Friday, February 09, 2007

Plans to strip British public hospitals of maternity units

Midwives are cheaper so no doctor for you! Too bad there is a shortage of midwives too

Women in labour could face lengthy journeys by ambulance to distant specialist units under plans which would strip dozens of local hospitals of consultant-led maternity services. Department of Health proposals unveiled yesterday seek a smaller number of consultant units to deal with the most complicated births and the sickest babies. It would be left to local, midwife-led units to handle the majority of births, while more women would be encouraged to have their babies at home.

Unusually, the health minister responsible for maternity services, Ivan Lewis, was not present at the report's launch. Mr Lewis, the MP for Bury South, has been active in the campaign to save the maternity unit at Fairfield Hospital in his constituency.

The Conservatives have already identified 22 consultant-led maternity units which are threatened with closure, as well as 21 midwife units. Andrew Lansley, the shadow health secretary, demanded to know why Mr Lewis was unavailable for comment at the briefing to launch the report, Making it Better for Mother and Baby. He said the Conservatives had repeatedly asked for clinical evidence to show the need for a reconfiguration of maternity services and the report failed to provide this. "Government nationally seems to be saying that everything has got to change and smaller units have got to be shut down, while locally, Labour ministers say they don't believe it and it's not justified. There's a hypocrisy in that. "These changes are being driven by financial deficits in the NHS and this kind of nimbyism displayed by health minister Ivan Lewis and Hazel Blears, the Labour Party chairman, is patronising to expectant mothers who want to access good maternity services within travelling distance, and to midwives who tell us that they are unable to get a job," he said.

The report, and another on services for children and young people, comes from Dr Sheila Shribman, the maternity and children's health tsar. She said the plans were about change not closure. Dr Shribman, a paediatrician, said she was not able to say how many consultant-led units would close. Decisions would be made locally and reflect local needs, she said."There is no national blueprint. Women will not be losing access to a consultant should they need one. They might not be just down the road — there might be midwifery care down the road."

She denied the move was about saving the NHS money. "I don't believe that the changes are about budget. In fact, if you look at some reconfigurations proposed there might be a need for increased investment."The report was about normalising childbirth which had become too technical in recent years, she said.

The Royal College of Obstetricians and Gynaecologists was cautious in its response.It said the care and safety of mothers and newborn babies should be at the heart of maternity services planning and women should always have the choice of where to have their babies. Prof Shaughn O'Brien, the vice-president of the college, said no woman would be forced to have her baby at home or in a midwife unit and all should receive "full and accurate" information on the risks if there were complications in labour.

The Royal College of Midwives said there was a shortage of 10,000 midwives and the service was facing cuts, job freezes, shortages and financial crises.Miss Blears is the most prominent Labour MP among about a dozen to be protesting on behalf of constituents about local maternity unit closures. She was criticised for joining a demonstration against the closure of the maternity unit at Hope Hospital, Salford, while remaining in the Cabinet.


British obstetrics bad and talk of improvement unconvincing

Childbirth has leapt from the outer reaches of the NHS, where I and many other mothers have laboured in what I can only describe as the Dark Ages, on to centre stage. Ten ministers have broken ranks to campaign against the closure of maternity units in their constituencies. Patient groups are lining up to highlight the risks of longer travel times to fewer regional centres. The Tories are calling the moves "a desperate bid to save money" - although it used to be Tory policy that thrift was a good thing. It is, frankly, confusing.

Are these threatened maternity units as god-awful as the ones that I and my friends have suffered in? In which case, should we rue their demise? Will they be replaced by the warm, cosy corners evoked on Tuesday by the Government's maternity czar (I kid you not), who offered a rosy vision of home births and small, midwife-led centres nestling alongside larger, regional centres with consultants 24/7? It is hard to say, since her report was almost entirely data-free. She also refused to say what distance between home and hospital was considered safe. Ivan Lewis, the minister responsible, did not even turn up to the launch of Sheila Shribman's report. He, of course, has also been campaigning to save maternity units in his constituency.

If the minister is not convinced, should we be? The consensus that all closures are bad is almost certainly wrong. But government really has to do better in selling them to us. Announcing closures soon after trusts went into debt was bound to convince campaigners that the first was a consequence of the second, although it was not.

The plans for larger units are being driven partly by neonatal paediatricians who want to increase the survival rates of sick babies. In Manchester, they hope to save up to 30 lives a year by reducing the number of units in the city. In Nottingham, consultants want to merge two units that are only five miles apart, because they feel that they cannot provide adequate neonatal care if they are spread across two sites.

There is a logic to this. Consultant time is fixed. Junior-doctor time has been severely limited by the Working Time Directive. Consultants want trainees to be trainees, not amateur stand-ins. You can make better use of doctor time at delivery if you make patients travel farther. Several doctors have assured me that a longer journey rarely affects the outcome, because few deliveries are that quick. But it would be nice to know what the consensus is about how far is too far. We could have one unit treating all 722,000 births a year. But we don't. So where do you stop?

Other doctors say that we have already gone too far: Britain already has the largest and most centralised maternity units in Europe. The largest French unit handles about 4,000 births a year, and the largest in Germany 3,000. Each of the units that would be merged in Leeds and Nottingham are already considerably larger. A report by the think-tank Reform in 2005 found no evidence that larger units were safer. Reform also pointed out that maternity care now generates more than half of all negligence claims against the NHS. Most are allegations that brain damage or birth defects were caused by mistakes at delivery. The bill is potentially enormous, up to 4 billion pounds. That is eight times the size of last year's deficit.

It seems to me that there is a simpler argument in favour of larger centres. This is the need to bring more women closer to doctors who are actually available. Only about 60 per cent of women now achieve a normal birth. About a quarter end up having a Caesarean and the rest need forceps or ventouse deliveries. All of these require a doctor. It is impossible to predict which births are going to be tricky. As new mothers get older, it is frankly meaningless to offer them a "choice" of home births and midwife-led centres. The reality is that fewer and fewer clinicians will let them make that choice.

Dr Shribman's vision of 24-hour consultant care is a myth. Even the biggest units have consultants on site for less than half the time. But maximising access to a doctor during delivery - the time when most women are at greater risk than at any other time in their lives - is surely a sane objective. My first child was born at a weekend when the doctor arrived only after the midwives had had me pushing for an hour and a half. He said it was too early and was putting the baby at risk. Only three days ago one friend was told that she was not in true labour and did not need a bed, when in fact she was fully dilated. The stories are endless. Many of us who expected a normal delivery ended up relieved to see the operating table, because it was the first time we felt we were in the hands of a professional.

Midwives are the weak link that no one wants to talk about. When there are 10,000 midwife vacancies, when 60 per cent of those who do work are part-time, some cannot even spot a woman in labour, let alone provide the one-to-one support that controlled trials have shown can significantly reduce adverse outcomes. And when so many are patronising or panicked, the effect can be disastrous. One reason that the number of Caesareans is so high is because so many women become terrified by the feeling that no one is in charge. It stalls their labour.

Ministers are talking about efficiency. Mothers are talking about feeling safe. Right now, we do not. We need far more good midwives. We need to know how far is too far to travel, so that we can distinguish between what is inconvenient and what is life-threatening. We need a minister making the arguments, not a community paediatrician masquerading as a "maternity czar". If we had that, then frankly the proposed closure of 14 out of 282 maternity units might not have become such a controversial issue


`Test teaching ideas before imposing them on children'

So sad that this is not axiomatic everywhere

Children are missing out on the best possible education because teaching techniques have never been tested rigorously, one of Britain's most senior scientists has said. Education needs to learn from medicine and other scientific disciplines by using rigorous experiments to determine which approaches work best, according to Mark Walport, director of the Wellcome Trust, the country's largest independent funder of bio-medical research.

He told The Times that Labour and Tory governments had reformed the education system on the basis of political dogma without any reliable evidence that their policies would benefit children. Whereas the merits of drugs were assessed by randomised controlled trials before they were given to patients, children were taught according to the ideological hunches and opinions of politicians and educationists, who could not know whether their strategies would work.

Questions such as optimum class size, whether boys and girls were better taught separately, and how best to teach literacy and numeracy, had never been investigated by scientific experiment, he said. The best way to identify the best methods was to split similar children into study and control groups and teach them differently, emulating the way that drugs were tested against a placebo. "Many more matters of public policy are susceptible to experiment than is often assumed," Professor Walport said.

The notion of conducting controlled experiments in education is often criticised as unethical, as one set of children would miss out on the superior technique, but Professor Walport said that that was no worse than subjecting every child to untested policies. "It's not unethical to do experiments in education. It is unethical not to," he said. "Many of the educational policies that are put into action are experimental as it is. They are just experiments without controls. When I raised this in Whitehall, I got the response: `You don't possibly expect to compare educational outcomes like this, do you?' But that missed the point. The point is that you do this when you don't know."

Some policies are tried out in pilot studies, but these rarely feature control groups, and the initiatives are introduced nationally before the study's outcome has been evaluated. Research is often conceived to find evidence to support existing policies, rather than to decide what works before policy is decided. "The scientific method, which is to ask the question, is almost the antithesis of the political method, which is to say I'll tell you the solution," Professor Walport said.

The Department for Education and Skills's research budget, now about 4.5 million pounds, was far too low, he said, and the department needed to appoint a chief scientist responsible for ensuring its research meets rigorous scientific criteria.

His call was welcomed by Nick Gibb, the Shadow Schools Minister, who said that too many education policies had been introduced without evidence. He said: "The look-and-say method of teaching children to read is a prime example. Where were the pilot studies that showed it worked? When the first proper study was done in Clackmannanshire, it found that synthetic phonics was a much more effective strategy. It was so successful that children were withdrawn from the control group as it would have been immoral to continue."

Professor Alan Smithers, the director of the Centre for Education and Employment Research at the University of Buckingham, said that it was not always simple to conduct controlled experiments into educational strategies. "There are so many factors that affect success, including the background and ability of pupils and the skill of teachers, that it can be hard to separate out the effect of any one factor," he said. "And the findings of research are rarely strong enough to overturn prior conceptions."

In the balance:

Reading: Whole-word approach to learning to read was introduced without evidence that it was more effective than phonics. Phonics is now making a comeback after research suggested it was more effective

Coeducation: There is little good evidence from properly controlled studies that shows whether boys and girls learn better when taught together or separately

Literacy and numeracy strategies: Introduced across the country after only minimal pilot studies into their likely effects

Specialist schools and city academies: Introduced across the country even though there was no research showing that either would have a beneficial effect

Class size: Little good research exists on the optimum size of the groups in which pupils are taught


Must not criticize "Obesity" -- unless you are the government, of course

From Batty Britain again:

"An award-winning television producer was sacked after describing her boss in e-mails as "Blobby" and a "big fat thing", a tribunal heard today.

Agnes Wilkie, 49, former head of features at Scottish Television, said she regretted sending the messages, but claimed they were typical of the "world of creative television production".


Interesting article by the British National Party here. The so-called "Fascists" have embraced libertarianism -- the diametric opposite of Fascism! Liberty is a great British tradition so there is no contradiction in them doing so.

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