hon. Lady spells out exactly the case for changing commissioning.

[Ms Stuart]

The report was the result of the chief medical officer’s concerns from the early ’90s onwards. What concerned the CMO was that, although we reduced inequality, this particular area was not addressed, going back to well before the Labour Government.

[Anne Milton]

I appreciate that, but for the past 13 years the hon. Lady’s party has been in government. In many ways, she could not have made a better case for changing commissioning. It is not very sexy to talk about it, but the weakness of commissioning is what has been at fault in many ways. It is what has failed to drive up the quality of services and achieve the outcomes that we want. The Health and Social Care Bill gives us the chance to refocus the NHS on what is important to its users and the staff providing the services, and to achieve the results that are important to them.

I assure hon. Members that I will continue to work on maternity services, and I remind the hon. Member for Islington South and Finsbury (Emily Thornberry) that it is simplistic in the extreme to say that this is just a numbers game. As far as health visitors are concerned, her Government presided over this dramatic loss in the health-visiting work force. We have promised to increase the number of health visitors to 4,200, and that vital work force will work with midwives and other professionals across the board to ensure a universal visiting service and targeted help for the most vulnerable.

The hon. Member for Birmingham, Edgbaston put across the exact case for why the changes to commissioning are so important, why our pledge to increase the number of health visitors is vital, why we need to create the maternity networks and why ring-fencing public health money is so important. Crucially, they are important because we are determined to improve the health outcomes of mothers and their babies.