MP demand minister intervenes over maternity unit and makes promises over choice a reality

17/08/2004

Mike Hancock, MP (Lib Dem – Portsmouth South) has today demanded that the Secretary of State for Health intervene personally over the closure of the midwife-led maternity unit at St Mary’s in Milton, Portsmouth and make his much-publicised promises over choice in the Health Service a reality for his constituents. Mike says that he will raise the issue in Parliament as soon as it returns in early September.

Mike Hancock said: “A large section of Portsmouth’s women will be deprived of a local midwife-led unit if it closes. Similar sized populations in Gosport, Fareham and Petersfield will continue to have local units – yet it is as difficult to get to Queen Alexandra from south Portsmouth as it is from these towns. The whole trend in maternity services is to offer women a choice – home births, midwife-led units as well as the traditional hospital labour wards. The Government must now put its money where its mouth is and give my constituents that continued choice. I am disappointed that this has come out in August when Parliament is not sitting but I am determined to raise this as soon as Parliament returns in early September. That’s why I am writing today to the minister to demand a meeting and that he personally intervenes so my constituents can continue to have a choice in how they give birth. His words about the health service must not be empty ones.”

Mike Hancock has written detailed four-page letters to the Secretary of State and the Portsmouth Primary Care Trust (which is responsible for commissioning maternity services from the hospital trust) drawing on the detailed report from the all-party Select Committee on Health, evidence given to it by the Royal College of Midwifes, the responses from the Department of Health to the Select Committee and the report from the Maternity and Neonatal Workforce Group to the Department of Health’s Children’s taskforce.

Indeed ironically it was evidence to the Health Select Committee from Portsmouth Hospitals Trust and the Southampton University Hospital Trust that stressed the importance of choice to women. They told the committee: “For women to make a choice that is right for them as individuals, they need to know about the options available and feel supported by skilled and confident professionals whom they trust. It is anticipated that by increasing opportunities for women to give birth in midwife led units and at home, choice will become a reality.”

Letter to Sheila Clark, Chief Executive, Portsmouth Primary Care Trust:

Dear Sheila

Thank you for a copy of your Strategy for Maternity Services and the opportunity to meet with you over the past year about this. I know that you and your colleagues in the neighbouring PCTs have worked hard looking at local maternity services and thank you for this work. As you know a large amount of discussion has centred on the Mary Rose midwife-led maternity unit at St Mary’s and the relocation of all maternity services to Queen Alexandra following its redevelopment which will leave Portsea Island without a maternity unit. I note that the report leaves the door slightly open to reconsidering this. However I remain very concerned about its possible closure.

The overwhelming reason for my concern is that it will leave a large population in South Portsmouth without a local maternity unit. Those that say Queen Alexandra site is near to those living in South Portsmouth have not had tried to get to it both in terms of expense and hassle. If the unit is closed then we will be left with a sizeable population left without a local maternity unit. Your own figures show that the Mary Rose Unit caters for some 400 medium and low risk births from Portsmouth City, although I accept that some of these will live closer to Queen Alexandra and some also currently opt for the Mary Rose Unit because it is co-located in the main maternity unit.

Nevertheless I feel strongly that there remains a strong case for the people of South Portsmouth being offered the same facilities that those of other areas with similar populations such as Petersfield, Gosport and Fareham are – namely a local midwife-led maternity unit. It seems to me that it is as difficult to get from South Portsmouth to the QA site as it is from these places. I also believe that is quite strong evidence that a midwife-led unit at St Mary’s along with a co-located unit at QA and the current other peripheral units would be a viable plan as well offering the choice that local people want.

I would particularly like to bring to your attention paragraphs 48, 49 and 50 of the ninth report of House of Commons Select Committee on Health “Choice in Maternity Services”:

48. The most fundamental reason for the closure of so many birth centres is that there remains broad faith in the notion of centralised services as being safer and more cost effective. Like our predecessor committee we have not seen any evidence to support such a stance. It is not only birth centres that have been under threat: a number of midwifery developments were closed, for example the BUMPS project in Leicester, despite evidence of good outcomes. One problem may be that such schemes and centres are closed because they are an identifiable part of the budget and can easily be lopped off, a point Baroness Cumberlege made in evidence to us. We accept that local configuration of services is a matter for local determination but given that pregnant women are not able to travel long journeys to give birth, if midwife led units are not available local choice is severely constrained.

49. In costing proposed closures the Department should ensure that local health services take into account the full and long term costs and benefits of the services being considered, including the likely impact on the recruitment and retention of midwives, on breastfeeding rates, postnatal depression rates and reduced intervention and caesarean rates which these units tend to achieve. We believe, as did our predecessor committee, that there should be a presumption against closure of smaller maternity units because without them the shift in attitude which they wanted and we want to see will be very much harder to deliver.

50. We believe that our recommendations above, calling for a shift towards midwife bookings, greater autonomy for midwives in delivering services and sufficient priority given by trusts to maternity issues would reverse the worrying medicalisation of birth reported to us.

As you are probably aware there was written evident given to this committee for this report by Southampton University Hospital Trusts, Southampton University and Portsmouth Hospitals Trust about their Birth Places Choices Project. It is to be welcomed that locally a relatively high number of births (25%) – indeed as you say in your report the second highest in the country – happen outside the traditional labour ward setting. However this memorandum from the local trusts ends by saying: “For women to make a choice that is right for them as individuals, they need to know about the options available and feel supported by skilled and confident professionals whom they trust. It is anticipated that by increasing opportunities for women to give birth in midwife led units and at home, choice will become a reality.” It seems to me that closure of a unit at St Mary’s will reduce this choice.

I believe have already brought to your attention the report to the Department of Health’s Children’s Taskforce from the Maternity and Neonatal Workforce Group of January 2003 which stated:

· Many women prefer to receive care through pregnancy and during labour as close to home as possible, and in a domestic rather than a clinical environment.

· Good maternity care starts with the wishes of the woman herself and her family, and aims to meet these as far as possible, whilst also ensuring the safety of both mother and baby.

· Around the country maternity services have become safer and in some more responsive to the wishes of women and their families. At the same time there have been some contentious changes, with smaller maternity units closing and resource constraints (financial and human resources) limiting the extent to which women have really been able to exercise their choices.

· There has been a progressive increase in the role of dedicated midwife-led units. Situated in a variety of settings they are popular with women who have used them. These units offer a real alternative in terms of the model of service provided, and can also enable women to deliver in smaller (and therefore more local) units where it is no longer possible to provide on-site medical cover. There are several examples of NHS Trusts successfully maintaining a significant number of births away from the main hospital site e.g. Bath [Wiltshire and Swindon Health Care NHS Trust] and Shrewsbury. The Royal Shrewsbury NHS Trust, which includes five freestanding units, has the highest normal birth rate in England and the lowest caesarean section rate. These results are very encouraging, although they can only be fully interpreted when the results from other types of maternity services can be compared.

And this report was sited and backed by the Royal College of Midwifes in their evidence to the Select Committee which said:

3.6 The RCM believes that there is a need to reverse the medicalisation of maternity care. There must be a clear promotion of a philosophy of normality in maternity services, with the resources to support that philosophy.

3.7 And that is being achieved in some Trusts at present. In maternity units in which women are given the support they need to have a normal birth, such as at the Royal Shrewsbury NHS Trust, intervention rates are low.

3.8 In Shrewsbury, the CS [Caesarean Section] rate is comparatively low at 12% in 2001-02. This is the result of a long-term strategy of promoting normality in childbirth, which is an approach the RCM would support. In this Trust, a quarter of births take place at home or in low-risk midwife-led units. For mothers with babies in the breech position or who have previously had a CS delivery, where most hospitals would opt for a CS, the Royal Shrewsbury provide women with the opportunity to achieve vaginal births.

3.9 This approach—where pregnancy and birth is treated as a normal physiological process in which medical intervention is unnecessary unless there are clear indications otherwise—results in less intervention. Most women do not have this style of care open to them and so are not free to choose it. We need sufficient numbers of midwives to provide antenatal preparation and support in labour.

There is also the case that there are areas in Portsmouth of comparatively severe deprivation – for example Charles Dickens is I believe in the top 200 most deprived wards in the country. I feel that not having a maternity unit on Portsea Island will seriously impair the work of midwifes and maternity services in improving care to local women and their families and have an impact on the good work that is already going on in various initiatives. I accept that good work has been done locally to have a very high degree of births outside the traditional labour ward and that local PCTs have difficult decisions to make both in pure medical terms and in balancing financial priorities. There is also a difficulty with the maternity services strategy of the Department of Health not as I understand it having been fully formulated and there being less than full data nationwide on comparing different strategies for the delivery of maternity services. But these are not reasons to impair choice for local women.

There is becoming an increasing direction in favour of midwife-led “birth centres”, against the over-medicalisation of maternity services and in favour of choice including midwife-led units along with traditional labour wards and home births. Finally there is the problem that may arise in not having a maternity unit on Portsea Island in the event of it becoming difficult to get off the island – particularly in extreme weather or in the event of an emergency.

So I strongly believe that not having a midwife-led unit on Portsea Island would be a seriously retrograde step. I welcome the paragraph in your report that says: “Portsmouth City PCT appreciates the strength of opinion expressed by some groups during the development of this strategy in support of an additional midwifery led service on Portsea Island and will invite and consider an option appraisal based business case during the 2006/7 planning round informed by such developments as the Birth Choices project and updated assessments of demand and costs.” I hope that these are not empty words and that you will look very carefully indeed at the closure of maternity services at St Mary’s.

I look forward to receiving your reply on the points that I have raised in this letter and I hope that we can meet shortly to discuss these issues. I will continue to press the case with the Department of Health for funding of maternity services in Portsmouth so that local women can have a choice and I am also copying this letter to the Secretary of State for Health and the Chief Executive of Portsmouth Hospitals NHS Trust.

Best wishes

Yours sincerely

MIKE HANCOCK CBE MP

Letter to Dr John Reid, Secretary of State for Health

You will remember that I wrote to you last year about the possible closure of the midwife-led maternity unit at St Mary’s Hospital in Portsmouth. The local PCTs have now completed their strategy for maternity services. This proposes the closure of the midwife-led maternity unit at St Mary’s when the main maternity services move to Queen Alexandra Hospital as part of its redevelopment. In the strategy the door is left slightly open to a midwife-led unit at St Mary’s in the following paragraph: “Portsmouth City PCT appreciates the strength of opinion expressed by some groups during the development of this strategy in support of an additional midwifery led service on Portsea Island and will invite and consider an option appraisal based business case during the 2006/7 planning round informed by such developments as the Birth Choices project and updated assessments of demand and costs.”

You, your department and the Prime Minister have talked a lot recently about offering choice within the health service. There is perhaps no service that it is more important that there is choice than in maternity services. These must not be empty words and I am therefore writing to you to ask you to intervene personally and find a way forward that will allow a midwife-led unit to remain at St Mary’s and for a large population in Portsmouth to continue to have a choice in their maternity services.

I enclose a copy of the letter that I have written to Sheila Clark, Chief Executive of Portsmouth PCT which sets out in some detail, a variety of evidence including to the Health Select Committee including, ironically from Portsmouth and Southampton NHS Hospital Trusts about their Birth Places Choices Projects how important it is for women to have a choice about their maternity services – including the availability of local midwife-led units.

The closure will leave the south of city and Portsea Island itself without a midwife-led maternity unit. For those that don’t know the geography of Portsmouth, I would particularly like to stress that there is a large population in South Portsmouth and it is expensive and often difficult to get off the island to Queen Alexandra Hospital. There is a population of some 90,000 people in South Portsmouth that will find it difficult to get to Queen Alexandra and indeed this is a larger population then nearby areas such as Gosport, Fareham and Petersfield that will keep their midwife-led maternity units and indeed in some instances, it is easier to get to QA from these areas.

As you know there is a trend in maternity care for women to be given more choice away from the traditional labour wards to include home births and midwife-led “birth centres” as well as the traditional hospital setting. And as I say, I have included a copy of my letter to the Chief Executive of Portsmouth City PCT which sets out in some detail how this is trend is emerging with extracts both from the Select Committee for Health’s report on choice in maternity services, evidence to it from the Royal College of Midwifes and the report to the Report to The Department Of Health Children’s Taskforce From The Maternity And Neonatal Workforce Group (January 2003). As I understand the maternity chapter of the Children’s National Service Framework is yet to be published and indeed it would be useful if more data on differing maternity strategies were available. It is not for me to make medical judgments, however it does seem to me from all these sources that there is a clear trend towards offering women the option of having a local midwife-led maternity unit.

Indeed Portsmouth and the surrounding area has the second highest rate in the UK of births to residents outside a main hospital unit. However this is no reason for choice to my constituents to be reduced – indeed the very opposite.

In addition to the reduction in choice to a large section of Portsmouth’s population, there are further reasons to keep the maternity unit at St Mary’s. Firstly there is the problem that may arise in not having a maternity unit on Portsea Island in the event of it becoming difficult to get off the island – particularly in extreme weather or in the event of an emergency. Secondly there are areas in Portsmouth of comparatively severe deprivation – for example Charles Dickens is I believe in the top 200 most deprived wards in the country. I feel that not having a maternity unit on Portsea Island will seriously impair the work of midwifes and maternity services in improving care to local women and their families and have an impact on the good work that is already going on in various initiatives.

I remind you of a number of responses that your Department gave to the Select Committee on Health’s reports on maternity services: The Select Committee’s recommendations are first followed by your department’s replies

28 Moves to implement the New Deal and the European Working Time Directive have already had a profound impact on the levels of experience that obstetricians gather as trainees and are already threatening the viability of maternity units which currently serve as consultant obstetric units. This might create welcome opportunities for the development of midwifery-led units for women with low-risk pregnancies but we are extremely concerned that women who experience complications in pregnancy and in labour should have access to skilled, experienced and confident obstetricians. We welcome the Department’s work to assess the implications of the EWTD but are concerned that any action on this work will come too late for the current generation of trainee obstetricians, and indeed for those units threatened with closure. If the EWTD is to be implemented, more investment in training and recruitment of doctors is required so that adequate levels of staffing and levels of experience can be maintained. We are very concerned that the Government is not sufficiently aware of the difficulties the professions face on account of the European Working Time Directive. (Paragraph 192)

The Government is aware that the implementation of the Working Time Directive (WTD) creates challenges that the NHS can rise to. Implementation links in with ongoing work including Modernising Medical Careers, pay modernisation for medical and non medical staff, the Changing Workforce Programme, and the objectives of the Improving Working Lives for Doctors initiative. Keeping the NHS Local – a new direction of travel was published last year and set out to show that service redesign offers real potential to maintain a wider range of services in smaller hospitals than traditional models of care might allow. It did not address maternity and paediatrics specifically, but recognised that these specialities have their own complexities and made a commitment that we would consider them in the next phase of work, alongside emerging recommendations from the Children’s National Service Framework. This is now being taken forward as part of the Hospital at Night project. The Hospital at Night project is taking an evidence based approach to set up competency based multi-disciplinary teams to staff hospitals out-of-hours. Three pilots are specifically considering how the Hospital at Night approach can apply to maternity services. The Department is also funding over twenty WTD pilot projects testing different approaches to achieving WTD compliance for junior doctors. Some of these pilots are testing approaches that may help to achieve WTD compliance within maternity services.

6 We recommend that the Government uses the opportunity presented by its forthcoming NSF as an opportunity to recast maternity services to the advantage of both women and their carers. We feel that the current delivery of maternity services, which is generally led by acute general hospitals, overmedicalises birth. Through the NSF, PCTs should be given a lead role in ensuring there is choice and community-led services for women, wherever they live. (Paragraph 42) The Children’s NSF is likely to emphasise the objective of modern maternity care – to place every woman and her baby at the centre of services that are acceptable, designed around the needs of women and their families and provide flexible and equal access to high quality clinical and supportive care. The NSF will acknowledge that for the majority of women pregnancy and childbirth are normal life events facilitated by health care and other professionals during which medical interventions should only be recommended if they are of benefit to the mother and/or child.

7 We accept that local configuration of services is a matter for local determination but given that pregnant women are not able to travel long journeys to give birth, if midwife led units are not available local choice is severely constrained. (Paragraph 48) It is for local service developers to design services to meet the needs of their local population taking fully into account their views. The Government accepts that where a midwife led unit is a fair distance from the woman’s home this can have an impact on choice. Choice should be informed by the locally available options for pre-birth, birth and post natal care and an understanding of clinical risks. Some midwife led units are underused that is why the Department of Health is funding the research as detailed in the answer to recommendation 1. Even when services are close in proximity to a woman’s home, some women particularly those from vulnerable groups in society find it difficult to access, or maintain access with maternity services.

8 In costing proposed closures the Department should ensure that local health services take into account the full and long term costs and benefits of the services being considered, including the likely impact on the recruitment and retention of midwives, on breastfeeding rates, postnatal depression rates and reduced intervention and caesarean rates which these units tend to achieve. We believe, as did our predecessor committee, that there should be a presumption against closure of smaller maternity units because without them the shift in attitude which they wanted and we want to see will be very much harder to deliver. (Paragraph 49)

In February 2003, Keeping the NHS Local – A New Direction of Travel was published. This provided new guidance on service change that builds on the new arrangements for patient and public involvement in health that came into force on 1 January 2003. It challenges the view that ‘biggest is best’, and explores some innovative ways of keeping high quality locally accessible services within the bounds of patient safety. These service models are presented for consultation. The guidance sets out that when considering service expansion and redesign, there are 3 core principles to be followed: . developing options for change with people, not for them, starting from the patient experience and our commitment to improve choice, and working with staff to develop new ways of delivering services; . focus on redesign not relocate. Redesign can offer a high quality alternative to relocating services, etending the range of options for developing new configurations that meet local needs and expectations; . taking a whole systems view: the NHS needs to exploit the contributions of different hospitals, primary, intermediate and social care providers within a whole systems approach. These providers can expand the range of options available to meet centralising pressures by working in partnership, with genuine integration and joint planning of services. Wherever change is being considered, local health organisations, working with their partners, will need to satisfy themselves that their plans are in line with the core principles set out here.

I hope therefore that your and your government’s commitment to the health service are not simply words and that you will find a way forward for a midwife-led unit to remain open at St Mary’s. I would hope therefore that I could meet with you or a minister from your department about this and I look forward to receiving your reply as soon as possible.

Best wishes

Yours sincerely

MIKE HANCOCK CBE MP