Maternity Services

Debate between Baroness Hodge of Barking and Anne Milton

Wednesday 22nd June 2011 Commons Chamber

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

I congratulate the right hon. Member for Barking (Margaret Hodge) on securing the debate, and thank her for bringing this important issue to wider attention. Her message came across loud and clear. She has campaigned vigorously in support of her local health services for many years, both on the Government and Opposition Benches, and Members are to be congratulated on their vigilance in doing exactly what they were elected to do.

It is never good enough for patients anywhere to experience poor-quality health care, and it is clear that the problems at Queen’s maternity unit must be fixed now, so that the people of north-east London can regain trust in their maternity units. Regaining such trust is never an easy business. When mothers go to a maternity unit to give birth, they implicitly trust that they will receive the best-quality care. That is a vital part of maternity services, and it means that mothers can feel comfortable and safe with midwives, wards and hospitals. The shocking deaths at Queen’s maternity unit have put that relationship and that trust at risk, and I know that local concern is running extremely high. I offer my heartfelt sympathy to the families involved. To lose someone at what was expected to be a time of celebration is especially traumatic, and no words that I can say today will console those families. However, I believe that the message has been conveyed by the right hon. Member for Barking, the hon. Member for Ilford South (Mike Gapes) and my hon. Friend the Member for Ilford North (Mr Scott).

I understand that two investigations of maternal deaths are taking place at the unit; I hope Members will understand that I cannot comment on them at this stage. I know that the Care Quality Commission found that maternity services at the trust were failing to meet essential standards of quality and safety, but, although that was partly due to unsuitable staffing levels, they are not the only issue.

Unfortunately we cannot turn the clock back, but what we can do is ensure that decisive action is taken immediately to improve the position and ensure that the Queen’s maternity unit performs as it should have all along. In response to the CQC’s report, the trust has drawn up an urgent action plan and is taking steps to improve its maternity services. I understand that it has recruited an extra 60 midwives, and that a further 60 are shortlisted for interview. I also understand that it has revised the training programme for all midwives, created a new triage system enabling all women in labour to be seen by an experienced midwife within 15 minutes of arriving at the unit—the right hon. Lady particularly mentioned waiting times—and introduced a telephone triage system so that women can get advice even before they leave home. That is a start, although it is a start from a very low base. Although all those facilities should have been in place already, it is good that they are there now.

I have met Averil Dongworth, the new chief executive of the trust. She has assured me that everyone at the hospital—particularly the midwives and the support staff in the unit—is determined to improve standards and rebuild confidence. That may sound hollow to the Members who are present, who have probably heard it before, but Averil Dongworth struck me as an impressive woman with a steely determination to turn things around. She has also promised to keep in touch with and meet the local Members of Parliament regularly. I think it important for them to feel that, on behalf of their constituents, they are monitoring the position regularly and frequently. I have asked Averil Dongworth to keep me up to date. The position is very simple: nothing but the best will do for anyone who is seen in the NHS.

I also understand that NHS London, the local strategic health authority, is taking action to improve clinical leadership. It is important for that leadership to be in place, because its absence is often the reason why things go wrong, particularly midwifery in this instance. I understand that the authority has asked a senior obstetrician and an experienced midwife to spend time working in the team.

The right hon. Lady mentioned the health for north-east London review, which includes proposals to change the way in which Barking, Havering and Redbridge University Hospitals NHS Trust delivers maternity care. As Members have mentioned, under those proposals King George hospital would continue to provide antenatal and postnatal care, but would no longer provide maternity services during delivery. Maternity services would be consolidated at Queen’s with a new midwife-led unit that could deliver more than 2,500 babies a year. I understand that the unit is empty. The situation is extremely disappointing, but the proposals have been referred to my right hon. Friend the Secretary of State for Health, and the independent reconfiguration panel will advise him within the month, no later than 22 July. I know that Members look forward to hearing the decision, but obviously I cannot prejudge it.

The financial payouts in litigation that the right hon. Lady mentioned really pale into insignificance when compared with the human cost. There is not just the human cost when things go tragically and irreversibly wrong, but the poor experience that women have had, which is a very bad start to their new family life. Nothing can compensate for any of those things. She mentioned Sareena Ali and the unresponsive nature of the trust in relation to complaints. That has to change and I sincerely hope that Averil Dongworth will turn that around so that local people can start what will be a very long and slow journey to building that trust.

The right hon. Lady also mentioned that the problem is not just about recruiting staff but keeping them. That is the real challenge. When local people have lost faith in a local NHS organisation, the recruitment of staff becomes increasingly difficult. Keeping up morale is very important, which is why I think it is an important step in that journey for the chief executive to keep in touch with local MPs.

The right hon. Lady rightly said that this should be about the care of women and their babies and families, and not about other people’s convenience. My hon. Friend the Member for Ilford North reiterated many of the same points and I am always impressed when there is cross-party support on issues such as this. This place does not always have a good reputation but at times like this our reputation should soar because that cross-party working is extremely important to get things done. The hon. Member for Ilford South also spoke about the cross-party support and referred to the culture and institutional problems, the issues that are so very difficult to dig into and turn around. I sincerely hope that we can start to do that.

The Government are doing all we can to stamp out instances of sub-standard care. As I have said, nothing but the best will do for anyone. New standards of care are being developed for antenatal services and the management and care of women in labour, as well as for delivery and post-natal care. We are also keeping up the record number of midwives entering training—nearly 2,500 this year and 2,500 next year. I want to see the potential of the whole maternity team being realised. There are new technologies out there and new techniques improve care and deliver value for money while improving the experiences of women, their babies and the wider family. We will continue to work with the Royal College of Midwives to make sure that we have an appropriately resourced but also skilled maternity work force with the leadership they need. Of course, that will be of scant consolation to many of the families involved, but sadly I cannot turn the clock back.

[Margaret Hodge]

I am grateful for the Minister’s remarks, but in the last couple of minutes available, may I ask her to comment on two other specific issues? First, I think that we need an independent inquiry. I recognise all that has been done, but will she respond to that point? Secondly, will she respond to my point about the Barking hospital site where we have a brand-new, state-of-the-art maternity unit that is being kept closed?

[Anne Milton]

I thank the right hon. Lady for making those points, but I honestly do not know that an inquiry is the right way forward. The tragedy of this is that we know what some of the problems are and there has been a failure to turn them around. Certainly, an empty building and a midwife-led unit that could deal with 2,500 deliveries a year for women of low risk would be an important development, but I do not want to prejudge the Secretary of State’s decision on that. I hope that the right hon. Lady, her constituents and the families involved will at least take some heart from the fact that steps are going to be taken to prevent any of this from ever happening again. I will make sure that those efforts remain at the top of the trust’s agenda. I can assure her, my hon. Friend the Member for Ilford North and the hon. Member for Ilford South that I will take a personal interest in this and make sure that we monitor progress towards giving local people what they deserve—the very best from their local NHS.

Question put and agreed to.

Life Expectancy (Inequalities)

Debate between Baroness Hodge of Barking and Anne Milton

Thursday 3rd March 2011 Westminster Hall

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

It is a pleasure to be here this afternoon serving under your chairmanship, Miss Clark, for what I think is the second time.

I will endeavour to answer all the issues that have been raised in the debate. I welcome the report from the Public Accounts Committee. There is no doubt that health inequalities belong to another age and certainly have no place in modern society. Anything that brings this issue to the fore is entirely welcome. As the right hon. Member for Barking (Margaret Hodge) said, health inequalities are terrible, and it is shocking that they exist to such a great extent. I shall deal later in my remarks with the questions that have been raised. If Members wish to intervene, I will be happy to take interventions, but if they hang on, I will get to all their questions in time.

The hon. Member for Hackney North and Stoke Newington (Ms Abbott) was absolutely right to say that lessons should be learned. The problem with government generally, at every level and irrespective of political party, is that people tend to turn up bright-eyed and bushy-tailed but do not take any notice of what has gone before. In fact, the Government and politicians should have the humility to recognise that if things were not achieved earlier, it was not necessarily because of the incompetence of the previous incumbents but because sometimes it is difficult to do something, and this is one area where that applies. As was said earlier, this is not a partisan issue. It is something that we need to act on across the board. The important thing is truly to understand what we are talking about when we talk about public health.

I do not think that, strictly speaking, I have to register an interest, but I should mention that my husband is a public health physician, although not working as a director of public health. It is extraordinary that we have had this discussion this afternoon without yet mentioning the public health profession or directors of public health—members of the public health profession will be somewhat disappointed, because they are pivotal to many of the changes that we want to introduce.

My Government want to improve the health of the poorest most quickly. If we are to achieve better health outcomes, particularly compared with other countries, that must be more than a pipe-dream. My hon. Friend the Member for South Norfolk (Mr Bacon), who is, indeed, my favourite member of the Public Accounts Committee— [Interruption.] This is a love-in. He mentioned that it is extremely easy to assert things, but we do not want assertions but real action. That must be a fundamental part of our strategy in health care and in other areas such as housing, education and social care. We believe that the more devolved health system that we are developing will enable a sharper focus on disadvantaged areas across the country.

The Government want to provide far more opportunities for local people and organisations, including statutory organisations, to plan and run health initiatives specifically tailored to their communities. We have set out proposals to reform the delivery of health services in England. They are contained in two White Papers, which I am sure Members are familiar with: one is for NHS services, and the other is for public health. Reducing health inequalities must, and will, be embedded in the reformed architecture that we propose.

[Margaret Hodge]

I believe that, in principle, all of us would support devolution of power, but I draw to the Minister’s attention constituencies such as mine—this is more a constituency point than a general point. My constituency, which is a working-class area, is quite uniform in class structure. The whole public service infrastructure is weak, whether one looks at education, health, public health, GPs or the voluntary sector. If there is devolution to the poorest areas with poor infrastructure, it will be extremely difficult for them to grow from within themselves the necessary capabilities to tackle some of these deeply entrenched problems. There is a role for the centre, through Government, to intervene and try to build capability so that we can achieve an impact. I am concerned that if the whole mantra is about devolution, we will leave large areas of the country with concentrations of poverty and need struggling to achieve the kind of outcomes that she and we would want.

[Anne Milton]

I thank the right hon. Lady for that intervention. She is absolutely right to mention capacity building. There are areas where there is weakness across the board, and that is certainly something that we need to address. However, it is quite interesting what local areas can do with good leadership and the right levers and safeguards in place. I believe that it was out her way that I visited a scheme in an area with a high incidence of domestic violence. The local authority connected the council’s noise nuisance helpline and the domestic violence team, on the basis that where there is noise from neighbours there will probably be violence in the home. After a certain number of calls about a certain address, the domestic violence team is alerted and then goes in—a simple intervention, and a kind of capacity. Some of that is down to the confidence of the people working in the area, some of it is to do with expertise, and some of it—general practice has been mentioned quite a lot—involves putting in incentives to ensure that we get people with the skills that are needed to build that capacity.

I was not going to mention this, but we have made, for instance, a commitment to increasing radically the health visitor work force. One of the modules in health visitor training that we are looking at is about teaching new health visitors how to build capacity in communities. It is a nebulous thing, but it is important that we understand it. There is no doubt that communities, Governments and even empires have struggled for donkeys’ years with the question of how to improve public health. The hon. Member for Hackney North and Stoke Newington mentioned that in 1948, the NHS itself was a major public health advance. It secured health services for all, regardless of ability to pay. I make no apology for giving a history lesson. I am not a history scholar, but it is important to take on board the history of public health. At the same time, local authorities were given responsibilities for the health of children and mothers, and for the control of infections. At the same time, they retained their role in planning, sanitation and overseeing the health of their local population through medical officers of health.

In the NHS reforms of 1974, further unification of health services resulted in the transfer of some of those health functions from local government to the NHS, including many that we would recognise as public health functions. I draw Members back to the comments of the hon. Member for Hackney North and Stoke Newington about the status of public health. One of the reasons why the medical profession at that time pulled public health out of local authorities was to do with status, and the clout that they felt they had. Clearly, if one looks at what we are doing now, that was probably a mistake, but there were issues to deal with. The Government have to be clear about how we want the public health profession to look.

That period coincided with advancing knowledge that allowed us to identify the causes of chronic disease and health inequalities. All of those things needed to be tackled as they became apparent. The hon. Member for Blaenau Gwent (Nick Smith) mentioned the Black report, which was published in 1980. It showed that although there had been a significant improvement in health across society, there was still a relationship between class and infant mortality, life expectancy and access to medical services. It is shocking that one could write the same thing today, 31 years on.

That report was followed by the first public health White Paper, “The Health of the Nation”, which recognised that there were considerable variations in health by area, ethnic group and occupation. A new public health agenda was set, and it provided a foundation for action over the past 30 years. There has been a great deal of work, with the best of intentions. I do not doubt the previous Government’s intentions. As I said in my opening remarks, it is important to have some humility and understand that the intent was there. However, we did not get the results that everyone wanted.

We need a new approach, and that is backed up by recent data from the London Health Observatory and from the Marmot review team, which show that although life expectancy is increasing in all socio-economic groups, it also reinforces inequalities. The data also show the variation in life expectancy at birth between men and women and between local authorities, and the pronounced inequalities even within local authority areas including, for example, Westminster, which has the widest within-area inequality gap, at just under 17 years for men: a man born in one part of the borough can conceivably expect to live almost two decades longer than his friend born a short distance away.

I do not apologise for using figures, because when we talk about health inequalities, people glaze over and are not terribly sure what it is about. They think it is something to do with obesity, smoking or something like that, but the figures tell the real story. The smallest inequality gap for men is in Wokingham in Berkshire, at less than three years, and for women the smallest gap is in Telford and Wrekin, at slightly less than two years—so we all know where to move. It is worth repeating that those are the smallest differences in the entire country, so even in the areas with the best outcomes, we are still talking about differences in years.

It stands to reason that a community in Lancashire, for example, might face different health problems from one in Hackney, where I used to work. The public health White Paper therefore sets out a new way of working. It gives a different flavour to how we view public health, looking at our lifecycles and highlighting the points where we can intervene to make a difference. It is a way of working that shifts power away from central Government and into the hands of communities.

We had a short discussion about devolving power, and it is a brave Government who devolve authority for something for which they will be held responsible in the end. That is why I disagree with my hon. Friend the Member for South Norfolk, who said there has been a yo-yo between local devolution and centralised power; there has not. All Governments like to centralise things and keep control, because at the end of the day at a general election they will be blamed or otherwise for what has happened. It is quite brave to devolve power, but sometimes it is the right thing to do.

The new way of working will enable local areas to improve health throughout people’s lives, reduce inequalities and focus on the needs of the local population. The White Paper also underlines the priority we have given to tackling inequalities in supporting the principles of the Marmot review, which is important. The White Paper recognises the value of an approach that sees the importance of starting well, even before a child is born. Life chances are set well before someone pokes their head out into the world.

The new body, Public Health England, will have an important role. It will bring together what I suggest is a rather fragmented system and will span public health; it will improve the well-being of the population, targeting the poor in particular; and it will protect the public from health threats, which have not been mentioned, but they are an issue. There are inequalities in public health threats and, without a doubt, there are inequalities worldwide. Public Health England will need to work closely with the NHS, to ensure that health services continue to play a strong role and that NHS services play an increasingly large part in that mission. There has been a tendency for NHS services to see themselves simply as services to cure an immediate problem, rather than as part of a wider, more holistic approach to improving individuals’ health.

[Anne Milton]

The hon. Lady is right to raise the issue. That is what has happened. On a more general point, cherry-picking is a problem. It is very easy to get certain people to lose a couple of stone—[Interruption.] Actually, sometimes it is quite hard to get them to lose a couple of stone and go down the gym. To be rather crass and non-specific, it is easier to get the middle classes to go to the gym and to eat a better diet.

The hon. Lady is absolutely right to highlight the fact that some areas are very disparate and disconnected. I am an optimist, and I believe that there is social capital. Central Government are very poor at delivering in local areas. I have worked in the most deprived part of the country and lived in the most affluent, and there is a world of difference. It is extraordinary to see—they could be different planets. Central Government is a clumsy tool to deliver something that is very difficult to bring about on the ground, so we must ensure that we have levers and build social capital.

I mentioned health visitors as an example, and a universal health visiting service is extremely important. When we think about hard-to-reach communities, we forget just how hard to reach they are. For some people, the only interaction they have with any health or social service is when they have their baby. Their kids might not go to nursery school or might frequently play truant from school, and they are extremely difficult to get hold of. To be honest, a universal health visiting service is probably the single most important measure we have announced, because it will get hold of those families who are so difficult to reach.

There has been talk of increased health funding. I will not deny that the previous Government put a significant amount of money into health, and I welcome the rather cross-party approach in this debate to acknowledging that that did not always produce returns, certainly not in public health. One problem was that the budget was not ring-fenced, but it will be ring-fenced now. I will return to some points made on ring-fencing and localism and the tension between them. It is important that local government be given the responsibility and freedoms to make a major impact on improving health, backed by ring-fenced budgets.

The right hon. Member for Barking gave an interesting example about the ineffectiveness of one-to-one smoking cessation programmes. More generally, she said that it is extraordinary that we do not drive or back up with evidence what we do in health, which to most people is a science-based discipline with science-based professions. I may have a higher opinion of local government than my hon. Friend the Member for South Norfolk. I think that local government knows a lot about its local area and is often better at dealing with evidence than health services are.

The size of the ring-fenced grant will be important, because when the money was not ring-fenced it was an easy pot from which to pinch. The trouble is that the tabloid newspapers—I hesitate to mention one in particular—do not come out screaming about the poverty of the public’s health, although they come out screaming when services go. It was too easy to pinch the money, which is why it needs to be ring-fenced. It must also be based on relative population health need and weighted for inequalities, so that the areas with the greatest need will get the most.

Directors of public health will lead on action to address health inequalities. Public health physicians have done tremendous work. The public health observatories have done fantastic work, but they have tended to work in a cupboard and do not feel that they are getting their message across. Locating them in local authorities will bring together the threads that influence health, not only health care itself, but other determinants such as housing, transport, employment—the causes of the causes of poor public health, if you like.

There will be financial rewards for progress, and greater transparency so that people can see the results achieved. The new health premium will provide an incentive to reduce health inequalities and reward progress. That does not necessarily mean cherry-picking the easy cases. The programme will be designed to reward instances where progress has been made, and those places that have seen the greatest impact in areas with a poverty of outcomes in reducing inequalities. Almost by definition, those will be the areas where health inequalities are greatest.

[Margaret Hodge]

I understand the thinking behind the incentives and rewards, but my point was about the other side of that coin. Will there be penalties for those high-need areas with huge health inequalities that fail to perform? Although it is good to reward the good performers, that does not help people living in communities where there are bad performers. What are the Government’s intentions on that point?

[Anne Milton]

The right hon. Lady is right to raise that point. I was trying to stress that the healthiest areas will not necessarily be those that receive the most money. In theory, those areas that start from the lowest base should have the greatest opportunity to get those rewards.

Perhaps I can connect the right hon. Lady’s point with that made by the hon. Member for Hackney North and Stoke Newington. This debate is slightly premature because a consultation on the outcomes is currently under way, and we are also looking at the finances, at how much each local authority will have and at the size of the health premium. We are acutely aware—as I am sure are all Opposition Members—of the problem of unintended consequences.

Let us take an obvious example of A and E waiting times. It is right to want people not to wait in A and E for very long, and indeed they did not. If that is given as a target, the health service is good—as are most professionals—and it will fulfil that target. It will get people out of A and E. However, what was never measured was whether people got the care they needed. Did they get better or were they just transferred up to a ward sooner than they should have been? It is important to look at that. To some extent, this matter is a work in progress and we are keen to learn and listen to what people have to say. It is important not to have perverse incentives but to put in place the levers that we need to produce the right results in areas where there is possibly poor capacity, or areas that need building up or contain inequalities.

In some areas there are difficult cultural issues. To return to the issue of domestic violence, sometimes those working in the health service will collude with some of the men who perpetrate that violence. It gets very complicated and we need a system that takes account of all those issues.