Maternity Services (Gordon)
The first members' business debate is on motion S1M-1935, in the name of Nora Radcliffe, on maternity services in Gordon. The debate will be concluded without a question being put and it will be helpful if those who would like to take part in the debate would indicate that now.
Motion debated,
That the Parliament notes that under-use has been cited as the reason for a proposal to close the midwife-led maternity unit at Insch and District War Memorial Hospital and further notes that a recent local campaign making mothers-to-be aware of the option of local delivery increased the number of women choosing to be delivered there; recognises that there are legitimate local concerns that the midwife-led maternity unit which is to be retained at the Jubilee Hospital in Huntly, the next town, will also find itself under threat of closure in the future unless women are encouraged to use it, and therefore urges local GPs, Grampian Primary Care NHS Health Trust, and Grampian Health Board in consultation with the Scottish Executive to do much more to raise the status of midwives and make better use of their skills, to reverse the trend to "over-medicalise" childbirth and to promote the attitude that birth is a natural process and should be treated as such.
The genesis of the concern that prompted my motion was probably the loss of maternity services at Inverurie hospital 20 years ago, in the teeth of local opposition. However, the trigger was a recent review of maternity services that was undertaken by central Aberdeenshire local health care co-operative in my constituency. That review came to the conclusion that one of the two maternity units at Insch and Huntly should close and that maternity services should be centralised on the Jubilee hospital site in Huntly.
For those who are not familiar with the area, Insch and Huntly are market towns that are 12 miles apart. Each has a fairly evenly populated farming hinterland. Aberdeen maternity hospital is the main maternity hospital in the region and it is 28 miles from Insch. Although the nearest major facility for Huntly is Dr Gray's hospital in Elgin—which is 27 miles away—for historical reasons, Huntly would normally look to Aberdeen rather than to Elgin. The review was prompted by the steady decline in recent years of the number of mothers who choose to give birth in the local units. Another relevant factor is the demographic projection of a decline in the number of women of child-bearing age in the area over the next 15 years.
Obviously, midwives need a certain number of deliveries to maintain their skill levels. Existing local protocols for dealing with maternity emergencies rely heavily on the availability of GP support. It was suggested in the review report that in the area where Grampian doctors—G docs—provide out-of-hours cover, a GP who was responding to an emergency might not have obstetric experience. That might be looked at more closely as a justifiable reason for closing the unit because G docs is a co-operative out-of-hours service that is largely manned by local GPs.
Whatever the reason for proposing rationalisation of services on one site, my concern with the process is that it has started in the wrong place. Much more could and should have been done to investigate why the decline is happening. The decline should not merely have been accepted passively as a fact and reacted to.
The midwives in the units gathered some statistics that were published as part of the report. I find those statistics interesting. Over two six-month periods—one in 1999 and one in 2000—women were asked at the start of their prenatal care where they would prefer to be delivered. It was then noted where they had been delivered. In 1999, 26 out of 41 women in Huntly said initially that they would prefer to have their babies in Huntly and 15 said that they would prefer to have them in Aberdeen maternity hospital. In the event, the numbers were reversed. The place of delivery was Aberdeen maternity hospital for 26 of the women and only 12 were delivered in Huntly.
Initial preferences in Insch were more evenly split—18 for Insch and 19 for Aberdeen. However, again, there was a significant shift over the course of pregnancy and there were only eight actual deliveries in Insch, but 27 in Aberdeen. For those whose mental arithmetic is good, I should point out that the numbers do not tally exactly because some people moved house in the middle of the process.
In 2000, 26 women in Huntly said that their preferred place of delivery was Huntly and nine said that they would prefer to deliver in Aberdeen. In the event, 11 delivered in Huntly and 29 in Aberdeen. Twenty-four women in Insch said that their preferred place of delivery was Insch and 12 said that they would prefer to deliver in Aberdeen. The figures for the actual place of delivery were 13 in Insch and 20 in Aberdeen. Some of the women who would have preferred local deliveries were delivered in Aberdeen because of complications or possible complications. That is absolutely as it should be, but I would like to know more about why there is such a big shift away from local delivery during the course of a pregnancy. I find it hard to believe that it is all for genuine medical reasons.
Another interesting factor is that the National Childbirth Trust mounted an awareness-raising campaign in Insch, to ensure that local women knew that they could choose to have their babies in the local hospital. That had a measurable impact. Whereas, over the period monitored, there were 12 Huntly deliveries in 1999 dropping to 11 in 2000, in Insch there were eight deliveries in 1999 rising to 13 in 2000. Those statistics cover a limited period, but raise questions that are wider than events in Insch and Huntly. They reflect national trends and those questions need to be answered.
According to an article in The Times earlier this month, pregnancy and childbirth were taken over by doctors in the 1970s, when the Peel report recommended hospital deliveries and took away the traditional autonomy of midwives. As a result, mothers lost the right to have one familiar midwife to see them through pregnancy, childbirth and antenatal care—ironically, that is something that every Victorian mother expected as a matter of course.
It is true that more women died in childbirth when babies were routinely delivered at home, but that was before antibiotics, improved housing and nutrition, contraception, and NHS expert care for the small percentage of problem pregnancies that really require a doctor's help. Today, in the Netherlands, 40 per cent of women have their babies at home with the help of midwives. The Netherlands has one of the lowest perinatal mortality rates in the world. America's maternity system is led by obstetricians, but its perinatal mortality rate is higher than Cuba's.
Medical intervention can be crucial for some mothers and babies. No one would deny that or try to obstruct such intervention in any way. However, some of the statistics suggest that we have got the emphasis wrong. The World Health Organisation says that the rate for Caesarean sections should be no higher than 10 per cent to 15 per cent of births. The British percentage is 19 per cent overall—which is bad enough—but, in some areas it is as high as 30 per cent.
According to the Royal College of Midwives, staff shortages in the NHS are a factor. If two thirds of women are left alone during labour because there are not enough staff for continuous care, the anxiety and stress that that can cause contribute to those ever-rising rates of Caesareans and the other avoidable interventions that are more dangerous than natural birth. A midwife who was quoted in the article in The Times stated:
"There are millions of women with scars from Caesareans or from forceps deliveries … who have been taken in by one of the biggest lies in the past 100 years."
I do not know whether I would be quite as forceful as that, but I do think that we have the balance wrong and that it is time to hand back to midwives authority for the vast majority of births. They are ready and waiting. There are 90,000 registered midwives, but only 32,000 are practising in the health service. Many have gone into private practice where they are able to offer the sort of care that they want to give.
We have been over-medicalised for so long that shifting the balance back will need a concerted effort by all those who are involved. Doctors must let go. We have to encourage the midwives to take over; they have the skills and they know where medical intervention is necessary. Women must be given the information and the confidence that they need to make informed choices. The Scottish Executive should be running the sort of awareness-raising campaigns that a voluntary organisation ran so successfully in Insch. The whole thrust of modern health service provision is to bring it as near to the patient's home as is medically and practically sensible. I look forward to pregnant women being seen as patients only in the few instances in which that is necessary, and to their being able to choose to have their babies safely and happily in their own local midwife-led facility.
The closure of maternity services at Insch is still just a proposal that technically, even at this late stage, need not and might not happen. At the very least, we must ensure that conditions are right—that could possibly be as simple as ensuring that attitudes are right—for Huntly to flourish and for Insch, if it does not close, and even Inverurie, eventually to be brought back to midwife-led use.
I pay tribute to Nora Radcliffe for bringing this matter to the Parliament. She has covered a wide range of the issues. This debate is to do not only with Insch; it is to do with rural maternity services in general. We still have a considerable number of community hospitals in the north-east of Scotland—some people might suggest that we have a disproportionately high number. I do not know what the minister, Malcolm Chisholm, will say in his winding-up speech, but I welcome the fact that we still have so many of those hospitals.
Will Brian Adam rephrase that, and say that other areas have a disproportionately low number of community hospitals?
Since the north-east has seven of the 18 that are left in Scotland, we have a very high proportion.
The trend of maternity services in the north-east has been towards centralisation. Initially, it appeared that all services would be centralised at Aberdeen maternity hospital, but largely through the efforts of people in Moray—in particular, my colleague Margaret Ewing—an agreement was reached to set up a significant maternity service in Elgin. That, of course, came at a price—the closure of maternity units at Spynie, Keith, Buckie and Forres. Welcome as it is to have proper full-scale maternity services in Elgin, those who lived in the other areas regretted the loss of services in places such as Keith and Buckie.
I am old enough to have been born at home, but my brother and sister, who are somewhat younger than me, were part of the over-medicalisation that Nora Radcliffe referred to, and had the privilege of being born in Keith maternity hospital, which no longer exists. Turner memorial hospital in Keith is now largely a geriatric hospital. That is a matter for significant regret.
A problem with the over-centralisation of maternity services in the north-east is the roads. In the winter, it is not always possible to get quick access—even for helicopters, if we are in the middle of a blizzard. The distances that are involved are considerable, so the only way that one can deal properly with the problem is to manage patients. Nora Radcliffe quoted statistics to show that patients are being managed. Despite an initial intention to have a baby locally, medical interventions mean that many babies end up being born in Aberdeen, often unnecessarily. It is not just a question of there being more Caesarean operations, because there is a greater number of induced births. There are dangers with the inducement of births, but it is convenient, when trying to manage a service, for births to happen where there are most staff. In the north-east there was a particularly bad period when we had a lot of managed births that happened to correlate with staffing levels. That is not the best way for babies to be born, and it certainly is not best for the mothers and families that want to be involved.
How do we redress the imbalance? It may be that the Executive will refuse to close the hospital in Insch, which is an option that is open to it, but we want to ensure that the required medical support is available locally. The LHCCs will have to address that, because they will have to provide support, so that when appointments are made, people with the appropriate obstetrics and gynaecology backgrounds are available. G docs provides out-of-hours services, and I am sure that it would be possible to provide cover through that scheme, but that would require some lateral thinking.
Will you wind up please?
Are you encouraging me to stop?
I welcome the motion. We should have another look at the issue. We should not encourage over-centralisation of what is a natural process. It strikes me that much of what is happening is driven by medical desires and not by clinical needs.
I remind members that the usual four-minute speaking rule applies.
It is interesting that last week in the chamber we were espousing "breast is best". It was interesting to hear Brian Adam putting forward the great benefits of natural childbirth.
My first point is on Arbuthnott funding. We have a problem, because Grampian did not do well out of that funding. I say that because the Highlands did exceptionally well. I believe that Grampian had one of the lowest settlements from Arbuthnott, which wanted increased access for all. I have serious concerns about many of the community hospitals and facilities in Grampian, because the area has undoubtedly had a poor settlement this year.
Nora Radcliffe mentioned the over-medicalisation of maternity services. My children—they are not children now—are 26 and 27 years old. When they were born, we were being told in this country, "You cannot possibly have a home birth. You have to go to the acute hospital. You would put your child's life at risk otherwise."
It is interesting that, at the same time, mothers in the Netherlands were being told the opposite and were being encouraged to have home births. Nora Radcliffe said that in the Netherlands, 40 per cent of women were having babies at home. I was told today that more than 60 per cent of children are born at home in the Netherlands. I lodged a written question to the Minister for Health and Community Care some time ago to ask whether NHS staff will be allocated to assist with home births, because that is the preferred option of parents. Like Nora Radcliffe, I think that we are considering parents' choice. That point has come through in the debate. Many parents would like to have that choice, provided that the appropriate services and skills are available.
The Royal College of Midwives also mentioned a serious lack of consultation in the area that Nora Radcliffe referred to. It is not the first time that members of the Health and Community Care Committee have heard that. Such comments were made during our investigation into the Stobhill situation. Whenever local services are changed, reconfigured or restructured, there seem to be serious problems of lack of consultation. I understand that account was not taken of the wider catchment area or that questions were not asked to ensure that risk assessment took place so that people were reassured about that.
The distance between Insch and district hospital and Aberdeen maternity hospital is 28 miles and the distance between Huntly and Elgin is 27 miles. If Nora Radcliffe's colleague Jamie Stone were present, he might compare those distances with the 150 miles' travel that many parents will face in Caithness and Sutherland in the Highlands, given that the consultant-led service there might be reduced. Compared with that, 27 miles is almost next door.
Central Aberdeenshire local health care co-operative said:
"Both communities have expressed an opinion that would suggest that Insch residents would not use the Huntly facility nor would the Huntly residents use the Insch facility."
That seems to be the Gordon equivalent of the Falkirk bairns not wishing to be born in Stirling. The issue is emotive. It does not matter where a patient has a hip operation or has their appendix taken out, but where children are born matters to families—it is important. I hope that whatever great clinical health guidelines are produced take account of that basic point.
Women must have the information that will allow them to make informed decisions by balancing risks. I am not sure whether that information is available. I will not read out statistics, but there is something odd about the total number of bookings for Huntly and Insch. Comparison of the total bookings with the total deliveries illustrates stark figures. Why are only a quarter of children who are booked to be born in Huntly and Insch delivered in those places? Is that the parents' choice, or is the medical profession giving other advice?
I am grateful for the opportunity to speak. The debate concerns the changes to maternity provision in Gordon, but my neighbouring constituency is similarly affected by the decisions of the health trust involved. Many of my constituents use the facilities at the Insch and District War Memorial hospital and will be adversely affected by its closure.
We must address why the changes to the maternity services in our rural Aberdeenshire hospitals are taking place. The changes are driven by funding difficulties caused by the Arbuthnott formula, which allocates the lowest health spending to Grampian. Grampian will receive just £991 per person for health services. All the other health areas will receive funding of much more than £1,000 per person. For example, Tayside Health Board—a similar authority to Grampian—is to receive £1,166 per person. The situation cannot be right. The Minister for Health and Community Care, Susan Deacon, provided a table in answer to a written question that I lodged on per capita funding for 2003-04 and long-term planning. The figures are stark. The only one of the 15 health boards to receive a three-figure sum rather than a four-figure sum is Grampian.
I am grateful to Mike Rumbles for making that point, which he has illustrated well. Will the Liberal Democrats join us and lodge a motion to reverse the Arbuthnott formula? We need to send the formula back so that we can have it reassessed.
I do not want to play party politics in a member's debate. I am speaking up for my constituents and for the north-east.
What is the reason behind the figures? I recently discovered that the formula used by Arbuthnott to allocate funding to our health boards may have changed the definition of rurality. That in turn is causing great difficulties for Grampian Health Board. I wonder why, when the Minister for Health and Community Care has said consistently that the funding formula favours rural areas and when half the population of Grampian Health Board area lives in rural communities, they receive one of the lowest levels of funding from the Scottish Executive.
Apparently, the reason is simple: the further away people are from medical services, the more funding they get. In the north-east, we are fortunate to have a good network of community hospitals and GP services. However, our health service managers have worked out that if they centralise medical services in Aberdeen and close down rural medical services, because of the Arbuthnott formula the population in Grampian Health Board's area will receive more money from the Scottish Executive. That is a perversion.
Closing down Aberdeenshire community medical services and using so-called economies of scale in the city of Aberdeen's hospitals is ridiculous and it should play no part in our health managers' thinking. When we consider such issues, are not we forgetting the patient? The closure of the maternity services at Insch typifies the trend in our NHS managers' thinking. I am afraid that I do not trust the trusts in such matters.
The Arbuthnott funding formula is at the heart of the problem. The board has to manage on the funding that it has. What I want to avoid at all costs is a penny-pinching approach to our community medical services. Only by changing the flawed Arbuthnott formula will we save community hospitals that are under threat from the centralisers. I say to the minister that it is in the chamber of the Scottish Parliament that we will secure the future of our much-needed community hospitals at Insch and throughout Aberdeenshire and the north-east.
I could not resist the opportunity to try to get into the debate. I thank Nora Radcliffe for lodging the motion that brought it about.
I have some supporters—I hope that I can call them that—from St Ninian's Primary School in Gourock sitting in the public gallery.
I want to make a plea on behalf of the local Rankin maternity unit. The St Ninian's Primary School pupils' presence is timely, as many of them will have been born in the Rankin maternity unit. They will surely verify the concern that exists in my community about the future of the unit and how much the unit is valued by the community.
I welcome the establishment of Mothers for the Rankin. My colleague Trish Godman and I met some of its members on Friday. It is a powerful alliance of mothers who are not politically affiliated. We also met GPs, who outlined their demands, which are not the same as the consultants'.
The consultants in their ivory towers have deemed that a maternity unit needs to have 1,000 births a year. If we accept that principle, we accept the centralisation of maternity services throughout Scotland—not just in Argyll and Clyde, in Greenock or Port Glasgow or in Gordon. That will inevitably drive us down the road of competition.
I ask the minister also to consider the artificiality of health board boundaries. The fact that trusts and health boards are forced to consider maternity services within artificial boundaries has thrown up some massive contradictions.
When Trish Godman and I spoke to Mothers for the Rankin on Friday, what mattered to them was access to quality care, choice and continuity of care. They said that they do not want super-duper maternity units that do not meet those criteria and that force them to give up their choice. I hope that others will, like me, take every opportunity—in the Parliament and with the health boards and trusts—to make that point forcefully on the mothers' behalf.
I congratulate Nora Radcliffe on securing the debate and on giving members the opportunity to discuss the important matter of maternity services.
The motion was well timed, since we are starting to implement and address the action points in "A Framework for maternity services in Scotland", which Susan Deacon launched in February. At the beginning of that document, various broad themes are emphasised that are consistent with several points made by Nora Radcliffe.
First, the framework reminds us that pregnancy and childbirth are normal physiological processes in women's lives. Nora Radcliffe's motion points that out. Secondly, the framework states that maternity services must deliver a woman and family-centred approach to care and support, planned in partnership with the woman. Finally, it reminds us that maternity services should be essentially community-based and midwife-managed wherever possible, with an emphasis on continuity of care.
Stand-alone midwifery and GP units such as those in Gordon have developed in rural areas to meet the needs of people who make the choice not to travel to a distant, consultant-led centre. As Mary Scanlon said, their use involves careful balancing of risk and choice, but they meet the very real needs of a number of women. Provided that the risks are fully explained, appropriate criteria for early transfer in emergencies are strictly adhered to and appropriate consultant advice and regular updating and training of staff in key skills such as resuscitation and stabilisation continue, such units will continue to provide a valuable service.
However, from time to time health boards and trusts must consider all their services to ensure that they are still consistent with need. Such assessment is rightly for NHS bodies to undertake locally, on the basis of their detailed knowledge of local circumstances, so members will not expect me to become closely involved in the details of the situation in Gordon.
I have listened carefully to the minister. Does he agree that the Arbuthnott formula is forcing Grampian trusts and Grampian Health Board to centralise their services to save money, in the mistaken belief that that will lead to economies of scale? Does he further agree that the excellent community services that we have in the north-east are under threat because of the flawed Arbuthnott formula?
I will not comment on the particular issue of Insch hospital, but I am assured that the proposed changes, which have not yet been before the health board, do not entail any cost savings. Mike Rumbles was wrong to pursue that route in relation to the motion. I remind members that the Arbuthnott settlement gives Grampian a 5.5 per cent revenue increase this year. Although we do not have detailed allocations for the next three years, we have announced that Grampian will receive minimum increases of 6.5 per cent in 2002-03 and 7.4 per cent in 2003-04. By any reckoning, those are large increases, which are unprecedented in recent times.
Duncan McNeil moved us on to a different area. I cannot get too involved in that, but I remind members that there are no specific proposals yet for the Rankin. When proposals are drawn up, they will be subject to full and proper public consultation and will have to be consistent with the princi-ples of the framework. Duncan McNeil referred to health board boundaries. The framework makes it clear that cross-boundary issues must be considered.
Decisions must be taken following detailed consultation. Mary Scanlon reminded us how important that is in relation to many reviews and that is made clear in the Scottish health plan, "Our National Health: A plan for action, a plan for change". The maternity framework builds on that and emphasises that public and professional consultation is fundamental to the planning, development and provision of local maternity services.
It is vital that women's care provides continuity, from pregnancy to childbirth and beyond. Midwives have a central role to play. They are by far the best placed to deliver the one-to-one support that women have a right to expect during such a major event in their lives.
Inevitably, most expectant and new mothers' contact with the NHS takes place during pregnancy and after birth, but it is crucial to get all the interactions, including childbirth itself, right. Midwives have always been instrumental in ensuring that that happens and the framework reinforces and supports their role.
Individual choice is an issue that often comes up when matters affecting maternity services and childbirth are under discussion. That is right and proper, as Nora Radcliffe emphasised. Women's experience of childbirth—and that of their partners and families—can be hugely affected by whether the birth takes place at home, in a small, homely, local maternity unit or in a specialist unit in a large hospital.
Is the minister satisfied with the recruitment and retention of midwives in rural areas, as that is a significant factor?
That follows on from the importance that we attach to midwives in our strategy. I hope that I have reassured members about that.
Many members have emphasised the importance of informed choice, with women as equal partners in decision making. However, we must remember that pregnancy and childbirth are not risk-free. Obstetricians, GPs and midwives all have important roles to play. They should not promote one model of maternity care over another, but it is for them to explain to individual women the risks associated with any given model of care. It is for them to provide all the information that women need to help them to make the appropriate choice and it is for them to involve women as equal partners in the decision-making process.
Community-based, midwife-managed services will in many cases be the first option, not only for antenatal and postnatal care, but for childbirth. They might well offer a model for service provision in the more remote and rural parts of Scotland where the only alternative is a long journey to the nearest specialist unit, but they cannot be divorced entirely from specialist care. It is extremely important in every case to maintain links with a designated consultant obstetrician. The framework makes that clear.
It is obvious that the role of the specialist maternity unit and of consultant-led care must not be sidelined or undervalued. In many ways, it is because of the advances that have been made at the high-tech end of obstetric care that pregnancy and childbirth entail so much less risk than in times gone by.
Will Mr Chisholm give way?
I am almost out of time.
As I have said on more than one occasion, we are in the process of implementing the framework across Scotland. We are doing so in close partnership with health boards, trusts and professionals who provide services on the ground. The framework does not pretend to be a blueprint for the ideal maternity service, but it offers a set of key principles that we expect the NHS in Scotland to apply when developing its strategies for services in the areas that it serves.
I commend the framework as essential reading to everyone who has participated in the debate and to anyone who is interested in how we want to take forward this vital aspect of the many services that our NHS provides.