I thank Mr. Speaker for granting me this debate on maternity services. I have been planning it for a while, but it is well timed, given the publication of the Healthcare Commission review last Friday.
Along with our colleague, Sir Nicholas Winterton, I am an honorary vice-president of the Royal College of Midwives, and very proud to be so. I pay tribute to the college and to midwives. They are professional and effective in the cause of first-rate maternity provision in this country. They are one of the major reasons why giving birth has become safer for mothers and their babies.
I also want to pay tribute to the management and midwives at Whipps Cross hospital in my constituency. It has improved and, in a way, has bucked the trend in London. I shall say a bit more about that later.
Giving birth is a major, life-enhancing experience in a woman's life—and in her partner's. It should be a happy experience, not a traumatic one, and high-quality national health service maternity services that are consistent across the country are essential for that.
The Minister was recently the guest of honour at a Royal College of Midwives event to honour those who did a lot of innovating. She will have seen the brilliance and enthusiasm that midwives bring to improving their profession and their service. As a former nurse, she has been on the NHS front line, and she is aware, more than most, that the front line is vital to delivering quality treatment. So it is with midwives for mothers and babies. I hope that she will excuse the pun, but I know that she is keen to have the best service on the NHS front line. However, that requires action.
The Healthcare Commission's report shows a service that is patchy. It is good in many areas, but inadequate in too many. The trend is in doubt: some factors seem to indicate a worsening. I know that that is not the Government's intention, but they must act promptly to ensure that the needed improvement happens all over the country.
I shall come back to the commission's report, but let me quickly give examples of how the press reported the situation: four in 10 maternity units give poor or below average care; nine out of 10 are not meeting the National Institute for Health and Clinical Excellence screening guidelines for maternity; one in five of the 148 trusts surveyed failed to carry out scans, discharged too quickly or did not follow up with post-natal visits; one third of trusts do not have a consultant on the ward for at least 40 hours a week, which is considered the norm; in one quarter of trusts, three times as many babies were readmitted for jaundice or dehydration than in the best trusts—that is a serious disparity; the maternity care in 31 NHS trusts fell below the approved standard. Those were reports in the press, and they are, of course, a matter of concern.
MPs are concerned. An early-day motion was put down by a Liberal Democrat colleague, Mr. Foster, in mid-November. It already had 119 signatures yesterday, and the turnout for this debate indicates that many MPs are concerned about maternity services.
On the Healthcare Commission's report, is the hon. Gentleman aware that the Royal Cornwall Hospitals NHS Trust, which had a very good result in the report, has a maternity unit, the Princess Alexandra suite, where the roof often caves in despite the good and professional standards and dedication of its staff? In fact, the unit itself is structurally unsound, and people often say that they are surprised that it had such a good report, given the capital challenges that the service faces.
I hear that point. Those structural matters must be addressed. It is crucial that the strategic health authority makes provision for and sorts out the problem.
Some key factors are putting the service under intense strain. The Government have guaranteed that by the end of next year, England's NHS will deliver a world-class maternity service, but with less than 24 months to go, action is needed now. The emerging baby boom is placing additional demand on a service that already has to cope with an inadequate and shrinking budget and insufficiency of the midwifery work force. In addition, there is a declining number of student midwives, which means a failure to produce the next generation of midwives—that is a concern. If action is not taken now, it is difficult to see how the Government can avoid failure to honour their guarantees. That would be deeply depressing to midwives and a let-down for women.
The Government gave guarantees in the past two elections. In 2001, the Labour manifesto stated:
"By modernising all maternity units, increasing the number of midwives and giving women greater choice over childbirth, we will ensure that women receive the highest quality maternity care."
In the last election, the manifesto stated:
"By 2009 all women will have choice over where and how they have their baby and what pain relief to use. We want every woman to be supported by the same midwife throughout her pregnancy."
A good document was published by the Department of Health in April last year. "Maternity Matters" included guarantees that by the end of next year, all women would enjoy the choice of how to access maternity care, they would be able to go directly to a midwife or via a doctor, they would have a choice of antenatal care, they would be able to choose between midwifery care or care led by both doctors and midwives, they would have a choice of place of birth, depending on their medical history and circumstances—they and their partners would be able to choose between home birth, giving birth in a midwifery unit or in a hospital with midwives and doctors—and they would be able to choose how and where to access post-natal care. The Royal College of Midwives congratulated the Government on that document, and it still does. It says that it wants to work constructively with the Government to achieve those objectives, which are important.
However, let us look at what happened with the health care report. It was the single most comprehensive assessment ever made of maternity services in England. It was based on evidence gathered throughout 2007, and it found significant variations in the provision and quality of maternity care provided by the NHS. Thirty-eight trusts secured the top ranking, or best performing; 47 achieved the second highest ranking, or better performing; 32 trusts—22 per cent. of trusts—attained the third best ranking, or fair; and 31 trusts finished with the bottom ranking, or least well performing.
In London, the worst performing region, 19 out of 27 trusts—70 per cent. of London trusts—got the worst ranking. Like me, the Minister is a London MP. I do not think she is happy that London is behind the rest of the country. She will want London trusts to reach the best standard. That is a matter of concern that the commission's report brings to our attention.
I agree with what my hon. Friend is saying. Does he, like me, welcome the Healthcare Commission's report, because of which we actually know what the situation is now? However, the problem is that we do not know what we are comparing it with, because this sort of survey was never done before. The real answer will tell us whether it has improved next time.
I hear my hon. Friend's point. That will be a factor, but I do not think that it is the only factor, because the report clearly shows a service that is under strain and that a significant number of trusts, including in the capital, appear to be underperforming and are below the approved standard. The Healthcare Commission review stands on its own in the present as well as being a factor for the future.
I shall run through some important points made by the Healthcare Commission in its press papers. It says that:
"those trusts that were least well performing should as a matter of urgency take steps to improve and we shall be checking that they do so."
"The review raises real concerns about performance in London. There are a number of factors that may have influenced these results, such as lower staffing levels and the mobility and mix of the population. But London trusts need to rise to these challenges."
In fact, the Healthcare Commission has said that it will do a more detailed assessment of what needs to be done this year, but says that
"very low staffing levels may be associated with poor overall performance".
That certainly seems to be so in some London trusts. It said that
"antenatal and postnatal care tended to be consistently poorer"
in London and that
"the quality of care around the time of birth was mixed."
It says that there needs to be
"greater continuity where women are getting different aspects of their care from different trusts."
The Healthcare Commission mentions mental health issues in respect of pregnant women, which is important, because depression and suicide are associated with pregnancy. It states:
"All trusts ask women about their mental health at a woman's first antenatal appointment, however only 55% conduct all the mental health checks identified in NICE guidance...42% of trusts said that they did not have access to a specialist mental health service."
That aspect needs to be addressed.
The commission says that
"64% of trusts are providing women with a named midwife",
"34% of trusts are providing a named midwife sometimes"
"2% of trusts are not providing a named midwife at all".
That is a serious criticism. All trusts should provide a named midwife.
In respect of the London factor, on bookings, the Healthcare Commission says that most trusts took
"1.5 weeks or less from the time between a woman making contact and having her first booking appointment."
However, in some London trusts it took "4.1 weeks or more". I put it to the Minister that that is not acceptable.
The last point that I want to quote from the Healthcare Commission report is on breastfeeding. Initiation rates are "58% or less" in some trusts, whereas in the higher performing trusts the rates are "78% or more", because of the quality of the advice. We know how important breastfeeding is for the health—and the future health—of the child. Those are serious flaws that the Healthcare Commission has outlined.
The report also outlines some challenges facing NHS maternity services: the emerging baby boom, cutbacks to the budget, shrinking midwifery numbers and student midwife numbers. I want to deal briefly with each one in turn. On the baby boom, the birth rate in England between 2001 and 2006—the latest year for which figures are available—rose from 563,744 to 635,679, a 13 per cent. increase. The number of births in London increased by 16 per cent. in those five years. Addressing the Labour conference last year, the Secretary of State for Health said:
"We have initially planned an extra 1,000 midwives by 2009. If birth rates continue to rise, we will need to train more."
Well, they are continuing to rise. I should like to know what the Minister's reaction is to that. I would also like to know whether that figure of 1,000 is a head count or refers to full-time equivalents, because if it is just a head count it will not do the job. The Royal College of Midwives estimates that some 5,000 extra midwives are needed if it is to meet the targets on one-to-one care that the Government have been talking about.
On a new projection, there would be 652,000 births in 2006-07 and 673,000 by 2009-10. If those official predictions are correct, the number of births in England will have increased by more than 100,000 in less than a decade. The BBC has talked about that in terms of migrant labour, but I think that that is just a factor. The BBC estimates that that increase will add a £200 million bill on to NHS costs in terms of maternity services. The Government are putting in £122 million. Putting those two figures side by side shows that more needs to be done in that respect. Migrant and immigrant labour is vital for the NHS and for many other industries as well, but that factor must be taken into account if we are to meet our aims in terms of maternity services.
The budget has been reduced. There was a cut of £55 million in NHS cash spent on maternity services in 2006-07, which is equivalent to £87 less per birth than in the previous year. In 1997-98, maternity services received 3.1 per cent. of the NHS budget, but by 2006-07 that had fallen to 2 per cent., so those are getting a lesser proportion. If the figure had remained at the higher proportion of 3.1 per cent., maternity services would have received, on average, £1,274 more per birth than they actually received. There have been reductions in the budget. That has to stop. In fact, it must go the other way if we are to achieve the target.
The work force issue is important. There is general party political consensus that we need more midwives; I could quote all parties saying that that needs to be so. However, I want to make a point about what the experts say. The various royal colleges in this field talk about a level of one midwife per 28 women—a ratio of 1:28. Let me give the figures for the increase in births per full-time equivalent midwife in 2006, compared with 2001: in the north-east the number of births is 29, which is an increase of 16 per cent.; in the north-west it is 27, up 8 per cent.; in Yorkshire and the Humber it is 33, up 10 per cent.; it stands at 40 in the east midlands, which is an increase of 25 per cent.; in the west midlands it is 32, up by 10 per cent.; in the east of England it is 38, down 5 per cent.; the figure in London is 36, down by 3 per cent.; in the south-east it is unchanged at 37; in south-central it is 43, up 19 per cent.; and in the south-west it is 31, up 15 per cent. The trend is mainly in the wrong direction and well above the 1:28 ratio that the experts say is needed. That is not good.
In 2004-05, 2,374 NHS midwife training places were commissioned in England. That fell to 2,200 a year later, and fell again to 1,990 in 2006-07. Does the Minister have the latest figures, and do they show a fall? There is a serious problem for future generations, partly because the Government reduced the bursary for midwives—the amount that they receive in training. A big push is needed for more midwives in training, or there will be an even bigger problem.
I am running out time, because plenty of hon. Members want to speak, but I want to draw attention to a few points. UNICEF has introduced a baby friendly initiative and says that in trusts where it is in operation breastfeeding has increased by about 10 per cent., but it is not in operation in the majority of trusts, and it should be.
The Royal College of Obstetricians and Gynaecologists agrees that 5,000 more midwives are needed, but says that more obstetricians are also needed on the wards to provide a consultancy service. It points to the huge litigation costs in maternity services, which are second only to those in general surgery. When something goes wrong, the costs may be in the millions, and the RCOG makes the good point that if there were a better overall service, it would save on some of those litigation costs. I do not have time to give the figures, but the point is relevant and worth making.
More proactive intervention is needed from Ministers and NHS management to address the situation and to achieve our manifesto commitments and aims. There should be more resources. I welcome the £122 million, but that is the figure that will be reached in three years. What will happen this year and next year, and what are the figures for those years? The figure should be higher if we are to have the necessary increase in the number of midwives and student midwives, higher consultant cover, and more choice, as we were promised.
The poorest performing trusts, particularly in London, must be forced to improve their maternity services up to the standard of best practice. The guarantees were clear, and are still being made, but time is running out. I urge Ministers to will the means and to require the relevant authorities to fulfil them. That is what our top-rate midwives and, more importantly, mothers and their babies richly deserve.
Order. I intend to start the winding-up speeches at 10.30. A number of hon. Members have indicated their intention to speak, so I appeal to them to be suitably brief.
I congratulate Harry Cohen on securing this important debate. He highlighted some of the specific problems in London but, as a predominantly loyal member of the governing party, he downplayed some of those concerns. However, the Minister has plenty of food for thought.
I have direct experience of maternity services. Six weeks ago, my first son was born. It is with some regret that my wife and I decided to go private, partly because of the acute problems with midwifery and maternity services in London. We went to the Lindo wing at St. Mary's hospital, Paddington where we received tremendous service throughout from Dr. Raj Rai.
I was born in the health service, albeit at a British military hospital in Germany, and I was educated in the state sector, so I did not take lightly the decision to use a private hospital; it was a reflection of the problems in the national health service. Those problems predate 1997 so I am not trying to make a narrow political point. Although we rejoice at some of the great successes of our national health service, there are some real problems, which platitudes from politicians on both sides of the House do little to resolve.
My wife had a caesarean and she had to stay in hospital for four days after the birth of our son, Frederick. I reflected that the service we received, which was tremendous, was unlikely to be received by mothers who had given birth a few hundred yards away in the main St. Mary's hospital. I know that from a number of constituents. There have been too many horror stories from friends in central London who have gone through the national health service, not just at St. Mary's, Paddington, but at the Chelsea and Westminster hospital. I shall refer to one or two examples from a letter that I received only this week.
There are problems because women are passed from pillar to post, from trainee midwife to locum midwife during the pregnancy, and there are problems after the birth. Such problems are particularly acute in the capital for a number of reasons. As I have often said, the trade unions may like national pay bargaining, but in a nationalised health service it does no great service for people living in London. That also applies to the education system. There are acute problems with our public services in London, and in the south-east, because the cost of living is so enormous.
There has been an explosion in the birth rate, to which the hon. Member for Leyton and Wanstead rightly referred, largely due to immigration. There is no doubt that a vibrant, young work force have come to work in the UK, particularly in London but also in other parts of the country and in other large cities. Young people in their 20s and 30s are at the fertile age and they are likely to have children. Since enlargement of the European Union three and a half years ago, we have known that there would be an explosion in the number of young people coming to live and work in the UK, yet there has been insufficient planning. The hon. Gentleman was too polite to make the point as blatantly as I have.
The problem applies not just in London, but outside. There is little doubt that in central London there are specific problems of hypermobility and hyperdiversity; many people are moving around and living in our cities, and 90 languages are spoken in the diverse population in my constituency. Regrettably, that puts undue pressure on inner-city health care.
I shall refer to a constituency case. A letter from Mrs. Sarah Meier of St. George's square, Pimlico arrived in my office only last week. Her experience is not typical, but it is not unusual, and on a personal level it was one reason why I decided that the national health service was not fit for purpose in my constituency. I regret that, but I have seen the problems as a Member of Parliament, and as someone who has friends who have used central London hospitals for childbirth in recent years.
Mrs Meier said:
"I am writing to bring your attention to how dissatisfied I am with the treatment my baby son and I received after giving birth at the Chelsea and Westminster Hospital on
Episiotomy. I bow to my hon. Friend's medical knowledge.
Mrs Meier had
"an episiotomy with extensive associated bleeding. So I had to stay in hospital overnight and was moved to the...Ward. The conditions of hygiene and care in that ward were appalling. During my 24 hour stay my bedding was never changed. I had to sit in my own blood and nobody came to check me. Later that week, after I had gone home, it was found that I had an infection. I, and the GP who several days later saw me as an emergency, are both sure that this was due to the conditions in the ward and the lack of interest taken in my wellbeing. I thought the prevention of infection was supposed to be"—
a top priority. That episode occurred only two and a half months ago. Mrs Meier continued:
"The GP also diagnosed me as having anaemia. Again this could and should have been picked up on by someone on the ward, but nobody had bothered to come and check on me...This is my first child and I was attempting to breastfeed him. This was particularly challenging as my milk had not yet come in properly. The midwife on duty shouted at me for not doing it the 'correct way'. My son and I were discharged from hospital on Saturday 10th November. My son was checked by the paediatrician prior to discharge."
It transpired that the baby had suffered from post-birth jaundice, so within 24 hours of leaving hospital he had to be rushed back into hospital at the behest of a GP. The whole episode was very traumatic, but it could have been avoided if the paediatrician had picked up the problem before discharge. That is by no means an untypical experience. I am sorry to have to bring it up on the Floor of the House, but it is appropriate to do that in this place, rather than going through a lot of platitudes about various targets and figures and saying how marvellous the health service is.
In many areas, such as central London, the health service is not fit for purpose. Mrs. Meier said her experience was a contrast to the excellent care and attention that her sister-in-law received only last year when she gave birth in Harrogate district hospital. She said:
"It is difficult to believe that both hospitals are part of the same health service."
That goes to the heart of the issue about a national health service. Mrs. Meier said that in no circumstances would she have another child at the Chelsea and Westminster hospital. She advises all her friends to avoid the place.
As I said, I am sorry that I have had to bring up the matter on the Floor of the House. However, such distressing episodes are increasingly common in central London, and not only in relation to maternity services; there are difficult problems in respect of hypermobility and hyperdiversity, to which I have referred. Problems stem from the explosion in the number of young people who come to the UK and give birth in this country. There are specific problems in London, to which the hon. Member for Leyton and Wanstead rightly drew attention. The Minister, who is also a London MP, will be aware of some of the issues that have been raised, although that is not to say that there are not some very positive stories.
There are positive stories about some of our hospitals, even though they are under great strain in central London. None the less, I hope that the Minister will consider some of my specific concerns, which are not just about money, although the hon. Member for Leyton and Wanstead got it right when he said that we face a financial crisis in London in relation to maternity care. I hope that the Minister will give maternity services proper investment and attention in the months and years to come.
I am aware that other hon. Members wish to speak, so I will keep my remarks as brief as possible. I congratulate my hon. Friend Harry Cohen on raising such an important and topical matter. We could not have a better backdrop than the current Healthcare Commission report. I have some direct experience of the impact of the restructuring of the health service. A year ago, as a result of the proposals to reorganise health services in Gloucestershire, the maternity unit in Stroud—a small but invaluable unit—was under threat of closure. There was a massive campaign to keep it open. The authorities finally saw sense, and it is now flourishing, which shows that small units have a part to play. I pay tribute to Michelle Poole, who is in charge of that unit. Her stewardship is excellent, and she has always kept me apprised of the different maternity issues.
The Government's direction is absolutely right. Despite some of the recent criticism, maternity services is an area of which the Government should feel proud. I shall not go over the same ground as my hon. Friend. Clearly, he has made the case very strongly. We are looking at the issues of recruitment, training and retention of staff. From my experience, this, like many other public professions, is an ageing profession, so we have to ensure that we recruit more people into it. I am interested to hear how my hon. Friend the Minister responds to my hon. Friend with regard to getting the numbers right. I would like to put on record my welcome for maternity care assistants. Again, they do not necessarily get much publicity. After some initial worries in the midwifery profession, the role of the care assistants now seems to be both established and welcome.
I raised the issue of insurance in a debate secured by Andrew George last May. I am particularly concerned about independent midwives, who are an important part of the service. Have the Government made any progress in their talks with insurers to ensure that such a matter does not militate against smaller units and those who work as independents?
As my hon. Friend said, the numbers are up, and not just in the urban centres but also in areas such as Stroud. That is helpful because one of the accusations was that our numbers were going to decline and that such units would not be viable. That was the prediction in 2006. In fact, in 2006-07, the numbers born at Stroud maternity unit were up by 7 per cent. Again, it is manifest that a lot of that increase is due to migration. We now have a little Polish unit under the leadership of midwife Helen Conway. It is good to see that people can get the best of care even in a rural setting. I am referring here to the translation services. I do not mean midwifery care, but care in the wider social provision. That is very impressive.
I want to discuss the issue of maternal mental health, which was quite rightly raised by my hon. Friend. The problem is highlighted by the Healthcare Commission and the National Institute for Health and Clinical Excellence clinical guideline 45. One of the advantages of smaller units is that they can provide specialist care. Stroud has always prided itself on the fact that it has recruited midwives who, while not suffering medical problems, have learning difficulties, and who may not have English as their first language. That is helpful. There is a question mark over how the midwifery-led units work with the Gloucestershire Partnership NHS Foundation Trust. Mental health is not an area that is well resourced or an area in which one can easily cross boundaries. What does my hon. Friend the Minister aim to do to ensure that there are more resources going into this area, that there is more co-ordination between the different trusts and that post-natal depression is given due attention?
The report "Saving Mothers' Lives" that was published last year stated that the number of suicides associated with childbirth was down. Will the Minister say how we can further reduce those figures, which reflect a very sad aspect of giving birth? How can we ensure that there is better overall care in this field? It would be good to hear what the Government's strategy is.
Finally, I want to congratulate the Government on their clear-sighted approach to childbirth and the very early years of childhood. I have been a great supporter of our nursery provision and the drive towards children centres. It makes sense that we have now linked health visitors with children centres. In Stroud, the health visitors are now based in the maternity unit. Okay there was space there, but it also made eminent sense to have health visitors working with midwives in the children centres.
The difficulty is, of course, resources. Children's centres are not always well resourced. I will not say that there is snobbery, but there is some questioning in the medical profession about the role of health visitors. The Minister smiles, but there is still some prejudice in the medical profession about what health visitors do. As we have moved them increasingly away from purely medical intervention, that has led to some questioning among GPs in particular, so I would welcome what my hon. Friend has to say about how we can reassure the GP community that health visitors are doing vital work, if in a slightly different way, and about joining them up much more with midwives and children's centres.
It would be remiss of me not to mention that linked to that are organisations such as Home-Start. In rural areas, we accept that because of the lack of concentration of facilities, we will never be able to provide Sure Start or children's centres in every rural location, much as that is a dream of mine. However, we have excellent organisations such as Home-Start, which fill in the gaps and provide support in the early years for both mother and child. It would be good to know how the Department of Health envisages the role of such organisations, which are very much supported by health visitors. If the Minister will say some nice things about that, I can at least go back to my Home-Start organisation and say that it is well loved even if it is not always as well resourced as we would like it to be.
This is a good story. I know that there has been criticism and that there is a lot of pressure in this area, but I hope that we continue to do what we have been doing and that we provide some more resources to ensure that we can do it properly.
For me, this is a timely debate because tomorrow my right hon. Friend Mr. Cameron, my hon. Friend Mr. Boswell and I will be giving evidence to the independent reconfiguration panel, seeking to persuade it that proposals to downgrade the consultant-led maternity unit at Horton general hospital in Banbury to a midwife-led unit, causing large numbers of women to have to travel some 26 miles to Oxford, is a bad and dangerous idea. I am sure that the House will note that, given the concept of collective government that we have in this country, my right hon. Friend the Member for Witney, part of whose constituency is covered by Horton hospital, speaks not only as the Member of Parliament for Witney but as Leader of the Opposition, and his views therefore reflect those of the official Opposition and the Conservative party. [Interruption.] Mr. Drew titters, but many communities in this country are desperately concerned at the downgrading of maternity services.
The "Keep the Horton General" campaign, which is ably led by a Labour district councillor, George Parish, evidenced the ambulance transfer times between Banbury and Oxford. These figures represent what actually happens at present. In only 5 per cent. of cases did an ambulance manage to get to Horton hospital in 10 minutes. Only in just under a quarter of cases could an ambulance get there in 30 minutes. In most instances, it took more than half an hour to get an ambulance to Horton hospital. That is before the transfer of a mother has even taken place.
When those figures were put to the Oxford Radcliffe Hospitals NHS Trust, Helen Peggs, the director of communications at the trust, stated the following in an e-mail:
"At the moment, the Horton General Hospital is classified by the Ambulance Service as a 'place of safety'. This means that the Ambulance Service treats calls from the Horton as 'urgent' but not as emergencies, which require a very rapid response, and they have a very long timeframe in which they can respond.
If the proposals are accepted by the Secretary of State, this will change. The Ambulance Service will treat any calls from the Horton General Hospital for women or children who need ambulance transfers as Category A (999) emergencies."
In other words, at present my constituents have a hospital that is a place of safety. If the changes go ahead, my constituents will no longer have such a hospital. That is disgraceful and disgusting.
I have another concern. Many women choose to attend midwife-led units, and another battle being fought throughout the country is to prevent the closure of such units. Is the hon. Gentleman concerned that in the longer term, if he loses this battle, which I hope he does not, he may be fighting yet another battle?
It is clear that even on the Oxford Radcliffe trust's own best figures, a large number of women who elect to go to Horton hospital in future will have to have their babies somewhere in transit, because even the most prospectively normal deliveries can go wrong. Indeed, an e-mail from one of my constituents the other day stated:
"My newest cousin Ewan was born at the Horton at 3.19 am on
A large number of women will be obliged to have their babies somewhere along the M40. That is simply unacceptable in the 21st century.
Time is short and I am conscious that Andrew George wants to speak, but I have two other points. We hear from the Government continuous rhetoric about choice and patient power. On
"the NHS of the future will be one of patient power, patients engaged and taking greater control over their own health and their healthcare too."
He talked about
"frustrations with access to services, with a service too often centred on the needs of the providers rather than those of patients",
"That is why giving patients choices through reforms to encourage plurality of provision, create a genuine level playing field between competing local providers and allow money to follow the patient are so important".
Frankly, my constituents and those of my right hon. Friend the Member for Witney and my hon. Friend the Member for Daventry think that that is complete tosh. When they are being denied choice—when choice is being taken away from them and existing services are being taken away—for the Prime Minister to have the impertinence to talk about patient power is just insulting.
We are seeing locally a health service that is in danger of going backwards. That a general hospital is told that it will no longer be a place of safety in the 21st century is insulting to large numbers of people living in north Oxfordshire, south Warwickshire and south Northamptonshire. It is a disgrace. I hope that tomorrow, and sooner or later, the independent reconfiguration panel will have the courage to say to the Secretary of State, "Enough is enough. A line has to be drawn on the downgrading of maternity services in the UK, which is putting at risk the lives of mothers and babies. It is simply not good enough."
I congratulate my hon. Friend Harry Cohen on initiating the debate and on the quality of his speech. We sometimes forget—we should say this because there will be women watching the debate who are anxious—that the United Kingdom is one of the safest countries in the world in which to give birth.
The point that I want to make is that things can change. Hon. Members have been going on about the problems in their constituencies and I can understand that. I made a similar speech about 15 years ago. In Carlisle, the maternity hospital was on the site of the old workhouse. The consultants worked at the district general hospital 2 miles away and they had to travel through congested streets if there was an emergency. An independent inquiry at that time concluded that, because of the facilities and the split site, babies were dying. I brought that point to the attention of the House. I shall not go into the politics of it and which Government were responsible; in fact, probably both Governments—Harold Wilson's Government and the previous Conservative Government—take some of the responsibility.
However, the situation is transformed. We had the first private finance initiative hospital in Carlisle. I can tell the Minister that that was not without its problems—one never wants to be at the cutting edge on such matters. One of the advantages of the new hospital was that we got rid of the split site and provided an excellent maternity facility with birthing rooms for mothers. The Healthcare Commission now says that the quality of maternity care in the North Cumbria Acute Hospitals NHS Trust area is excellent; in fact, it is the third best in the north of England. Dr. Gwyneth Lewis, the medical lead in maternity services, has been to the area recently, and she said that the service is exemplary.
There are problems with the service, but I cannot understand why Members say that we should have a uniform NHS. It will never be that way because provision depends partly on the quality of staff and buildings, for example. We need to bring standards up everywhere. Obviously, Cumbria is a rural county. We have community midwifery services from the north at Brampton down to Millom in the south, and another excellent maternity unit at West Cumberland hospital. Those things have been achieved because of the commitment of the staff in Cumbria, and not only the maternity unit staff. I should like to place on the record my appreciation to the work force in Cumbria, and to the Government, who provided the investment so that we could move forward.
I hope to be going to the maternity unit on Friday to congratulate the staff on their good work. I am sure that the Minister will agree that they should be congratulated.
I congratulate Harry Cohen. Although I endorse much of what Mr. Martlew said, I urge him to examine the perinatal mortality figures. Mr. Drew referred to a debate that I was fortunate enough to secure on
When I intervened on the speech of the hon. Member for Leyton and Wanstead, I referred to the fact that the Princess Alexandra unit at the Royal Cornwall Hospitals NHS Trust has excellent and professional staff who provide a very good service, despite the tremendous structural problems within the building. Despite the problems, the unit was given the status of one of the best-performing maternity units in the country. People who have experienced the service will say, "If this is the best, God knows what services are like in the rest of the country".
The issue of community midwives has not been properly addressed in the debate, which is a pity because there is pressure on those services. Community midwives are increasingly being asked to work in maternity suites, and the stress caused to them is significant, particularly for those whose skills and experience are not up to date.
"that only 3,000 midwives are needed".—[Hansard, Westminster Hall, 2 May 2007; Vol. 459, c. 481WH.]
We are still a long way from recruiting those 3,000 additional midwives into the service. They are desperately needed, but many trained midwives are not finding their way into the service.
I wish to ask the Minister some questions about last Friday's Department of Health press release, which followed the Healthcare Commission's report. The Secretary of State for Health says that
"funding for maternity services will increase over the next three years to reach an additional £122 million"
nationally. The press release seems to say that the increase will come between 2008 and 2011. Do I understand that correctly? It also says that the money will be used to implement the Government's "Maternity Matters" strategy, which needs to be in place by the end of 2009, so how come it will not be fully in place until the 2010-11 financial year? The increase is welcome, but can increases in spending be set centrally in the era of payment by results? Perhaps the extra money will filter into the system through increases in the tariffs for maternity care. If that is the case, will trusts not simply siphon off the money generated through payment by results from maternity care and spend it on other services?
In the financial year 2006-07, spending on maternity services fell by £55 million, as was mentioned earlier. We do not yet have the spending figures for 2007-08, but there may have been a further drop. Will the Government commit to a further injection of money into maternity services if NHS spending on maternity services falls again in 2007-08? If not, the extra £122 million will simply make up for money that has been siphoned off out of the service. I hope that the Minister will address those finance questions.
I should like to deal briefly with three challenges, and then to say something constructive about the future. First, I urge caution on those who describe us as being in the middle of a baby boom, as my hon. Friend the Member for Leyton and Wanstead did. The fact is that in the years up to 2006, there was a gradual decline in our birth rate, such that there are now debates up and down the country about closing schools because of falling rolls. It is true that the Office for National Statistics figures for 2006 show an increase of 30,000 births in England on a total of about 600,000, but it is early days to be calling that a baby boom. There are distributional effects, and issues concerning the diverse ethnicity of mothers create specific problems, which is why, I suspect, the debate has focused on London.
Secondly, there has been an increase in premature births and hence the challenges they create for maternity services—other hon. Members have not mentioned that. For whatever reason, there has been an increase in premature births and, thanks to advances in medical science and in the skills in our health care services, more babies are surviving. Of course, the child and parents must be given support for much longer, and that support is resource-intense, which puts additional pressure on services. The issue was brought to our attention by a BLISS report last autumn, "Too little, too late?", and was repeated in an article in The Observer last Sunday.
Thirdly, the Healthcare Commission review of maternity services, which was the first of its kind, and which the commission described as comprehensive, draws attention to both best practice and poor services. The challenge is to make the best practice common practice everywhere, which—to be constructive—is where I begin, with one minute of my time remaining.
First, we should praise the staff who work in the service. Often in debates about NHS services, we say how dedicated and committed the staff are, but we can give particularly great thanks to the people who work in maternity services. I have enormous admiration for midwives and health visitors for the work they do. We have put support in place for them and provided a framework. We have the national service framework and the National Institute for Health and Clinical Excellence guidance, but next we need to get training right.
My hon. Friend the Member for Leyton and Wanstead mentioned the baby friendly initiative, which NICE recommended should be part of the level of care that maternity units ought to provide. The initiative is a worldwide programme, created by the World Health Organisation and UNICEF, and accredits units for their level of service; it promotes breastfeeding—a subject that I am very keen on—and it suggests that there are health gains for parents, increases in the rate of breastfeeding and reductions in costs for services if the initiative is followed. I suggest to my hon. Friend the Minister that one important way to spread best practice to all maternity units is to improve take-up of the baby friendly initiative in accordance with the NICE guidelines.
I would have said much more about tackling health inequalities, Mr. Williams, but I am out of time.
I congratulate Harry Cohen on securing this debate and on his timing; in the wake of the Healthcare Commission report, the issue has understandably become rather high profile. The commission's report highlighted patchy performance. We see a service under considerable strain.
I am not sure whether there is a baby boom; all I know is that Southampton has seen a large increase in the number of births over the last few years. That is causing considerable strain locally and is forcing the decision to close small midwife-led units in order to centralise services. That has proved somewhat controversial.
All that is unfortunately set against only the tiniest of increases in midwife numbers. In 1997, we had the equivalent of 18,053 full-time midwives in the NHS. By 2006, the number had risen to 18,862—a rise of only 809, or 4.5 per cent. over nine years. Even worse, last year the number had fallen by 87 from the previous year. Put simply, we need the equivalent of about 22,000 full-time midwives, and we need them quickly.
The hon. Member for Leyton and Wanstead highlighted the drop in the number of student midwives, which is serious. The headcount number of midwives also fell by 375 between 2004 and 2006, so despite the Government's claims over the seven years since I became a Member that they are planning to address recruitment and retention rates, they have seriously failed to address the problem of retention. Many midwives leave the profession after only a few years. We have a demographic time bomb on our hands, because the age profile of the midwife community is skewed towards the upper age limit, with a large number due for retirement within the next 10 years. That will have a real impact on services.
The regional picture is patchy. Areas such as Yorkshire and Humber have seen a decrease of 141 in the number of midwives. It would be interesting to hear from the Minister what exactly is being done to increase the number of student midwives. Will the Government reverse the trend that has been evident over the past couple of years? How will they improve the retention rate?
How do the problems and pressures manifest themselves? The Healthcare Commission report showed that only 64 per cent. of trusts provided a named midwife for antenatal and post-natal care in 2008. That is not good enough. Most women have the realistic expectation that they should know who is to provide their care, but 34 per cent. of trusts meet that expectation only sometimes and, rather worryingly, 2 per cent. do not meet it at all. London trusts experience delays in booking, with consequent effects on the number of antenatal appointments that a woman can have.
The closure of small maternity units has been alluded to briefly. It decreases the choice available to women. Although a lot of women choose to have their first baby in a unit with a consultant unit attached, many women assess the risk and decide that they would prefer to give birth in a midwife-led unit—something they are happy with—so it is a pity that some of those units are closing.
When a woman goes into labour, she should be guaranteed one-to-one care by a midwife. Having heard the previous Prime Minister's wife exclaim proudly that she had two midwives attending the birth of her last baby, I tabled a parliamentary question to ask for a definition of one-to-one care.
The Minister shakes her head. I was at the meeting when the comment was made.
The Department seems unwilling to provide a definition of one-to-one care during labour. Many people contend that it should mean that a woman has the undivided support of a midwife to give encouragement and to help her through the birth process. That is clearly not happening.
In October, the Royal College of Anaesthetists, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and the Royal College of Paediatrics and Child Health issued a joint report entitled, "Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour". To achieve the standards highlighted in the report, we need to double the number of consultant obstetricians and provide an extra 5,000 midwives. The colleges said that unless dramatic changes were made, the shortfalls would become a problem that would have
"disastrous effects for mother and baby".
It was also disclosed that, of more than 100 obstetric and midwifery units in England and Wales, only 27 per cent. have the equivalent of a midwife for every woman in labour. That is far from the Government's stated aim.
Other manifestations of the problem can be found in a woman's opportunity to have her choice of pain relief. Although the Healthcare Commission report highlighted a relatively high satisfaction rate of 78 per cent., it still leaves nearly a quarter of women dissatisfied with the pain relief they receive. That situation can only get worse. If more women are giving birth, it will put more pressure on the system. If an anaesthetist is not available, an increasing number of women will be deprived of their choice of pain relief.
Mr. Drew touched on some of the mental health issues connected with pregnancy. That is important, because the Birth Trauma Association has established a strong link between a negative birth experience, which is often related to pain control, and post-natal problems. It is not overdramatic to suggest that some women see the problem as akin to post-traumatic stress disorder.
None of us wants to see another Northwick Park, but reports from my local hospitals include some frightening experiences. There are regular reports of one midwife looking after two or three women in labour; of staff being pulled off post-natal wards to help cope with risk periods in antenatal wards, which means that some post-natal checks are not done; and, echoing the comments of Mr. Field, of things such as filthy toilets with dried blood not being cleaned up within 24 hours. If those problems were a one-off, I would not have mentioned them, but there is a consistent theme that unfortunately keeps returning to me and to other hon. Members.
The drive to reduce the length of stay has led to an increase in readmissions. When that happens care must be taken to ensure that women have regular post-natal contact with a midwife, and that those visits are made. Problems can develop post-natally and it is important that we look after those women.
The lack of midwife cover can lead to an increase in caesarean sections. It does not reflect well on our country that the rate of caesarean sections is well over 20 per cent., when the World Health Organisation says that 13 or 14 per cent. is probably the optimum.
Mr. Kidney highlighted problems with breastfeeding. In some maternity units, only 58 per cent. of women initiate breastfeeding. I fully endorse the hon. Gentleman's comments about the UNICEF initiative on breastfeeding.
Sadly, I am out of time. However, I must say that what is really depressing is that although there have been numerous Select Committee reports about maternity services over the years, we are still discussing the same old problems. Will the Minister tell us when those problems will be tackled?
Sandra Gidley has given me my cue to start. She mentioned the number of reports on this issue. I would refer all Members here, including the Minister, back to "Changing Childbirth", which I believe was published in 1993; it still holds good today. We are still facing very clear gaps in the delivery of service on maternity care.
I congratulate Harry Cohen on securing this debate. He gave us a very good basis on which to launch this discussion and highlighted many of the issues that the Healthcare Commission has referred to in its report on maternity services. For me, the biggest issue that he raised was choice—where and how a woman has her baby—and the fact that childbirth is meant to be a happy experience for women, not a traumatic one. Although there is scant research at the moment, anecdotally we know that the experience that women go through during labour has a profound effect not only on their own health—including their mental health—in the years ahead, but on their baby's.
My hon. Friend Mr. Field highlighted the issue of mothers feeling as if they were being passed from pillar to post. That is a common theme and a number of other Members have highlighted it. My hon. Friend also mentioned the particular problems facing London, including problems with mobility and diversity, which create particular challenges for the capital's work force. Ensuring that we reach the groups that are hardest to reach, who are often the most mobile and often do not have English as a first language, is vital.
I noticed that while my hon. Friend was speaking, the Minister shook her head. I ask her not to deny the problems, and to accept that he was speaking in good faith and relating the experiences of his constituents, particularly one who had a very sorry tale to tell of poor care that led to infection.
My hon. Friend Tony Baldry spoke with considerable passion, as he always does, about the Horton hospital, which it has been my privilege to visit. He also raised the issue of travelling times, which, although no other Members here today have raised it, is of concern in places across the country where smaller maternity units are closing. He rightly said that the Horton is a place of safety. Again, we come back to the issue of choice. If the Minister and the Government want to deliver choice, the message from my hon. Friend is loud and clear: his constituents would like to have the choice of their babies being delivered at the Horton hospital.
Although my hon. Friend Grant Shapps is not present, I should point out that he introduced me to a constituent of his whose wife's pregnancy sadly ended in tragedy when the doors of the local maternity unit were closed due to staff shortages. Smaller maternity units offer a place of safety. They are often what women and their families want. I ask the Minister specifically to address the issue of the closures of any such units.
We also heard from a number of other Members. Mr. Kidney raised the issue of premature births. In fact, the figures on premature births are dreadful and I will refer to them again a little later. Mr. Martlew praised his local maternity services; it is always good for us to do so. The hon. Member for Leyton and Wanstead began by paying tribute to midwives, and I am sure that all of us would pay our tribute to them and to the administrators, health visitors and members of the other allied professions, all of whom support women in childbirth. I certainly pay tribute to them.
I could go on quoting from similar figures. For example, Mind has produced several sets of figures on this issue. Mr. Drew talked about mental health problems. In fact, Mind estimates that 13 per cent. of women will face mental health problems in the first 13 weeks after childbirth, and that figure rises to 20 per cent. in the first year after childbirth. That is a significant proportion of women. If we do not have the midwives, if there are staff shortages, and if we lose the smaller, local maternity units, those figures will undoubtedly get even worse, because there will not be the support staff—in particular, the midwives—to identify any problems at an early stage.
The story is one of a rising childbirth rate. The hon. Member for Stafford said that he was not sure whether we were experiencing a "baby boom"; whatever we are experiencing, the childbirth rate is rising by 13 per cent. across the country. I make particular reference to London, where the rate has risen by 16 per cent. The story is also one of closures of smaller maternity units. Indeed, Lord Darzi's plans open the door for the closure of up to 10 obstetric or maternity units in London. That would have a profound effect on an area whose problems have already been highlighted.
We also have a shortage of midwives. There has been a 4.5 per cent. increase in the number of midwives over the last 10 years, but recently the number of midwives has reduced by 87. I have heard Ministers quote the number of midwives. The trouble is that we hear about the number of midwives and not the number of full-time equivalents. The latter number is what matters when it comes to providing care for women in labour.
We also have a retirement bulge coming up. The Royal College of Midwives estimates that half our midwives will retire in the next 10 years. Furthermore, there are reductions in the money available for maternity services. They used to take 3.1 per cent. of the total NHS budget, but now, that figure is down to 2 per cent. The ratio of midwives to women is also going in the wrong direction—it is getting worse, not better. Moreover, we have problems with staffing levels. The Healthcare Commission's report on maternity services associated poor staffing levels with poor performance. In addition, there has been a 16 per cent. drop in training places in the last two years.
Other issues have been raised. I have mentioned that of premature babies, particularly premature twins, which the BLISS report, "Too little, too late?", has highlighted. Some 35 per cent.—more than a third—of sets of twins are looked after in separate units. One can only imagine the trauma for a mother who, having just given birth, has to visit her two children in two separate hospitals. There is also a problem regarding the number of consultants coming through to train as obstetricians. The Royal College of Obstetricians and Gynaecologists estimates that the number of students putting themselves forward for training has gone down from 4.8 per cent. to 2.8 per cent. The issue frequently raised is fear of litigation.
The hon. Member for Romsey mentioned caesarean sections. A quarter of women now have caesarean sections; in 1980, only 9 per cent. did. The current figure is well above what we should expect. We must also consider the issues associated with mental health and breastfeeding; in particular, we must consider those women in society who are vulnerable and hard to reach, and who often have a number of other related problems in raising their children.
I finish by referring to what Dame Karlene Davis, General Secretary of the Royal College of Midwives, has said on this issue. The RCM has welcomed the "Maternity Matters" report, but Dame Karlene, summing up the problems identified in the report so well, says:
"It also shows that everything is far from rosy in the garden, and it should be a wake-up-call that jolts the Government from its slumbers. They need to rub the sleep from their eyes and reverse the lack of action on maternity services and galvanise the NHS. They are sleeping while mothers and babies are not getting the high quality care they deserve, while maternity services are crumbling and while midwives are working themselves into the ground."
This is a wake-up call for the Government. All that I ask of the Minister is that she tell me what she and, indeed, the Government have been doing for the past 10 years. The problems that we are discussing are not news—they have been around for the past 10 years. Will the Minister therefore tell me what she is going to do about increasing the number of midwives and the percentage of the NHS budget that goes into maternity care? What is she going to do about giving women the choice that she has promised?
I congratulate my hon. Friend Harry Cohen on securing a debate on the important subject of maternity services in the NHS, and on his fortuitous timing. As always, he has put his finger right on the button. I appreciate all the comments that have been made and I congratulate all Members who have spoken. I particularly congratulate my male colleagues on showing such a remarkable interest in childbirth, as we knew they would, and on being so supportive of mums and families. Members have always held this issue in the highest regard because of its personal nature.
I congratulate Mr. Field and I wish him and his family well. I should add, however, that the comments that he mentioned should not have been made about the NHS. There is great joy and happiness every day, hour and minute in the NHS and in the independent sector, although there are also tragedies in both sectors. It would be unfair of me not to acknowledge that the NHS is the safest place in this country to give birth, and that is well acknowledged and well recognised. In whichever sector someone chooses to have their children and the marvellous experience of childbirth, they should always expect safety. I hope that the hon. Gentleman will take the case that he raised to the trust and that there will be a satisfactory outcome, given that the care received by those involved appears, from his description, to have been totally unsatisfactory.
Last Friday, the Government announced the funding for maternity services for each of the next three years, which totals more than £330 million. That funding will ensure that mothers get the best possible care and are guaranteed a full range of choices. Trusts will have access to that additional money from April.
I shall deal with that if time allows.
Ensuring that all women and their babies and families receive high-quality, safe and accessible maternity care is a top Government priority. Of course, we have a rising birth rate, which always seems to be the case under a Labour Government—perhaps people feel safer and more secure in their employment and that their families will be cared for financially, so they continue to increase the size of their families.
The recent Healthcare Commission survey of mothers' experiences showed that 89 per cent. of women are pleased with the care that they receive when they have a baby. That shows that there has been improvement since the survey of maternity services undertaken by the Department in 2005, when 80 per cent. of women said that they were satisfied with the maternity services they had received.
It is worth putting on record that, on publishing the findings of the maternity services review, the chief executive of the Healthcare Commission said:
"Being put in the least well performing category does not mean that a service is unsafe. If we believed any unit to be unsafe, we would take immediate action to ensure patients were protected. We would not hesitate."
It is important that that be put on the record, because women and families will be watching this debate, and it is essential that Members on both sides of the House unite in saying that the United Kingdom is one of the safest places to give birth. That will have an impact on the recruitment of midwives, which is so important to us all. If a negative view is promoted that does not show the true picture of maternity services in the health service, that could have a knock-on effect on recruitment.
I therefore encourage all those Members who have participated in the debate and all those who have shown an interest at other times to help us work on work force planning with the Royal College of Midwives. The RCM is often quoted, and Dame Karlene Davis deserves to be quoted. As she has said:
"This review provides a good base to measure Trusts' delivery of maternity services, and it is encouraging that over half of the Trusts are performing well."
We must remember that this country remains among the safest in the world in which to give birth, and it is Dame Karlene's members, as well as doctors, who provide the services.
My hon. Friend Mr. Martlew congratulated Cumberland infirmary this morning, and I look forward to visiting there to acknowledge its work myself. My hon. Friend Mr. Kidney certainly supports his local service, and he has raised concerns about premature births. I am of course aware that Tony Baldry will be giving evidence to the independent panel tomorrow, and it is fortunate to have him there. Andrew George mentioned a number of issues, but I shall need to write to him about them, given the time restrictions.
My hon. Friend Mr. Drew raised some important mental health issues. Following the publication of "Maternity Matters", which also covered mental health issues, we should never underestimate the fact that although births go well for many mums and families, they can be a traumatic time. Some aspects of the mum's mental health have been ignored in the past, and we encourage all commissioners to be very much involved in providing integrated maternity services, as part of the maternity mental health networks.
In the time that remains, it is important that I look at some of the other issues that have been raised. In my area, West Middlesex University hospital is part of the UNICEF baby-friendly scheme. My hon. Friend the Member for Stafford, among others, has worked hard on the issues of breastfeeding and a breastfeeding manifesto, and he should be congratulated on that.
There has been much change since I worked in the health service, and there was much change in the '80s and '90s, when closures were a significant aspect of meeting financial need. Today's reconfiguration of many services, however, is clinically and locally led. Maternity units are special to their local communities. "Maternity Matters", "Changing Childbirth", which has been mentioned, and past Health Committee reports have all shown the great significance of change to the way in which we manage maternity care for mothers and babies.
The work of paediatricians and health visitors, which Members have mentioned, is very important, because there are still inequalities between families. We have heard reports today about how migrant mums have made a difference to some aspects of our maternity services. However, we should remember that we have a migrant work force in the national health service and that the NHS has provided excellent services throughout the years since its inception in 1948. As we go into the 60th year of the health service, we can be proud that we are the safest country in the world in which to give birth—much safer than America and France. We should be proud of those figures.
When things go wrong, it is important that clinical areas are monitored differently, because such experiences are totally unnecessary in today's health service, and I look to local management and local leadership to put such things right. I also look to all Members to work with us in the next few months, when we will be ready to launch a bigger recruitment campaign. There is difficulty recruiting, but we must acknowledge that, look at the reasons why and put in every effort to change things. NHS London is certainly doing that, and I shall be happy to let Members know of the work that is taking place.
It is for all of us to raise concerns, but we should not be negative, because there have been improvements. We need to work together to ensure that we recruit and maintain midwives, and that we acknowledge and thank them for their continuing work. I thank my hon. Friend the Member for Leyton and Wanstead for raising such an important debate today.