§ Mr. Mohammad Sarwar (Glasgow, Govan) (Lab)I am grateful for this opportunity to debate maternity provision. The Government have made a firm commitment to improve quality and safety in maternity care. That is at the heart of the reform agenda in our health service. Every year, the NHS spends £1 billion on maternity services, which affect all our lives, accounting for one in seven hospital admissions and 600,000 births across the country. The subject provokes emotive debate in our communities as we face major changes.
Last summer, the Health Committee raised concerns about women receiving variable care in different areas. That is unacceptable and I welcome the Minister's work to tackle inequalities in service access and health outcomes for mothers and babies. More women are now encouraged to have the birth that they want but the main barrier to equality and choice has been the shortage of midwives and obstetricians.
There have been different responses to the problem across the country. In Scotland, Ministers promised to train 375 more junior doctors. South Tees Hospitals NHS trust closed a unit due to a shortfall of 14 full-time midwives. Neath Port Talbot had to close several times due to a consultant shortage and is now developing a midwife-led centre. The Oswestry unit had to close for six months when 22 midwives became pregnant. A lack of Leicester midwives resulted in a drive to attract new recruits and entice former midwives back. Flexible working was seen as the key. Will the Minister assure me that extra resources will continue co be prioritised for recruitment?
Investment in NHS maternity services has increased. The £100 million upgrade of 200 units in England has made a real difference. Last year, the Commission for Health Improvement found that maternity units were often the best run in NHS hospitals. Many showed best practice in patient involvement and risk management. It is important that units share ideas to deliver improved services and tackle inequality.
We clearly saw the disparity between hospitals in different regions two years ago. A Dr. Foster survey identified the busiest units and also found low staff levels, often in the south-east, an area of special interest to the Minister. Twenty-one hospitals had more than one baby born for each delivery bed per day. The national average was 0.76. Large hospitals in our cities faced the greatest pressure. Smaller units and community hospitals with a midwife-led service tended to have fewer births. Since the survey, Ministers have reaffirmed their commitment to consistent standards for all mothers.
We are now seeing more involvement for mothers, and midwives, doctors and hospital managers listening more to mothers' views. It is vital that women feel that they can make an informed decision about their care. As Professor Hewison concluded in her August report, antenatal care is strongly influenced by the type of care that each GP wishes to provide. We need women to be better informed at all stages of pregnancy. To that end, I welcome the "You're Pregnant" magazine launched by the Minister in December. It provides free local information about maternity services to women in a 54WH clear and presentable format. It is important to have choice in planning individual care and involvement in planning local services. That is vital with regard to formal consultation and can address inequality effectively.
The Select Committee identified problems with access to interpreting services for women who do not speak English as a first language. That may contribute to the high perinatal mortality among Pakistani-born mothers; it is nearly double the UK average. We see good practice to rectify that in Leeds. Local women work with midwives to translate antenatal classes into three common languages and to base them in community centres, reaching out to diverse groups and reducing inequality in the service. In areas with the highest numbers of asylum seekers—not only London and the south-east, but places such as Glasgow—more women are being offered appropriate care through awareness of the wide range of languages spoken, which can change each month.
I recognise the importance of maternity services being covered by the children's national service framework. I am sure that the Minister can assure me of further progress in that area of modernisation. The role of midwives is crucial, as they often lead reform. In Manchester, they improved the service for drug-dependent mothers, while Derbyshire midwives increased breastfeeding by using mothers who had breastfed to encourage others.
In breastfeeding awareness week, I must congratulate the national health service and the breastfeeding initiative in my home city. Glasgow's rates are increasing faster than those of anywhere else in the UK; 36 per cent. of women are breastfeeding at six weeks compared with 25 per cent. seven years ago. New mums appreciate backing from other mums who have breastfed successfully.
We have significantly more midwives and midwifery students than we did in 1997. The "Celebrating Midwifery Leadership" event and the Royal College of Nursing conference have taken place this past week. I hope that the Minister shares my optimism about the future of those important professions and support for their enhanced role.
The biggest area of contention in maternity services is the balance between consultant-led services and midwife-led units. There have been different responses throughout the UK. Merging North and South Durham NHS trusts meant that Bishop Auckland maternity unit was run by midwives, with mothers transferred to Darlington if a doctor was needed. The new board felt that the link between them would mean shared skills and ensure greater choice for mothers, with faster access and better clinical care. In Liverpool, plans were made to transfer neonatal and obstetric services from Aintree to Toxteth. The falling birth rate could no longer justify the provision of specially trained staff on each site, but antenatal services were kept at both and jobs were not adversely affected.
More recently, the transfer of the Mary Rose unit in Portsmouth was announced. The local branch of the National Childbirth Trust criticised the lack of consultation, as managers were not quick to consider midwives' and patients' views. It called for a midwife-led 55WH unit on Portsea island, as losing the Mary Rose unit would mean
no local option other than a home birth".Consultation on such changes remains the most important arena for genuine patient involvement, as communities must have confidence in major decisions made locally by the NHS. That affects both rural and urban communities.The low number of births at Caithness made it difficult to retain consultants, and a report stated that the service was unsustainable. Last month, the need for change was compounded when the remaining consultant went on sick leave. NHS Highland is consulting on a new midwife-led unit, but critics say that there is no understanding of rural geography, arguing that Norway and Canada design their services around the patients in remote communities.
There is also concern at the impact on other local services. There are good examples of patient involvement in Wiltshire. In July, West Wiltshire trust asked mothers, staff, unions and key groups to take part in a wide-ranging assessment of its services. Gloucester and Somerset mothers accessing care in Wiltshire were included in the consultation. Neighbouring Kennet and North Wiltshire trust asked all women who gave birth in 2002 and 2003 what they thought of local services and where they would prefer to deliver. It also reviewed two units where only one bed in three is used and the birth rate is dropping. Locally, the hospitals are considered to be vital community resources. Last month, the board gave the consultation a welcome extension.
Last year, Scarborough and North East Yorkshire trust proposed ending maternity services at three sites. The board appointed a non-executive director to measure public opinion and gave an assurance that any change would not place lives at risk. In Northern Ireland, every woman will live within an hour of a consultant-led unit but there is more choice through new midwife-led units and other approaches. In Downpatrick, for example, a new hospital offers antenatal and post-natal care but the falling birth rate does not justify a maternity suite.
After nine years of vigorous debate over potential sites, a decision has been made on Belfast's new maternity unit, which will also act as a regional speciality centre. The Royal was finally selected after detailed consultation by the Under-Secretary of State for Northern Ireland, my hon. Friend the Member for Basildon (Angela Smith). Every neonatologist and paediatrician taking part said that it would provide the best possible service. Millions of pounds have been spent on the new children's hospital, offering strong links to full neonatal services for premature and sick babies.
In Scotland, the report by the expert group on acute maternity services said that our current set-up was "no longer sustainable". The birth rate is the lowest since records began; women are having fewer children, later in life. The working time directive is another major factor. There are also pressures on training and a need to ensure clinically safe, cost-effective practice. The group said that care should be provided as close to women's homes as possible. Those with low-risk pregnancies should be 56WH able to give birth in midwife-led maternity units that are supported by specialist care for those at risk of complications. Scottish midwives accepted that such changes would not be easy but the response to similar moves in England had been positive; women enjoyed having the choice, backed up by specialist care if needed.
In the west of Scotland, consultant-led care is centred on Paisley's Royal Alexandra hospital. Mothers still have a choice of care, but Inverclyde and Vale of Leven are becoming midwife-led. NHS Argyll and Clyde considered its consultation to be "transparent and robust", using market research and discussing the plans with professionals, Voluntary groups and the public in open forum. Although most mothers should be able to give birth in community units, low-risk births can quickly become high risk, and 10 to 20 per cent. of women will be transferred to consultant-led care during labour, mostly for epidurals.
Scotland's Health Minister approved the plans but was unconvinced by the numbers assumed to opt for Paisley rather than Glasgow. It is important to look at patient choice between the two. Taken alongside plans for Glasgow, this concentrates consultant services for one in four Scottish women at two hospitals only seven miles apart. In 1999, the Greater Glasgow board decided that it had one hospital too many, due to falling birth rates. A pre-consultation proposed the closure of the Queen Mother's hospital, concentrating maternity care at the excellent Southern General hospital, and the new Princess Royal hospital in the east end. There followed a three-month consultation period, during which a strong campaign was mounted by theEvening Times, which amassed 156,000 signatures in support of the Queen Mother's hospital.
The biggest fear was a reduced standard of care. Glasgow would no longer have a leading position in the UK, with an integrated service; the Queen Mother shares its Yorkhill base with the Royal Hospital for Sick Children. The hospital is seen as a national centre of excellence, with eight national services for women and children, including the specialised ECMO life-support system, one of only four in the United Kingdom. The hospital treats babies from every health board in Scotland and from further afield.
However, almost all city clinicians accepted the reduction to two hospitals, and NHS Greater Glasgow felt that the decision could not be delayed. The board said that its plan involved the least risk to mothers and babies, as the Queen Mother's hospital offered intensive care only for children whereas the Southern General could provide intensive care for both. The Scottish Parliament Public Petition Committee was not impressed by the consultation; nor were a number of experts in the field. None the less, Greater Glasgow insisted that its pre-consultation and consultation process exceeded current guidelines. Last month, the closure was endorsed, but on the basis that Scottish Ministers must be satisfied with the substance of the proposals and the adequacy of the public consultation.
In responding to the need for change, NHS Greater Glasgow recommenced measures to provide sustainable and safe services for mothers and babies, including a new public health midwife service and midwife delivery beds in the hospitals That is commendable, but it also seems right to have a real centre of excellence that is integrated and co-located. However, the actual site is 57WH less important than delivery of integrated care. The board will now consult on whether the Royal Hospital for Sick Children should be moved to a site alongside adult and maternity hospitals.
It is crucial that there is more patient involvement in planning maternity services throughout the UK. It is also vital to maintain a high level of reform and investment in the NHS. If those are coupled with the Government's commitment to increasing the number of midwives and consultants, we will see lasting improvements to an excellent service.
§ Mr. Deputy SpeakerI call the Minister for his first stint in Westminster Hall this afternoon.
§ 4.3 pm
§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)I am grateful to my hon. Friend the Member for Glasgow, Govan (Mr. Sarwar) for introducing the debate. I am tempted not to reply to it, since he has done such a thorough job of setting out the issues that affect maternity services in the UK and of explaining both the strides forward that the Government have taken and the challenges that face us in the future. However, I am pleased to have the opportunity to add a few comments.
My hon. Friend will appreciate, however, that I cannot comment on some of the local issues that he raised in respect of Scotland, since those are matters for the devolved Administration, and my brief is for England. I hope, however, that my response will be of general interest to him and his constituents, and I am sure that he can arrange for his comments in theOfficial Report to be made available to Members of the Scottish Parliament and to Scottish Ministers.
The Government recognise that women and their families throughout the UK currently benefit from a high standard of maternity services provided by dedicated and hard-working NHS staff. I would say that those services are possibly the most successful of the NHS services. Huge advances have been made in the last few years in changing the experience of women during pregnancy and childbirth. Over the past 50 years, the NHS has made childbirth a much safer process for both mothers and babies, and women are now more actively involved in making decisions about the maternity care that they receive.
The NHS, throughout the UK, offers birth facilities of various types and sizes in maternity units in different locations, as well as at home. We do not support one model over others, but want diversity of provision, so that each woman can choose what best suits her needs and wishes. Real progress has been made in recent years towards providing a more personal, woman-centred service, tailored to meet the health needs of the local population. Maternity services have led the way in partnership working and midwives have played a key role, working with women and with other health professionals to ensure that NHS maternity services are safe and comfortable.
Of course, the rate of improvement and availability of choice may be governed by the recruitment of midwives. My hon. Friend highlighted that issue. The number of midwives working in the NHS is increasing, I am glad to say. There are now 1,560 more midwives working in the 58WH NHS in England than there were in 1997. Also, since 1999 more than 1,200 midwives have returned to the NHS, and another 270 are in the process of returning.
Despite what I have outlined, we need to do more and we want to build on those successes and boost the rate of growth. That is the reason for the midwifery recruitment and retention six-point action plan in England. It incorporates actions to help midwives return to practice, giving them better working terms and conditions, raising the profile of midwifery and improving training and leadership. It also involves our studying the geographical variations in vacancy levels. Thus I can give my hon. Friend the assurance that he wanted that we shall continue to put resources into the recruitment of midwives. For the record, I take no responsibility for the 22 midwives in Oswestry who all became pregnant. It was none of my doing.
My hon. Friend is aware that we are also developing a national service framework for children, which will cover maternity services. The aim of the maternity module of the national service framework is to ensure that modern maternity services place all women and their babies at the heart of acceptable services designed around their needs. Those services must also provide flexible and equal access to high quality clinical care and support for all women.
The two key issues to be dealt with in the NSF will be the reduction of inequalities and the increase of choice. I make no apologies for placing the issue of inequalities first. My hon. Friend referred to many of them. Fifty years ago, the Department of Health took the unprecedented step of setting up a confidential inquiry into all maternal deaths, a system that is still in place today. The results have led to many important changes in obstetric and midwifery practice, and it is a source of pride to me and my colleagues that that methodology is now being implemented in many other developed and developing countries to help to improve clinical maternal care.
It is also a source of pride that our NHS has helped us to achieve one of the lowest overall maternal mortality rates in the world. However, our confidential inquiry still has important work to do, and has recently been examining the wider determinants of maternal health. The findings of the last report show that women from the most disadvantaged groups in society are about 20 times more likely to die from factors related to childbirth than women in the highest two social classes. Their babies are more than twice as likely to die before their first birthday.
The infants of women born in Pakistan have particularly high rates of stillbirth and infant mortality. They are nearly twice as likely to be stillborn and more than twice as likely to die in infancy, compared with the average. Those are horrifying figures and we must get to grips with them.
Overcoming those inequalities in outcome, some of which can be helped by improving access to antenatal care services, is perhaps the biggest and most important challenge for us. We know that women from the most vulnerable groups in society often find it difficult to gain or maintain access to maternity services and have poorer maternal and neonatal outcomes.
Although we may not be alone in facing such problems, as surveys in other developed countries have shown, what makes us unique is the opportunity that we 59WH now have to tackle them through the forthcoming national service framework. We will grasp the opportunity with both hands. It is vital that a modern maternity service should ensure that women from all groups of society have easy and equal access to the full range of high quality services to ensure that the needs of the most vulnerable are given equal importance.
That means enabling every woman to seek early in pregnancy care that she feels happy with and to continue to maintain regular contact throughout her pregnancy and in the post-birth period. That is what we intend to achieve through the provision of individualised and flexible care plans designed by the woman and a health care professional to meet her specific needs and wishes.
Pregnancy, particularly for first-time parents, is the beginning of a process of transition to lifelong parenthood. It can be a period of great joy, excitement and anticipation, but may be combined with concerns about the health of the mother and baby, the process of birth and the prospect of becoming a parent. Pregnancy, birth and the post-birth period are also significant events for the wider family, taking place within their own social and cultural context and beliefs. The care and support given during this period is crucial to help expectant and new parents enjoy as straightforward a pregnancy and birth as possible and start to adapt to their new roles and responsibility before the baby is born.
High quality maternity care does not just provide a supportive clinical environment to ensure a healthy pregnancy, delivery and post-birth period; it also provides a gateway to other services and helps to achieve the best possible start to life. Those services include birth and parenting classes and the provision of multidisciplinary support for women with particular medical, social or psychiatric needs and for those from the more vulnerable groups in our society. It is vital that a modern maternity service ensures that women from all groups have easy and equivalent access to the full range of high quality, antenatal services and that the needs of the most vulnerable are treated with equal importance. That means enabling every woman to seek the care that she feels happy with early in pregnancy and to maintain regular contact throughout her pregnancy.
60WH The NSF is not the only work being done to shape maternity services. For example, our work with the National Institute for Clinical Excellence has led to the publication of several clinical guidelines to be implemented throughout England and Wales. We already have guidelines on induction of labour, the use of electronic foetal monitoring and antenatal care. Guidelines were recently launched on the use of Caesarean section, and guidelines on the management of uncomplicated labour and birth and the post-partum period will follow later. Those guidelines will complement the national standards set out in the NSF.
Another area of our activity is based around choice, and my hon. Friend highlighted several of the steps that we have taken. Maternity services were included in the national consultation exercise "Choice, responsiveness and equity", designed to improve patient and user experience in the national health service. The results of the consultation were published on 9 December 2003 in "Building on the best: choice, responsiveness and equality in the NHS", which encourages local health services to publicise contact details for midwives and promote the use of birth plans.
That is why one of the first outcomes of our drive to improve choice was our work with Dr. Foster to produce the "You're Pregnant" local maternity guides, to which my hon. Friend referred. They enable women and their families to make real choices about the type of maternity care that they wish to receive. Without information, choice can be just a theoretical exercise, but "You're Pregnant" gives women the information that they need to make it a practical reality.
I hope that I have demonstrated the Government's commitment to maintaining and improving the quality of maternity services. I want all women to have the birth experience of their choice in the environment of their choice, to have access to midwife-led and doctor-led units and, subject to their safety, to make the choices that meet their own needs. However, the rate of improvement can be governed by factors such as resources, the speed of building projects and the pace of recruiting more midwives.
Our highest priority is to tackle inequalities in access to services and health outcomes for women. We are also committed to improving and promoting choice for all women and their families in use of maternity services. I am delighted that my hon. Friend approves of so many of the initiatives that the Government have taken, and I look forward to having further discussions with him in the coming months.