Maternity Services

Anne Milton Excerpts

Tuesday 1st February 2011 Westminster Hall

[Emily Thornberry]

Although the Government have said that, in principle, there is a ring fence to the NHS budget, a closer analysis will show that that is not true. The real position is that there is double-counting of over £2 billion—

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

indicated dissent.

[Emily Thornberry]

The hon. Lady is welcome to intervene if she wants to get into an analysis. The Government’s promise of a ring fence and a year-on-year increase in the NHS budget is one that does not stand up to scrutiny. There is double-counting going on. Currently, given the increased demand, we must have 4% efficiency savings each year in the NHS. In fact, we will see cuts. It is simply not right for the Government to continue to say that the NHS budget is ring-fenced, that the NHS is safe with them and that services will not be cut. The reality is that the NHS is going through a very difficult time, and, on top of that, this Government are putting it through an absolutely needless reorganisation, which means that we will not get a national steer on things such as maternity services.

Simply giving commissioning to GPs will not help. It has been a matter of policy for years that we keep pregnant women away from doctors if we can, because they are not ill. We pass their care into the hands of the midwives, and hopefully everything will be fine. If a doctor is needed, bring the doctor in. Essentially, women go to a GP to find out that they are pregnant. They then go to a midwife and the midwife looks after them. That has always been the case. GPs do not have an understanding of midwifery or services for pregnant women. The difficulty is that such services will be sidelined and that is not fair on women. That argument was made to the Government when the point was being made that midwifery and post-natal services should be commissioned nationally. I do not know why the Government have changed their mind about that, and it is one of the questions I want to ask the Minister.

The NHS is going through great economic trauma. It is used to having a year-on-year increase in budget. Now, its budget will be cut year on year at the same time as the service is being reorganised. Will we have proper tactical decisions on midwives, community nurses and all those things on which mothers rely, or will we simply allow such services to be given to GPs—at a time when a cold wind is blowing through the national health service?

I think I have got through most of my questions to the Minister. I have just a few more. How will she drive improvements in maternity services? Before the election, the Prime Minister talked about maternity networks. What levers does he have that will make them a reality? Why did the Government ignore the representations of professional bodies such as the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists in relation to commissioning? Furthermore, why has the Prime Minister handed over commissioning to GPs and maternity services? Will the Minister give us an assessment of the involvement of midwives in GP pathfinder consortia?

[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.

[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.

[Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)]

Does the Minister agree that, although choice is very important, in a constituency such as mine, which is in the east end of London, public health issues, such as nutrition, access to advice and quite low-tech care during pregnancy are just as important to good maternal health outcomes? Underweight babies are one of the big problems in my constituency. They often have poor educational outcomes later, and cost the taxpayer tens of thousands of pounds, because they have to be put in incubators and so on. That problem is to do with the sort of advice that those young mothers receive and it is a public health issue.

[Anne Milton]

I thank the hon. Lady for her intervention; I think that we broadly agree on this issue. That is why we are focusing on public health. Preparation for pregnancy and having a healthy baby starts long before a woman gets pregnant. The education and support that women receive, the social networks that they are part of and improving the public’s health all matter. Nothing could be more important than improving the outcomes for women and, indeed, their babies.

Choice is important and it is also important that women can make informed choices; choices must be well informed to improve the outcomes for women and their babies. Furthermore, it is important that women have access to maternity services at an early stage in their pregnancy. In fact, ensuring such access is probably one of the most fundamental characteristics of high quality maternity care, which is why we have included the 12-week early access indicator as one of the measures for quality in the NHS operating framework for 2011-12.

Of course, it is also important that there are appropriate numbers of trained maternity professionals to provide the maternity service. The number of clinicians needed by mothers depends on several factors, ranging from the mother’s medical circumstances, to the complexity of the pregnancy, to wider societal factors, which can have a considerable impact.

Looking at the bigger picture, the birth rate must be considered when we are planning maternity services. Although the number of births in England has been rising since 2001, as I mentioned earlier, the birth rate peaked in 2008 and fell, by just less than 1%, in 2009 to about 671,000 live births. We are determined that staffing rates should be calculated purely on how many staff are needed to provide safe, quality care. We are considering ways to improve midwife retention and recruitment, and the planned number of midwives in training in 2010-11 is at a record level of about 2,500. Therefore we expect a sustained increase in the number of new midwives who will be available for maternity services during the next few years.

Complete and absolute focus on staffing numbers is totally ridiculous. If the birth rate shot up, 3,000 extra midwives would not be enough. Ensuring that the maternity work force has an effective skills mix is also an important consideration. I was recently in an extremely busy maternity unit, and the midwife there made it clear that what they needed was not more midwives but more support staff. Doubtless in other units there will be support workers in place, but not enough midwives. We want to focus on using the whole maternity team, including obstetricians, anaesthetists and support workers. It is not just the number of qualified midwives that is important, but their experience, and one issue that we need to address is attrition. A newly qualified midwife does not have the experience, nor perhaps the skills, to lead the team in a way that a midwife who has been in practice for 10 years or so can.

[Emily Thornberry]

Although I agree with what the Minister says, surely the difficulty she has is that the Prime Minister promised us 3,000 more midwives. Although I accept that we need experienced staff to ensure that midwives are trained up properly—the same applies to a number of different skills—the Prime Minister promised us the 3,000, so is it right that the Government are rowing back on that promise?

[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.