Dear all

It's rather a large file, (taken from the website of House of Lords Hansard)
so if you've already seen this report, please forgive the duplication.  I
decided it was important that everyone should read it.

Baroness Cumberlege initiated a debate on Maternity Services, and although
we had short notice, several of us wrote to her (and also to other Peers)
with issues which we hoped would be dealt with in the debate.  We were on
the whole fairly successful.

Regards to all
Ishbel


Debate: Maternity Services
House of Lords, 12th January 2000

8.55 p.m.
Baroness Cumberlege rose to ask Her Majesty's Government what action they
propose to take to improve maternity services.

The noble Baroness said: My Lords, in introducing this debate, I start by
declaring an interest. I am a patron of the National Childbirth Trust and, I
hope, a friend to the Royal Colleges involved in maternity services.
This is a new millennium, a new year, a new beginning, new Labour, an
appropriate time to discuss a new life coming into the world.
"Pregnancy is a long and very special journey for a woman. It is a journey
of dramatic physical, psychological and social change; of becoming a mother,
of redefining family relationships and taking on the long-term
responsibility for caring and cherishing a new born child. Generations of
women have travelled the same route, but each journey is unique",
or so I wrote in my introduction to Changing Childbirth, a policy welcomed
by all three political parties, by users, community groups and most
professionals working in the field.
The expert committee which I chaired found that women and their partners
wanted three things: choice, continuity of professional carer--"all I wanted
was a familiar face" was a phrase which haunted us wherever we went--and
control over their care. Those are such very simple aspirations and are so
possible to achieve.
I know that it can be done because I have witnessed it. I have spoken to
countless parents, midwives and obstetricians and there is no doubt that
where there is continuity of carer, the satisfaction rates are high and the
waiting list is long--long for midwives wishing to work in those units. But
more importantly, as research into the pioneering one-to-one scheme
introduced by Professor Lesley Page shows, the intervention rates are lower
and, as a result, the schemes are cost effective. We know that they are cost
effective because they have been evaluated very thoroughly by York
University.
Where those schemes have closed, the disillusionment has been enormous.
Midwives have left because they could not bear to go back to a poorer
quality service which satisfied no one. The shortage of midwives does not
require rocket science. It is quite simple. We need to stop the closure of
one-to-one maternity-led schemes, introduce others, trust midwives, and
ensure that they have autonomy over their work.
I know that my noble friend Lord Howe will deal with some issues relating to
the midwife crisis and I look forward to hearing the Minister's reply on
that. I believe that my noble friend Lord Chadlington will deal with some
issues relating to autonomy of midwives.
But I am aware that the Government view Changing Childbirth as yesterday's
policy. Although it has been reaffirmed by each successive health Minister,
there really is no sense of ownership. I am not proprietorial; I am not
proud; I understand government; I also understand the needs of childbearing
women.
Along with those working in the field, I want the principles in Changing
Childbirth to be adhered to. But I really do not mind if the Government
tinker with it at the edges. The Government could call it "New Labour", or
in deference to the Minister, who I knows feels strongly about this
issue--he is the father of five children--we could call it "Hunt the baby".
However, I really believe that all of us should recognise the common
principles, the common sense, the proven value, the NICE qualities inherent
in this policy--and invest some political will.
In her new year press release, Yvette Cooper, a Minister in another place,
stated that maternity services are at the heart of government. I am
delighted, but what does that mean? Can the Minister tell us where maternity
services stand in the list of government priorities? Are they third or
fourth or 44th? Can the Minister be specific on this issue because we need
to know?
The Government are determined to reduce inequalities, and rightly determined
to reduce the number of low-weight babies. The Sure Start programme is a
brave attempt to do that, with its target of a 5 per cent reduction by 2002.
I believe that it is disgraceful that in this country we have a higher
percentage of low-weight babies than even Albania and Latvia.
Research shows that intensive support during pregnancy reduces the chance of
a low-weight baby, and improves the physical and psychological health of the
mother. Joined-up government should target resources and introduce schemes
that offer continuity of care by a midwife, caseload midwifery, one-to-one
midwifery, or whatever one wants to call it, in areas of poverty and
deprivation. Will the Minister take that modern suggestion of mine to his
colleagues and ensure that babies born to the most vulnerable parents have a
sure start to life?
Your Lordships recently debated, with grave concern, the rising caesarean
section rate. Mr Nigel Perks, an obstetrician in Greenwich, spoke for many
when in Monday's press he highlighted the dangers of a caesarean section and
the fact that several women in London have ended up in intensive care.
I strongly support women-centred care and the right for women and their
partners to choose the place and type of birth that they would like, but the
choice should be informed. How many women choose to have what is a major
abdominal operation without being given all the facts? Are they told about
the risks of both mortality and morbidity; the pain; the discomfort; the
delays in returning home; the separation from their baby; secondary
infertility and the increased risk of complications including deep-venous
thrombosis and infection? Do they really appreciate the effects that that
type of birth will have on their baby, including the greater risk of
respiratory disorders?
Does the Minister agree that,
"Because hard evidence of net benefit does not exist, performing Caesarean
sections for non-medical reasons is ethically not justified"?
Those are not my words, but the words of the International Federation of
Obstetricians and Gynaecologists. Do the Government agree with that expert
committee and, if so, what action will they take? Is the high rate of
caesarean sections associated with the lack of experienced obstetricians in
labour wards? That is an issue that I hope that the noble Lord, Lord Patel,
will explore. I believe that no one in the House is better qualified to do
so.
Does the Minister realise the cost to the NHS? With every 1 per cent
increase in the caesarean section rate, we add £5 million to the maternity
bill--the equivalent of 167 midwives. If the caesarean section rate reached
50 per cent, it would consume a third of the total budget. People may feel
that that is a ridiculous statement to make, but the figure has already
reached 29 per cent in some places and it is still rising. Does the Minister
agree that action is essential?
I know that an audit is being undertaken by the Royal Colleges but that, of
course, is a one-off exercise which will take months, if not longer, to
complete. We need systems in place that will produce annual audits, close
monitoring and consistency, and information UK-wide in the same format so
that comparisons can be made on an annual basis. Those systems need to be
put into place now. Just as with winter pressures, where exact information
is not available when planning starts months ahead, so the Government should
start to think about this serious and costly issue now.
I wanted to mention GPs and commissioning by primary care groups, but I
believe that the noble Lord, Lord Clement-Jones, will speak on that issue.
Lastly, can the Minister tell us the Government's policy on home births? I
know that he will be aware of the huge concern felt by many that the United
Kingdom central council has sought legal clarification regarding the
obligation of health authorities to provide a domiciliary service for women
planning a home birth. I really want to know the Government's view of that.
Are women
to have the assurance that they will be attended by a midwife? If not, what
will that mean for those who wish to give birth at home? Is it the intention
of the Government to restrict choice? If not, will they ensure that the
position is clarified and define once and for all a woman's right to choose
that place of birth?
I believe that the start to life is crucial. I leave your Lordships with the
sobering thought that each and everyone of us has been touched by a midwife!

Lord Patel: My Lords, I thank the noble Baroness, Lady Cumberlege, for
initiating this debate, and in particular for all that she has done to
improve maternity services in this country for the benefit of mothers and
babies.
Having worked for over 30 years as an obstetrician--I mean as an
obstetrician rather than a gynaecologist--I believe that there is no other
branch of medicine that is more rewarding, exciting and at times frightening
as obstetrics. Of course, I am not biased in any way!
I also assure your Lordships that pregnant women and their partners value
above all the safety of their baby. Today childbirth in Britain is very
safe, but it could still be safer. We have the skills in our midwives,
nurses, doctors and scientists to deliver the best care to the mother and
the baby, and to create a healthier population with only a little more
effort and commitment, and with not a great deal more resources.
How does one judge the quality of maternity services? The key indicators of
a good service are, first and foremost, client or patient satisfaction with
the service. Others are hard indicators such as maternal and perinatal
mortality; morbidity such as reduction in birth handicap, early childhood
illnesses and infections. A good service that meets the needs of the
consumer will be successful in recruiting and retaining high quality staff.
So where are the shortfalls in the service? As recently as 1935, one in
every 200 pregnancies ended with the death of the mother; that is, one death
every two weeks in my city of Dundee. Today the risk is less than one in
10,000 pregnancies--one death every three years in my city. That improvement
was not the result of better social conditions--although that too has
improved--but of better care from midwives and doctors, and with
antibiotics, safe blood transfusion, safer abortion and better treatment of
medical diseases such as diabetes and high blood pressure.
How do we compare with the rest of the world? The lowest maternal mortality
in Great Britain was in 1985. Some of our European partners--Scandinavia,
the Netherlands, Germany, France and so forth--report lower figures. We need
to match and better those figures.
The risk to the baby is 100 times greater than to the mother. Before the
last world war, perinatal mortality was 6 per cent; one in 15 babies died.
Now it is 1 per cent. But that figure, low as it is, represents over 6,000
stillbirths or neonatal deaths in Britain every year. Most are due to
prematurity or complications that cannot be prevented in our present state
of knowledge, but sadly some of those deaths are preventable.
All deaths of babies and infants are now analysed by the Confidential
Enquiry into Stillbirths and Deaths in Infancy--CESDI for short--which
recently produced its sixth annual report and with which I have been
involved from the outset. It monitors the causes of death. Two years ago it
carried out a detailed analysis of 873 babies who died as a result of
labour--so-called "intrapartum" deaths. Those were babies who were normally
formed and were not premature; at the start of labour the baby was healthy
and then something went wrong.
Of those 873 cases, no fewer than 78 per cent were criticised for suboptimal
care. Those criticisms were made by panels of experienced clinicians. In
over 50 per cent of those cases, better care,
"would reasonably have been expected",
to have made a difference; in other words, the baby's life should have been
saved, but we failed to do so. Four hundred and fifty dead babies is not a
large number when compared with over 600,000 born safely every year in this
country. The chance of a healthy baby dying as a result of labour in
hospital is one in 1,500 births. That is two deaths a year in an average
maternity hospital. We know that one of those can be prevented. Why is it
not prevented?
For the past 50 years, the medical care in Britain's labour wards has been
provided by trainees--something I have never accepted and not considered to
be correct. In the 1990s, 40 per cent of forceps deliveries were carried out
by young doctors who had done fewer than 20 such deliveries before. Those
young trainees have done remarkably well, but women now deserve better care
from fully trained midwives and specialists.
Last year, the Royal College of Obstetricians and Gynaecologists and the
Royal College of Midwives together produced a guidance document called
Towards Safer Childbirth--minimum standards for the organisation of labour
wards. One of its recommendations was for a consultant to be present in the
labour ward for at least 40 hours a week--at least; there ought to be
more--in all large maternity hospitals. The function of the consultant would
be to educate and train younger doctors as well as to look after women with
complications in labour; to work with midwives as a member of a team; and to
formulate policy in co-operation with the clinical midwife manager.
There is some evidence that in units such as Portsmouth, where those
recommendations have been implemented, there has been a reduction in
mortality in intrapartum deaths. The question will be asked: can Britain
afford a safe service, properly staffed by fully trained midwives? If not
from a humanitarian point of view, then from a financial one, the answer is
that the NHS cannot afford an unsafe service. Litigation costs
the NHS over £300 million every year. Obstetric claims account for 50 per
cent of this total. The average sum awarded to a "brain-damaged" baby is
£1.5 million. This means, potentially, one £2 million case in the average
maternity hospital every year. The number of such tragedies can be reduced.
Preventing them would more than pay for improved services.
What about other areas of maternity services, such as pre-pregnancy care and
advice, prenatal care, diagnosis of foetal abnormalities, and antenatal
tests? Currently, the expertise to deliver care in all these areas varies
from region to region and from hospital to hospital, with a lack of national
guidance.
I shall now speak briefly about the rising rate of caesarean sections. Of
course the noble Baroness is right, the caesarean section rate has risen in
the past decade and in some hospitals--mainly tertiary referral
hospitals--it is nearly 18 to 20 per cent. I agree that any decision to
undertake major surgery such as a caesarean section, which carries a risk of
mortality and morbidity, should be taken seriously.
Advances such as the ability of paediatricians to care for smaller and
smaller babies; increasing numbers of pregnancies as a result of assisted
conception and multiple pregnancies; increasing numbers of older mothers;
successful pregnancies in women with medical conditions; and an increasing
number of women wishing to have a caesarean section by choice, particularly
if they have had a caesarean section previously--I agree that that choice
should be based on informed consent and should be clearly understood--have
also contributed to this increase. Because of the complexity of factors
involved in human birth, and both the changing circumstances and outcomes
that are desired, defining the optimal caesarean section rate is difficult.
I believe that a proper audit needs to be carried out, particularly to find
the reasons for inter-hospital variations in rates of caesarean sections for
the same cause. There are three major causes: Cephalo-pelvic disproportion
(failure to progress), foetal distress, and repeat caesarean section. This
matter needs to be explored. There is also a need for guidance and
monitoring of the rates of caesarean section. I hope that the audit that is
being carried out by the two Royal Colleges will provide some answers in
this matter.
I believe that the time has come when all the good recommendations in the
variety of reports on maternity services compiled by professional
organisations, government and other bodies should be brought together in a
national service framework for maternity services. Standards should be
subject to audit. I believe that this would help to improve maternity
services and make childbirth in this country even safer and a happy
time--which I believe that it ought to be--for parents. I have no doubt that
we can make maternity services in this country consumer friendly and safer
and that we can match the best outcomes that exist anywhere in the world.
Will the Minister's department consider the proposal to develop a national
service framework?

Lord Chadlington: My Lords, I also am grateful to my noble friend Lady
Cumberlege for introducing this important debate. I speak this evening very
much as a layman although I am also the father of four young children and
have taken a keen interest in the National Health Service all my life. I
served on the policy board of the National Health Service between 1991 and
1995.
The health of mothers and babies is clearly of paramount importance in this
country. The midwifery profession, despite increased pressures both in terms
of changes in society and the resources available to it, has continued to
provide a service to mothers and babies which is a shining example to other
countries. We have a midwifery profession of which we can justifiably be
proud and we must make all efforts to preserve those aspects which make this
profession so exceptional.
Since 1983 midwives have shared their legislative framework with nurses but
the profession has been recognised as quite distinct. It benefits from a
mechanism which is held up as an example of responsible nursing to the rest
of the world--the statutory supervision of midwives. That mechanism must be
preserved. It provides both the midwives and the mothers whom they serve
with a unique support structure which in turn gives the babies in their care
the best possible start in life.
The first point that I wish to raise concerns the recognition of midwifery
as a profession distinct from nursing. Indeed I should like to see this
distinction strengthened and reinforced by further empowerment of midwives,
allowing them to practise autonomously. It seems to me that the most
effective way to do this is to take midwifery out of consultant hospitals
and put the emphasis on midwife-led birth centres.
In accordance with this view I therefore wholeheartedly support the Changing
Childbirth policy which my noble friend Lady Cumberlege has both championed
and spoken of already in this debate. I believe that my noble friend is
absolutely right and that it is a first-class policy which should be
reaffirmed. There can be no doubt that the role of the midwife in our
society is a highly valued service. We need the health service to support
pilot schemes for midwifery-led care, which have been run in parts of the
country already, and to show a determination to implement that policy on a
nationwide basis.
What stronger signal can we give women that the Government take this issue
seriously than a network of midwife-led birth centres devoted to the health
of mother and child? After all, midwives are not just there to assist with
the practicalities of the birth itself. The responsibilities now taken on by
midwives are wide ranging, dealing not only with the dissemination of
information to the expectant mother but often providing much needed
emotional support.
To pick up the point made by my noble friend Lady Cumberlege about the
regular monitoring of services, I suggest that the Commission for Health
Improvement should review all of the Changing Childbirth pilot
schemes and, in addition, should consider why we are experiencing such a
rapidly increasing caesarean section rate in this country.
Secondly, I should like to see every woman in this country guaranteed that a
midwife will be present at the birth of her child. The current situation
allows for one-to-one care solely in the case of a home birth or where an
epidural is required. Provided that there are enough midwives available to
provide such a service, perhaps with the comfort and support of midwives at
every birth the need for obstetric intervention may be lessened.
The resources are there in human terms--although admittedly thin on the
ground--but we need, in addition, a way of mobilising and motivating
midwives, especially when, for some reason or other, the number of women in
labour at any given time is particularly high.
Having access to a midwife before, during and after a birth has proved to be
of real benefit for both mother and child. A 1998 national survey by the
Audit Commission, which researched women's views of maternity care, clearly
highlighted this. One of the findings of the survey was that when
participants were asked the question,
"How strongly do you agree or disagree with the following statements about
the time during your pregnancy",
66 per cent strongly agreed with the statement,
"Midwives talked to me in a way I could understand",
while only 47 per cent strongly agreed with the statement,
"Doctors talked to me in a way I could understand".
This is further evidence--if one would need it--in what seems to me a common
sense argument that midwives provide a service which women perceive to be of
real and relevant benefit. Surely no woman should be denied the opportunity
to take advantage of what this country can proudly assert is a first-class
service.
Maternity services can and must be improved. The Changing Childbirth model
ensures that improvements are executed. I understand that midwifery-led care
would certainly be popular with those in the profession and that large
numbers of midwives would be keen to be part of teams in midwife-led units.
Midwifery-led care has been demonstrated to be perfectly possible and the
next step is to progress with the implementation of such a policy.

Baroness Emerton: My Lords, I, too, wish to thank the noble Baroness, Lady
Cumberlege, for introducing the debate. I declare an interest as chairman of
Brighton Health Care NHS Trust, where, for the past five years, I have been
very involved in developing maternity services to improve the quality of
care to pregnant women during their pregnancy--from the antenatal period,
through the intrapartum stage, the delivery and postnatal care. We aim to
incorporate the Changing Childbirth aims of choice, continuity and control.
Within the five years we have actively evaluated any changes that we have
made. Indeed, after four years of introducing a pilot scheme of midwifery
with three teams of midwives, changes were made to ensure that instead of
three geographical areas having team midwifery, midwives were reorganised
into five groups to ensure an equity of care, although this meant that a
smaller package of care was given because we needed to cover a larger
geographical area.
Fundamental to the development of team midwifery was the philosophy of
integrated patient care which during this time involved a total capital
expenditure of £2.3 million to develop the unit. That included bringing
together the ante-natal facilities and all the facilities concerned in the
maternity department, including foetal assessments and diagnostic procedures
as well as a modern delivery suite and a birthing pool, a post-natal ward
and an intensive baby care unit, as well as developing role descriptions to
allow multi-skilling among the staff within the unit.
The first evaluation showed that, where appropriate, care was given in
women's homes. The numbers of bookings rose by more than 120 per cent
between 1993 and 1997. Home-based ante-natal visits increased by 37 per cent
and home assessments rose from nil to 68 per cent. Continuity of care was
assured, with two midwives being present at all home deliveries. That
illustrated that there was an increase in women's choice for home
deliveries. The current home birth rate in my trust is 8 per cent.
However, the evaluation demonstrated that there was a need to give parity of
care which could not be afforded by developing and maintaining team
midwifery across the geographic area while at the same time ensuring that an
optimum number of midwives was available in the hospital unit.
The reorganisation for midwives has resulted in continuity of care during
the intrapartum period but allows less flexibility to ensure continuity of
ante-natal and post-natal care. Even to achieve that the addition of six
whole-time midwives is required. In the period between 1995 and 1999 the
number of hospital midwives increased by 12. Those in the community rose by
four and then the number was reduced by four. The total number of midwives
is now 88, with a vacancy factor of five. Funding is currently required for
an additional six midwives. That has been discussed by the primary care
group and the health authority. We know that if this funding is not
forthcoming a further reorganisation will have to be undertaken. That will
inevitably reduce the continuity of care which is our aim.
It will be impossible to sustain the home birth rate of 8 per cent.
Therefore, women who wish to have a home birth will be asked to deliver in
hospital. Should those women refuse to transfer into hospital, that will
present a grave clinical risk as midwives will be unable to attend. The
number of midwives on call will be reduced; therefore flexibility will be
reduced. Ante-natal clinic continuity will be reduced, resulting in women
not knowing their named midwife. Post-natal continuity will be compromised,
resulting in inconsistent advice and a reduction in effective care.
Midwife availability to provide breast feeding support at home will be
greatly reduced. Intrapartum continuity of care for any women will be
impossible. Outreach work for non-attenders at risk will cease. Ante-natal
clinics, which are currently provided at small GP surgeries, will have to be
withdrawn, thereby necessitating those women to attend hospital for
ante-natal care. Such care currently delivered in the home will cease.
That is a grim picture when women have been promised a safe standard of care
to which they have become accustomed over the past five years. The neo-natal
intensive care unit responded to an increased demand of ITU cots, and a
further £258,000 was invested by the health authority to pay for the extra
activity. That resulted in the appointment of a second neonatologist and a
part-time specialist registrar, together with 4.5 whole time equivalent
nursing staff.
Activity has continued to rise. The occupancy of the 20 cots has risen from
93 per cent to 119 per cent during the period 1999-2000. Special care
occupancy peaked in September to November at 136 per cent, which caused a
bottleneck in our ability to accept intensive care admissions.
Quality of care is costly. Evidence-based practice, taking into account the
best practice and consumer views, has to be gauged within available
resources. Maternity services urgently need to know what actions Her
Majesty's Government propose in order to improve those services and maintain
standards that have already been established in these pilot schemes in the
interests of providing a quality service, resulting in a healthy mother and
a healthy baby.

Lord Mancroft: My Lords, we are indebted to my noble friend Lady Cumberlege
for bringing this important issue to our notice this evening. It is, as
other noble Lords have stated, appropriate to acknowledge my noble friend's
expertise in this subject and the enormous contribution she has made through
the work she did in producing the excellent report Changing Childbirth in
1993.
There is, I suppose, a temptation to cut the debate short by asking the
Minister why the Government did not continue the implementation of my noble
friend's recommendations: if that had been done, the need for the debate
would neither be so great nor so pressing. However, it has not been done,
and today we face a situation which, rather than having improved, has
obviously deteriorated since 1993 or 1994.
I am no great expert in maternity care, but, like many men, I developed a
degree of interest when I first became a father over six years ago. Although
I am no greater expert now than I was then, I consider myself to be a
reasonable amateur mid-husband, in part due to my wife's decision to give
birth at home and in part as a result of my increasing interest in
midwifery, following the absolutely outstanding level of care that
my wife and children received from our midwife--which experience, sadly, is
in contrast with the national trends that we have heard about tonight.
My noble friend's report clearly made the point that there are not enough
midwives, and every noble Lord has emphasised that point. The figures that I
have seen show that at present only 36 per cent of registered midwives are
practising today, and the increase in midwives nationally is only 3.3 per
cent. Although new admissions to the UKCC Register have increased by 1.7 per
cent, I am told that this increase is entirely due to the number of
registrants from overseas. One reason for this situation appears to be that
the career and pay structures for midwives act as active disincentives to
them to continue in practice. Can the Minister explain what the Government
are doing to address the situation?
One of the consequences is that the choices open to women as to the way they
give birth, which we all consider to be so important, are more limited. It
is interesting to note that, while midwife numbers have been in decline,
during the same period the number of obstetricians has remained stable. That
is a good thing, but it means that women are bound to be pushed in the
direction of a hospital-based medical birth as opposed to a midwife-led home
or hospital birth, regardless of their individual wishes. I suspect that
this may be compounded by the post-natal fees that general practitioners can
claim, which are bound to encourage them to steer their patients in the
direction that suits them rather than that which suits the patient, thus
further limiting choice.
These two factors must contribute to the alarming increase in birth by
Caesarean section, which every speaker this evening has mentioned. The
figures that I have seen indicate an increase of 27 per cent in recent
years. While Caesarean births will always be an important feature of
childbirth, they cannot be ideal or desirable in cases where they are not
absolutely necessary; nor can any other medical intervention unless
necessary.
I shall take a lot of persuading not to conclude that too many of these
operations are performed to suit the consultant rather than the patient.
Clearly, all women are vulnerable at the time they give birth, and they need
to be able to trust the professionals who care for them. It is therefore all
to easy for the consultant to steer the woman in the direction that is most
convenient for him, at the expense of the patient and also at the expense of
the taxpayer. Clearly it is more costly to provide medical intervention in a
hospital than a home birth or a midwife-led birth in a hospital.
I believe that some of these problems, if not all of them, occur because of
our attitude to childbirth. The health service exists to help people who are
ill or injured, or at least who are not well. But pregnancy and childbirth
are not illnesses; they are part of the natural healthy process of life.
Only in the minority of cases where something goes wrong with the mother or

child do they become issues of ill health. The problem with hospital and
doctor centred maternity care, wonderful though it is, is that it is
naturally focused on what might go wrong rather than what, for the majority,
goes right.
The very fact that the Minister who is to answer the Question of my noble
friend
tonight--which I am sure he will do extremely well--speaks for the
Department of Health, amply demonstrates that point.
But maternity care is not primarily a health issue. It is a women's issue.
Eighty per cent of the women in this country give birth at some time in
their life. For many of them it is one of the most significant experiences
of their whole lives and it is not being given the attention it needs or
deserves. In that respect I have to say that I am sadly disappointed not to
see the Minister for Women in her place this evening. In a recent newspaper
interview, the noble Baroness said that, now that the House of Lords Act was
on the statute book, she could turn her attention to her more important role
as the Minister for Women. Indeed, in the Guardian newspaper on Wednesday,
8th December, she wrote saying that she had,
"spent the last year on the road ... listening to what women desire from
government ... I heard from 30,000 women and they stated very clearly that
they want to be fulfilled at work and also as mums.

This government is committed to ensuring that women have choice ... The
proof of our intent is the long list of policies that have been implemented
since May 1997 that directly benefit women".
I shall not read the whole letter because noble Lords may read it in the
Library. However, at the end she stated:
"The Women's National Commission is rightly celebrating 30 years of
existence, but for a large part of that time there have been Conservative
governments who failed to do anything to improve the lot of women. As well
as celebrating the birthday of the organisation ... we should also celebrate
the fact that, at last, we have a government prepared to put women at the
heart of its agenda".
Well, tonight we are debating one of the most important, if not the most
important, of all issues affecting women. Yet apparently the Minister is too
busy either to attend or to participate in this very important debate.
Perhaps we should reluctantly conclude that the Ministry for Women is like
the rest of New Labour, all talk and no substance.
The final point I want to make is this. This debate is, quite properly,
focused on the narrow area of maternity care because, as we know, it needs
careful attention. But there are other factors to be taken into account. In
particular, the report entitled Poor Expectations, published in 1995 by the
Maternity Alliance, draws attention to the problems of poverty and
nourishment in pregnancy--as my noble friend Lady Cumberlege mentioned, the
problem of low weight babies. However carefully we look after women during
childbirth and immediately afterwards, it will always be an uphill struggle
if, in the months between conception and birth the mother and child do not
receive the food and warmth they need. It is clear from that report that the
benefits paid to pregnant women at present are not sufficient to provide for
an adequate diet. It is also clear that, for those on income support, this
problem is compounded if, for example, they are compelled to service a fuel
debt during pregnancy.
In answering the Question, I have no doubt that the Minister will seek to
lay at least part of the blame for the failure to implement my noble
friend's report on the previous administration; but not too much, I hope.
The previous government did implement a great deal of it. However, this
Government appears to have stopped or prevented many of those initiatives
from moving forward. I should like to hear what the Minister has to say
about that.
I shall of course listen with great care to the Minister's response, but,
having listened to it, I suspect that my noble friend may well want to
return to this matter before too long.

Lord Chalfont: My Lords, I hope that I may have the indulgence of the House
to say a few words before the noble Lord, Lord Clement-Jones, addresses
noble Lords from the Liberal Democrat Benches. I have much appreciated the
opportunity to be present at this debate this evening. I had not expected to
attend. I confess that I am here only in the wake of the debate on the
international situation that took place earlier. Knowing the noble
Baroness's interest in and commitment to this issue, I believed that it
would be a debate worth listening to, and it has been. The debate has been
most instructive, informative and, in some cases, even moving, and I am most
grateful to the noble Baroness for her presence.
The noble Baroness might have felt some discouragement at the sight of all
the empty Benches around her when she initiated a debate of this importance.
I hope that she will not be too discouraged. Not only will everything that
has been said appear in Hansard, which I hope those interested in this
matter will read and find informative, but I am also aware that the noble
Lord, Lord Hunt of Kings Heath, who has a deep interest in and commitment to
these problems, will take these matters back to his colleagues. I hope it is
not inappropriate to say that the noble Baroness can be assured that all
that she has said will have the impact that it should have on the
Government's thinking.
Like many other noble Lords I am not knowledgeable about this subject.
Although my wife is a doctor and I have had some second-hand experience of
these problems, certainly I am not an expert. However, I believe that at the
end of this debate I know a little more about it than I did at the
beginning. The only reason for rising to my feet in the gap is to express
heartfelt thanks to the noble Baroness, Lady Cumberlege, for introducing a
debate of this kind which is in the very best traditions of your Lordships'
House.

Lord Clement-Jones: My Lords, with all other noble Lords I join in thanking
the noble Baroness, Lady Cumberlege, for initiating this debate. I pay
particular tribute to her long involvement and expertise in this field. I
wholeheartedly agree with the noble Lord, Lord Chalfont. Having listened
with enormous interest to the debate, the range of expertise displayed
is not something that I can possibly hope to match in my contribution.
I declare an interest as a patron of the National Childbirth Trust. I pay
tribute to that body, the Royal College of Midwives and other organisations
in this field in their campaign for better maternity services. My own recent
experience of maternity services occurred when my son was born across the
river at St Thomas' on the first day of spring 1998. My motives in
supporting the NCT arise particularly from the desire to see other mothers
have the same quality of care as my wife and I experienced at the hands of
the community-based Alpha Team at that hospital.
With great deference to the noble Lord, Lord Patel, like the noble Lord,
Lord Mancroft, perhaps I have the rather unreasonable prejudice that the
best births are those without doctors, if possible, despite the fact that
both my nephew and his wife are obstetricians. It appears that my nephew's
wife shares this prejudice since recently she gave birth to a healthy
eight-pound girl at home.
There are many issues with which the maternity services currently have to
grapple, and they have been graphically described by your Lordships during
the course of this debate. Many of them stem from shortages. The most recent
report of the English National Board for Nursing, Midwifery and Health
Visiting shows that numbers entering the profession each year have fallen
since 1994. Based on those figures there are about 2,500 fewer midwives than
two years ago. Many senior people have left the profession and, as a result,
there is a shortage of experienced staff.
In a reply before Christmas to a supplementary question that I put to him,
the Minister seemed to imply that with the recent recruitment campaign the
problem was now solved. Is that indeed the case? Has the shortage of
midwives now been fully made up? After all, London hospitals such as the
Chelsea and Westminster were turning away women in labour as recently as
November because of lack of staff. Are we still recruiting midwives from
abroad as we were last year?
I believe that our shortages will not be made up until we improve radically
the pay of midwives and have much more flexible patterns of working. Without
adequate midwives I fear that the grave picture painted by the noble
Baroness, Lady Emerton, is only too accurate. By contrast there is an
alleged oversupply of obstetrician and gynaecological doctors in training.
What an argument for a massively improved workforce planning system.
There appears to be a strong link between shortages and the rising rate of
caesareans outlined by the noble Baroness, Lady Cumberlege, and the noble
Lord, Lord Mancroft. We shall have to wait for the Royal College's audit
referred to by the noble Lord, Lord Patel, to see whether that is indeed the
case. Be that as it may, the shortages have militated against what should
have been the very essence of maternity care as
described by the Winterton report, Continuous Care and Choice. There is
clear evidence that staff shortages have meant that midwives have not been
in continuous attendance. There is equally good evidence to show that
continuous care has a major impact on outcomes.
As regards choice, the NCT survey carried out last year and published in
August, showed that there was a lack of awareness among expectant mothers
about the full range of options, and then a lack of choice about the lead
professional. There was also felt to be a lack of unbiased information.
There were of course as well wide variations in frequency of seeing a
consultant obstetrician. Very importantly, there was a lack of choice as
regards home births. The majority of GPs seem actively to discourage home
births, as that survey showed. I share the desire of the noble Baroness,
Lady Cumberlege, to see the matter clarified.
There has been a long gap, as the noble Baroness illustrated, between the
end of the period of the original 1993 five-year strategy, Changing
Childbirth, of which she was the author. That has clearly not been
implemented in full because of lack of resources, as the Audit Commission
clearly showed in 1997. Do the Government now plan a national service
framework, mentioned by the noble Lord, Lord Patel, which can set a truly
high standard for maternity services? Are the Government planning a
replacement strategy for Changing Childbirth? What guidance are they giving
to primary care groups which are now thrust into the commissioning of those
services? When the Health Act was going through this House, we were assured
that user groups would be involved closely with PCG commissioning. Is that
happening with maternity services?
What emphasis is being given to particular aspects of training? Is this
being adequately resourced? I am sure that the House is aware that there are
worrying issues about standards and some alarming cases pointing to a lack
of training. Indeed, the joint report of the Royal College of Midwives and
the Royal College of Obstetricians showed that a lack of adequate training,
for example in the use of heart monitors, is at the root of a great many
problems in delivery.
I hope that the Minister can at least respond to some of these questions.
The NCT's 10-point plan published in 1998 seems to me to provide an
excellent basis for the way forward. There are many aspects of the 10-point
plan and the objectives of the Association for Improvements in the Maternity
Services, which I could highlight. The aspects which strike the greatest
chord with me, however, are the need, first, for user involvement in PCGs
and in maternity service liaison committees; much improved recruitment and
retention of midwives, in particular senior midwives; the importance that
the NCT and others attach to integrated services, so well described by the
noble Baroness, Lady Emerton, and, above all, the need for a national
strategy to tackle inconsistencies and anomalies in maternity care.
I have one final point. Like the noble Lord, Lord Chadlington, I am also
very sympathetic to the establishment by midwives of autonomous group
practices within the NHS. As has been pointed out to me, however, there is
the legal right for midwives to do so, but no structure within the NHS by
which that can be done. Can PCGs be stimulated to encourage the growth of
such practices and of such birth centres?
Those and other questions that have been put to the Minister are of vital
importance to expectant mothers from 10 Downing Street outwards. I look
forward to hearing his reply.

Earl Howe: My Lords, I thank my noble friend Lady Cumberlege for the
characteristically capable and heartfelt way in which she introduced her
Unstarred Question tonight. I hope that the Government will pay close heed
to what she said. My noble friend has a deep understanding of maternity
services, based on many years' experience in the NHS and in government.
However, there was one matter on which she did not dwell but which ought to
cause us particular concern. It is the current fragile state of morale among
midwives. Midwifery is a special discipline and one that is quite distinct
from mainstream nursing. Like nursing, it is a vocation and not just a
profession. That means that midwives will always work longer hours and
shoulder additional burdens, rather than compromise the professional
standards of care given to the patient. I have no doubt that the commitment
of midwives to their work has protected maternity services from the full
effects of resource shortages over the past few years. I believe that but
for that, the situation on the ground--by which I mean the situation as felt
by the patients--would be far worse than it is.
If we believe that midwifery is a vocation--and I venture to suggest that we
all do--it must be a cause of special worry that so many midwives are
choosing to leave the service. That is not a sustainable position for the
NHS if, as is now the case, more midwives are leaving the service than are
joining it. This year's RCM survey shows that three out of four midwifery
units are currently carrying vacancies and that the number of long-term
vacancies has increased to 55 per cent of all vacant posts. Up to one-third
of trusts are unable to provide one-to-one care for women. Pilot schemes
promoting continuity of care have been discontinued. I have heard of some
hospitals having to shut their labour wards and send women down the road to
other hospitals.
When just before Christmas we debated the issue of the rising number of
caesarean sections, the Minister said that the shortage of midwives in
England as a whole was 2 per cent, based on those midwifery posts that had
been vacant for more than three months. I do not dispute that figure but,
like all averages, we should treat it with caution. In North Thames, the
long-term vacancy rate is 5.9 per cent; in South Thames it is 6.1 per cent;
and in Anglia and Oxford it is 4 per cent. Some units in London are
operating with as many as 20, sometimes 30, vacant posts. In other words,
there are particular parts of the country where the shortages, both long and
short term, combine to create acute
difficulties in service provision. Nor do even those figures tell the whole
story. Because the proportion of midwives working part-time has increased
during the past five years, there has been a reduction in the number of
hours per midwife available to the service.
No one is saying, not even the midwives, that the answer is simply more pay.
It is about much more than that. It is about the status accorded to midwives
as a profession distinct from that of general nursing. It is about the
ability of midwives to exercise real autonomy and to contribute to
improvements in the quality of care on the ward and outside it. Midwives
need to feel that there is a proper career structure open to them that
offers real opportunities for advancement. Many midwives feel that these
things are being denied them and, as my noble friend Lord Mancroft said,
that the grading structure within the profession offers inadequate reward
for the level of responsibility and commitment that midwives undertake.
I have no doubt that until these issues are addressed, the recruitment, but
more particularly the retention, of midwives will continue to pose a
problem. Indeed, with the forthcoming reduction in the hours of junior
doctors, the pressure on midwives is likely to worsen. In turn, that will
lead to a diminishing ability to develop the standard of care to expectant
and new mothers. That can only run counter to the Government's declared and
worthy aim of providing women with greater continuity of care and with
choice and control over their experience of childbirth.
Lest the Minister accuse me of setting out a stall full of problems rather
than solution, let me offer one thought. One of the difficulties facing
hospital managers--and, I suspect, Ministers--is that relatively few
maternity units can claim to have coherent systems in place for defining and
reviewing staff levels. The estimates made of staff shortages are,
therefore, bound to be subjective to a greater or lesser extent. Yet, if the
quality agenda is to mean anything and is to be delivered, proper planning
is essential. As variations in care outcomes begin to attract more intensive
scrutiny, it is certain that maternity units will have to justify both the
quality of service provided and the number of staff employed to provide it.
What is needed is a robust planning system such as Birthrate Plus that
matches staffing and workloads to ensure that if more midwives are needed,
the case for them is convincingly made to trust boards, health authorities
and government.
However, we cannot examine the current state of maternity services without
taking a hard look at what has happened in obstetrics. Some five years ago
it was recognised that the number of consultant obstetricians and
gynaecologists was too few in relation to the total number of senior house
officers, registrars and non-consultant doctors. What the NHS had was a
service that was consultant led, at least nominally, but which, in practice,
depended far too heavily on non-specialist medical staff. What it needed was
a service that benefited more directly from the professional input of the
consultants themselves; in other words, more consultants actually on the
labour wards.
The introduction of the Calman training programmes was intended to remedy
this by ushering in a more structured, less disjointed and foreshortened
training scheme for obstetricians and gynaecologists. The hurdle of
progressing from registrar to senior registrar was removed and a new grade
of specialist registrar was created. Because the training programme was to
be condensed, more trainees would be completing their training in a shorter
period of time than they would otherwise have done. It was therefore agreed
that the numbers of specialist registrars should increase at a rate of 6 per
cent year on year until the planned total of approximately 2,000 consultants
had been reached. The process of gradual expansion was programmed to take
place over a period of about 15 years.
In the event, the increase in consultant posts over the past five years has
fallen considerably short of the planned rate of 6 per cent. The result is
that we can now look forward to large numbers of trainees completing their
training in 2000 to 2003 with no consultant jobs to which to go. For some,
this is already a reality. At the moment, there are some 128 individuals who
have completed their specialist training and who are not employed as
consultants. Most of these, if they are unable to find work abroad, face
imminent unemployment. However, over the next four years the position will
become even worse with three times the current number likely to find no
consultant posts available to them.
That is serious enough for the individuals involved, but it is even more
serious for the NHS. The direct consequence of the failure to create enough
consultant posts is that the number of trainee obstetric posts is now being
dramatically cut back in step with this. Simultaneously, the money which
would have funded the planned number of trainees is being siphoned off into
other specialties. We are fast being drawn into a vicious spiral in which
standards will be compromised and the individual who will suffer most is the
patient. If both consultants and trainees are being cut back, who will there
be to provide the necessary service? The answer is that midwives and
gynaecological nursing staff will have to bear the brunt of it--the very
thing that in their current depleted state we should not be asking them to
do. The case for expansion in consultant numbers and for increasing labour
ward cover for consultants is as strong as it ever was. But where is that
expansion to come from if the Government refuse to facilitate it?
Dr Ian Bogle, chairman of the BMA, has said:
"The frightening thing is that the government thinks it has a good workforce
plan when in fact it is shambolic. These doctors have been betrayed and
deceived".
I must urge the Government to address these issues as a priority. The
Minister ought now to say whether the Government and the NHS Executive are
committed to a long-term expansion of consultants in obstetrics and
gynaecology. If they are, a useful start would be to introduce an element of
central direction to NHS trusts to ensure that something approaching the
planned rate of consultant expansion can be
reinstated. The money that is being siphoned off from disestablished
obstetric and gynaecological posts should be retained by postgraduate deans
to fund a sensible level of recruitment into those disciplines. Does the
Minister agree that these things are both logical and desirable?
If we needed any convincing as to the importance of maintaining standards in
obstetrics and gynaecology, we need only look, as the noble Lord, Lord
Patel, emphasised, at the two most recent annual reports of CESDI--the
Confidential Enquiry into Stillbirths and Deaths in Infancy. In 1995, 453
babies died as a result of asphyxia or trauma suffered during labour or
delivery where care was suboptimal and where different care would reasonably
be expected to have made a difference to the outcome. That number
represents, as the noble Lord said, just over half of infant deaths
occurring during childbirth. I do not draw any inferences whatever from that
statistic in terms of the total numbers of consultants or midwives
practising nationally. What it does raise is a number of far-reaching issues
related to the training, supervision and practice of skills of
professionals--in all grades--looking after women in labour and newly born
babies. That is not just my conclusion; it was a key part of the
recommendations made by CESDI itself. Painful as it is, we need to remember
that more than 40 per cent of all litigation costs incurred by the NHS
relate to obstetrics and gynaecology. In terms of patient safety and all
that flows from it, we simply cannot afford to short-change those who rely
on this vital area of our health service.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt
of Kings Heath): My Lords, this has been an important and instructive debate
and I certainly intend to reflect on the points raised by noble Lords. I
congratulate the noble Baroness, Lady Cumberlege, on securing the debate. It
is a particular pleasure for me to respond to her Unstarred Question. I
worked happily with her when she was chair of the National Association of
Health Authorities. She went on to greater things as a regional chair and
then a Minister. As other noble Lords have said, her leadership and
commitment have led the way, along with many other people, to bringing about
real and lasting change to maternity services over the past decade. All
Members of the House will be indebted to her for her contribution. I know
that she intends to continue championing this area in the new millennium and
certainly intends to keep me on my toes.
Although the noble Baroness expressed concern about where maternity services
stand at the moment, it is my contention that as a result of her work and
the work of many other dedicated people huge advances have been made over
the past decade. I believe that the experience of women during pregnancy and
childbirth has radically improved. As the noble Lord, Lord Chadlington,
suggested, the Audit Commission report, which reflected the views of many
women,
underpins that view. The noble Baroness, Lady Cumberlege, deserves enormous
credit for everything she has done in that area.
The noble Baroness went on to ask what priority the Government give to
maternity services. I want to assure her that we are fully committed to the
principle of high quality, women-centred maternity care that offers greater
choice, continuity of care and control to women. The ethos of putting women
at the centre of maternity service planning is now firmly embedded in
mainstream practice. I also believe that further improvements in maternity
services can be made and are being made from the wider government
initiatives that we are taking to modernise the National Health Service,
improve public health and strengthen family life.
The noble Baroness asked me to say where I would place maternity services in
the list of priorities. She asked whether they are number three or number
44. I shall not fall into that trap. The noble Baroness knows as well as I
do the dangers of priority setting in the National Health Service; one may
veer from picking two or three particular issues and focusing on those to
setting 59 different priorities. In that case the messages to the service
are mixed and the conclusion is that nothing is a priority.
I would look at the situation in the following way: maternity services, as I
have stated, are a clear priority. The NHS is not in any doubt as to the
philosophy and framework in which those services need to be developed. In
the light of the commitment that I have given on our underscoring and
supporting the principles of high quality, women-centred maternity care, I
hope that the noble Baroness will take from this debate an understanding
that we remain firmly committed to high quality maternity care services.
The noble Lord, Lord Patel, asked about the national service framework.
There are of course many claims on the national service framework process.
It would be wrong for us to hold out hope that there could be an NSF in
relation to maternity services. Those matters must be considered from time
to time against many bids and pressures put forward. If one looks at the
areas where we have started to develop NSFs, the priority must be in those
areas where there is a lack of policy and consistency within the health
service. The position in regard to maternity services is much better in
terms of the philosophy, based on Changing Childbirth, and actually in
practice, than many other services. While I understand why the noble Lord,
Lord Patel, would wish to see a national service framework, and while we
shall consider that suggestion along with many others, I cannot hold out
much hope to him.
I turn to the issue of caesarean section rates which we debated in this
House only a few weeks ago. We are determined to tackle areas of practice
where there is a lack of clarity about appropriate standards, as is the case
with caesarean section rates. We are aware of the concern expressed over the
variation in rates between different maternity units. I assure the House
that we have an active programme of work in hand to address
that issue and the rise in caesarean section rates overall. I do not need to
repeat the words of the noble Lord, Lord Patel, as to the reasons for that
increase. The reasons are complex: they include technical advances; the fact
that women are leaving motherhood until later; the risk of intervention
increasing with age; and the increasing demands that women themselves are
making, being more aware of the available options. On that point, I should
say in response to the noble Baroness, Lady Cumberlege, that the decision
about whether to perform a caesarean section should be based on clinical
need. We agree with the words of the international committee that she
mentioned.
Noble Lords are probably aware that the World Health Organisation does not
make specific recommendations about the rates of caesarean delivery, which
it has concluded will inevitably vary from place to place. They will reflect
the health and nutritional status of pregnant women and the level of
maternity care provision. However, the Department of Health has an active
programme of action in hand in line with WHO's view that countries with
caesarean section rates over 15 per cent and under 5 per cent should
consider the possibility of whether the intervention is either over-used or
under-used. That is why--as the noble Lord, Lord Patel, suggested--we have
commissioned a national audit study of caesarean section rates from both the
Royal College of Obstetricians and Gynaecologists and the Royal College of
Midwives, which will then set standards in an area where they are badly
needed. We shall be looking carefully to see what lessons can be learned
from the audit and to ensure that the results can be used in best clinical
practice in the future. I understand the noble Baroness's impatience
regarding when the results of that audit study will come to hand. The audit
will start in May this year. We expect that it will cover every NHS trust
and that the results will be available early next year.
In the meantime, we have taken steps to strengthen local audit processes by
publishing for the first time figures for caesarean section rates by
individual NHS trusts. I understand that the publication of those rates has
at the very least started the process of trusts considering how they stand
in comparison with other trusts, and has led them to start to question
whether they have in operation the correct policy and clinical practices. As
I believe the noble Earl, Lord Howe, suggested, that will, of course, be
underpinned by the whole process of clinical governance which, in itself,
should be leading to the process of evaluating those figures and the
caesarean rates in operation in individual NHS trusts.
The noble Lord, Lord Clement-Jones, asked about the position of electronic
foetal monitoring. The department has commissioned the Royal College of
Obstetricians and Gynaecologists to produce evidence-based clinical
guidelines on the use and interpretation of electronic foetal monitoring.
The main aims of the guidelines will be to ensure that technology is used
appropriately in clinical practice and that those using it are competent in
their
interpretation. I hope and, indeed, wish to see that that should result in a
reduction in some unnecessary caesarean and instrumental deliveries.
The noble Lord, Lord Patel, asked about the 40-hour recommendation. My
understanding is that that is in the process of being implemented and is
something which we very much support.
As the structure of the NHS changes, we must consider the impact of those
changes. A number of noble Lords raised the question of primary care groups
and the impact of primary care groups on the commissioning of maternity
services. Of course, primary care groups have the ability to shape and
commission the services that they consider appropriate for their patients
and for the community they serve. However, commissioning decisions by those
primary care groups should be made in agreement with all the local partners
involved, based upon a shared vision contained in the local health
improvement programme. I regard the role of the local health authority, in
partnership with the primary care group, as being extremely important in
ensuring that those commissioning decisions are consistent with the overall
policies which we wish to see developed in the National Health Service. In
addition, I understand that there are 16 midwives who are serving on the
boards of primary care groups. On those groups where a midwife is not a
member of the board, there are arrangements for the midwifery voice to be
heard. Again, that is something which I very much wish to support.
The noble Lord, Lord Chadlington, asked a number of questions in relation to
the position of midwives. First, he asked about the continuation of the
statutory supervision of midwives. We are committed to the continuation of
that position. We believe that it is a valued and valuable system and one
which we see as being an integral part of clinical governance in the future.
The noble Lord asked also about the recognition of midwives as distinct from
nurses. We expect that the new regulatory arrangements in relation to nurses
and midwives will make it possible to take a mature and collaborative
approach to that issue in ensuring that midwives play a full and active role
in the new arrangements for self-regulation.
I turn to the matter of midwives. A number of noble Lords raised questions
in relation to morale, shortages and the overall position and contribution
which midwives make. We are all agreed that we owe much to the midwives in
this country and to the enormous contribution which they make and the hard
work that they do in so many settings.
In relation to recruitment issues, the noble Earl, Lord Howe, quoted back to
me the statistics which I gave in December. I confirm that the position is
that 2 per cent of midwifery posts have been vacant for three months or
more. But we are not complacent about that. I take the point that 2 per cent
can hide greater shortages in some trusts. Our aim is to work closely with
trusts facing particular issues and pressures.
There are some positive signs. The noble Earl, Lord Howe, chided me about
the morale of midwives. I say to him gently that nothing was more damaging
to that morale than the staging of pay awards introduced by the government
of whom he was a member. One of the most important decisions which this
Government made when the pay review body recommendations were put forward
last year was not to stage the awards.
There are other positive signs. Applications for midwifery training have
risen by 50 per cent, so there are far more midwifery students now coming
out of training as a result of the expansion which this Government have
funded over the past two years. Again, I should say to the noble Earl, Lord
Howe, that between 1992 and 1995 the number of nursing and midwifery
training places was cut back by as much as 28 per cent. That has had a
fundamental effect on some of the issues we have been facing in relation to
nurses and midwives.
The future looks brighter. This year there are almost 19,000 nursing and
midwifery training places available--4,000 more than three years ago. The
noble Earl will know that more than 5,000 nurses and midwives are either
returning or planning to return to work in the future.
I shall not respond in detail to the issues raised in relation to
consultants in obstetrics and gynaecology. Of course we are aware of the
problems. I listened carefully to the points raised. We have the benefit of
a working group set up with the Royal Colleges, the BMA and others which
made recommendations some time ago. We have held a series of regional
workshops involving NHS managers and the relevant professions to explore how
we can improve the staffing position in that specialty area.
I should say to the noble Earl, Lord Howe, that co-operation rather than
direction is the key to good workforce planning. One of the great problems
in workforce planning over many years in the health service has been that
far too often in the past decisions were made by great and good committees
at the centre without being relevant to needs in the field.
The new workforce planning arrangements, parts of which were put in place by
the noble Earl's government, are starting to pull together the interests of
local managers and those concerned at a national level in medical workforce
planning. I believe that we are moving to much more sensible arrangements.
But it takes time.
I was extremely interested in the remarks of the noble Baroness, Lady
Emerton, who gave us an interesting insight into the experiences of her
trust. I was really impressed by the figure of 8 per cent for home
confinements. Her trust is to be congratulated.
She gave us a flavour of some of the challenges which NHS trusts face. I do
not run away from the fact that they do face challenges and pressures in
deciding where to spend their money and where their priorities should be.
But such decisions must be taken in the context of the overall increase in
resources which this Government have and will continue to put in to the
National Health Service.
I turn to the issue of home births. The noble Lord, Lord Mancroft, made some
helpful remarks. As I understand it, although the NHS has a legal duty to
provide a maternity service, there is not a similar legal duty to provide a
home birth service to every woman who requests one. However, I certainly
hope that when a woman wants a home birth, and it is clinically appropriate,
the NHS will do all it can to support that woman in her choice of a home
birth.
On the point that the noble Baroness, Lady Cumberlege, raised about the Sure
Start programme, which I believe is an important aspect of any maternity
service, it is to provide £452 million over three years to give support to
the children of families most in need. From a maternity service perspective
Sure Start will integrate and build on existing antenatal and postnatal
provision. Specific targets have already been identified in relation to
caring for mothers with postnatal depression. We are working closely with
the Sure Start unit to identify examples of good practice so that we can
learn lessons.
In the short time available--I realise I have overshot my time quite
considerably--I hope I have assured noble Lords that we are anxious to
ensure that we continue to improve and develop good quality women-centred
maternity services in this country.
I have listened to all the contributions tonight in this extremely
interesting and informed debate and I assure noble Lords that I shall
reflect seriously on many of the constructive points put forward.

House adjourned at twenty-two minutes past ten



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