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Maternity Services (Ashford And St Peter's Hospitals)

Volume 404: debated on Wednesday 7 May 2003

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4 pm

May I ask you, Mr. Deputy Speaker, to convey to Mr. Speaker my thanks for this opportunity to raise a very serious quality of care issue affecting my constituency and that of my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond)?

I have two preliminary points. First, I do not view this opportunity as a party political occasion. That is the last thing with which I wish to get involved. Secondly, although there may be criticisms of individual people, the overwhelming majority of the trust's staff work their socks off under very difficult circumstances and I mean no criticism of them in any shape or form.

I shall start by setting the scene for this brief debate. The Ashford and St. Peter's Hospitals NHS Trust was set up in 1998 from a merger of two separate hospital trusts. One was the Ashford hospital trust, which is in my constituency and serves my constituents and those of the hon. Member for Feltham and Heston (Alan Keen), and the other was St. Peter's hospital trust in Chertsey, which is in the constituency of my hon. Friend the Member for Runnymede and Weybridge. Therefore, we have a joint interest in the matter.

The merger was, to put it gently, controversial and problematic. From its first moment, the trust has lurched from one financial crisis to another. As a result, in 2000–01 it was awarded no stars at all and the upshot was that it was selected for franchising of its top management. That was a controversial experiment. All that I will say about it, because it is not immediately relevant to the debate, is that luckily the franchise plan seems to have disappeared without trace. I urge the Minister not to look for it because he will realise if he rediscovers it that to implement it he would have to find much more money than would be needed to deal with the financial issues that I am about to raise. In fact, it would be useful if he tore up the plan because it mainly contains attempts to make yet more cuts at Ashford hospital, and he will have a battle on his hands if he tries to do that.

Ashford's maternity unit was closed the year before the merger. It goes without saying that that was fiercely opposed as well. Essentially, there were two justifications for the closure of what was then the maternity unit in my constituency: first, that it was unsafe and secondly, that if it continued as it was, the royal colleges would withdraw their recognition of it for training purposes. Given such arguments, I suppose that one had to listen carefully to them.

The objections to the closure were that St. Peter's simply would not be able to cope with the extra work, however hard-working and dedicated the staff, and that it would lead to poorer services and, in the most extreme case, to personal tragedy. That is exactly what has happened.

Among its many recommendations, the report of the Commission for Health Improvement on maternity services at Ashford and St. Peter's hospitals suggests doing more maternity work at Ashford hospital. I agree, but we should go further and reopen the maternity unit at Ashford. That decision would have the support of the trust. There are many examples in this country of midwife-led delivery units and such a unit would go a long way to solving the problems. I urge the Minister to back that idea.

My hon. Friend may be aware that I have received a written answer from one of the Minister's colleagues that indicates that although there will not be any additional money for the implementation of the recommendations of the report there will be a Government response. Will he ask the Minister whether that response will cover not only the wider issues that the report raises but those that it raises that relate to Ashford and St. Peter's?

I do not think that I need to ask the Minister, as my hon. Friend has done exactly that and I am sure that we shall receive an answer in due course.

As I read the report, two themes underlie what has gone wrong. The first is inadequate funding; the second is insufficient staff. I do not want to put the matter too indelicately, but the trust is bankrupt. It is trading illegally and ran out of cash to pay its bills last Christmas, as did other hospitals. Despite the fact that it is making cuts, the trust has been kept afloat only by annual bail-outs. It has a brought-forward debt of more than £7 million. Last year's debt was £11 million and the trust is predicting the same or worse this year. The trust faces a stark choice: continue to trade illegally or cut even more services. Unless the Government end the underfunding of that trust, there is no way that the 40 recommendations will ever be implemented.

The other underlying theme is staffing. Recruitment and retention at the trust are huge problems and the facts speak for themselves. The midwife vacancy rate is 28 per cent. and the maternity registrar vacancy rate is 40 per cent. That is the extent of the staffing problem. However hard the people in post work, it is no surprise that that situation causes service quality problems or that it leads to the use of locums and agencies, which adds to the financial crisis.

The primary cause of that inability to recruit and retain is the local cost of living. There are some simple facts in the report. The average cost of a house nationally is £145,000, whereas the average cost in Ashford is £195,000 and in Chertsey, in my hon. Friend's constituency, it is £231,000. Those prices must be considered in the context of national pay scales. The situation has been made worse since the closure of the maternity unit at Ashford because all the staff on the Ashford site get the outer London weighting, which is £2,522 a year, but none of them do at St. Peter's. When the Ashford unit was closed, people did not go to St. Peter's—surprise, surprise—but went into London. The consequence was catastrophic. The Minister must deal with the pay pressures of south-east England and the pay differentials across the two sites.

I shall now deal with the details of the report, although there are far too many to talk about in such a short debate, so I have had to select what I consider to be the two biggest problems: the staffing problem and a consultant problem.

The staffing problem involves not only vacancies but funding, which is also wrong. One example of many says it all: established posts for midwives. Although the Minister will put me right if I am wrong, as I understand the matter, the Government and the national health service use Birthrate Plus to say what the standards should be. If the trust operated up to the Birthrate Plus standards, it would have 152 whole-time equivalent midwives. However, the Government funds the trust for only 99 midwives, not 152. That is bad enough, but the reality is that the trust only has the equivalent of 70 whole-time midwives. Given that fact, it is no surprise that page 35 of the report says:

"The trust's funded establishment of midwives is one third less than the establishment recommended by Birthrate Plus. The trust's current permanent midwifery staffing levels are less than half the Birthrate Plus recommendation."
The midwives that we have work as hard as they possibly can and are skilled and dedicated, but they do not stand a chance while those circumstances continue. Not only must the underfunding of the trust end, but the proper funding of establishments must become a priority.

I shall now discuss the consultant problems. I am talking only about two of the trust's eight consultants. I would not want anyone to think that my criticism is levelled at all of them. The report's key conclusion on the subject is nothing short of damning. At the bottom of page viii in the executive summary, it says:
"The consultant obstetricians and gynaecologists do not function as a team. There are poor working relationships and very challenging human resource issues within the consultant group. These difficult circumstances have diverted management time and have been a barrier to more effective team working within the service. The situation is unacceptable, poses a risk to the quality of patient care and requires urgent resolution."
That is blunt and damning and requires action.

Part 8 of the report spells out the issues a little more clearly:
"CHI found substantial evidence of problems that impact upon the ability of consultant obstetricians and gynaecologists to work as a cohesive team. Other bodies are currently involved in some of the associated issues. The General Medical Council has made a judgement about the professional conduct and fitness to practise of one of the clinicians working in the maternity unit. The National Clinical Assessment Authority has been contacted for advice. The Centre for Effective Disputes Resolution…is working with the trust to provide a mediation service. It is not appropriate for CHI to investigate or comment on individual clinicians".
Why ever not?

I spoke to the chairman about the issue and on 1 May he wrote as follows:
"You are aware that Kevin Gangar had a case concerning his conduct considered by the GMC in February 2002. He was reprimanded but returned to work in the Trust in March 2002 with the recommendation that he should only work under specified supervision. Under these circumstances the Trust were deterred from 'stronger action".
I think that the time for stronger action has come. I have a simple question for the Minister: will he back the dismissal of Dr. Gangar? I hope that he will.

Another issue arises from the subject of consultants, but it is almost totally ignored by the report. There is just a brief mention of it in the introduction. That, really, is the reason why the report came about in the first place. It says:
"This followed the death of a baby in the trust's maternity unit. At the time of writing, the death of this baby is still the subject of a police investigation."
That is all there is on the subject in the report. What actually happened was that the trust properly and swiftly reported the death to the coroner, and I applaud them for it. The coroner, having considered the circumstances, called in Surrey police, who investigated what they described as a potentially serious offence.

The clinician concerned was a locum employed by BUPA. He was suspended by the trust. He then left the trust and went back to BUPA. BUPA was formally informed of what had happened, and—amazingly—did not do much except place its locum in Chichester, where he remained carrying out his work until he left the United Kingdom. That cannot be right and my question to the Minister is, will he investigate? What, if anything, was the health service in Chichester told about what had happened? I have not investigated, as it is not in my constituency, but I have had a discussion with my hon. Friend the Member for Chichester (Mr. Tyrie).

There is a further aspect to this deeply disturbing issue. For reasons that will become clear, I shall approach this aspect with care. The police investigation resulted in a decision to charge someone. What happened during that investigation and what has happened since a decision was taken, is worthy of further inquiry, consideration and debate. Earlier this week, I received from Surrey police the following statement, which is headed "Dr. Vladan Visnjevac":
"Proceedings against a man have been commenced by obtaining a warrant for his arrest. This warrant has been obtained because he is no longer within the jurisdiction. These proceedings are now active for the purposes of the Contempt of Court Act".
I respect that statement, as I respect the rules of this House, and I am aware that I am protected by parliamentary privilege so the last thing that I want to do is prejudice justice or a fair trial. There will come a time, however, when the Minister will need to investigate that issue.

The picture that emerges from the report is that my local maternity unit has serious problems. My constituents are receiving an inferior service. The report confirms that the investigation was justified and I applaud the trust for requesting it.

I shall end with a few questions for the Minister. Will he end existing underfunding? If he does not, things will get worse, not better. Will he increase the number of funded midwives? If he does not, the problems will continue. Will he arrange for St. Peter's staff to receive the same outer London weighting as the Ashford staff? If he does not, staff vacancies will continue. Will he back the dismissal of Dr. Gangar? If he does not, consultant troubles will continue. Will he investigate BUPA? If he does not, more tragedies might happen. Will he scrap the trust franchise plan? If he does not, he will have to find even more money. Most of all, will he support the reopening of a maternity unit at Ashford? If he does not, the unacceptable pressures and troubles at St. Peter's will continue. If he does, however, he will deserve and receive the thanks of us all.


I congratulate the hon. Member for Spelthorne (Mr. Wilshire) on securing this debate on the future of maternity services at Ashford and St. Peter's trust.

As the hon. Gentleman knows, we are committed to modernising all maternity units throughout the country, to increasing the number of midwives and providing women with greater choice in childbirth, and to ensuring that women receive the highest quality of maternity care. Those aims are key to the direction in which we are travelling and to much that the Government are doing in this area.

Maternity services are a core function of the NHS. About 560,000 deliveries took place in England in 2000–01. We are committed to ensuring that the care provided in maternity units throughout the country, including St. Peter's hospital, is of the highest quality.

I acknowledge the concerns that the hon. Gentleman raised and I am aware that the maternity service has experienced well documented problems. I reassure him that the Department, the strategic health authority and the trust take such issues seriously. Unfortunately, he will know that even in the best units there are, occasionally, tragic events. The families involved in such tragedies have my heartfelt sympathies. The NHS and the Department strive to eliminate all causes of such events and to learn from them to continue to improve service safety and quality.

For that reason, in May 2002, the Department and the trust asked the Commission for Health Improvement, an independent body, to undertake an investigation into the management, provision and quality of maternity services provided by St. Peter's hospital, so that women, their partners and the wider public could be reassured about its services. The report published in March this year identified various areas for improvement, including problems with staffing, concerns about patient information and involvement and the need for improved team working. However, overall the unit was found to be safe and improving, despite many of the challenges.

The CHI also identified some examples of good practice, including the one-to-one parent education support for teenage mothers, work with mothers expecting multiple births and the births reflection service. It is correct that when we discuss matters of this kind we put them in context and pay tribute, saying where things have gone well and where they have not gone as well.

The report was published only a month ago, but the trust has already taken positive action to address the concerns highlighted by the CHI. The trust has implemented various modifications, as follows: a new managerial structure, implemented in February 2003, to provide clearer lines of communication; the appointment of a consultant midwife, who will lead and further develop the provision of "home-from-home" delivery of care led by midwifery; and improvements in clinical governance arrangements, which have been led by the appointment of a new consultant in charge and a new directorate committee.

One of the CHI's main concerns for health improvement relates to staffing problems and I am pleased to report that the trust is actively working to recruit additional midwives. The trust has a strengthened team of support staff, including 16 midwifery care assistants, who provide support to women before and after they have their babies. Midwifery care assistants free the midwives so that they may concentrate on using their own skills to best effect. In addition, there are 40 hours of consultant cover on the ward, out-of-hours ward rounds and on-call arrangements.

In February this year the clinical negligence scheme for trusts gave St. Peter's a positive review of its risk management process; its maternity care scored 100 per cent. against the pass mark of 75 per cent. for level 2.

The Minister talks about improvements the trust is making, but my hon. Friend the Member for Spelthorne (Mr. Wilshire) made it clear that it is under severe financial pressure; it is supposed to clear its accumulated deficit within the next two financial years. Can the Minister make it clear, for the record, that he will support the trust if it decides to invest in services to correct the appalling deficits in the maternity unit, rather than to clear the accumulated deficit, as his Government require it to?

I wanted to put on record the improvements in the trust and the work that it is doing following the CHI report to make sure that the real challenges that it faces—which the hon. Member for Spelthorne has set out—are being addressed. That is the right context in which to have this debate. In opening the debate, the hon. Gentleman was keen to ensure that it was not partisan, as am I.

I will speak about the finances, but I want to make it clear for the record that we have given the primary care trust a record allocation this year, and, as the hon. Member for Runnymede and Weybridge (Mr. Hammond) will know, the deficit problems in the area go back a decade or so. In a sense, when he lays much of the blame for the matter at the Government's door, that is not entirely the picture. I hope to move on to that.

I accept that the Minister has given the PCT a record amount, but what will he do about the PCT pointing out that it is £20 million short on its budget and if it does not receive £20 million, it will have to cut £20 million pounds worth of services this year?

Those are issues that I want to move on to, but I know that the hon. Gentleman wants me to deal with them now. I cannot deal with them other than in a political way. In another Chamber in this House, a debate is taking place about foundation hospitals. It centres on the Government's thrust to localise services. The hon. Gentleman will know that there are members of his party who believe that that is the right direction in which to be going.

We have said that we cannot run every hospital, every primary care trust or every GP practice from Whitehall. The hon. Gentleman asked what the Government will do. The Government's job is to set out the standards and to ensure that increases in funding and investment are made at local community level. There was an increase of 9.29 per cent. in cash terms for the strategic health authority that is responsible for the hon. Gentleman's local trust. Once that decision is made, it is for the trust, working with the hospitals, to take it forward. It cannot be right that we should micro-manage, from the centre, what is going on in an individual trust. We cannot do that, and we should not do that. How have we made the position easier? We have given that allocation over three years—the hon. Gentleman's local trust will be experiencing that—so that the plans can be put in place and individual trusts can work closely with the strategic health authority to make the position better.

Not only is the PCT underfunded, but the trust itself has made it clear that, notwithstanding the extra money that it is given, it will have to cut services if that is all the money that it is to receive. To say how much it is given is irrelevant; it is how much it costs to provide the service that matters, and that is what the Government must address.

The debate is unfortunately descending into politics, which is the business of the House of Commons, so let us get on with it. As a Conservative Member of Parliament, the hon. Gentleman cannot, on the one hand, vote in the Lobby against the 1 per cent. increase that we want to give the NHS through the national insurance budget, and, on the other hand, have an Adjournment debate and ask the Government to give even more money to an individual trust. That does not stand up ideologically, intellectually or politically.

I say to the people of Ashford and St. Peter's that, as a Government, we are doing our part. We have increased the funding by 9.29 per cent., and by 2005–06, the rise will be 29.97 per cent. There are massive increases, and it is for the NHS locally to decide how that money is spent. Ideologically, the hon. Gentleman must decide whether or not he supports a nanny state, but it must be for his local managers to decide how that money is spent and, at the same time, to recognise that the maternity unit is undergoing £1.4 million of modernisation and refurbishment. That has created not just a new antenatal department, but new rooms for consultants and consultations, a new parent education unit, and more.

The list goes on. Despite the challenges that exist, we invest in the NHS, and people living in the hon. Gentleman's constituency will benefit from that, as will people throughout the country.

It being half past Four o'clock, the motion for the Adjournment of the sitting lapsed, without Question put.