Maternity Services (Caithness)
The final item of business is a members' business debate on motion S2M-746, in the name of Rob Gibson, on maternity services in Caithness. The debate will be concluded without any question being put.
Motion debated,
That the Parliament notes the current review of maternity services in rural and remote communities of Caithness and north Sutherland; believes that no "one size fits all" model will deliver satisfactory solutions across the country; considers that staff shortages and widely differing geographical circumstances have to be accommodated, and further considers that the Scottish Executive should instruct NHS Scotland to draw up consultant contracts so that medical staff gain competencies in both large and small hospitals and therefore fulfil the Executive's pledge that every child in Scotland be given the best possible start in life.
It is timely that this debate on maternity services in Caithness should take place this evening, as the Calder report has just been published and Highland NHS Board will meet in Wick next Tuesday to discuss the outcome of proposals that would, in effect, downgrade maternity services in Wick and Caithness general hospital.
It is with great sadness that I read the first line in the executive summary of the report, which states:
"The provision of specialist obstetric care at Caithness General Hospital is unsatisfactory to the extent of being unsafe in the view of obstetricians currently working in the Highland Region."
That should be set against Mary Mulligan's statement when the expert group on acute maternity services—EGAMS—report was first published. She said:
"Giving every child in Scotland the best possible start in life is a top priority for the Scottish Executive."
If we are to resolve the issue of providing for people in the far-flung parts of Scotland who live in a geography that has been fixed and who rely on the Government to equalise its expenditure to make services work, Caithness has an extremely strong case. We must meet the needs of patients where they live and ensure that some form of consultant-led maternity service is maintained there. I believe that the many people who will watch the webcast of this debate expect the Parliament to ensure that the Executive provides a service that meets those needs.
Professor Calder reports against a background of low and decreasing birth numbers in the Caithness area, recruitment difficulties and wanting the delivery of the best possible services that modern medicine can offer in small hospitals. Therefore, it is necessary for Highlands and Islands representatives to ask how we will provide the services that are needed in areas such as that in question, where there are 100 miles between the small Caithness hospital and Raigmore general hospital. How will we deal with such situations?
Professor Calder describes the situation in Caithness as being more acute than in any other part of Scotland. That said, we could find that the birth rate in Caithness increases in the future. We know that the birth rate in the countryside is better than it is in many cities. Indeed, if there were to be a dispersal of Government jobs and good reasons for people to stay in Caithness, many young families would want to bring up their children there, if they could. Many people who want to set up businesses want to know that a full service will be available in the area. Such a service attracts people to set up businesses in Caithness. If that service is put in jeopardy, there could be an economic downturn. I am delighted that Highland Council and Highlands and Islands Enterprise are doing an assessment that will give us an idea of the social and economic effects of the reduction in health services in our area.
The nub of the issue are the staff who would be recruited to work in maternity services. On the EGAMS report, Mary Mulligan said:
"We need to realise the full potential of our midwives … We need to think across professional … and organisational boundaries".
I will dwell on those matters, which are at the heart of the argument.
We are used to the fact that not enough doctors are trained. The difficulty in obtaining consultants occurs in many countries, as well as in Scotland. It is a great difficulty in modern medicine, because of the way in which specialisation takes place, but we are asking for some out-of-the-box thinking. We are asking that consultants should be employed on a contract that allows them to keep up their competencies in a large hospital, such as in Inverness, and work in Caithness.
Midwives have said that they want to have more responsibilities. Since around two thirds of births ought to be reasonably uncomplicated, they could take on such responsibilities. However, examples flow from many other places to suggest that there must be consultant back-up when emergency caesarean operations are required. Professor Calder's report does not say how that should be delivered. It is mentioned, but the solution has to be found. It involves consultants working in Caithness who do not just deal with out-patients, and who have the skills to deal with the emergencies that can crop up.
Much play has been made of the distance from the hospital in Inverness. Rightly, the people of Caithness and north Sutherland feel that road journeys for expectant mums—over bad roads in what can be bad weather—should be deplored. If we were working in other countries, we might expect there to be more aircraft, such as helicopters, but we do not have the investment in those facilities in Caithness and the north. For example, we do not have a commitment to mend the second runway at Wick airport, so that aircraft can work in different weathers.
Above all, we do not have a commitment to get consultants to move to and work in Caithness, or to fly them in. It takes half an hour to set up a theatre for an operation and it takes half an hour to fly from Inverness to Caithness, so why not make it a central part of our argument for the future of maternity services in Caithness that services are consultant-led and that consultants are flown in as and when needed? Not every operation will require that, but people want to see that spelled out, and want to know what the minister is going to do to address the issues of geography and need that we face in the north of Scotland.
I have a very long list of members who wish to speak in the debate, so I ask for speeches to be kept to three minutes. I will review later whether we need to extend the debate.
I am grateful to Rob Gibson for lodging the motion, which I fully support.
Many of us in the chamber have spent a lot of time lobbying for the retention of the present services in Caithness. The review of maternity services has caused great anxiety to the community. Understandably, people are angry about the threat to their consultant-led maternity services. The position is fairly dire. Three consultant obstetricians delivered the service in Wick, but now those consultants have all left and Highland NHS Board is endeavouring to find temporary replacements until a decision is made about the future of the service. The situation is unsatisfactory, because it is impossible to attract consultants to a service that might not exist in a few months' time.
Professor Calder's review of maternity services has done much to dash hopes. He talked about why consultants are in short supply and the small number of confinements at Wick. We know that we have challenges to overcome. He says that the challenges mean that the hospital does not attract the right calibre of consultants, but surely there are ways in which we can attract the right calibre of person. For example, Professor Calder noted that there are no opportunities for continuing professional development and a lack of evidence of any on-going medical audit or appraisal for revalidation. Questions must be asked of Highland Acute Hospitals NHS Trust about the level of support that has been given to the Wick consultants. How can it be that when the first review was carried out two years ago, the consultants were content with the service and said that it was safe, whereas now, two years later, there is a huge question mark over the service? Something has fallen down a black hole in the past two years and I want to know what it is.
If clinicians feel that the present service is not safe, we must make it safe, perhaps, as Rob Gibson said, by encouraging Wick and Inverness to work together more closely to retain the consultant service. We must also consider how the obstacles to recruitment can be addressed and whether we can enhance the professional experience for consultants at Wick by rotating them regularly with Raigmore staff. The key question is: what are the clinicians in Raigmore prepared to do to support the Wick maternity unit? In the end, it will be up to the clinicians in Raigmore to say that they will go up to Wick. Because of the consultants' contracts, we cannot force them to do that, which means that we must try to get their support.
As we are all aware, if there are no locally based consultants, complications in labour or fears for the health of a baby result in an arduous journey to Raigmore, which is 100 miles away. We do not need to rehearse the arguments on that issue—we know what the roads are like. Professor Calder pointed out that, as it is configured, the air-ambulance service would not be much quicker than going to Raigmore by road. We cannot have that. As Rob Gibson said, we must consider basing an enhanced air-ambulance service in the north. We must ensure that there is close working between Raigmore and Wick to deliver the service that the people of Wick want.
I congratulate Rob Gibson on securing the debate and I associate myself entirely with his remarks. The minister will be aware of the arguments about distance and inclement weather and so on, which members of all parties have made. That is an important point to which I will return.
Mr Gibson is absolutely right to say that we need to think outside the box. Professor Calder has produced a report that is factually correct in strictly logical and medical terms, but when one places this vital service in the wider contexts of economic development, geography and the weather, one realises that a much broader view must be taken. It is no accident that the Scottish Enterprise network and Highland Council have come out courageously on the issue. The convener of Highland Council, Mrs Alison Magee, has resigned from Highland NHS Board over the issue. That demonstrates amply that responsible individuals in local government and the Scottish Enterprise network appreciate the gravity of the situation that is being thrust upon us.
The minister will hear the same message from members of all political parties, which is an unusual and precious thing in the Parliament. Members who have met people in Caithness, including Rob Gibson, Maureen Macmillan and I, have always heard the same message and sung from the same hymn sheet. We have stood together on the issue. Given that the united front extends throughout the Parliament, we are talking about the will of Parliament on the issue.
Ministers must consider the issue in the wider context. Highland Acute Hospitals NHS Trust will consider Professor Calder's report and I should not be surprised if it decides that the proposals are exactly what it wants.
Does Jamie Stone agree that, as has been done in Lochaber, a solutions group that includes representatives of the community and the medical profession should be set up to consider the issue?
That suggestion is entirely appropriate and we should forge ahead with it.
The issue is of such gravity and will affect people's lives; in fact, it will endanger lives. Rob Gibson's point about the cross runway at Wick is correct, as is Professor Calder's point about flights. We cannot gainsay the distance to Inverness. What if the A9 is blocked when somebody is being taken there? Rob Gibson's idea of having a rotating system whereby consultants who work in Raigmore also work in the small hospitals is entirely sensible.
Mr David Sedgwick, a consultant in Fort William, has demonstrated that the consultants there are doing useful other work outside their own fields. Mr Sedgwick is doing small operations such as the removal of small benign lumps. Such multiskilling is the way forward for the future.
I will conclude my remarks, as I do not have much time remaining. I thank Mary Scanlon for giving way in my favour. I remind the minister that I do not doubt that this is the single biggest issue that Rob Gibson, Maureen Macmillan and I have faced in the far north of Scotland. I ask the minister to consider the matter seriously. It should be placed on the Cabinet agenda because it cuts across other ministerial responsibilities and could fly in the face of many of the good things that we are trying to do in the Scottish Parliament.
I will refer to Professor Calder's independent review of maternity services, which was published this week. There were 570 births in Caithness general hospital in 1966, but that figure had decreased to 224 by 2003, with another 133 births in Inverness in that year. There are likely to be 112 births in the midwifery-led unit in 2004. I worry that in 2006, we will analyse the number of births and ask whether the unit is viable.
Professor Calder's report states that the review visit and
"subsequent developments have reinforced the strength of local feeling and have persuaded the Review Group that there is probably no issue currently of greater concern to the people of Caithness and Sutherland."
I hope that the minister takes that point on board tonight.
I will discuss section 6 of the review. I was under the impression that consultants who work at Caithness general hospital spend two or three days each month at Raigmore hospital. I was told a couple of years ago at one of our regular meetings with NHS Highland that such visits took place to give the consultants the opportunity to maintain their skills and training and to learn about new technologies. I do not know whether such visits have stopped.
The section of the review dealing with midwifery issues states that although the midwives at Caithness are positive about the future,
"they did raise some concerns",
including
"Reservations regarding safety if no obstetrician is available … Specialist help more than 100 miles away … Potential for no resident obstetric cover …Issues of transfer, retrieval and transport."
If the midwives remain concerned about the recommendations in the report, I will remain concerned and the local population will remain concerned. Assistance must be sought from 100 miles away. If there were such problems in the minister's constituency, mothers in Edinburgh would have to travel to Carlisle, Newcastle or Aberdeen. I invite him to think about that.
An important point is made in the report's conclusion, which states:
"We believe that the preferred configuration should be the Community Maternity Unit model and that it should be developed under the following stringent conditions".
I will not list all the conditions, but it is enough to say that six of them include the phrase "should be" and the other one includes the word "must". If the community maternity unit model is chosen, many questions will remain unanswered and many commitments will not have been met.
I thank Rob Gibson for lodging this motion. It was good to read Professor Calder's report in advance. Jamie Stone said that there is cross-party agreement on this issue. I think there is—because we recognise the legitimate aspiration of the people of Caithness to have a sustainable, quality service in their community.
I would like to be somewhat more positive about the report than other members have been. As I recently worked in NHS Highland, I know about recruitment problems. There is nothing worse than a service that exists on paper but does not exist on the ground because posts cannot be filled.
I will not quote extensively from Professor Calder's report, although it has some interesting aspects. The decline in popularity of obstetrics as a specialty for new medical graduates reflects societal changes. We are more litigation minded and medicine has become more defensive as a result. Medical professionals feel a bit more under threat and a bit more under scrutiny. It is regrettable that that makes a unit such as the current Caithness general hospital obstetrics service unviable. Professor Calder also points out that the unit at Caithness is a specialist unit only in so far as it has three consultant obstetricians. There is a lot of back-up that it does not have, such as neonatal intensive care facilities.
I mean no offence, but Rob Gibson's idea of a flying squad is a little naive. There will not be a plane waiting on the tarmac. It might take only half an hour to fly to Caithness, but the flight still has to be organised. There will not be a pilot waiting, so it would take a lot more than half an hour to get someone there. What we need is not to fly people up to Caithness, but careful selection of cases so that does not have to happen. There is no point having emergency services to deliver babies when there are no neonatal intensive care facilities. We might be able to sort out the mum, but what happens to the baby when there are no paediatricians or neonatal intensive care nurses? I do not think that the suggestion is on.
I feel fairly positive about the Calder report, because it suggests a way forward. I agree that the service should be consultant led; I just do not think that the consultants who are leading are necessarily going to be on the ground all the time. The model of their helping with the assessment of patients to determine which ones are suitable for delivering in Caithness and which should travel to a specialist facility is good. I believe that that model is followed in other areas, such as Orkney, so it could be followed in Caithness. I suspect that people will not like it, but they would like it even less if we tried to keep obstetrician consultants in Caithness but were unable to fill the posts, which I suspect would continue to be the case, and in the meantime did not do what Professor Calder says we must do to make a midwife unit viable. There are training issues to consider as well as other issues about support. We should address those issues and not pretend to be running something we just do not have.
I congratulate Rob Gibson on securing the opportunity to debate this crucial issue. From what we have heard tonight it is clear that the proposed centralisation of maternity services and the closure of the consultant-led service in Caithness can have only adverse effects, the most compelling of which is that it will undoubtedly place at risk the lives of mothers and their newborn children.
The Calder report applies a centralist logic that would be fair only if Caithness had been given a fair chance to compete and build both its economy and population, but that was never the case; no such chance was ever forthcoming. The Executive culture of centralisation is liable to centralise more than it bargained for: it is liable to reduce inexorably the population of Caithness at a faster rate than ever before when any Government should be trying to achieve the entirely opposite effect.
The Registrar General for Scotland's data on young economically active people show that he is forecasting a loss from Scotland of 270,000 economically active people in the next 23 years. Given that the greater conurbations of Glasgow, Edinburgh, Dundee, Aberdeen and Inverness can be expected to grow in that period, those data mean that there will be a disproportionately heavy blow to the smaller towns of Scotland, such as Wick, Fort William and Oban. It is clear from the campaigns that we have seen that people see the threat.
Will the member give way?
No. I have only three minutes.
And that is why the people of Caithness, Lochaber, Lorn and the isles have united to bring about a change of culture. It is a stand worth making. After all, under successive Governments in my lifetime, the economically active population has fallen, particularly in the north.
Will the member give way?
I have only a minute left.
A further reduction in population is not acceptable, nor is the prospect that the new European accession states could push us further down an extended life-expectancy league table. That is why we need to demand change and latitude verging on what might be called unreasonable in some quarters. It is arguable that in the past we have been too reasonable, too accommodating and too willing to accept the unacceptable by being too trusting of the powers that be. The results do not justify that trust.
Strenuous opposition is the only option. We know that the only thing that ever forces a change of heart on the part of Government is its being confronted by an argument that exposes the weakness of its position. Surely we must say no to centralisation and yes to proper services that attract investment, encourage people to stay and justify more job relocation that could fuel the process of recovery. That is what we need from the study, as well as the recognition that consultant-led services are a crucial component in any competitive proposition.
In The Herald today, Professor Calder said that the provision of specialist obstetric services was
"Unsatisfactory to the point of being unsafe".
My proposition is that the withdrawal of those services would be unsafe for the economy and the community and detrimental to social cohesion.
I agree that the withdrawal of obstetric cover in Wick will definitely be unsafe. The degree to which it will be unsafe should be quantified, but that has not been examined. I join all members present who are sticking up for Wick, but I will also stick up for maternity services in general. There needs to be a rethink. All maternity services are suffering from a lack of planning and a lack of advanced resources to deal with the consultant contract and recruitment and retention problems, all of which could have been foreseen, planned for and avoided.
Mary Scanlon referred to the concerns that have been raised about midwifery. It distresses me that those concerns are merely noted as bullet points in the Calder report and that there is no explanation of the background, no details of the concerns and no explanation of how they might be addressed. As a result, the concerns remain outstanding: there has been no reassurance about how they will be dealt with.
I do not have time to cover all my concerns about midwifery, so I will pick just one. It involves a woman whose pregnancy and delivery are normal and whose baby is fine, but who retains her placenta. That cannot be predicted. Even if she and the baby remain safe and well and the only impact on her of there being no consultant to deal with the situation is that she has to transfer to Inverness or Raigmore, the consequences socially and emotionally in terms of the establishment of the bond between the mother, father, child and other relatives are not acceptable. For example, transferring the mother to another hospital would have dire consequences for the establishment of breastfeeding, which is supposed to be an Executive priority.
The report says:
"In particular there is a fear that a reduced requirement for emergency anaesthetic provision could impact on the job satisfaction of the anaesthetists"
and notes that it would then become increasingly difficult to recruit and retain such specialists and that
"these specialties are themselves already facing the same types of pressures as confront the obstetric service."
In other words, the report accepts that it is inevitable that anaesthetists will be lost as well. The loss of maternity services will result in the loss of anaesthetic services, which will threaten the future of Caithness general hospital. The hospital is in great peril and the report implicitly accepts that.
The report also says:
"It is now accepted that to provide a rota of round the clock on call duties will in future require at least eight and ideally ten individuals."
As I said earlier, that could have been foreseen. The people of Wick will suffer as a result of that lack of planning and resourcing.
There are ways around the problem. We need to come at the situation from a different angle. Rather than simply accept the situation and say that Caithness hospital will have to close, we and the clinicians should assert that it is imperative, for the good of the economy and for the good of mothers and babies in Wick and Caithness, that there is a full maternity service in Wick—and get to grips with how we propose to deliver it.
I fully support the campaign to retain Wick hospital. However, the problem is pronounced and not localised in Caithness and north-west Sutherland. Many areas of the Highlands and Islands have experienced a creeping, steady reduction in all sections of medical provision, particularly in areas that are remote from the central hospitals. That reduction in service applies not only to maternity and midwifery services but encroaches on almost all existing rural medical provision, which is slowly but surely being centralised at the main hospital in Inverness—to the detriment of existing rural provision.
The centralisation of provision, which is a continual pressure to downgrade hospitals throughout Scotland, will doubtless damage rural medical services. It might also prove to be damaging to the economic potential of those areas. The economic development of an area is not based solely on investing money. To grow an economy, we need public services such as health, education and transport.
As we know, the Executive is trying to develop Scotland's economic potential by encouraging people to come and live and work in Scotland through its fresh talent programme, but moves to downgrade the hospitals in Wick, Fort William and Oban will prove to be a barrier to that initiative.
There is no doubt in my mind that if Wick is downgraded, the lives of mothers and children will be put at risk because they will be forced to travel more than 100 miles to Raigmore hospital. Recently, a young woman from Skye lost her baby and her own life was severely threatened because she needed to travel to Inverness for emergency care. A helicopter was ordered. It picked her up at the hospital in Skye seven hours later. We can enthuse about the helicopter service, but that is no service at all.
I stress that we need to retain and expand medical provision at a more local level so that our general practitioners and their patients can feel secure and confident in medical services in rural communities.
I thank Rob Gibson for bringing the debate to the chamber. As members have said, consultant-led services are diminishing all over Scotland. We cannot possibly sustain communities if they do not have medical services, including general medical services and general practitioners.
No matter how good GPs and midwives are, they love to know that if they get into difficulties, they can call upon consultants who are more specialised. It is up to the doctors, the colleges and anyone who is thinking about such services not to withdraw those services but to find out how they can get round the need to withdraw them. It is imperative that paediatricians, obstetricians and anaesthetists rotate and stay overnight in places such as Caithness.
Weather plays a part when we think about the north of Scotland. I trained in Aberdeen and I was a full-time anaesthetist for eight years. Once I went out in an ambulance from Aberdeen to Dufftown behind a snowplough to attend a lady who had a normal pregnancy. We expect such people to deliver safely in any community; her placenta was retained and we had to go out there to try to retrieve it, but there were difficulties and we ended up having to bring her and her baby safely back to Aberdeen behind the snowplough. Everything went well.
A hospital anaesthetist working in obstetrics sees the worst side of obstetrics: things can go wrong very quickly. Everything can be going along all right, then the staff might find that they have about three minutes to get their heads round what they are going to have to do and get into theatre. If they have to wait for helicopters, aeroplanes or ambulances, they might as well forget it; they will have lost the case.
We have to sustain our communities and get our doctors and the royal colleges to accept that doctors must rotate and stay overnight in those remote communities. It is up to the profession. It should be ashamed, and so should a country that cannot look after its people. We are never going to get people to work and live in Caithness, or even beyond Vale of Leven, if they do not have general medical services and maternity services.
I appreciate the opportunity that I have been given—thanks to Rob Gibson's motion—to spend a couple of minutes speaking about Scotland's maternity services. I am here to remind members that the issue affects not only rural areas but every area in Scotland.
Of course, we all know that we are culpable, because we all joined the campaign to reduce doctors' hours. Who was against reducing junior doctors' hours? I see no hands going up. Which members of the Health Committee were against improving general practitioner and consultant contracts? None of us. However, we failed to secure the flexibility within those contracts that would allow us maximum access to services. What depresses me and frustrates me as a politician is that we have not tackled that issue over the past few months and years.
The minister needs to take into consideration the need for active engagement of consultants. The Rankin maternity unit was closed down not by Malcolm Chisholm but by the consultants who informed the health board that they could no longer sustain a safe service. The same happened to the Vale of Leven hospital. We all get emotional about that, but it is very dangerous to go down the road of allowing politicians to instruct clinicians about what is and is not safe.
Eleanor Scott set a commendable example—although it might be quiet in at least one household tonight—by putting the case from the clinical perspective. However, too few clinicians have been prepared to do that. During Argyll and Clyde NHS Board's consultation on maternity services, which went on for years, not one consultant was prepared to turn up at any of the meetings. They were not prepared to face the public and to explain that as well as receive an increase in wages they would work fewer weekends and that services would have to be centralised as a result.
We need to tackle that issue and I hope that the cross-party Health Committee will provide us with an opportunity to rally to that challenge. If we do, it will be the first time Parliament has done that. Carolyn Leckie was right that Parliament has had four years to tackle the planning issues in the national health service that we all knew were coming, but we neglected to look at them. The Health and Community Care Committee did not consider those issues at all, but the Health Committee is now beginning to consider them. The horse might have bolted—I concede that we may be chasing it—but I hope that we will be given the opportunity to get clinical opinion to join the debate that needs to take place. I also hope that we can bring out these people who call themselves the "royal colleges". We need to find out not only who they are but what decisions they make, when those decisions are made and what impact they have on our communities.
I will be brief because I am conscious of time constraints. Like others, I congratulate Rob Gibson on bringing the issue before us and I am delighted at the consensus that we have heard tonight. That shows the importance with which we regard our communities in Scotland.
As a regular attender at members' business debates, I know that we often concentrate on many specific health issues, but today's debate is on a particularly important dimension. Over the years, Scotland's national health service has had a strong centralising philosophy of providing centres of excellence in the big cities and of closing down small units in rural areas and in the suburbs of our cities. However, people want good local services. Rob Gibson's motion does not demand that heart transplants or brain surgery be available in Wick; rather, it asks for services to support one of the most basic events of life—the birth of children.
Picking up on Jean Turner's reference to Dufftown, I had to fight against the closure of hospitals such as the Turner memorial hospital. Grampian Health Board's philosophy was that every maternity unit in Moray would have to close and that people would have to travel to Aberdeen. The campaign that was run in Moray was opposed by many of those who sat in their ivory towers in Aberdeen. They paid no attention to the strength of our arguments, which came from the whole community and from all the political parties in the area. We have to examine the centralising philosophy that exists so that we do not lose many more of our rural community hospitals.
I do not think that we sell hard enough the advantages of living and working in some of the most spectacularly beautiful parts of our country, where there are good school facilities and all the rest of it. That is the way to retain and attract people, but they will not come unless units such as the one that we are debating exist.
I think that it was Maureen Macmillan who said that although there are challenges, they can be overcome. We did that in Moray. We have attracted the obstetricians and consultants and we are proud of what we have done. Yes—there have been little hiccups from time to time, but we are proud of our achievement. My message to all members is that we must ensure that communities unite and take on all the organisations that stand in their way. We must have the courage of our convictions.
I certainly understand the concerns of the people of Caithness and I was pleased to meet a delegation from Wick when I was in Inverness recently. In reconfiguring and redesigning services, the guiding principle is that there should be the maximum access to local services that is compatible with clinical safety and quality of care. Across Scotland, many services are being moved into local communities from a more central location, as I pointed out at question time. Sometimes, however, change may mean centralising some services where there are good clinical reasons related to safety or service quality.
It would be premature, and procedurally impossible, for me to come to conclusions at this stage on the specific circumstances of Caithness, but I would like to set out some general issues surrounding maternity care and the need for service redesign. The birth rate in Scotland is falling, women are having their first babies at a later age and family size is decreasing. Moreover, women's lives have changed, with many women working throughout their pregnancies and returning to work relatively quickly. There is therefore more demand for flexible, local antenatal and postnatal care and for less medicalisation of pregnancy and childbirth. That is what the NHS aims to provide.
Some women who have been assessed as high risk, will require specialised care during childbirth. In a country such as Scotland, that cannot be delivered locally in every area, and women may have to travel for delivery or for some specialised aspects of their antenatal care. However, most of a pregnant woman's care can be delivered in her local community, regardless of where she will actually deliver.
In 2002, I set up the expert group on acute maternity services. Membership consisted of people from a wide range of professional backgrounds and geographic interests. The group concluded that the current configuration of acute maternity services needed to change. Women at risk of complications in pregnancy should have consultant-led care, but the falling birth rate means that some maternity units will not care for sufficient numbers of women and babies to ensure safety and quality. Some consultant-led units may therefore close and, where that happens, the group advocates the establishment of midwife-led community maternity units, a large number of which are already operating successfully throughout the United Kingdom.
In those units, the midwife's role will be maximised and midwives will lead the management of pregnancy and childbirth for low-risk women. Overall, our aim is to ensure that services are maintained at the local level rather than lost. That approach is already reflected on the ground—in Orkney and Fort William, for example. The crux of modernising maternity services is to ensure a quality service that is woman centred, provided as locally as possible and provided by the most appropriate professional.
Remote and rural areas present specific challenges for the provision of maternity care. Professor Calder's report spells out the impact on hospital consultants of dealing with only a small number of pregnancies each year. That affects the quality and safety of the service as well as the ability to attract and retain consultants. It is difficult for consultants to maintain clinical competence in the absence of regular and appropriate clinical practice.
Rob Gibson began his speech by quoting the first point made in the executive summary of Professor Calder's report. I will repeat it:
"The provision of specialist obstetric care at Caithness General Hospital is unsatisfactory to the extent of being unsafe in the view of obstetricians currently working in the Highland Region."
I do not think that that can be easily discounted. As politicians, we have to listen to the views of clinicians. There may be a range of ways of addressing the problem, but we cannot simply dismiss it out of hand.
I fully agree with the minister that the concerns of clinicians should be taken into account. Does he agree with me that the concerns of the people on the ground, the midwives who are dealing with most of the deliveries, need equally to be taken into account, but that those concerns are not fully addressed in the Calder report?
I absolutely agree with that—when I use the word "clinicians", I mean doctors, nurses, midwives and other health professionals. As we know, there are a range of views among midwives. As Carolyn Leckie knows, the Royal College of Midwives is very positive and supportive about the development of midwife-led units, but I accept the fact that Carolyn has concerns about that, which reflect the view of some midwives. I reiterate, however, that a large number of midwives are very positive about midwife-led units. A large number of those units are operating successfully throughout the United Kingdom.
The various challenges to existing services need to be met with innovative ways of working to support pregnant women before, during and after childbirth. Innovative solutions to local problems might require professionals to develop a different range of skills. They certainly require professionals to involve the community in devising different arrangements and patterns of provision. Moreover, as Professor Calder points out on page 19 of his report, there is a possibility of consultants working across sites, as Maureen Macmillan and others have highlighted. That is something that NHS Highland should certainly explore, although I agree with Eleanor Scott that Rob Gibson's specific suggestion in that regard is naive.
Can the minister give some positive examples of where the new consultant contract will make a difference so as to ensure the flexibility that will be necessary to give the people we represent accessible services?
The job planning for that is being undertaken now. Those issues should certainly be addressed in the context of the consultant contract, which is a great lever for service redesign. Part of service redesign involves the possibility of working across sites. At question time today, I mentioned my visit to Stracathro on Friday. I was enormously impressed by the number of clinicians from Ninewells who are prepared to go and work at Stracathro on the basis of doing elective sessions there. That is a model that should certainly be pursued. As I was saying before that intervention, it is something that NHS Highland should explore. Clearly, there are difficulties. Under the current arrangements, consultants cannot be compelled to work across sites. Indeed, if they could be, who knows whether they would want to stay in post? While recognising the difficulties, I think that such options should certainly be explored.
The other dimension that is mentioned in Professor Calder's report is the suggestion that "pluripotential practitioners" should be developed. I do not know whether members are familiar with that phrase. Perhaps Jamie Stone's "multiskilling" of staff is a more straightforward way of putting it. That has already been taken on board. The remote and rural areas resource initiative has a joint project with the north of Scotland regional planning group to identify potential models of maternity care in rural and remote settings, and that involves multiskilling.
Will the minister give way?
How am I doing for time, Presiding Officer?
I am quite relaxed if you want to take a couple more minutes.
Professor Calder's report discusses considerable investment in transport, accommodation and the way in which consultants will work. The minister has not mentioned anything about the Government's ability to back that up. On a number of occasions, he has mentioned that NHS Highland has to make up its mind about those things. Does the minister not agree that the problem is a bigger one than NHS Highland can solve on its own?
Absolutely, which is why the matter is first on my agenda. There are many dimensions to it. In particular, we had a debate about the work force, and I noted what Rob Gibson said about consultants. The consultant work force is in fact growing more strongly than before. Indeed, there have also been 1,000 extra junior doctors over the past three years. However, there have been particular difficulties and challenges because of having to deal with the working time directive in that connection.
More broadly, we have done the work through EGAMS, there is a national framework for maternity services and we are doing general work on providing a framework for the reconfiguration and redesign of services. There is a balance between national decision making and local decision making, and I do not think that members would want me to sit in St Andrew's House and decree the shape of maternity services throughout Scotland.
On the notion of balances, the good professor has clearly weighed up what he sees as the clinical risks in terms of what services are provided. What is the minister's assessment or evaluation of the risk that is related to the travel factor that could be added if he goes down the midwife route?
I suggest that that should be the last intervention.
Jamie Stone makes an important point. There is obviously a balance between safety and quality on the one hand and access on the other. Notwithstanding the general comments that I made about midwife-led units, about which I am very positive, we all recognise that the distances that are involved are greater than in most other situations. That is an important material factor, but I do not think that Jamie Stone would expect me to give an instant risk assessment of it. However, it is obviously a crucial issue and it will be looked at by NHS Highland.
I have further general points to make, but I suspect that I ran out of time a long time ago, so I will just mention them in summary. I mentioned work that is being done with the north of Scotland regional planning group. I note that the regional dimension is important; as colleagues will have heard me say, we have provided £150,000 for three regional maternity services co-ordinators—that is just part of the regional dimension.
I want to mention the recent establishment of the national maternity services work force planning group and the establishment of the Scottish maternity development unit. The work force group will oversee the development of a strategic approach to integrated work force planning and service development for maternity services. It will consider a wide range of issues, including the specific needs of rural communities and tools such as birthrate plus—I know that Carolyn Leckie is keen on that, and indeed so am I. There will be a response from the Executive on the work load report on nursing and midwifery soon. The development unit will provide low-cost, multidisciplinary training in key areas of maternity service provision.
In conclusion, I emphasise that the key criteria for reviewing maternity services have always been clinical safety and the quality of patient care. In the Highlands, distance and reliability of transport links overlay those considerations, as I acknowledged to Jamie Stone. I am confident that NHS Highland will thoroughly explore these difficult and complex issues with maximum public involvement— indeed, it will be required to do so. If proposals for change come forward, I will certainly scrutinise them with great care before coming to a final view.
Meeting closed at 18:08.