Choosing Where to Have a Baby

The latest NICE Guidance on childbirth suggests that straightforward births are safest in a midwife lead unit, and that for ‘low risk’ women having their first baby, there is a ‘small increase’ in the risk of serious medical problems, such as death and brain damage. These occur at home in 9 per 1000 of first time births, compared to 5 per 1000 births in an obstetric unit. The risks are small but the outcome can be catastrophic. So how is a mother supposed to choose?

Many NHS obstetric units are creaking at the seams which is why a home birth sounds so tempting. As one midwife told MD: ‘We know what we could do to give families brilliant care and we desperately want to do it. But we just don’t have the staffing levels. So the service has become a production line where we try to deliver a minimal safe standard of care where mother and baby survive unharmed, but we don’t have time to put into building up meaningful relationships, getting breastfeeding off to a brilliant start, making sure the stitches are okay, etc. You know the parents want to ask you all sorts of questions and they want your time and reassurance, but we have to send them home as quickly as possible. And some end up with episiotomies and C-sections that we may have prevented. Sometimes we have to close the unit and turn mothers away because we’re full.

On the worst days, when there simply aren’t enough bodies on the ground, I wouldn’t want to have a baby on the unit I work on. I love being a midwife but not being able to deliver the standard of care I dreamed of when I was training is the biggest disappointment of this job. That, and the constant fear that we’re going to harm a mother or baby by not spotting their distress in time. And that we’ll be blamed and hung out to dry if things go wrong, and the ‘system’ will get off scot free. 20% of the obstetric budget gets spent on litigation. It’s madness, but if you speak up you worry for your job.’

Obstetric care in the NHS is as safe as it’s ever been, and serious harm to mother or baby is rare. But harm does happen, and most of the NHS litigation spend goes on compensation for birth injuries. It’s also common for women to say they were left alone for long periods during hospital labour. The NHS is short of up to 4000 midwives to provide a safe service, and obesity and older mothers are making childbirth harder and riskier. Homebirth seems very attractive but nearly half of women who start off having their first baby at home end up getting transferred to hospital. And not all mothers are aware of the risks.

As one told MD; ‘I was young and fit for my first pregnancy, and I can remember being strongly encouraged to try a home birth by my midwife. I did hypno-birthing, which was very effective, and the pain was the easy part. The hard part was trying to persuade the two midwives allotted by the NHS to come to help us. It took seven and a half hours from our first call saying I was well into labour and three and a half hours from our call saying we were really in need of assistance from a midwife. They simply wouldn’t believe me when I calmly said I was in labour. But I was. I remember feeling afraid, telling myself they were going to come soon, surely they would. They finally arrived just as I was about to deliver. Our daughter was born 12 minutes later, grey and cold with an Apgar of 2 and was whisked off to hospital. She’s now fine, but we were very, very lucky. If I meet anyone now thinking of a home birth, I say you may not be believed if you call the midwives and tell them calmly that you’re in labour and need help. You need to scream, shout and go into a full One Born Every Minute act. Being relaxed, self-hypnosed and in less pain at home is no use if no one believes you’re about to deliver.’

Home birth can be wonderful with the right support, but only if the risks are fully understood, there are enough midwifes on duty and women in labour are listened to and believed. The NHS needs to address these issues carefully before we encourage more women to give birth at home.

Here’s a letter from Jeremy Hunt to Dr Kim Holt pledging his support for NHS staff who speak out about poor care or wrong doing. It also announces the Francis review of NHS Whistleblowing which should have reported by the end of November. If it is delayed until after the election, I shall be very annoyed and saddened, but not surprised.

Jeremy Hunt letter to Dr Kim Holt June 2014

Choice Words

When MD debated the Health and Social Care Act with its creator, Andrew Lansley, on BBC 1’s Question time 3 years ago, my main concern was its focus on competition (86 mentions) over collaboration (0). The most competitive, consumerist health service in the world (America) is also the most expensive, unfair and wasteful. It spends 16.9% of its GDP on health, compared to the UK’s 9.27%, and yet average life expectancy is lower. The UK also spends considerably less than Holland (11.77%), France (11.61%), Denmark (10.98%) and Canada (10.93%). No wonder it’s struggling.

Competition and choice require spare capacity which the NHS was never going to be able to provide with an ageing population and a £30 billion black hole in its finances, and it’s not easy to shop around and travel for treatment when you’re ill. Yet when the Bill was enacted, a ‘factsheet’ was produced by the DH claiming ‘choice and competition are a powerful means for the NHS to deliver high quality services for patients, and value for money for taxpayers’ and ‘there is emerging evidence of the benefits of competition in the NHS. Where there is competition and choice, it leads to better outcomes.’ Strange then that the Five Year Forward View written by NHS England boss Simon Stevens last month doesn’t mention the word competition once.

Even more surprising, in a recent interview with the Health Service Journal, Lansley’s successor Jeremy Hunt admitted patient choice ‘was not the main driver of performance improvement, contrary to the emphasis placed on it by various governments and senior NHS leaders since the early 2000s… there are natural monopolies in healthcare, where patient choice is never going to drive change.’ He also admitted ‘the market will ever be able to deliver in the top priority area of integrated care…’, ‘choice is ‘particularly irrelevant in emergency care’ and market forces’ would not create good integrated community care – one of the service’s main priorities.’

This apparent about-turn in ideology coincided with an excellent report by the New Economics Foundation called ‘The Wrong Medicine’, which summarises the overwhelming weight of evidence that competitive markets are bad for healthcare. Pointless competitive tendering is risking the ruin of some excellent, well established sexual health services. And lobbying by Spinwatch and 38 Degrees has finally managed to get NHS England to publish where its money goes, and has revealed how expensive it is to run a hugely complex health market that doesn’t work, with vast sums still spent on management consultancy and legal fees. The NHS has now hit a wall financially, with foundation trusts posting their first ever overall deficit. To balance the books, services are being widely rationed and restricted, and patients are being prevented from moving around the NHS to the hospital of their choice. So for Hunt to promote choice now would have been politically disastrous.

The Steven’s plan may now be the only game in town, but his belief that the NHS can somehow conjour up another £22 billion of savings in the face of an increasingly demanding, sicker, older population beggars belief. What is clear is that, once the election is out of the way, the NHS is going to be ‘transformed’ (not reorganised or restructured) like never before. GPs can’t cope with demand and half of GP practices have vacancies, emergency departments are stuffed to the gills and critically ill patients are dying when they could be saved. So Stevens has come up with Multispecialty Community Providers (MCPs), Primary and Acute Care Systems (PACS) and a redesign of urgent and emergency care. It looks faintly plausible on 40 pages of A4, enough to encourage George Osborne to pretend to put £2 billion more into the NHS (but only £1billion extra). But it will require a massive effort of collaboration across the NHS where organizations stop fighting over their individual pots of money. Steven’s first challenge – to get the few Foundation Trusts that are still sitting on profits – to share them with the rest of the NHS is facing stiff opposition. Managers are still being blamed and sacked for missing their targets, so why give up your nest egg?

The Rt Hon Jeremy Hunt MP

Secretary of State for Health

Department of Health

Richmond House,

79 Whitehall,

London SW1A 2NS

 

 

Wednesday 10 December 2014

 

Dear Mr Hunt,

You will be aware that on November 18 the Patients Association published a report outlining numerous failings on the part of the Parliamentary and Health Service Ombudsman (PHSO). We included in our report the personal accounts from a sample of seven patients, or their relatives, who had experienced an unacceptably poor service from the PHSO. The report provides evidence of incompetence by the PHSO in its flawed investigations process, unacceptable delays, bias in favour of the service being complained about, lack of transparency and, perhaps most shocking of all, a complete lack of compassion in their dealings with people who are seeking their help.

We are greatly concerned for the impact of the failing PHSO on those people who have contacted the Patients Association to tell us of their experiences. What is of equal concern is that a key part of the role of the PHSO – to ensure that learning from these tragedies takes place at local level – is not happening. The PHSO should be finding out why and how these incidents have happened and what learning has taken place to ensure that there is no recurrence. Instead, the PHSO is simply compounding the problems already encountered by these patients and their families and apparently doing nothing to prevent repetition. In our report we asked both Government and the Public Administration Select Committee to read our patients’ stories, consider our recommendations and to hold the PHSO to account for its actions. We now repeat that request.

As a result of the publicity surrounding the publication of our report, we have been inundated with further complaints about the PHSO’s mishandling of referrals made to it – more than 140 cases so far. The Patients Association is a charity with far more limited resources than the PHSO, but we are being approached by patients and families on a daily basis who feel they have nowhere else to go. The situation is critical and many of the people who have approached us are feeling let down, exhausted and desperate for someone to listen to them and put right the wrongs they have suffered. Some of the accounts are harrowing and heart-breaking and it is hard to believe that these things are happening to vulnerable people in hospitals and other care settings.

If the PHSO was a school or a hospital, evidently failing so demonstrably, special measures would be introduced as a matter of urgency to stop the rot and prevent the situation from deteriorating further. Why is equivalent action not being taken in relation to the PHSO?

Your priorities as Secretary of State for Health, of compassionate care and transparency, mirror those of the Patients Association and I appreciate how seriously you view these aspects of your role. For the sake of the patients and their families who continue to be so badly let down by a service which is just not fit for purpose, I urge you as the Secretary of State, to take action to arrest the torrent of poor practice by the PHSO. I believe that as a matter of urgency, interim measures should be put in place to ensure effective management of all cases referred to the PHSO.

We are compiling a summary of all of the complaints we are receiving and I will be happy to provide you with a copy of this information if you would find that helpful.

I must add, that we are also hearing of many examples of excellent care provided by staff across the NHS and we will be reporting on these in our relevant publications. For now though, these patients and their families are our priority.

 

I look forward to hearing from you.

 

Yours sincerely

 

Katherine Murphy,

Chief Executive, the Patients Association

 

Cc Mr Bernard Jenkins

Chairman Public Administration Select Committee

 
 

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RESPONSE FROM PHSO PRESS OFFICE

Parliamentary and Health Service Ombudsman Julie Mellor said:

 

“We are the final tier of the complaints system and our job is to give final decisions on complaints about public services. We help 27,000 people every year. Because we are doing more investigations we have upheld a record number of complaints this year, giving more people justice. We have succeeded in doing this whilst maintaining customer satisfaction levels with our service and decisions.

“We are disappointed that the Patients Association, despite several requests, has chosen not to provide us with details of people’s concerns about our service.

“We stand by the quality of our decisions. Any poor experience of our service really matters to us. The biggest driver of satisfaction with any Ombudsman Service is whether the complaint is upheld or not. We recognise that sometimes it has taken us too long in coming to a decision and that we need to get better at talking to people. That’s why we are modernising so we can provide an even better service to the tens of thousands of people we deal with every year.”

 

 

Jeremy Dunning

Senior Press Officer

Parliamentary and Health Service Ombudsman

T: 0300 061 4220

E: Jeremy.Dunning@ombudsman.org.uk

W: www.ombudsman.org.uk

 

 

 

This one of my favourite investigative reports by the brilliant, much missed Private Eye journalist Paul Foot. The current PFI debt disaster facing the NHS was entirely predictable, and predicted by many even before Labour took office in 1997 (most notably Professor Allyson Pollock and her colleagues) We now know how truly staggering PFI debts for the NHS are. For example,

North East build cost £812 million,  total repayment  costs by NHS  £5512 million

North West build cost £1345 million, total repayment costs by NHS 10,325 million

North (Leeds area) build cost £903 million, total repayment costs by NHS £4,388 million

Even allowing for maintenance and running costs, these mark ups would amaze any loan shark. Especially given that the NHS wont even own the buildings even if it does manage to pay back the outrageous loans.

PFI was the brainchild of the Tory frontbencher David ‘Two Brains” Willets.  Labour and the TUC vigorously opposed it in 1996, and in a commons debate on May 1, Labour frontbencher Sam Galbraith nailed its attraction to the Treasury: ‘The Private Finance Initiative is basically about government bodies borrowing money but not having to set it against the public sector borrowing requirement. Today the private sector will only get involved in the PFI within the health services if it carries no real risk. The result is a financial sleight of hand, a massaging of figures as a result of which the increase in the public sector borrowing requirement is not shown and is this a matter of deceit.’

Labour’s Harriet Harman was equally unimpressed; ‘When the private sector is building, owning managing and running a hospital, that hospital has been privatized.’

Paul Foot’s fascinating report may be a decade old, but it remains a very powerful contribution and warning of the dangers of poor value deals in the public sector, the appalling debts that result, the greed and profiteering of the private sector and the reckless stupidity of politicians who are still trying to keep PFI alive with PF2. Instead, the government should buy back these debts and renegotiate the deals for an amount that represents fair value to the NHS and the taxpayer.

As Paul Foot concluded in 2004

‘What is already clear is the awful legacy PFI has left behind. Is it cheaper for the taxpayer? No it is not. In every area it has been adopted, it has cost more, and will go on costing more. The PFI buildings are as prone to disaster as buildings constructed by any other method…. ‘Borrow more and charge more’ will forever be the  PFI slogan of government, even if that means wholesale abdication from responsible accounting and eventually from all democratic government.’

PFI Report Private Eye 2004