Obstetric and Neonatal Care

HC Deb 10 June 1982 vol 25 cc523-8

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Thompson.]

12.55

Mr. Lewis Carter-Jones (Eccles)

Shall we now return to reality and forget Members' salaries?

Earlier in the week when I asked the Minister whether the minimum standards of obstetric and neonatal care had been referred to the maternal services advisory committee for consideration, the answer was "No". As recently as two days ago the Minister was saying that he had not referred the question of minimum standards to the appropriate committee.

In 1976 I started a campaign to reduce perinatal mortality and handicap. I had a substantial amount of support from a wide variety of organisations and people. First, I should like to pay tribute to the Table Office, which assisted me from time to time to table innumerable questions on the problems. The questions revealed that it was a vital issue.

The second group of people to whom I want to pay tribute are those from RADAR, such as George Wilson and Peter Mitchell, who helped me with my researches. In addition, there are the people from MENCAP, who are very concerned about mental handicap. In that context I must also refer to Brian Rix and Mary Holland. I pay tribute also to Tim Yeo and Amanda Jordan of the Spastics Society. One could say that it was the Spastics Society which took up the campaign in 1978. Next week it enters the third phase of the campaign.

It would be wrong to pretend that we have not been able to bring down substantially the perinatal mortality rate in Britain. It has come down from about 17 deaths per thousand to 13 per thousand. That is a big improvement, but it is not good enough. One must accept that there should be a minimum standard of care for the pregnant woman and her new-born baby. That is the only means by which we can make comparisons.

The House and a variety of Ministers have been deceived by the Minister's Department. From time to time it would say that it would cost too much to collect that information. The low-weight, pre-term baby is the one at greatest risk. After a battery of questions and much support from the Library and the Table Office, I was told that it would be too costly to collect this information. I thought that I was asking the Minister to share information with me. The reply was that it would be too costly to collect the information.

The Minister will be very surprised to know that a professor in Liverpool, who had followed the questions, told me that he could not understand why I had not been told the information, and he supplied the answer that had been provided by the Minister's Department. I do not know why the Minister or Parliament should be denied information on minimum standards of care, On the basis of the minimum standard we can make our judgments about what should be done. I can understand the Department's concern about not interfering in the activities of area health authorities and regional health authorities. However, we are saying that that is the minimum standard. Anything more would be very welcome.

I intend to raise this issue over and over again. I shall speak briefly, for a Welsh Non-conformist. I shall speak for only 10 minutes. That will give the Minister twice as much time as me. En that time, I expect him to give a full answer and I expect to be able to intervene briefly, Over the years we have tried to obtain minimum standards. I have been involved since 1976. The Spastics Society has been involved since 1978. The Minister will find report after report from 1945 onwards. The Opie report, the Court report, the Short report, the Black report and the Peel report all say that there must be minimum standards.

I have a substantial number of friends in the Department, but, strangely, the section that deals with the prevention of handicap among the new-born seems to be evasive. I could say that it tells lies. If one severely disabled baby survives it costs the State £½ million. I would willingly pay that. Life is important. However, if the handicap was avoidable and someone did not insist on minimum standards, someone must be called to account. That is the point.

After all these years, after eminent report after eminent report stressing the importance of minimum standards, why have we not got them? The all-party group met the Secretary of State following the publication of the Short report. The Secretary of State said that the Government had announced their intention of establishing minimum standards in a debate on 5 December. Which 5 December? It was 5 December 1980. It may sound unkind, but some civil servants will have been drawing their pensions for five to eight years, while minimum standards have not been laid down. I would settle tonight if the Minister said that the Government would implement minimum standards with effect from now. I would accept that and I would feel that the debate at this late hour had been worth while.

I am concerned about the fact that complacency is creeping in. The campaign that has been conducted since 1976 reveals that there has been a fall from 17.7 cases of infant mortality per 1,000 births in England and Wales to 13.3 per 1,000 in [980. The figures are good, but they are not good enough. One of the answers is that a standard that is acceptable must be laid down.

From time to t me the Department has been sceptical about what is called positive discrimination in favour of those at risk. There are certain women who become pregnant and who are at risk. These women must be identified at an early stage. The Department has said "No. We are not sure that your facts are right." Immigrant women, for example, could be in difficulty. It was said repeatedly that positive discrimination has been applied in Sweden and that the women of the poor Mediterranean countries have a better rate of perinatal mortality than Swedish women.

At long last we have evidence in Britain that at Sighthill in Edinburgh, where a policy of positive discrimination for those who are weakest in our community who are pregnant is pursued, it is possible to achieve dramatic results. After the debate the Minister will have to return to his Department to say "The Spastics Society, MENCAP, RADAR, the professionals and the House have proved that positive discrimination reduces perinatal death and handicap. It brings in the community midwife and gives her a vital and positive role to play in our society. We must employ her skills to the maximum capacity. At the end of the day, when this has been done, there is a fall in mortality rates and a dramatic improvement in health." Will the Minister now say "Yes, I will implement our promises to produce a much better standard of minimum care throughout the country"?

1.8 am

The Under-Secretary of State for Health and Social Security (Mr. Geoffrey Finsberg)

I shall try to give as full an answer as the hon. Member for Eccles (Mr. Carter-Jones) has requested. He will realise already that he exceeded the 10 minutes to which he undertook to restrict himself. I shall give him as broad a picture as I can.

The hon. Member's interest in perinatal mortality and the prevention of handicap is well known to the House. When we last discussed this topic he claimed already to have tabled about 500 questions on the subject and to judge from my recent "in" tray he must be well on the way to his sixth century.

The hon. Gentleman has raised the question of establishing minimum standards in the maternity and neonatal services. He has voiced the suspicion that we may be seeking to get out of the undertaking that we gave about 18 months ago, or that we are taking an inordinate time over its implementation. I hope to be able to cover both these points.

To begin with, I ask him to recognise that the setting of minimum standards has been a novel departure by this country, in which we have few precedents to guide us. I know that there are some people who look on minimum standards as little more than another name for central prescription, who make no secret of their distrust of the freedom accorded to health authorities to decide their own local priorities, and who see minimum standards as a means of limiting their exercise of this discretion in an important field. However, this has not been the Government's view of the matter, nor do I believe that it is a view held by the House.

We had, therefore, to think long and carefully both about what sort of standards would be most helpful and how they should be drawn up and promulgated. We looked at the French decree on minimum standards, which has frequently been quoted as an example, and found that it was largely concerned with requirements so basic—things like running water and electric light, the availability of an operating theatre, and so on—that, thankfully, we could largely take them as read where NHS hospitals are concerned.

We studied other suggestions helpfully offered to us from various quarters but found that these were often concerned mainly with questions of professional opinion and good practice which, while important in themselves, were in our judgement rather matters for consideration by the professions concerned than for prescription by central Government. Nor, in our view, should minimum standards be concerned, except occasionally, with the siting of services or overall levels of provision. These are decisions which are best taken on the spot, in the light of local circumstances and needs. A minimum set by reference to the pattern of needs in one area can so easily be quite inadequate for the needs of another, and grossly excessive somewhere else.

The conclusion to which this led us was that minimum standards should be concerned essentially with the quality of the services provided—to provide an up-to-date yardstick of the staffing and equipment on which every woman admitted to a maternity unit should be able to rely, for her own safe delivery and for the care of her newborn child. On this basis we approached the professional bodies informally last year for their advice on the level at which such standards should be pitched. We did not want to set standards so high that health authorities could not hope to match them in the foreseeable future, but equally there was no point in setting them so low that they would provide no stimulus for improvement. On the basis of much detailed and helpful professional advice we prepared a first draft set of minimum standards.

By this time, however, the maternity services advisory committee was fully established and getting down to work. It soon became apparent to us from reports of its progress that in its study of antenatal care the committee would be tackling authoritatively a number of the subjects which we had at first envisaged including among the set of minimum standards.

To prevent unnecessary and confusing duplication of advice, and to avoid pre-empting the committee's judgments in later stages of its work, we have, therefore, been endeavouring during the past few weeks to eliminate the overlap between the work of the committee and the draft standards. We are now close to producing a core of standards relating to the staffing and equipment of maternity and neonatal units while the committee will, we hope, produce a series of authoritative guides as to the uses to which they should be put.

I can assure the House that it is our intention to put our draft minimum standards to the maternity services advisory committee before the House rises for the Summer Recess. We should expect its comments in the autumn, and a revised draft will then be put out for wider consultation to professional bodies, the National Health Service, and to representatives of the consumer interest, as we have already agreed.

These last would include both the Spastics Society, to whose long-standing interest in these matters I wish to pay tribute, and the maternity alliance, a more recently established body with which my hon. Friend the Minister for Health recently had an outstandingly constructive meeting.

The Government see the raising of standards in maternity care as a continuing process in which public opinion, Parliament, the Government and the health services all have a part. I am encouraged by what has been achieved during recent years and by the increased awareness and debate among the professions and the public on what might be done to improve maternity service further. The discussion in newspaper and magazine articles and on radio and television programmes were generated to a large extent by the 1980 report of the Social Services Committee on perinatal and neonatal mortality which was produced under the chairmanship of the hon. Member for Wolverhampton, North-East (Mrs. Short).

The Government welcomed the Committee's report and shared its concern to achieve further reductions in perinatal mortality and handicap. More recently, early in 1981 our policy handbook "Care in Action" reaffirmed our decision to accord a high priority to achieving those aims by the improvement of maternity and neonatal services and our undertaking to establish minimum standards of staffing and equipment that are attainable within a reasonable time and with reasonable staffing and finance.

I am pleased to agree with the hon. Gentleman that the pace of the reduction in the perinatal mortality figures has quickened in recent years. After registering a reduction of about 25 per cent. between 1974 and 1979 there was nearly a 10 per cent, fall between 1979 and 1980 from 14.6 per 1,000 births to 13.3. That was the biggest percentage fall in a single year since records began in 1928. There were two other interesting and encouraging developments. The difference between the least and most favoured health regions continued to narrow, from 7.9 points in 1974–23.6 to 15.7 per 1,000 births—to 4.5 points in 1980–15.3 to 10.8 per 1,000 births.

Mothers in social class V had a large improvement in perinatal mortality rates in 1980 compared with 1979 from 18.7 to 17.0, leading to a narrowing in the social class gradient so that the ratio of perinatal deaths in social class V to those in social class I is now 1.75 as compared with 1.82 in 1979.

Mr. Carter-Jones

Is not the Minister arguing my case, namely that we need positive discrimination, because the difference for social class V is still enormous although there has been an improvement? Will he now consider much more carefully the question of positive discrimination for those at risk?

Mr. Finsberg

I have an open mind, and of course I shall consider the hon. Gentleman's point. However, he does not do his case, which he has argued eloquently, strongly and with great passion for many years, as much good as he might wish by dismissing the advances. The facts show that with the work that is being done, we are narrowing the gap. I shall consider what he said, but I should need to be convinced that what we are doing is right before I consider a major switch in policy.

It is also pleasing to note that national neonatal mortality rates for England and Wales have reduced from 9.7 per 1,000 live births in 1976 to 7.6 in 1980. I am sure that many different factors have contributed to those reductions in perinatal and neonatal rates, but the devoted work of many NHS medical, nursing and midwifery staff have undoubtedly been among them.

Having made substantial progress we want to keep up the momentum so that further advances can be made. Advances do not always necessarily depend on the injection of extra money; a more effective use of available resources and a stringent examination of established procedures can lead to greater efficiency and job satisfaction as well amongst staff and, very important, a more effective and humane service to the expectant mother. The House knows that the maternity services advisory committee was set up last year to look at the maternity and neonatal services. The committee was asked first to look at ante-natal care because this was an area of particular concern to the professions, organisations and individual women who had expressed dissatisfaction at overcrowded clinics and impersonal care.

The committee, under its first-rate chairman Mrs. Alison Munro, has responded with energy and enthusiasm, and its work on ante-natal care is approaching completion. We look forward to its report, and to inviting it to move on to the next stage of considering care in labour. It is our intention that the committee's reports will get a wide distribution and we will expect health authorities to respond positively to action recommended in them. My right hon. Friend the Secretary of State will be discussing progress with the health authorities under the recently introduced arrangements for annual review meetings between Ministers and regional health authority chairmen.

The importance which we attach to ante-natal care is further underlined by the support we are giving to the Health Education Council for its national campaign to make women more aware of the need for early and regular ante-natal care. In this financial year we are giving the council nearly £½ million specifically for this "Mother and Baby" campaign. The importance of ante-natal care is also a part of many local health education campaigns in association with the national efforts of the council.

Many health authorities have recognised the importance of obtaining a clear picture of what is happening at local level in the maternity services as the first step in tackling problems and reducing perinatal and neonatal mortality. I commend these initiatives. I should like to see more such regional and district surveys, and in order to encourage authorities that have not yet carried out such surveys but who might be helped by information held at a central reference source my Department has funded a project of the national perinatal epidemiology unit to establish an archive of locally based perinatal surveys.

I hope, without being considered complacent, that we can therefore claim to have made considerable progress in tackling many of the problems of the maternity services, but it is, of course, the Government's intention that health authorities should continue to give priority to these services. We can play our part centrally by supporting the work of the Maternity Services Advisory Committee, by funding the Health Education Council and by research, but the standard of service both in the human and technical senses is primarily a matter for health authorities and the professions in their day-to-day approach to the expectant mother and her needs.

The hon. Gentleman should be satisfied with what I have been able to tell him. I do not say "wholly satisfied", because I know enough of him to understand that nothing will satisfy him until we have reduced the mortality rate to zero. I fear it will be not only civil servants who will be drawing their index-linked pensions by then but also some of our children or grandchildren. The hon. Gentleman does a service to the House by raising these matters. I hope that at 1.23 am he has not too much of a guilty conscience for keeping you in the Chair, Mr. Speaker, for a rare but welcome appearance at adjournment debates. I hope that he will feel content at what I have been able to say.

Question put and agreed to.

Adjourned accordingly at twenty-four minutes past One o'clock.