Maternity Services

Debate between Andrew George and Baroness Stuart of Edgbaston

Tuesday 1st February 2011 Westminster Hall

[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.”

--- Later in debate ---

[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.

--- Later in debate ---

[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?