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§ Mr. Alan Hurst (Braintree)
I am grateful for the opportunity to open this important debate. The national health service is half a century old and can rightly be proud of its progress on safe deliveries during that time. In 1960, there were 30 stillbirths per 1,000; by 1992, that had been reduced to eight per 1,000. That is real progress, but there are still concerns as regards the poorer parts of our community and ethnic minorities. Firm progress is required in that respect.
By 1992, 99 per cent. of babies were born in maternity units. Until that time, the thrust of the Health Department's policy was for all children to be born in maternity units. That assumption was challenged by the Select Committee on Health under the chairmanship of the hon. Member for Macclesfield (Mr. Winterton) in 1991 and 1992, which concluded that women should be given far more information about childbirth and the opportunities open to them, and the choice of home delivery or delivery in a maternity unit.
The Committee's report led the Government to set up their own inquiry, the expert maternity group, under Lady Cumberlege. Its extensive investigations led to the milestone document, "Changing Childbirth" in 1993, on which our assumptions about childbirth are now based. In particular, it enjoined local health authorities to review what progress they should make in the light of the recommendations over five years.
Stress was laid on several points. First, the prospective mother should have a named midwife to ensure continuity from the moment of knowledge of conception through to the birth and after. Secondly, the mother should be entitled to see her medical notes. Third of the salient features was that she must be given a choice about where the baby is to be born. That could be in a general hospital under the guidance of a specialist, in a general practitioner-led unit, a midwife-led unit or at home. There was some evidence that GPs were loth to recommend prospective mothers to go anywhere other than a general hospital, under the guidance of a specialist. That led to the under-use of small maternity units, especially in small towns and rural areas.
Polls have been carried out on maternity. One by MORI earlier in the decade showed that the overwhelming majority of women would like choice and that many would consider a small maternity unit or the opportunity to give birth at home. Such opportunities have been missed for decades. While we were improving the safety rate, choice was going out of the system. Mothers were being guided—that is the lightest word that I can use—towards a certain pattern of giving birth. Control was not in their hands but in those of the authorities. I am loth to use clichés such as "women-centred" or "child-centred" but, to revert to English, they mean that the person in charge of the operation, the mother, should make the decisions. That is the clear thrust of "Changing Childbirth".
I have introduced the debate, knowing that some of my hon. Friends have similar problems in their constituencies, because several health reviews are going on in the counties. I heard the end of the previous debate on health services in our neighbouring county of Kent. There appears to be some diversity of view about how to proceed. I was greatly reassured when my hon. Friend the Minister of State for 309 Health stressed the importance of real consultation. It might be well said, "Heaven preserve me from consultation," since consultation—not invariably but sometimes—results in conclusions that are at odds with the views expressed by those consulted.
The reports of the Select Committee and of the Government's expert maternity group work, and "Changing Childbirth" have a clear emphasis. The Committee's report states:We recommend that the policy of closing small rural maternity units on presumptive grounds of safety be abandoned forthwith. We further recommend that no decision be taken to close such a unit unless it can be explicitly and incontrovertibly demonstrated that they are failing to provide value for money and that the costs to the consumers are carefully taken into account in making such calculations. We recommend that in considering an appeal against the closure of such a unit, the Secretary of State should make presumption against closure unless the case is overwhelming, since we believe that there is a shift in attitude towards maternity care which can only be met by maintaining such units as a realistically available option.That is the kernel of my case.
Our health authority in north Essex has recently been through a consultation exercise ironically entitled, "Taking the Initiative". Unison has drawn up a report entitled, "Taking Liberties". Local people often refer to it as taking the mickey. In essence, the consultation exercise has gone through. The term "taking the initiative" may be right if taken at face value, since the initiative has been taken to defy every guideline and inspiration in "Changing Childbirth": the conclusion is at complete odds with that which one might have assumed if the exercise had followed the guidelines.
Although the hon. Member for Maldon and East Chelmsford (Mr. Whittingdale) is not here, he spoke to me yesterday. In Maldon he has a problem similar to mine in Braintree. The closure of both our maternity units is proposed. I think that I have his authority to say that what I have to say about Braintree he would echo on behalf of Maldon. In Braintree, it is proposed to close the William Julian Courtauld hospital and move its facilities to another site. Maternity services will slip during that move, so that no maternity service will be based in the town of Braintree.
The consultation exercise took the views of local residents. Some 600 or more attended public meetings, and unanimously expressed the opinion that the maternity service should remain. It took the view of local GPs, who thought that maternity services should remain in a local unit in the town of Braintree. It took the views of the local authority, Braintree district council, which thought that maternity services should remain. It took the view of the community health council, which thought that maternity services should remain. The local authority spoke to midwives, who said that maternity services should remain. It spoke to parish councils, which said that maternity services should remain. Everyone the local health authority spoke to in the town of Braintree and the surrounding villages gave the same answer.
§ Mr. Ivan Henderson (Harwich)
Does my hon. Friend agree that health authorities not only have failed to listen to the people who care for people and provide front-line services but ignore proposals put to them by midwives, doctors and others involved in local health services? Is that the case in my hon. Friend's constituency?
§ Mr. Hurst
I am grateful to my hon. Friend who has similar problems to those who represent Braintree, 310 Maldon and Chelmsford. He makes the point well. The word "ignore" is perhaps too strong, but it appears that health authorities have misjudged—if I may put it that way—the views expressed to them by the local people. That is especially true in Braintree.
The W. J. Courtauld hospital may be familiar to hon. Members. It was founded and set up by the Courtauld family shortly after the first world war in recognition of the contribution made by its work force in Braintree, Bocking and Halstead to the war effort and the success of the Courtauld family. It was further supported by subscription of the working people of Braintree. It has become a hospital for which people have great love and affection.
In the previous debate, the hon. Member for Teignbridge (Mr. Nicholls) said that there was great importance to be attached to local hospitals and the affections that they bring forth in local people. They are an asset that should be lost only slowly if they are to be lost at all.
§ Mr. Bill O'Brien (Normanton)
In my constituency, we have the same problem. My health authority wants to transfer maternity services away from Pinderfields general hospital, leaving a large area without cover. One of the reasons given is that the number of births in the area is too low. Another is the difficulty in recruiting qualified and efficient staff. I have listened to my hon. Friend giving the details of his case. Has he been given the same reasons?
§ Mr. Hurst
It is clear that the same arguments are used in every area. The ratio of midwives to patients at our local hospital is 1:19. I believe that, in the town of Maldon, it is 1:16. In Chelmsford, to which mothers from Maldon and Braintree will have to go, it is 1:48. There is a section in the consultation document entitled "Equality". It is an old form of equality that I thought went out a long time ago, with the collapse of the Soviet Union. It is called levelling down. The argument is that, because we in Braintree, Maldon and certain other country towns have a good service, it should be taken away from us. The terrific result is a move from 1:48 to 1:42 in Chelmsford. So the people of Chelmsford do not benefit substantially, but the people of the country towns of north Essex lose substantially.
The people who lose most of all are the poorer residents of country towns in north Essex. They have to travel to the nearest large town at enormous inconvenience to them and their relatives—the woman's husband, mother, father or whoever wishes to visit her. The closure of the local hospital is a fundamental attack on the rights and equality of poorer people, especially those living in country areas and small towns. That was mentioned in the debate last Wednesday about rural poverty. I am disappointed to hear that the problem is not localised; it is clearly occurring in other areas.
My hon. Friend the Member for Harwich rightly said that health authorities do not appear to listen. I referred earlier to the W. J. Courtauld hospital, founded by the Courtauld family. A hospital support group has recently been formed to support services. Its committee is chaired by a descendent of the Courtauld family, Julian Courtauld. It has led an active and well-researched campaign to show that there is no benefit in financial or material terms to the proposals.
311 The exercise started out as an attempt to save money. The argument was that the health trust and hence the health authority were not balancing their budgets so savings needed to be found. The original figure floated around was some £6 million. I fully accept that the Government have provided north Essex with additional funding of £17.5 million, which I believe in growth terms came to £7.8 million. So on the face of it, the deficit was balanced. But health authority deficits are rather like a mirage. When one gets close to them, they disappear, only to reappear further down the road, probably in rather larger form. I give some humble and modest advice to my Government. When money is given to health authorities, they should ensure that it will be spent on what we wish.
I shall draw my remarks to a close, because I know that several other hon. Members are anxious to speak about problems similar to those in Braintree and north Essex. I am sure that hon. Members agree that an enormous advance was made with the publication of "Changing Childbirth". The principles enshrined in it appear to be welcomed by everyone in every profession and walk of life connected with health. It will be a great tragedy if health authorities take it on themselves to undermine those principles without even saving any money. My health authority has pledged that the money saved by closing the Maldon and Braintree units will be transferred to a new low-cost unit in Chelmsford. So there is no cost saving. The closures are a further attack on the rights of women to give birth where they wish and on the rights of poorer country and small town people.
I conclude by quoting from the latest document, the White Paper entitled "The New NHS". It follows the same principles. It appears that the Government do not live in the past—in 1992 or 1993. The White Paper says:Too often in the past community hospitals have been sidelined. Their potential contribution to managing the pressures of rising emergency admissions has often been ignored. Patients will be able to use local community hospitals to the full rather than having to travel to more distant acute hospitals. This will be particularly significant in rural areas.I am grateful for the opportunity to bring this case before the House today. I look forward to the speeches of hon. Members on both sides of the House who, I fear, have experiences similar to ours in Braintree.
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§ Dr. Jenny Tonge (Richmond Park)
I am delighted to speak in this debate not only because I have delivered babies, but because I have been delivered of three babies. I have personal experience, but I shall not bore hon. Members with the details of my labours. I am sure that they suffer under that yoke far too much with their own families.
Until I arrived on this planet, I was involved with the management of and liaison with community maternity services in the health area in which I worked. So I am delighted to speak in support of the hon. Member for Braintree (Mr. Hurst). I thank him for introducing the debate. No one would dispute the need for a woman-centred approach to childbirth. It is welcome that we have moved away from the notion that women should give birth wired up like robots. That used to be the case in the not so distant past. If we are to move away from that model, we have a lot of things to think about. I should like to share them with the House.
312 First, if we are to have woman-centred childbirth and maternity care, in which care and time is spent on each patient, with midwives travelling from home to home and community base to community base as well as working in hospitals, we will need more midwives. There will be big staffing implications: the more time that is spent on patients, the more staff will be needed. Therefore, we cannot get away with the present exhausted band of midwives. Although they do the most fantastic job, they are frequently overworked, terribly pressed and unable to take proper holidays. We must remember that the staffing implications of any new policy also have financial implications.
Although we want women to be able to exercise choice about where they give birth, we must also consider their safety and that of the child. I fully appreciate that, in the majority of cases, childbirth is a perfectly easy thing—women are delivered of babies and babies are born whatever happens. It is worth noting, however, that the reductions in perinatal and maternal mortality rates achieved in recent years have been due to medical intervention and good obstetric care. We must consider safety.
If we are to provide safety, we must have midwives out in the community, backed up by ambulances that are specially designated for maternity care. In the 1960s, they used to be known as flying squads. Those special ambulances should be able go out to patients and babies who are in distress and bring them to a properly equipped centre. We must also have GPs who can competently intervene, and obstetricians on call to intervene if necessary. All those requirements need extra funding.
We must also make sure that special care baby units, or SCBUs as they are fondly known by my medical colleagues, are easily available and well equipped, and that their staff are well trained.
In my area of Kingston and Richmond, great efforts have been made to personalise maternity care. Kingston hospital has one of the most beautiful new maternity units that I have seen, with wonderful wards for women in labour, which look like hotel rooms. They have comfortable reclining chairs for the poor old husband, who, as we all know, suffers far more than the woman, as well as televisions and drinks facilities. At the flick of a switch, however, such rooms can be converted into a delivery room with high-tech hospital care. Unfortunately, the pressure on that unit is so great, with women coming in thick and fast, and the staff are so short on the ground, that those lovely hotel-like facilities which enable women to relax and enjoy their childbirth are not used very much. The switch is always flicked to the delivery mode, and as soon as one mother has delivered, she is out, and the next mother has to come in. Again, it is a matter of resources.
The Liberal Democrats would support women-centred childbirth, but, like care in the community, it is not a cheap option. That is the major point I want to stress. As with care in the community, if the policy is to be introduced properly so that women have choice, adequate funds must be provided. We know how difficult that is. I am not saying that the Government should spend, spend, spend, but the provision of women-centred childbirth is not as easy as it sounds, it needs additional resources.
313 We believe that maternity services and child health are probably among the top priorities for our health service, and we would like such priorities to be drawn up nationally. I hope that the House realises, however, the huge financial implications.
§ Mr. Ivan Henderson (Harwich)
My hon. Friend the Member for Braintree (Mr. Hurst) mentioned briefly the fact that, this year, extra money has been given to North East Essex health authority. I should like to thank the Minister and the Government for that, as well as for the additional winter pressure money and money for breast cancer treatment. That funding has been well received in my constituency.
Maternity services are of great significance within my constituency. The overwhelming impression that anyone would gain from reading "Changing Childbirth" is that it is designed to promote and increase the choice available to women and their partners. I am sure that every hon. Member would agree that that is important as long as choice is exercised on the basis of sound advice and good information and is in the interests and safety of the mother and unborn child.
I am concerned because my local health authority is seeking to replace the excellent maternity units at the Clacton and Harwich hospitals with no more than birthing units. I saw no mention of such units when I studied "Changing Childbirth". I also asked the Library to provide me with some evidence of the work of such units around the country, but it has been unable to supply me with one bit of information. I have no evidence to show how those units have operated, their success or the take-up of their services.
I know that the North East Essex health authority has set up one birthing unit at Halstead, but, in a year, just five people have used it. The take-up at such units is not great, and we need far more information about them.
The community needs to know that the services of the large general hospitals are available if patients need them. In Harwich, all we are asking is that the basic needs of my constituents should be met. As the hon. Member for Richmond Park (Dr. Tonge) has said, there is always the possibility that specialist treatment may be needed, and it is nice to know that it is available. The maternity unit at Harwich has worked well for many years and has enjoyed good support from constituents, midwives, local GPs and other health professionals.
In my constituency, savings would be made only by withdrawing proper choice. The emphasis of "Changing Childbirth", however, was to give women more choice—for example, by opting for a home birth—and the document discussed the safety of that. The evidence supported women's right to have that choice, but said nothing about removing women's choice for in-patient care at local hospitals. But that is exactly what the change to birthing units is all about.
If local services at Harwich and Clacton hospitals are withdrawn, the only alternatives to a 40-mile round trip to Colchester general hospital is either to opt to have a baby at home or to go into a birthing unit for just a few hours. There is no real choice for those who want to opt for in-patient care.
In the past, the services at Harwich hospital, which is an extremely good community hospital, have been taken up by many women. They all enjoyed the care and comfort provided by the staff.
314 Among the evidence that I collected from the Library was that given by the Maternity Alliance. One of the problems of my constituency is poverty. Many problems are caused in Harwich and Clacton by homelessness, poor housing, bad transport facilities and lack of car ownership. My hon. Friend the Member for Braintree referred to similar problems. That organisation expressed its fears about the new proposals and said:The Maternity Alliance raised concerns that the reduction in average length of stay post-natally should not be achieved at the expense of the health and well-being of women and their babies.It highlighted the need for lying-in wards in rural and urban areas for young and single mothers, homeless women, those living in unsuitable accommodation, women with heavy domestic responsibilities and those who had multiple births.
In keeping with the Government's stated commitments to increase choice, every pregnant woman should have the opportunity to receive care in the community or in the hospital of her choice, from the health professionals of her choice, and for as long as she feels necessary. That choice—among other things—has been taken from my constituents at Harwich and Clacton.
In return for putting all my constituents through the pressures and trauma of the review, and in return for removing choice at both hospitals, £37,000 will be saved each year-although, in the first year, only £10,000 will be saved.
Despite all the public meetings, all the opposition, the petition bearing 25,000 signatures—10,000 of which, as the Minister will see, went to the Department of Health—postcard campaigns against the changes, and women marching in the streets with doctors and midwives in front, no notice has been taken.
My hon. Friend the Member for Braintree mentioned concerns about consultation. The North East Essex community health council will appeal against the decisions to reduce services on maternity and casualty. It says:It is also unfortunate that the Authority clearly stated 'the fact that a majority of people may be unhappy with a proposal would not, in itself, be a criterion for a rejection'.The authority is not listening. Some health authorities are not listening to the people.
During my weeks and months in this place, I have heard the Minister say that the service is not our service or the health authorities service but the people's service. Those people have spoken out—in petitions, in public meetings, in marches and in health authority-organised workshops—and they have not been listened to. They have been put through a traumatic time.
The health authority agrees that we shall have less choice. When it published the proposals, it said:Drawbacks: There would be no inpatient services at Clacton and Harwich … For some women resident in Clacton and Harwich this means less choice about where they would like to have their babies.As the hon. Member for Richmond Park said, women need to know that they are in control, and that their choice has been met. It places more pressure on a woman to be separated from her family—not to have her loved ones near her—at what can be a highly emotional time. The family may be 20 miles away, perhaps without means of transport. In my area, car ownership is low and public transport facilities are poor. There is high unemployment 315 and much poverty. Family members may be unable to afford to be present for the birth, and if they get there they probably cannot afford to return the 20 miles from Colchester.
I have looked through "Changing Childbirth". Given the way in which it was presented and the investigations that took place in 1991, 1992 and 1993, I urge the Minister to consider how some health authorities are interpreting "Changing Childbirth" to pursue their own agenda. We need to consider that seriously; if we had done so earlier, we might not have had to put the public in my constituency and the Braintree constituency through the experiences to which they have been subjected over the past few months.
In my constituency, the midwifery teams at Harwich and Clacton have made several excellent proposals for retaining the maternity units—such as a proposal to reduce the beds in one unit from six to four—following the guidelines of "Changing Childbirth" and team midwifery. They have gone a long way with that concept, but they still have not been listened to.
The health authority has not listened to the people on the front line; it certainly has not listened to the public; it has not listened to me. I have had the chair and chief executive of North Essex health authority up to visit me in the House several times. Recently, he said to me in the House, "The reason why we are making cuts in your services both in Harwich and Clacton is because they are too good. There is inequity across north-east Essex." As my hon. Friend the Member for Braintree said, the sole aim of the consultation appears to be to level down.
As a Government, we should be identifying best practice throughout the country and building on it. We should be paying attention to community hospitals such as those in Harwich and Clacton, building on best practice and praising those people for nurturing the services over the years. They need the praise.
Doctors, nurses and health workers have put a great deal of effort into retaining small community hospitals, but we are putting those people through as much trauma as the public, if not more. They feel very strongly about their local hospitals, and so do the public—they are theirs. As probably happens in all constituencies, in my constituency, charity events are held, the proceeds of which help to buy equipment for the local hospitals. People believe those hospitals are theirs, and they believe that they should be listened to and heard.
I urge the Minister to look at the way in which some health authorities are interpreting the recommendations of "Changing Childbirth", and to try to stop the traumatic things that are going on out there.
§ Mr. Kerry Pollard (St. Albans)
I feel passionately about this subject, but few hon. Members are in the Chamber to discuss it today, and they apparently show a lack of interest in it generally. Also, it is mainly the middle-aged men in grey suits who are here rather than the people who would benefit from midwife-led units—
§ Mr. Pollard
Blue pinstriped suits as well, then.
316 I want to talk for a second about my credentials. Mine are backed by the highest authority; I have a papal productivity medal, having seven children, and I believe that I could also be classed as a "hero of the Soviet Union", if such a place existed.
I want to focus on the maternity services provided by midwives. Many births are home deliveries, with the baby being delivered by highly trained and dedicated midwives—much the best option for many women. In my family's case, we preferred home deliveries, and four of our babies were born at home. When my daughter Sally was born, my wife was upstairs with the midwife, I was making the tea and the four boys were sitting on the stairs, and it was one of the proudest moments of my life when I could take the new baby and show her to her four brothers and say, "Here's Sally; she's your sister." That was a birth at home, with a midwife whom we all knew and trusted.
Undoubtedly, many women prefer, and some need, the facilities of a large district general hospital, with all the expertise that that involves—in obstetrics and so on—but there is a place for home delivery and, increasingly, for midwife-led maternity units.
Since the formation of the national health service 50 years ago, midwives have delivered 35 million babies and provided care for those babies' mothers. Midwives have made a major contribution in the reduction in maternal and baby mortality rates. The number of women in the United Kingdom who die in labour and the number of babies who die in the first month of life is at an all-time low. We are the envy of the world.
During this time, there have been massive changes in the NHS, major reorganisations and many different professional views about what is right for mother and baby, but the midwives' commitment, adaptability and high level of skill have remained consistent throughout.
The present Government believe—as did the previous one—that a woman has the right to choose her carer during pregnancy. The 1911 National Insurance Bill was amended to provide that the mother shall decide whether she will be attended by a medical practitioner or a certified midwife and shall have free choice in such selection. Today mothers throughout the country are choosing to have midwife-only care at midwife-led units—especially when their childbirth is likely to be normal—and to use the skills of obstetricians and their medical colleagues only when there is a perceived risk. I want to give two examples of units: first, the midwife-led unit at Royal Bournemouth general hospital; secondly, the Edgware birth centre.
In the first example, a study compared the level of care and service satisfaction at Poole hospital with that at the midwife-led unit at Royal Bournemouth general hospital. It concluded that there was some difference in the care received but little difference in the outcome for either mother or baby. The study found that the general hospital births were more likely to involve higher rates of induction and greater use of anaesthesia—particularly pethidine and epidurals—whereas Bournemouth babies were more likely to be born in a birthing pool. It also found that there was very little difference in the care provided for low birth weight babies and those requiring special post-natal treatment—a satisfactory outcome for the midwife-led maternity unit.
317 The second example, the Edgware birth centre, is a relatively new unit, which came into being as a result of the closure of Edgware hospital as a district general hospital. The unit is funded completely by the Department of Health, so it does not impact on the budgets of the local health authority or trust. The unit opened on 1 September 1987 and cost £84,000. It comprises five rooms, each with its own en-suite shower, and one room with a plumbed-in birthing pool.
Initial interest in the unit among the local population has been high—indeed, more than 100 visits have been requested by local pregnant women. A survey of local women found that 61.6 per cent. would like to deliver in a stand-alone midwife-led unit at Edgware. The most common reasons given for that decision were proximity to home of the place of delivery and confidence in midwives. The Royal College of General Practitioners and the Royal College of Midwives support the concept of midwife-led units and believe that the unit at Edgware is "safe".
In 1996, The Lancet published a study that concluded that women who received midwife-led care exclusively were less likely to be given labour-inducing drugs; less likely to be given an episiotomy but no more likely to have a perineal tear; and were less likely to have interventions. The NHS spends £1.1 billion on maternity care. If midwife-led units of sufficient size could be developed—and retained, bearing in mind the earlier comments of my hon. Friend the Member for Braintree (Mr. Hurst)—money could be saved and targeted to those women who need specialist care and the life-saving services of an obstetrician. More money might also be released for general NHS use—perhaps it could be devoted to reducing waiting lists.
I pay tribute to all the midwives in my constituency of St. Albans, who do a brilliant job. My good friend Ita McCracken, who is a sister midwife at our local antenatal clinic, recently went with a group of other local midwives to visit Heatherwood hospital in Ascot, which has a midwife-led unit. They found that mothers and staff were very satisfied with the unit. Staff morale was high, as was staff retention. One mother said, "We are special here; it's like going from home to home." They also believe that the unit is cost-effective.
The previous Government set a target that, by November 1998, 70 per cent. of mothers would know their midwives. In my area, that figure is only 30 per cent., and I believe that a low-risk maternity unit would redress the balance. Staff at a midwife-led maternity unit would have easier access to their clients and families. Such a unit would form part of community services, readily involving the various agencies and professional bodies and working towards improving maternity care.
There is wide support for a midwife-led maternity unit in St. Albans. I have met various trusts and the health authority to further that cause and I am confident that, before long, we shall have our own midwife-led unit in St. Albans.
§ Ms Rachel Squire (Dunfermline, West)
I pay tribute to my hon. Friend the Member for Braintree (Mr. Hurst) for his excellent speech and for securing this Adjournment debate. He covered many of the points that I wished to draw to the attention of the House. I join other hon. Members who have spoken in the debate in praising midwives, in particular.
318 The provision of maternity services in the national health service is of great interest to many—if not the majority—of our constituents. However, their interests, views and voices are often ignored by the current system of decision making in the health service, which is conducted by unelected and unaccountable health authorities in England and Wales and by health boards in Scotland. The comments of my hon. Friend the Member for Braintree also apply north of the border. In 1991–92, 33,000 people in Dunfermline and west Fife signed a petition seeking to keep their local maternity hospital, or at least retain a maternity ward in the new hospital. Their views were ignored. Even though a new hospital opened in 1993—the same year the maternity hospital closed—with a specially built and equipped maternity ward, it has been allowed to gather dust ever since because of the decision to centralise services at one town in Fife.
My hon. Friend said that health authorities carry out strategic reviews and call them "health initiatives". That also sounds horribly familiar. As part of its integrated care strategy, Fife health board has suggested turning the specially equipped maternity ward at the Queen Margaret hospital into a grannies ward for long-term care of the elderly. It proposes to spend millions of pounds more on centralising the service further, despite community views to the contrary.
It is claimed that centralisation is cost-efficient. We must question whether it is cost-efficient to leave a specially built and equipped ward empty and spend millions of pounds transferring services to another hospital. Mention has been made of poorer communities and transport difficulties. The closure of maternity services at Dunfermline has hit hardest the villages of west Fife, which are some of the poorest communities. The bus service in the area runs only once every two hours—and babies are not known for synchronising their arrival to fit in with the bus timetable. Many people in those communities cannot afford the bus fare for one journey to the hospital. The Government must tackle the problem of power without accountability. We must provide locally based maternity services.
The issue of the NHS complaints procedure was raised with me in respect of maternity services, but I believe that the same points are relevant across the board. Tragically, some parents still experience the death of a baby, and some babies are born with disabilities. In recent months, more than 50 families from all over Fife have contacted me to express their concerns about the medical intervention that took place during the birth of their child and the treatment that they received when they started asking questions. As a result of pressure and publicity, an independent review panel was set up and it is about to produce its report. Therefore, I shall not question the objectivity of the panel or anticipate its findings.
I speak for parents when I say that the NHS complaints procedure does not allow them a proper say. For some time, it has not allowed them to speak directly to the independent review panel, and parents feel that it is difficult for them to put on paper the trauma of what they went through. I emphasise that in no way do I denigrate the excellent services that are provided by maternity and other staff in Fife in delivering thousands of babies. Despite changes and improvements, the NHS complaints procedure still fails to give a strong voice to the few, but important, people who suffer tragedy or trauma in our 319 health service. I hope that that will be addressed by the Government, especially in terms of questioning medical accountability.
Once again, I place on record my praise for the thousands of health service staff, especially midwives. Throughout the country they bring great happiness to people. I hope that the Government can ensure that those who provide such an excellent service and the families who seek such a service will have a greater voice in making decisions on the future of our maternity services.
§ Mr. David Drew (Stroud)
I congratulate my hon. Friend the Member for Braintree (Mr. Hurst) on initiating the debate. I also congratulate all those who have participated. The debate is fortuitous because the maternity hospital in my constituency is under threat of closure, and it is useful to be able to speak about that. However, I shall not engage in special pleading; the current review is right and proper, although many of us feel that we know the answer. I hope that the hospital's future will be assured.
The review is part of Gloucestershire health authority's strategic review, and plans for the hospital form one of the few firm proposals in it. The idea is that closing the Stroud maternity unit will save about £150,000 from a budget of £248 million. I hope that hon. Members will agree that that is a drop in the ocean. Much support has already been garnered by local people who are organising a campaign to keep the hospital open. On Stroud's streets on Saturday one could not fail to bump into people who had either signed a petition or were about to sign it. People were taking car stickers and offering what help they could. That is a tribute to the strength of support for the hospital. The local newspaper, The Stroud News and Journal, and the National Childbirth Trust have engaged in a well-organised and, I hope, successful campaign—if one judges it by the many letters that I have received.
There is an emotional spasm when there is any proposal for closure in the NHS. It is usually opposed and there is support for the facility which may not have been apparent before. Our debate is about much more than that. As hon. Members have said, people are voicing their concerns and arguing for choice, which is what the debate is about. It is especially about choice for women, but other issues need to be highlighted. There is a perennial battle in the national health service between high-tech and low-tech. Consultants tend to favour delivering babies in large general hospitals, which is against the wishes of GPs and other professionals such as midwives. I wish that that did not happen, but that is part of the real world.
As we wrestle with trying to form a new NHS using the White Paper and, I hope, the Bill that will follow, those matters are at the root of the dilemma that faces us. We cannot underestimate the importance of patient choice. We must listen to not just women but men. I declare an interest because my wife had one child, Christopher, in the maternity unit at Stroud, and another, Esther, was delivered at home with the help of community midwives. I can vouch for the excellent care, support, advice and other assistance that were given by the teams who worked to the best of their ability.
I shall fill in some details without elaborating, so that the review can take its natural course. It is important to give some of the history of the problems that have been 320 mentioned in the debate. The Stroud unit opened in 1953, which is some time ago, on the site of the current hospital, which dates back to 1875. The unit must not be considered in isolation. It is an important part of a complex of services in the community hospital. It has a unit for in-patients and has consultant out-patient services on the site. There is an elderly persons unit for those who suffer mental health problems. The accommodation for elderly persons has been moved from another unit to the community hospital in Stroud, and it is sad that we now face the closure of a key part of the complex.
There was major refurbishment of the maternity hospital in 1993 at a cost of £140,000. It was reopened by Dr. Mark Porter, who I am sure is known to some hon. Members as the television doctor. The refurbishment was part of an upgrade at the hospital and was partly undertaken as recompense for the loss of the Berkeley maternity unit in the south of my constituency. At that time, we were assured that that would be the end to the so-called cuts and that community provision would continue at Stroud for ever and a day. Now we are faced with closure. History teaches some lessons and returns us to issues that we faced before.
The maternity unit is now run by community midwives with GP support and that has been done by agreement. My GP friends assure me that delivering babies is not a skill for irregular practice, and say that they were more than happy when the community midwives took on the major part of running the service. The hospital unit employs 21.53 whole-time equivalent midwives, 6.24 unqualified staff and one administrative and clerical person. It employs a considerable number of people because it delivers the range of services and provides 24-hour cover.
It is important to appreciate that a nine-bed unit can offer not just intra-partum care, which I understand is labour and delivery, but antenatal and post-natal care. Women are offered an informed choice on place of delivery, and the options available are to give birth at one of the two district general hospitals at Cheltenham and Gloucester, or at Stroud, or to have a home birth.
In July 1997, the midwifery-led service took over completely. It has tried to keep to the letter of the report "Changing Childbirth" so that, wherever possible, women have a named midwife and the service is open to all. I know that consultants have the authority to recommend, certainly with the first born, that the birth take place in the district general hospital. However, one of the great benefits of the unit in Stroud is that, after the birth, women can come back to that community unit. That should not be underestimated.
An integrated midwifery model of care is in operation, with midwives having both a hospital and a community role. The midwives work in teams and provide 24-hour cover. Two peripheral consultant clinics are held at the maternity unit by visiting consultants from Gloucester and ultrasound scanning facilities are offered on the general hospital site.
Parentcraft education is offered in homes, hospitals, health centres and surgeries and there are day and evening sessions. My fear would be the loss of that service. It could be seen as an easy way of making genuine cuts and such advice could be reduced or removed completely.
§ Mr. Tony McWalter (Hemel Hempstead)
Does my hon. Friend agree that, given the substantial additional 321 funds that the Government are making available in the NHS, perhaps the first priority should be a freeze on the cuts in the pipeline from the previous Government? They are causing damage to the NHS in all our constituencies.
§ Mr. Drew
I thank my hon. Friend but, as I have said, it is right that the review takes place. It should take place against the background of trying to improve—the aims are mentioned in the White Paper—community-based provision and primary-led care. Some of the so-called reviews seem to be going in the opposite direction.
There was some disappointment that, until recently, there was a decline in the number of births at Stroud. I am pleased to say that, with the new approach of midwives taking the lead, that has turned around. Between December 1996 and March 1997, there were 67 deliveries in the hospital, but it is expected that the figure until March this year will be 118. That is a significant increase. One of the good things to come out of the campaign is that it will emphasise that this service is available, and it is hoped that more women will make use of it.
Home confinements are on the increase. Between April and September 1996 there were seven home births, and between April and September 1997 there were 15. If women do not have the choice of a local community facility, I am sure that many more of them will want home births. I understand that that is more expensive. However, having had one of my children at home, I think that it is important, to offer that service.
A 24-hour advisory service is in operation and, during the past year, some 1,244 advice calls were taken. That is important, because people trust the service when it is provided locally. They may know the person giving the advice in a community such as Stroud. That service has now been extended to the forest of Dean.
The breastfeeding rate is 71 per cent. at discharge. I understand that that is substantially higher than the national average. There are many day cases, including foetal monitoring and assessment of women for spontaneous rupture of membranes, blood pressure checks, anti-D prophylaxis and early labour. In early labour, women may feel that they need a local facility. There may be more problems if such a service is available only at the district general hospital.
The average length of stay is 2.6 days. Good local provision is important for access. The arguments about poverty and access were rehearsed a week ago, but were re-rehearsed today by my hon. Friend the Member for Braintree. It is much easier to reach a local facility than the district general hospital in Gloucester or Cheltenham. More particularly, if the service is well provided locally, I believe that women will stay in hospital for a shorter time. Therefore, there is an inherent reduction in cost. If there is no choice and women have to go to the district general hospital, they may have to stay longer.
Thankfully, in 1996 and 1997, the rate for stillbirths, perinatal mortality and maternal deaths was nil. As has been mentioned many times, I am sure that that is due to the overall success of maternity services within the NHS. Long may that continue. I hope that we do not see any deterioration.
In January this year, there was a major investigation, through the district auditor, of the facilities available at Stroud. It looked at the scope and approach of the service 322 at Stroud, including the management and organisation, antenatal care, intra-partum care, post-natal care and the relationship with local GPs. The key findings were interesting. The report said that it was an effective woman-centred service, incorporating a high level of continuity of care and experienced midwives providing an integrated service between hospital and community setting. It also said that there were effective liaison arrangements with Gloucestershire Royal NHS trust—our major local district general hospital—to ensure that women who delivered there and moved to the Stroud unit received seamless care. It said that there was a good-quality maternity service at average cost. It is not more expensive. We are talking not about cost savings, but about a service that can be efficient and practicable.
There were many good examples of how the service was being operated to good effect. The only other key issue was the need to raise the figure for bed occupancy, which is currently about 50 per cent and rising. However, it needs to be higher. That is all part and parcel of getting the message across that community-based maternity units have a role to play, can do the job well and are the popular choice if people have confidence in them. I hope that people in the medical profession will try to get the message across.
An action plan looked at ways in which services could be improved and expanded. We have heard today about other similar cases, but I think that Stroud is as good an example as any we have heard about.
I should like to mention the problem caused by a split trust—an acute trust and a community trust—which is the position in the western part of Gloucestershire. The community maternity unit is within the community trust, whereas the acute trust is responsible for the district general hospital. There is always a temptation to suck money towards the acute end. I know that the Government are aware of that. That is why they have placed the onus on a primary care-led approach. It is important to understand that the salami-like cuts end up helping the acute end, but that the money has to come from somewhere. It often comes from the community end, which is completely contrary to what people want; they want choice in the local community.
I hope that, as part of this debate, we have managed to get the point across about the importance of choice. We are not talking about a more expensive service. We are talking about the service that people want in their local community and about understanding that, as we reform the NHS, people have the right to say what type of service they want. I therefore hope that the maternity units in Stroud and in the constituencies of my hon. Friends will continue.
§ 12.9 pm
§ Mr. Patrick Nicholls (Teignbridge)
I wish that time would allow me to deal in more detail with the six excellent contributions that have been made in the debate, but it is in the nature of these short debates that that is impossible. However, it would be remiss of me not to thank the hon. Member for Braintree (Mr. Hurst) for giving us the opportunity to talk about this subject. The hon. Member for St. Albans (Mr. Pollard) thought that the Chamber was not well attended. Compared with other attendances that I have seen over the years, it is not bad.
The quality of the speeches has shown what an important subject this is. If I may sum up his views in this way, the hon. Member for Braintree was concerned 323 that, because of present trends towards rationalisation, precisely those people who particularly need choice—those who live in remoter rural areas or who come from poor and disadvantaged backgrounds—might be deprived of choice. He rightly started off with what was, in a sense, the turning point of the wider debate: the report in February 1992 of the Select Committee on Health.
It is probably rare for a Select Committee report to change the way in which things are done to quite the extent that that report did. Any of us who visited maternity hospitals in the 1970s will have got the impression that the process was done to, rather than for, the woman. At times, one almost got the impression that some doctors were induction-happy, saying, "We are going to throw the switch now. You are going to have your child at this very moment." I perhaps exaggerate to make a point, but, in recent years, the atmosphere in maternity hospitals that I have visited is certainly different from that in the 1970s.
The hon. Member for Braintree rightly warned us against jargon. I dislike it as well, but it is useful shorthand to say that the Select Committee report wanted a "woman-centred" approach. That must be right. That is the key difference between the process before the report and the process afterwards.
I shall not go through the recommendations of the Select Committee in any great detail, but may I briefly mention four of the broad principles behind its recommendations? It recognised that the relationship between the woman and her care givers was of fundamental importance; that women needing intensive obstetric care in the NHS should also be able to enjoy continuity of care and carer, so far as that was possible; that, within a hospital, women should be able to exercise choice as to the personnel who would be responsible for their care; and, perhaps most important, that the woman having a baby should be seen as the focus of care, and that the professionals providing that care should identify her needs and develop arrangements to meet them that were based on full and equal co-operation among all those charged with her care.
Those were the key findings. As a result, the Select Committee was able to make several recommendations: that midwifery-managed maternity units should be developed; that practice in hospital delivery units should be changed to enable women to feel at home and to be in charge of their labour; that working practices should be changed to enable midwives to have their own case loads and to take full responsibility for the women for whom they cared; and that a duty should be placed on all general practitioner practices to enable women to have a home birth, if that is what they wanted.
In due course, as we know, the Government of the day published a report entitled "Changing Childbirth", which accepted the thrust of the Select Committee report. Again, if time allowed, which it does not, I would go through some of the particular ideas and recommendations, but, in accepting the Select Committee report, the then Government had it in mind that the woman should be at the centre of the process. She should be the person who was in charge and, so far as possible, in the driving seat, with home deliveries available to her.
324 It is interesting to note how the policy has developed over the years. To some extent, the evidence is anecdotal. Hon. Members have talked about "rationalisation", which is probably the kindest way to put it. The effect of rationalisation is to transfer maternity services away from the area where people live. Far from bringing the possibility of a home delivery closer, rationalisation means that the hospital where women are going to have their baby is much further away. Obviously, that is not in any shape or form within the spirit of what the Select Committee or, for that matter, the then Government had in mind.
It is interesting to consider the extent to which the aspirations of the Select Committee—and, I think, of all hon. Members who have spoken in the debate—have been fulfilled. In recent times, several reports have been published. I shall not go through those in any great length, but it is probably true to say that, subject to one or two caveats, the consensus seems to be that the process has worked and that making home births available has worked.
I mention three reports that I have spotted; the Minister may want to say something about the generality of the point, if not comment on its detail. In 1997, the Policy Studies Institute produced a document entitled "A leading role for midwives?". It expressed some reservations about the emphasis on the shift to midwife-led care. The report was based on three pilot "Changing Childbirth" projects. It suggested that, although there were undoubted benefits to both women and midwives in midwife-led care, it was important not to jeopardise good working relations between midwives and the medical profession. It said that the higher costs of providing such a service should not be overlooked.
The Audit Commission produced two interesting documents. One was entitled "First class delivery: improving maternity services in England and Wales". It suggested that there were considerable variations in patterns of care, which could not be explained by differences in "case mix" or local circumstances. Fragmentation of service delivery was highlighted as a problem, as was the issue of conflict between providing "women-centred" care and meeting other NHS service objectives such as increased efficiency.
There was a follow-up to that report, entitled "First class delivery:"—the puns are inevitably to be found—"a national survey of women's views of maternity care". It discussed the experiences of 2,400 women in pregnancy, birth and post-natal care. One part of the report focused on how women felt they were treated by their care givers, with between 50 and 60 per cent. of women "strongly agreeing" that they weretreated well as a personduring pregnancy, birth and post-natal care, and most of the remainder "tending" to agree. The authors suggested:depending on how you look at them, these results are either encouraging because the majority of women agree that care was good, or worrying because only just over half the respondents were able to agree strongly with the statements".
Inevitably, in medicine as in other things, fashion has a part to play. There is no doubt that the fashion was—rightly, in my view—for women to be able to make an informed choice, after taking medical opinion, on where they would have their child. Inevitably, pendulums tend to swing one way and the other. In his winding-up speech, 325 the Minister may say a word or two about whether that pendulum has swung too far. If there is solid and substantial evidence that the levels of mortality and, shall I say more loosely, of complication are much higher with home births, this will be as good an opportunity as any to discover that.
I end on this point because I am anxious to give the Minister as much time as possible to respond. It involves the key part of this debate. I dislike pinching clichés from my opponents but, if they are good clichés, why not? The whole point about the national health service is that it is not owned by consultants or politicians; it is a service for the people. Ownership of that service is vital.
Being the key player in an essentially natural operation—child birth—is not the same as being ill. Yes, medical opinion and expertise have their place, but they should start from the position that this is a normal, joyful experience, where the woman is the person who is calling the shots. In 1992, the entire emphasis was changed to ensure that that was exactly what happened. I hope that we will not hear from the Minister that he detects that there has been any backsliding in the system because of that change in emphasis.
Although the Minister will already have noted it, I draw to his attention the point that so many Labour Members have already made with some eloquence: rationalisation, even if done for very good medical reasons, can deprive people of the choice that all hon. Members want them to have.
§ The Parliamentary Under-Secretary of State for Health (Mr. Paul Boateng)
Ownership of the national health service is indeed important, which is why the Government and Labour Members have reclaimed it for the people. We need absolutely no lessons from Conservative Members on the importance of ensuring that people own the service. I make no apology for introducing a note of party political acrimony into this debate.
We have heard from one Labour Member after another, and from the hon. Member for Richmond Park (Dr. Tonge), of the importance of ensuring that consultation within the NHS is real consultation. We owe a debt of gratitude to my hon. Friend the Member for Braintree (Mr. Hurst) for ensuring that today hon. Members have had an opportunity to speak about the various consultative processes that are occurring in their constituencies and to make the points that have to be made about the value that their constituents attach to maternity services.
Importantly—I do not want to be parochial about the subject—this debate has enabled hon. Members to consider their constituencies within the context of the wider issues raised in delivering an effective and caring maternity service. Those opportunities are the true value of Wednesday morning Adjournment debates, which enable hon. Members on both sides of the House to speak to the issues and to increase our knowledge and engagement in the subject.
Some important points have been made in the debate and, in the short time that remains to me, I should like to deal with as many as I can. Unfortunately, I shall not be able to give hon. Members who are participating in a consultative process in their own constituency—whether it is in Essex or in Gloucestershire—the satisfaction that 326 they would like by acceding to their specific perspective, which they undoubtedly hold sincerely and profoundly. They will know that, as consultative processes are coming to fruition, it is not appropriate for Ministers to comment in detail or to express a view either for or against specific proposals, because those matters may eventually come to Ministers for a decision.
I can promise all hon. Members—I am conscious that my hon. Friends the Members for Braintree and for Harwich (Mr. Henderson) have a specific interest in the outcome of the current consultation in Essex—that the NHS in the hands of a Labour Government is a people's NHS, and that it holds a very different view on consultation from that which held sway under the previous Government. Hon. Members know only too well from our own experience what consultation in the NHS was like under that Government: the passage of a prescribed time before a predetermined conclusion was affirmed and implemented. That is what it was, but that is no longer what it is.
I promise my hon. Friends the Members for Braintree and for Harwich—and, should the circumstances arise, my hon. Friend the Member for Stroud (Mr. Drew)—that, if Ministers are called on to make decisions on maternity services, we will take on board all the points that are made and consider all the information presented to us in the light of the principles that we all share and that have been endorsed on both sides of the House.
I should like, without using too much time, to consider the current position of midwifery and maternity services, in which considerable gains have been made since the inception of the NHS. We owe a debt of gratitude to the dedicated midwives and clinicians working in maternity care for delivering a first-class service. In the past 50 years, since the NHS was founded, the rate of maternal deaths has been decreasing, demonstrating the high standard of antenatal care provided. At 5.5 deaths per 100,000 pregnancies, the rate is the lowest ever.
The hon. Member for Teignbridge (Mr. Nicholls)—who speaks for the Opposition with a considerable interest in and commitment on the subject—made an interesting point on the satisfaction with, and effectiveness of, midwifery care. The point was dealt with in an Audit Commission report published last year, which showed that the vast majority of women were happy with the antenatal care that they received. About 90 per cent. of them expressed happiness with midwifery care, and about 80 per cent. were satisfied with their medical care. We need to take on board that important message.
Important points have been made in this debate by Labour Members and by the hon. Member for Richmond Park—who, based on her own professional practice, speaks on the matter for the Liberal Democrats with considerable knowledge and experience—on the importance of the role of midwives and, significantly, on the need to ensure that there are sufficient numbers of properly trained midwives.
The Government—with the issues of effective recruitment and retention very much in mind—addressed the issue of additional funding. In the 1997–98 allocation, we made £350,000 of additional funding available for each region, to boost nurse recruitment and retention and to help nurses on career breaks go back to work. Last October, we made additional allocations for a publicity campaign to promote those objectives.
327 My hon. Friend the Member for St. Albans (Mr. Pollard) made an important speech—to which I shall reply shortly—and my hon. Friend the Member for Hemel Hempstead (Mr. Mc Walter) made an effective intervention. I should like to draw their attention to the work of the Barnet and Hertfordshire education consortium, which has sponsored a specific "return to health care scheme"—to which 61 nurses and midwives responded in person or by post, resulting in the commissioning of a "return to midwifery practice" course at the university of Luton which started last October. That is the type of initiative that we want to develop. We take on board also the points that have been made by hon. Members on the need to spread good practice. Good practice is obviously the key, and we cannot afford to be complacent.
The Edgware development was mentioned in a detailed and, I thought, important speech by my hon. Friend the Member for St. Albans. It is the Department's intention to pilot the development at Edgware hospital for two years and to ensure that there is an independent evaluation which we can then use to generate best practice elsewhere.
We know that there is good work being done out there—