Skip to main content

Maternity and Midwifery Services

Volume 459: debated on Wednesday 2 May 2007

I am particularly pleased to have secured this debate this week because it is the international week of the midwife, which, I am sure the Minister knows, culminates in the international day of the midwife on Saturday 5 May.

Being a reasonable chap, I will start with some sugar for the Minister before the pill arrives. I congratulate the Government on their record on investment in the NHS, which is most welcome. [Interruption.] As I think the Minister has just acknowledged, the Liberal Democrats have supported that investment and some, although not all, of the activities of his Department during the past 10 years. I am sure that to a far greater extent today than 10 years ago many consultants and GPs are happy with their personal circumstances, with the rewards that they have received and the conditions of service under which they operate. One would expect such investment to result in an improvement in outcomes and I am pleased that the Government have a record of some improvements, although not perhaps to the level that many of us would have liked. None the less, there has been an improvement in outcomes. I hope that the congratulations I have given to the Minister will dissuade him from filling too much of his response congratulating himself and the Government.

I have spoken to the makers of “Panorama” and, as the Minister is no doubt aware, they will be broadcasting a programme tomorrow evening that will demonstrate that there are matters of concern within maternity and midwifery services—obstetrics—across the country. I will refer to the national context, but I have spoken to and am well aware of the issues facing those involved in front-line maternity and midwifery services in Cornwall and the Isles of Scilly, as that is the patch that I represent. The “Panorama” programme shows some worrying and, one assumes, not necessarily exceptional cases from St. Mary’s hospital in Manchester and a hospital in Barnet that demonstrate the consequences of having an overstretched service that is supported by an insufficient number of midwives and insufficient resources for front-line patient care. In addition, the Minister needs to address some serious questions about safety.

On a more general point, the culture of good and wise Government requires transparency, clarity and a capacity to see the benefits of robust scrutiny as a contribution to service improvement and good governance itself. I shall be constructive in my comments, but I have recently asked the Minister and his colleagues a number of written questions about midwifery and maternity services, and many of the answers that his Department has provided reflect a climate of cynicism. Those responses would provoke even a normally calm person such as myself into raising stakes and using hyperbole and colourful adjectives that could otherwise have been avoided. That is not true only of the Department of Health; the climate is similar in other Departments. I will give examples of some of the literal interpretations and minimalist responses that I have received from Ministers in a moment.

There is not only a climate of cynicism, but a climate of secrecy. Would it surprise the hon. Gentleman to know that the Oxford Radcliffe Hospitals NHS Trust is refusing to publish the names of the clinical working parties that are determining the future of maternity and children’s services in my constituency and the Horton general hospital? Can the hon. Gentleman think of any possible justification for the names of those on a working party that is determining the future of hospital services not being a matter of public record?

I cannot. No doubt the Minister will have heard that intervention; he will have an opportunity to reflect on it and consult his colleagues before he responds to the debate. Perhaps the hon. Gentleman will receive an answer or explanation of why he has not been given that information.

I will give an example of the type of response that I have received by referring to a written question tabled on Wednesday 7 March, which received an answer on 23 March. The question was

“To ask the Secretary of State for Health (1) how many maternity-related compensation claims there were in each year since 1995; (2) how much her Department paid in compensation to patients in each year since 1995; and what proportion of such payments were for maternity-related claims.”—[Official Report, 23 March 2007; Vol. 458, c. 1196W.]

In response, the Government provided a table of claims and payments made on the basis of the date that the claim refers to. Therefore, it provides us not only with an impression that obstetric and maternity-related claims are reducing over time, but that the total number of claims is as well. We all know that many claims are still waiting to be resolved after the initial occurrence—for 20 years, in some cases. It would have been helpful if the Government had presented that information in the correct context.

Another question asked on 7 March was responded to on 23 March. The question related to hospital births:

“To ask the Secretary of State for Health, what the (a) minimum and (b) average period was that (i) primagravida”—

first pregnancy—

and (ii) all other mothers spent in hospital after delivery in each year since 1995.” —[Official Report, 23 March 2007; Vol. 458, c. 1189W.]

The answer provided by the Minister of State, Department of Health, the hon. Member for Leigh (Andy Burnham), was:

“information is not available in the form requested and it is not obtainable without disproportionate cost.”

Given one of the basic tenets of the Government’s health reforms is to keep copious records and capture hospital episode statistics, why would that information not be available and why would the Government not know how long a patient spends in hospital? Frankly, I find it beyond comprehension that the Government have provided me with such a response when it is clear that they have based their business case for health care reforms and payment by results on the application of tariffs that relate to the amount of time that patients spend in hospital.

The deliberate diversionary avoidance tactics used in many of the answers that I have received do not aid the process of constructive engagement with the issue. That does not set us off very well, so I urge the Minister to look again at the nature of the responses provided by his Department.

Does the hon. Gentleman accept that one of the advantages of payment by results—there are disadvantages—is that it can clarify how smaller maternity units can prove their business case, which is to be welcomed? I remember evidence from Torbay seen by the all-party group on maternity that showed clearly that a smaller unit is viable. Does he agree that that, at least, should be welcomed?

The hon. Gentleman makes a reasonable point, although an entirely different one from mine. Certainly, smaller units do not have the same high level of complex interventions—including obstetrics, clinical and anaesthetics—as tertiary centres. Certain accounting mechanisms can demonstrate a cost-effective service for relatively low-risk—one hopes—patients.

We welcome the policy statement on the future of maternity services set out in “Maternity Matters”, published on 3 April. Having spoken to those in the profession, I think that it has been universally welcomed as a statement on how the Government intend to improve services by 2009. One hopes that the Government can achieve a first-class NHS maternity service in that period.

I congratulate the hon. Gentleman on securing this debate. Although I am sure that the aims set out in “Maternity Matters” are welcomed by everyone, does he agree that too few people are training as midwives in the first place and that those who qualify often cannot find jobs? Although we can all support the aspirations in “Maternity Matters”, they are highly unlikely to come into practice.

I was about to come on to the hon. Gentleman’s point about dealing with the core services that the Government need to provide safely now.

Having investigated the problem with training posts, I think that the picture is mixed and variable. Evidence from some parts of the country suggests that midwife graduates have had difficulty getting jobs, particularly last year, when many posts were frozen owing to budget difficulties in many trusts. I hope that the Minister is listening to the general point: adequate work force planning is needed to maintain experienced midwives, who are crucial to the provision of a safe service, and to ensure that the training available—training in this country is excellent—is adequate and provides the required midwives.

Although it is desirable to improve services so that patients have the luxury of genuine choice, it is important that core services are in place first. That is the theme of my comments to the Minister today. The Royal College of Midwives provided a useful analysis of the policy statement in “Maternity Matters”. As I am sure that he knows, it has undertaken a rigorous analysis of the numbers of midwives required on the basis of actuarial predictions of births, which very often underestimate what actually happens. However, those predictions showed that England needs the equivalent of at least 22,000 midwives. The latest figures that I have show that we are some 3,000 full-time equivalent midwives short of that figure.

I congratulate the hon. Gentleman on his balanced and responsible argument. I welcome the RCM’s extremely fair assessment of “Maternity Matters”, but is he aware that, only a few weeks ago, its position was that there was a shortage of 10,000 midwives? Week after week, that figure was being repeated in the media. He just acknowledged that its assessment now—I shall explain in my speech our position on work force development—is that only 3,000 midwives are needed. Is it not curious that it went from 10,000 to 3,000, and yet still we see the former figure used in press reports week after week?

I am dealing with the situation as I see it now and with the briefing that the RCM provided me with. I shall not attempt to referee a spat between the Minister and the RCM over estimates that might have been made. Having looked at the basis on which the RCM’s calculation was made, I consider it to be a conservative—with a very small “c”—estimate. I think that the figure of 22,000 is an underestimate and that the RCM took a very conservative line. As I interpret the assessment, it is saying that we need at least that many.

I wish to draw out another point demonstrated in chapter 4 of the document, regarding roles and responsibilities—it has fallen open nicely at the right page. Acres of space on responsibilities are given to foundation, delivery, acute, ambulance and primary care trusts. A significant number of bullet points list those with responsibilities: general practices, local authorities, mental health trusts, maternity service liaison committees and so on—right down to 16th place and the smallest sentence of all, on the roles and responsibilities of the Department of Health.

According to the document, the Department’s responsibility is to develop

“national policy and guidance to support and enable local implementation”.

That is interesting. It demonstrates a culture of pushing away responsibility from the Government. In fact, that is in line with parliamentary answers that I have received in recent weeks. On 22 March, I received an answer providing a table on obstetrics and gynaecology figures. It was good to see that, between 1995 and 2005, the number of midwives increased from 3,406 to 4,580—a significant increase, owing largely to the working time directive.

According to the same answer, between 1995 and 2005, the number of registered midwives increased from 18,034 to 18,949, although I understand that the figure has gone down since. However, the figures fail to recognise a relative plateauing—proportionately there are fewer midwives in comparison with the overall NHS work force. Over those 10 years, the role of midwives has increased tremendously. They are now responsible for clinical governance, child protection and public health roles, dealing with, for example, teenage pregnancy, smoking, infant feeding, antenatal screening and the provision of information on choice and continuity of care. They are the overall professional leads for mothers. All those roles come on top of their role in the past, but that is not reflected in the figures.

On 22 March, I received answers to another four questions about average case loads, particularly of community midwives, and about other related matters. Once again, I had the following answer:

“This information is not collected centrally and we have not carried out an assessment of, or provided advice about, the size of case loads. It is for primary care trusts in partnership with local stakeholders to commission midwifery services in order to meet local needs.”—[Official Report, 22 March 2007; Vol. 458, c. 1141W.]

How can the Government publish a document such as “Maternity Matters”, which talks bravely about choices available at grass-roots level, when they do not collect the data and do not make an assessment of the case loads that community midwives are supposed to take on?

The Minister gave a similar answer when I asked what estimates the Department had made of the numbers of midwives needed by the NHS now and in the next five years. He said:

“It is for local planners with support from the workforce review team to determine their future requirement for midwives to meet local service needs.”—[Official Report, 14 March 2007; Vol. 458, c. 441W.]

How can the promises be made in a document such as “Maternity Matters” when it is clear that the Department takes no responsibility for making any estimate of the needs in the service?

Similarly, when I asked what factors were taken into account in estimating the average case load of community midwives, the Minister answered:

“Decisions about the size of community midwives’ case loads are made locally. It is for primary care trusts…in partnership with local stakeholders to commission services”.—[Official Report, 20 March 2007; Vol. 458, c. 863W.]

It is the same answer. How can the Government make the brave guarantees, the statements and the recommendations in a document such as “Maternity Matters” if they are clearly making no assessment and are not even providing any advice?

I thank the hon. Gentleman for giving way again. Can he explain how he squares his ambition for a command-and-control direction of the health service from Richmond house with his party’s rhetoric about localism, devolution and responsibilities being placed at the front line of people in local communities and in local public services? How can he square the rhetoric in his speech on that issue and his party’s underlying philosophy and policies on local devolution and freedom to make decisions related to local need?

The Minister’s statement exposes the problem. The written questions to which I have referred are about information and assessment. Yes, I agree that we should all aspire to achieve minimum levels of guarantee nationally. I see no difficulty at all with a Government taking a view that we should have aspirations to a minimum level of expectation of care at the front line. However, we would have democratically elected authorities delivering that on the front line, rather than those appointed by the Secretary of State to do her bidding, yet the Minister is now saying, “No. Once they are out in the field, on the front line, making decisions, it is their responsibility.” She and he take no responsibility. What is worse—this is the point of exposing the barrenness of those written answers—they make no assessment and they provide no information. There is no monitoring of the situation at all if that is what the Government are saying.

The Minister’s party believes in a more centrally controlled system, it seems. At least, they appoint the trust members to run—

Well, whether it is directly or indirectly, they are certainly not elected by the local populace to represent local people in the community and to defend local services. This is clearly an area of strong argument between the Minister and me. I query the capacity of the Government to talk about a choice agenda in 2009, when it appears that they make no assessment. They are not monitoring; they are not collecting the information that is clearly crucial to them in even talking about rolling out the services in the future.

The primary focus of this debate should be the role of the midwife. [Interruption.] I am trying to explain the main issue to the Minister. At least he understands that the Royal College of Midwives, which he is clearly listening to—at least, I hope that he is—has come up with a recommendation to the effect that 3,000 full-time equivalent additional midwives are required. There is serious pressure on the service.

The “Panorama” programme tomorrow evening will clearly show that in one case—I do not think that it is exceptional; certainly the anecdotes that I hear from front-line staff bear this out—one qualified midwife was responsible for 24 antenatal and post-natal mothers on an acute ward. There are occasions when that happens. The programme will also show that there are serious equipment shortages with regard to CTGs—cardiotocographs.

I hope that the Minister pays attention to the consequences of the resource constraints with which midwives are operating on the front line. Those out in the community tell me that they have been given new computer systems, but they argue that the Government and the consultants whom they use to roll out the information technology programmes need to consult the front line before rolling them out. They are finding that, even though they put all the information into the IT systems, they have to keep paper records, because they cannot get the information out again.

Of course, pay is an issue. It is interesting that, when speaking to midwives, one is aware that they are continually and clearly demonstrating their commitment to and support for the service and their professionalism. Hardly any of them mention, as their first concern, their quite justifiable gripe about the way in which the pay review body’s recommendation of a 2.5 per cent. pay rise for this year will be phased in. The Government have been tackled on that issue a number of times already, but midwives are caught in that conundrum. In effect, this year, they will receive a pay cut, which is poor reward when they are being asked to have ambitions for the future with regard to the rolling out of a policy proposal that is, of course, very welcome—although if it is to be rolled out, we have to get midwives on board.

The professionalism of the service is excellent. The Minister will acknowledge that. However, in this respect we need to consider, for example, the National Institute for Health and Clinical Excellence guidelines with regard to post-natal visits to mothers. The advice is to visit on day one, day five and day 10. If it is part of the Government’s assessment that that is when the community midwife will visit, it may be the professional judgment of many midwives that they should visit on more occasions than that, and that is important. Leaving a newborn baby without a midwife’s visit for the number of days that is proposed in the guidance concerns many professionals.

The Government have claimed that the UK is among the safest places to have a baby, yet following another written question that I tabled, answered on 16 April by the Financial Secretary to the Treasury, I received an answer from the Office for National Statistics that shows that it is almost impossible to make any international comparisons when assessing perinatal statistics, because perinatal information is recorded in different ways in different countries. Even then, however, if we look at the number of maternal deaths per 100,000 live births, we see that the UK does not perform terribly well at all. Yes, the figure is roundabout the European average, but the expanded European Union has many poor countries, as the Minister knows, and certainly the UK is behind Ireland and Italy in respect of maternal deaths.

My hon. Friend may not be aware that, in 2003, the EuroNatal working group reviewed, as an alternative to those difficult perinatal mortality and maternal mortality statistics, the statistics on sub-optimal care that may have led to deaths in maternity units. In a survey of 10 countries, it found that England had the highest risk.

The numbers are so small that a statistical blip can greatly change the statistics. The unfortunate and tragic circumstances at Northwick Park might well be one cause of the difficulties with the UK statistics on maternity deaths. Even so, we in this country should not necessarily be content with the overall figure. I hope that the Minister takes that point on board.

“Maternity Matters” is a welcome statement as far as ambitions for the future are concerned, but I urge the Minister to ensure that the Government can at least crawl before they try to run. Before anything else, they must get front-line and core services in place and ensure that they know how to assess and monitor those services so that they are properly assessed. They must also put safety first and ensure that health inequalities are addressed before they move on to the luxury of choice, which is what the document is primarily about.

Maternity services should be clinically audited to establish how mothers are being treated and where the inequalities are and to monitor how effective interventions are. At the moment, we monitor only mishaps, and stillbirths are recorded as being unexplained. I have spoken to Professor Jason Gardosi of the Perinatal Institute in Birmingham about this matter a few times—I believe that the Minister knows of his work. The professor proposes five basic performance indicators, which I urge the Minister to consider, particularly in relation to early booking and groups such as less well-off, young teenage mothers and other women who do not refer to a midwife early on.

I urge the Minister to address also continuity of care and, perhaps most importantly, the detection of foetal growth restriction, which is a clear indicator of later problems both at the point of childbirth and later in life. Will he consider carefully those proposals and the need for the Government to address issues of safety and the inequalities of health? Will he also consider whether there could be better central monitoring of the way in which the service is managed? We need to get the number of midwives right, to ensure that safety is put first and to get health inequalities right before we have the luxury of choice.

Order. I advise hon. Members that I intend to call the Front-Bench spokesmen at 3.30 pm. There should be ample time for Members who wish to take part to do so if they moderate their speeches.

It is a pleasure to have you in the Chair, Mrs. Dean. I hope that this debate is more constructive than the last one to which I contributed when you were in the Chair.

The debate is particularly timely for two reasons, one of which is close to home. Our sixth child was born two weeks ago at Chase Farm hospital, so I have a particular interest in, and some experience of, maternity services in Enfield. I shall focus my comments on those services, particularly the ones with which we had contact during the birth, and the challenges that they face. I shall not go through all six of our children’s births, given the time constraints. I expect also that my wife would prefer not to read blow-by-blow accounts of them in Hansard. I shall therefore focus on just two of them, which provide an example of the challenges that maternity services face.

The debate is also timely because Sir George Alberti’s report on the reconfiguration plans for health services in Enfield and Barnet was published today. The plans include the downgrading and effective removal of the Chase Farm accident and emergency services, and the transfer of consultant-led maternity services from Chase Farm to Barnet hospital. I commend the hard work of my colleague Nick de Bois in Enfield, North, who is campaigning hard on those services.

A little closer to home, our son Toby was born two weeks ago. We ticked all the boxes to qualify for a midwifery-led service—it was a low-risk pregnancy, and we chose to go ahead with that service at Ridgeway birth centre. Similarly, with our third child Dougal, we ticked the boxes and had a midwifery-led service. Those two births, indeed all six, had unique challenges. That is the first point that I want to make: each birth is unique and cannot be fully planned, strategised and targeted. Unexpected complications may arise midway through births or at any time during labour, and it is important when we look at such issues with the mantra of choice in mind that we realise that choice may be taken away unexpectedly during labour.

For Dougal’s birth, we took advantage of the midwifery-led service at Chase Farm and everything was going smoothly until the later stages, when worrying complications meant that we had to be transferred down to the labour ward. Happily, we currently have a labour ward and consultant-led service at Chase Farm, so they were literally just down the stairs. We went down in the lift, but the lift took some time and those seconds were absolutely crucial to me, as a father, and to my wife, who was in the throes of labour. Every second mattered during that transfer.

Toby’s birth, a few weeks ago, was similar. Everything was progressing normally and we were motivated. There was an interview of our leader on television with Andrew Marr, but that did not motivate Toby enough. Neither did the “Match of the Day” highlights. Eventually, he came, but only in his own time and, as he was on his way, there were again complications. If the birth had not happened within the hour, we would again have had to be transferred to the consultant-led service. Happily we had a safety net. We appreciated the fantastic care that the midwives provided, but we were happy to have the safety net of the labour ward just downstairs.

If the reconfiguration plans go through as advised by Sir George Alberti and others, that labour ward will be transferred to Barnet and we will not have that safety net. That is of great concern and might jeopardise children’s lives. We would have been profoundly concerned if we had had to be transferred by ambulance during those births when there were potential complications. We would have had to go to Barnet, but Enfield routinely calls Barnet at night and finds that it is full, and people then have to be transferred to Whittington or to another hospital that has space. Those practical realities must be borne in mind when we talk about choice.

The Ridgeway birth centre, which is a fine centre and which was opened not long ago in 2003, is at risk of being relocated to another area. It has the space and environment to encourage safe and healthy births, and it has one midwife at night—there should be more, but we have already heard about the lack of midwives nationally. The location of that centre is key, because the labour ward is there on hand, and there is no need for transfers further afield. That is important, and we and other parents in Enfield are concerned that the birth centre will be undermined by the loss of the safety net of the consultant-led labour ward that is planned as part of the reconfiguration.

We and other residents feel that the reconfiguration will break up Chase Farm’s maternity services, which have paediatrics and children’s services all under one roof. It will also fragment the midwifery training at Chase Farm. Midwives there tell me that they are very concerned about the plans to move the consultant-led service away from them. That change will also affect people’s confidence in the care that they will receive. Currently, they can be confident of the fine care that they will get at Ridgeway birth centre and confident in the security that if there is an emergency or unexpected circumstance, they will have the benefit of the service downstairs.

The case made by the hospital and, indeed, by Sir George Alberti, who seeks to garner the royal college’s support, is based on numbers. They say that 4,000 births are needed to cover the presence of consultants and that we can have only two consultant-led services in the wider area rather than three. That is one of my concerns, and perhaps the Minister can draw out some of the arguments. Why is the figure specifically 4,000? Is it a fixed figure? Is there flexibility? Should we take proper account of local circumstances? Should proper account be taken not only of the historical figures in Barnet and Enfield, which, it must be conceded, show that there were just about 3,000 births at Chase Farm last year, with just over 3,000 at Barnet and 3,500 at the North Middlesex, but of present demand? Perhaps my family is doing its bit to encourage the demographic trend, but one hears that there is an increase in demand for services. Should we really be hidebound by the 4,000 figure, when that might lead us to do a disservice to many parents who want an all-round choice? Should we look properly at local choice?

The Government have a national strategy of putting mothers and babies first and they talk about giving mothers choice over where to give birth, but the Minister must concede that the reality in Enfield is that choice will be limited once we lose the safety net of the labour ward downstairs. Indeed, the project director for the reconfiguration plans said that

“choice will be limited for those mothers who have been advised that there may be risks to themselves or their baby”.

However, the problem goes further, because life is not that straightforward, and birth certainly is not. As the cases of two of my children illustrate, complications can occur mid-birth, and one needs to be able to choose to have a consultant-led service on hand. Choice should not be limited at such a crucial time. My wife and I relied, happily, on Chase Farm hospital to help care for our new baby and cover for such unexpected emergencies. I am therefore resolved to continue the fight, despite Sir George Alberti and, indeed, the Government’s national strategy, because the same choice should be available to future parents and children at Chase Farm.

I rise to take part, albeit briefly, in this important debate. I congratulate the hon. Member for St. Ives (Andrew George) on bringing the issue before us once more—several of us have debated it regularly. If nothing else, the Government will hear our opinions and, I hope, act on them.

I have a vested interest in this issue, because the Stroud maternity unit has been reviewed more times than virtually anywhere in the western world. Reviews are a daunting prospect, and I feel for the staff every time they are reviewed. Sometimes reviews have a purpose, but sometimes they seem to take place without a purpose, almost as a way of escaping taking inevitable decisions that may not be palatable.

We have had another review, and the hon. Member for Cheltenham (Martin Horwood) will no doubt speak in due course about the implications of the proposals because they take in Cheltenham general hospital as well as Stroud maternity hospital and the Gloucestershire Royal hospital. All those institutions maintained some semblance of their maternity services, but it was a difficult process, and I thank the Minister for talking to me about it personally. It is fair to say the decision was a local one, although the Government did look at it because it sets precedents. Stroud maternity was and, I believe, still is the third biggest independent unit left in the country, so if it were to close, that would set important precedents for independent units elsewhere in the country. I therefore pay tribute to Michelle Poole and all the team at Stroud maternity.

I want to concentrate now on a couple of national issues. The first, to which the hon. Member for St. Ives alluded, is the relationship between the “Maternity Matters” Green Paper and the reviews that are being carried out by the King’s Fund and the National Perinatal Epidemiology Unit. Having been somewhat involved with those giving evidence to the various reviews, I am confused about the relationship between the different elements in the evolution of the Government’s policy. The Government have made their views clear in the Green Paper, and one hopes that it will be a good staging post.

There is also, however, the issue of the two independent reviews, which I totally support. One would think that safety was paramount in this area, but it is interesting that there is a lack of information nationally and internationally about what we mean by safety and what we would accept as the parameters of safety and about other elements involved in childbirth, such as the early take-up of breastfeeding and post-natal depression. There may be a lot of statistics about, but there is not much interpretation of them and there are not many comparisons of different units and different sizes of unit. I therefore welcome the two reviews. I just want the Minister to clarify what we expect the outcome to be. What is the timetable for the two reviews? How will they impact on Government policy, notwithstanding the fact that we cannot prejudge their recommendations?

Having taken part in the review in Stroud, I know that any reconfiguration, to use that dreadful term, is subject to the national picture, and local people certainly feel somewhat hamstrung because they know that things might happen locally as a result of the national driver. The Minister is looking a bit quizzical, but if he could say something about what we expect the two reviews to say, that would help me.

Suzanne Tyler did some good work on Stroud, which I hope will feed into the process. She made a quite devastating analysis of the arguments against shutting the unit and in favour of keeping it open. I hope that that work by an independent consultant and reputed expert in the field will be listened to.

My second national point relates to insurance, and it is the one about which I am really worried; indeed, I am a bit surprised that it has not come up yet. In the debate on Stroud, we got into the nitty-gritty of which unit should be the preferred one and what we meant by choice, but the backcloth to that debate was the issue of insurance. That issue has come up in relation to independent midwives, and I am unclear about what the Government are saying. What help might they offer independent midwives, who play an important role, not least because they can bolster the numbers in some of our units?

If I understand the picture clearly, it is a sad fact that more than half of litigation cases involve maternity incidents. That, of course, is a strong reason for people to have some form of indemnification against being sued. However, we cannot have it both ways. I very much support the choice agenda, and people want low intervention, starting with home births all the way through to midwife-led units, with consultant-led provision at the other end of the continuum. If people are offered choice, however, we must know that it is real choice. If deaths result because units cannot be kept open and midwives cannot keep operating because they cannot get insurance, that is not choice, and we need some clarity on the issue.

I have talked to midwives, I worry that they are beginning to practise very defensive medicine. That may be what any sensible practitioner should do, but if that is the only way in which people operate in their chosen profession, we will not have future generations of midwives, because they will be driven out of the profession. We need to know where we stand and we need to give a clear purpose to people who are doing a difficult job and offering choice. The choice should not entail their being held personally liable if things go wrong. As the hon. Member for Enfield, Southgate (Mr. Burrowes), whom I congratulate, made clear, we need to understand that these things happen and we cannot rule them out.

Recruitment is a key factor in the pressure that midwives are under. There is a dearth of people coming into the profession. I know—I hope that the Minister will say something about this—that more training places are being made available and that we are bringing people into the profession through training, but that is for the future. I am concerned about immediate problems.

We need some transparency. When people are offered a choice, it should be a real one and they should understand the risks. That can happen only through greater transparency. I hope that the Minister will attend carefully to my questions, and, even if we cannot have the answers now, I hope that we shall get some later, because midwives in general want such reassurance. If they do not get it, I fear for the profession.

I congratulate the hon. Member for St. Ives (Andrew George) on introducing the debate, and my hon. Friend the Member for Enfield, Southgate (Mr. Burrowes) on the birth of his child—although I hope that someone has explained to him that babies grow into teenagers. That has been my experience.

As the hon. Member for Stroud (Mr. Drew) said, what is important in the debate is choice. The Secretary of State says that as a consequence of “Maternity Matters”, every mother will have the choice of a home delivery or delivery in a midwife-led unit or a consultant-led unit. Although that sounds very good, behind it there will be the potential for considerable downgrading of services in various parts of the country.

The Horton general hospital in Banbury has served for more than a century a significant area of the United Kingdom—north Oxfordshire, south Northamptonshire and south Warwickshire. We have for a long time—decades, centuries, generations—had a consultant-led unit at the Horton, but that is now threatened with being downgraded to a midwife-led unit. We already have an excellent midwife-led unit at Chipping Norton hospital. Any mother who wants a midwife-led birth can go there.

When the proposals were made, local GPs responded as part of the consultation to the Oxford Radcliffe Hospitals NHS Trust. I think that what they said is worth repeating:

“We remain opposed to the proposals on the grounds of safety, sustainability and the reduction in access to basic health care and choice for our patients, which will affect especially the most vulnerable.”

They continued by discussing maternity services specifically:

“Under the proposed model mothers who may fail to progress or show signs of foetal distress in the second stage of labour, or who have prolapsed cord or haemorrhage, would require very rapid transfer to Oxford. Given the numbers involved this would carry significant risk and would be inhumane.”

That is a strong word. Their submission continues:

“There would be an increase in the burden of responsibility on midwives and ambulance crews. Legal claims”—

the comments of the hon. Member for Stroud are relevant here—

“following incidents where there was harm to the mother or baby might be very costly to settle.

Babies born in need of immediate resuscitation would incur a transit time of approximately one hour. The idea that paediatric cover could be provided safely from Oxford in these circumstances is false and dangerous.”

The submission states:

“We submit the opinion of Professor James Drife who wrote in the BMJ...about the shortfalls of midwife led units...It accords with recent publications by NICE on the safety of such units”

and adds:

“We are not reassured and maintain that a midwife led unit with a delivery rate of 450+ per annum, which is 25 miles away from the nearest obstetrician and paediatrician, is not safe. Through no fault of the midwives working in such a unit, GPs would have to consider the wisdom of recommending mothers to this service, numbers would drop further and the service soon become non viable”.

It continues:

“A midwife led maternity unit, possibly lacking the confidence of local GPs, may well wither. Kidderminster had to close its unit due to excessive neonatal mortality (6 avoidable deaths in under 2 years). Increasing concern about such units is being expressed by RCOG and NICE.”

RCOG is the Royal College of Obstetricians and Gynaecologists. The GPs’ submission continues:

The existing serious congestion at peak times and lack of parking facilities at the JRH site will be worsened by 1,000 to 1,600 extra deliveries per year. All emergency surgery and major gynaecology currently managed in North Oxfordshire will need to be absorbed by the JRH as will all paediatric cases requiring overnight assessment or admission.”

The GPs said:

“We conclude that the current proposals...will result in services which are unsafe and unsustainable into the future”


“are not in the best interest of our patients who will be faced with serious obstacles in both accessing services and visiting sick children or relatives. The most vulnerable will be hardest hit.”

They believe that the proposals

“will increase demands on the ambulance services and its crews and on already overstretched departments at the JRH...will have consequences both in medico-legal and human terms that are far reaching and expensive...adhere to an outmoded model of centralisation that ignores more modern trends to bring services closer to patients...ignore the clear recommendations of the Davidson Inquiry and the prerequisites of the agreement to merge into a single trust”

and that they

“are overly influenced by a small group of medical specialists in Oxford who have plans for centralisation that ignore the expressed and documented needs of this community.”

The GPs end their submission:

“These proposals offer neither a better deal for children nor security for a range of other services vital to our local community”.

Those views were in a document signed by 85 local family GPs from north Oxfordshire, south Northamptonshire and south Warwickshire. As a consequence, not surprisingly, the trust took its proposals off the table and set up two clinically led working parties on paediatrics and children’s services to see whether they could find an approach that GPs would find acceptable. They are still deliberating.

I have one concern and one question to put to the Minister in that respect. I can see no justification for keeping the membership of the working parties confidential. I understand why they might want to deliberate in private; however, I walk into the Court of Appeal every day, where the lords justices of appeal deliberate in private, but I know who they are and they are accountable. It cannot be right, as a matter of public policy, that clinicians should decide whether their participation in the working parties should be made a matter of public record. It undermines confidence in the system and the process if my constituents are told that they cannot know the membership of the bodies that will determine the future of services at their general hospital.

At the end of the process the working parties will, I imagine, make proposals, which will vary to some extent from those that were originally on the table. GPs will have to decide whether they think the amendments make the changes safe. They consider the existing proposals unsafe and inhumane. Unless there is overwhelming support from GPs for the changes, given their total opposition to the changes to date and given that the Horton will no longer have consultant-led midwifery services, I want to ask that, if in those circumstances the matter is referred to the Department, the Secretary of State look favourably on the idea of the proposals being considered by the independent reconfiguration panel.

I share the concern that was put to me by a GP, who said that he and his colleagues felt constantly worn down by academic professional pressure to accept as the least worst option something that they were not happy with but thought they would end up with. GPs have been put in an intolerable position in all of this, and I still have a very unhappy impression of the situation. We want to continue to have a general hospital in Banbury that provides the full range of services of a general hospital, including consultant-led midwifery.

Taking away the consultant-led unit from the huge catchment area that has had such a unit for as long as anyone can remember because there is a midwife-led unit down the road, or another consultant-led unit an hour away, does not enhance choice, but undermines it. It means that there is a worse service, and nothing that the Minister or anyone else does will persuade my constituents that a service that they see as worse than the present one is an improvement to the NHS. If the Minister believes otherwise, he is welcome to come to Banbury at any time and meet people from the “Keep the Horton General” campaign, which has been ably led by George Parish, a local Labour councillor. I do not believe that it is possible to get that message across because people realise when their services are being downgraded, and services are being downgraded in Banbury.

I join others in congratulating my hon. Friend the Member for St. Ives (Andrew George) on securing this debate. Given the subject, it is slightly bizarre that it is being conducted entirely among male MPs. That is yet another example of why Parliament needs more women. As my hon. Friend pointed out, it is appropriate that the debate is taking place during midwifery week, which celebrates the role of midwives and enables us all to congratulate them on the role that they so often play in making childbirth a healthy, happy and fulfilling experience for all concerned.

This year in particular, midwifery week is drawing attention to the fact that childbirth is not only a physical experience, but a social and emotional one. The hon. Member for Enfield, Southgate (Mr. Burrowes), who spoke about his personal experiences, illustrated that well. That means that where childbirth takes place and the nature of the experience are just as important as the physical outcome of the process, or at least important alongside the physical outcome. An increasingly important part of the philosophy of patient care is paying attention not only to the physical needs of patients but to their wants.

The Government’s national director for patients and the public, Harry Cayton, who is a brilliant man with whom I have had the pleasure of working, said that

“it is essential that we put the needs and preferences of patients and service users at the centre of all we do.”

In this respect, it is right that the words that emerge from Government policy are more often than not words with which we can agree. The trouble is that the practice is often very different, as hon. Members have pointed out.

Let us review the evidence on the policy itself. Going back as far as 2003, positive policy statements were made. “Keeping the NHS Local—A New Direction of Travel”, which was published in February 2003, contained the general aim of retaining good local services. It clearly stated:

“The mindset that ‘biggest is best’ that has underpinned many of the changes in the NHS in the last few decades, needs to change. The continued concentration of acute hospital services without sustaining local access to acute care runs the danger of making services increasingly remote from many local communities.”

I would certainly agree with that. The document pointed out clearly, as the hon. Member for Banbury (Tony Baldry) has done, that we should not be concentrating services in certain regional or other centres at the cost of providing a lesser service somewhere else. It said that the focus should be

“on redesign not relocate. Redesign can offer a high quality alternative to relocating services, extending the range of options for developing new configurations that meet local needs and expectations”.

Again, the emphasis was on what local people want. I have experienced a campaign in which 10,000 people marched through the streets of Cheltenham trying to get not just what they needed, but what they wanted. Many hon. Members have had similar experiences.

The document also specifically addressed maternity services, stating:

“The challenge facing maternity services is the need to identify EWTD-compliant models of care in the middle ground between large consultant obstetric units and midwife-led units.”

That was one of the clouds already looming on the horizon, because the European working time directive was clearly going to pose a challenge to the delivery of the existing model of maternity care. The Government were rightly thinking about how to respond, but in that 2003 document they were not thinking in terms of the large-scale centralisation of services, let alone of reductions in the number of midwives or of midwife training places. They were talking about developing the middle ground between very large units, of which we have an increasing number in this country, and midwife-led units. That sounds great: it sounds just like Cheltenham general hospital’s St. Paul’s wing. Its 2,500 deliveries a year makes it quite big for the rest of Europe, but in the middle to small end of delivery units in this country, where the trend is increasingly towards giant maternity units.

Other policy documents have been published. In July 2004, the wonderfully named “The Configuring Hospitals Evidence File: Part One” was published. One of the sections was specifically on maternity, where it was stated:

“Recent research shows that childbirth in such centres”

—midwife-led maternity units—

“is as safe as in consultant-led units, provided that a) admission is restricted to low-risk women or b) if the midwife unit is not located near a consultant unit, there are efficient escalation protocols for transferring the woman to an acute hospital.”

Other hon. Members have alluded to the need for proper escalation protocols, but that should reassure those hon. Members who were expressing concerns about the risks inherent in midwife-led units, as the hon. Member for Banbury seemed to be doing at times. I hope that the reviews that we know about will conclude that, when properly managed, and with proper escalation protocols, midwife-led units can be a safe and positive alternative. Certainly, the National Childbirth Trust believes that they offer the best outcome for those in low-risk categories, and often offer better continuity of care for women.

In 2005, the latest Labour manifesto was published. It contained the very positive statement:

“By 2009 all women will have choice over where and how they have their baby and what pain relief to use. We want every woman to be supported by the same midwife throughout her pregnancy. Support will be linked closely to other services that will be provided in Children’s Centres.”

I congratulate the Government on the approach based on children’s centres and on the use of Sure Start to support antenatal classes; those are positive things. I also support the words in that statement. As we have all said, choice is important and the way in which it is delivered is important. There is no reference in any of those documents to reduction in the number of midwives or to the centralisation of services.

Does my hon. Friend acknowledge that in many parts of the country antenatal classes are declining or closing? That is having a direct impact on the welfare of mothers, particularly as they need to build up social networks of other parents post-natally. That is important for their mental welfare after their child is born.

I am grateful to my hon. Friend for saving me time, because I was going to point that out later. Antenatal classes, by their nature, also help to reduce complications, so they are even a cost-saving device as well.

As I was saying, there is no reference in any of those documents to a reduction in the number of midwives or to the centralisation of services. The clear of thrust of stated policy was in the opposite direction, towards localism and more choice. That was reinforced in a health White Paper that supported the concept of care closer to home and more choice in maternity.

In February, Sheila Shribman, the Government’s maternity tsar, set out the choices that women should have:

“a home birth supported by a midwife, or…birth in a local facility under the care of a midwife such as a designated midwifery unit”

or—this was carefully phrased—

“birth supported by a local maternity care team that includes a consultant obstetrician. For some women, this type of care may be the only safe option.”

This is where we start to get to the nub of the problem with the concept of choice, because once the number of consultant-led units in an area is restricted, as we have heard is happening in Oxfordshire and may happen in Gloucestershire, there is the risk that for many women for whom such care is the only safe option, there is much less choice.

There were subtle differences in the phraseology used in “Maternity Matters”, which was published last month, because the parallel statement in that Green Paper was

“birth supported by a maternity team in a hospital.”

The word “local” was conveniently dropped. It continued:

“For some women, this type of care will be the safest option”.

That is not what Sheila Shribman said. She said clearly, and more realistically, that for some women such care may be the “only safe option”. The impression of choice is being given, but the reality is different when maternity units start to close.

I shall illustrate that with an example that might be close to a Minister’s heart. I gather that the Prime Minister might be moving house soon and that he may have a little more time to spend with his family. He will find that within nine miles of his new home in Connaught square, there will be 19 obstetrician-led maternity units. By contrast, the residents of Clyde crescent, which is one of the poorest areas in my constituency, will, if the planned changes go through, have a choice of just one obstetrician-led maternity unit within 20 miles—twice that distance. Their journey distance will change from just over a mile to Cheltenham general hospital to more than nine miles to Gloucestershire Royal hospital along the congested A40 into an unfamiliar city.

The hon. Gentleman keeps referring to a reduction in the number of midwives. Will he correct the record because that is entirely inaccurate?

How on earth can we pore over locally based geographic decision making from an office in Richmond house in Whitehall, Westminster and make the right judgments and the right calls, locality by locality in this country? Why mislead people into believing that that is possible or desirable?

Thank you, Mrs. Dean. I shall draw my remarks to a close by quoting the Royal College of Midwives, which makes it clear that the number of midwives is falling and not rising—[Interruption.] The Minister does not believe me, but in 1997, there were the equivalent of 18,000 full-time midwives. By 2006 that had risen to 18,862, but it has now fallen. That is so whether measured by full-time equivalents, head count numbers or even training places. In a recent survey, two thirds of heads of maternity reported that their unit was understaffed, and more than one in five reported that their midwifery staffing establishment had been cut. The general secretary of the royal college says:

“With this situation women are not going to get the choices they’ve been promised. Some areas are struggling to provide even basic services. Vulnerable and disadvantaged women who need the most intensive support will suffer the most."

I, too, congratulate the hon. Member for St. Ives (Andrew George) on introducing the debate and other hon. Members on contributing to it. The topic is important. It is vital that NHS services are both safe and accessible, and we thank midwives throughout the country for all that they do, often in difficult circumstances.

As we know, this is midwifery week. It was organised by the Royal College of Midwives, which does an excellent job of representing its members and highlighting the important issues for discussion.

There is no doubt that the Government have set out an ambitious programme to give women more choice and better maternity support, and they should be congratulated on that. However, there can be no substance to those proposals while the NHS continues to suffer a shortage of midwives and the closure of maternity units. Those problems cannot be denied and I shall be interested to hear the Minister’s response. Those two themes run through all the issues facing maternity and midwifery services.

Let us start with the number of registered midwives working in the NHS. I agree with the Minister that the Royal College of Midwives has estimated that an extra 3,000 midwives are needed if the Government are to deliver their promises in the document, “Maternity Matters”. However, what do we find? We find that overall the number of midwives has fallen for the second year running, having fallen during the last year in question by 339. The number of full-time equivalents—in our opinion the best measure of the availability of a midwife at any time—has risen by 4.5 per cent. since 1997 according to Government statistics, but that has failed to keep pace with the birth rate, which has increased by 9 per cent. since 2001. If the number does not keep pace with demand, it puts increasing strain on midwives.

In this place, we often bandy figures about in the hope that they illustrate our arguments and so on, but I propose to the Minister that the situation is even worse than the figures suggest because midwives not only work shorter hours than 10 years ago, but the maternity case load is even more complicated, with more mothers giving birth earlier and later in their lives. That is complicating the casework.

At a result, understaffed maternity units are overstretched. According to a survey by the RCM, an estimated two thirds of department heads thought that their units were understaffed, with posts being cut and too much reliance being placed on maternity care assistants. As we have heard from a number of hon. Members, a BBC “Panorama” programme tomorrow will confirm that picture, with overworked midwives afraid that they do not have enough time to give patients the right level of care.

On top of that, vacancy freezes brought about by financial deficits will only make matters worse. Figures confirmed by the Government show that by November 2006, a third of all midwives who had completed training since May 2006 had not found their first job in the NHS—a total of more than 4,200. Apart from the consequences for the NHS generally, the cost of training those professionals for unemployment was around £230 million. That money could be better spent on patient care.

Perhaps most disheartening is the impact of understaffing on the Government's own pledge to provide women with one-to-one continuity of care by a named midwife by 2009. That is an important aspiration—the gold standard in maternity care—yet it cannot be achieved without a substantial increase in the number of midwives. In view of all those concerns, will the Minister take this opportunity to state clearly and for the record what estimate he has made of the number of additional midwives needed to meet the challenges set out in “Maternity Matters”?

It is doubly worrying that the fall in the number of midwives is taking place against the backdrop of maternity units being closed throughout the country, as a number of hon. Members have said. Last December, we identified up to 21 midwife-led units under threat. Those centres are often based in the community rather than in hospitals, and they offer women a less medicalised birthing experience. They tend to be well loved resources and should be protected. I suggest that without local midwife-led units, the Government cannot realistically offer women alternatives to giving birth in a highly medicalised environment in hospital. Only by making those options more widely available can we enable women to question the received wisdom that medical intervention is the preferred option.

The only other alternative to hospital is home birth, but only 2 per cent. of women giving birth do so at home, although many more would like to. Again, the shortage of midwives impacts on that. There is already a striking north-south divide for women who are helped to give birth at home, with women in Devon seven times more likely to secure a home birth than women in Merseyside. The Government say that they want to make home births more widely available, but plans to reconfigure consultant and emergency services around fewer and larger regional centres works against that objective. As many as 15 per cent. of planned home births result in a transfer to hospital and those transfer times and distances are likely to be longer in future because of the Government’s plans to centralise services. That policy could put lives at risk.

Conservative Members are very concerned about the Government’s proposals to concentrate consultant services. First, there is still no clear evidence base or clinical model for the move towards fewer, larger maternity units, yet the Government seem to be hellbent on encouraging mothers-to-be to give birth in ever larger units. We are increasingly being told that larger, consultant-led units with more than 3,000 live births a year are safer for women, but the National Perinatal Epidemiology Unit is not due to report on the topic until 2009, so on what basis can those assertions be made?

Meanwhile, the move to larger units goes against the grain of maternity provision on the continent. The largest unit in Germany has only a little more than 3,000 live births a year and the largest in France has 4,000. In contrast, English maternity units, such as the one that is being investigated by the BBC at St. Mary’s hospital in Manchester, often deliver more than 5,000 babies a year. That is not to say that all larger units are worse, but the clinical case for ever larger units has not been made, and the Government should recognise that before they continue down the line of encouraging mothers to give birth in ever larger units.

I know that the Minister has taken issue with the Greater Manchester reconfiguration in his own backyard, but the problem is that the Prime Minister and the Secretary of State for Health have both endorsed the principle of larger, fewer units. Some people would argue that there is an element of hypocrisy in that state of affairs: the Minister who is present argues one thing in his own backyard while he peddles a national policy that goes against that local argument.

In the time allowed, I must mention independent midwives. The Government seem determined to ensure that independent midwives take out professional indemnity insurance, despite the fact that they are unable to obtain it because of the high premiums that reflect the potentially huge payouts involved. There is no clear evidence of a link between possessing insurance and being a safer midwife; if anything, the intuitive link runs the other way, because midwives stand to lose everything in cases of negligence. Their services are especially valued by women who are either fearful of highly medicalised interventions during childbirth, or have had a bad experience in the NHS.

Will the Minister explain why the Government seem hellbent on pursuing that argument and policy on insurance without at least granting a consultation? We have requested one, but we have not received an answer from the Government. I raised the issue in a letter to the Secretary of State on 29 March, but so far, I have not had the courtesy of a response. Will the Minister now respond by promising the House and all independent midwives that the Government will consult on their proposal?

In conclusion, the principles of one-to-one care and choice in maternity are the principles on which the future of maternity and midwifery services ought to be based. However, the Minister must right now start explaining how we can deliver the Government’s pledges without the appropriate increase in midwife numbers, and while the Government pursue the policy of closing midwife-led units.

In terms of equal distribution, the hon. Member for Billericay (Mr. Baron) has left me with less time than I should have had to answer what has been a substantive debate. However, I do not think that he did so on purpose.

I congratulate the hon. Member for St. Ives (Andrew George) on securing this important debate during the international week of the midwife. I pay tribute to the tremendous work that midwives do every day on the front line of maternity services in this country, to the contribution that the Royal College of Midwives makes to these debates and to raising the profile of such issues in Parliament, and to the leadership of Dame Karlene Davis. The RCM has been consistently supportive of the vision and the plan that was outlined in “Maternity Matters”, despite expressing genuine concerns about some of the issues that have been raised during the debate.

We have heard from hon. Members that, during maternity, women and parents will experience arguably one of the most important periods in their life, and all that I ask for is balance in the debate about the state of maternity services. It is the height of irresponsibility to suggest that somehow, the majority or even a significant number of women will have a poor maternity experience in our hospitals.

The balance of the debate has suggested it, but it is not supported by one jot of evidence.

Let us hear some statistics. We invested a total of £1.67 billion in maternity services in 2005-06. Between 1997 and September 2006, the number of midwives employed in the NHS increased by 9 per cent.—a whole-time equivalent increase of 5 per cent. The number of students entering the profession rose by 44 per cent. between 1996-97 and 2005, and the projection is that 1,000 additional midwives will qualify by 2009. How anyone in this debate can suggest that that represents a reduction in the number of midwives—

I have no time to give way.

The number of consultants in obstetrics and gynaecology in England has increased from 1,032 to 1,506—an increase of 46 per cent. In summer 2005, when women were last asked, 80 per cent. of those surveyed said that they were satisfied with the maternity services that they had received. In 2001, we committed £100 million additional capital investment to improve maternity facilities, and we are still spending that money. So let us be clear: there has been a tremendous amount of investment and tremendous advances in maternity services. Do we still have many challenges ahead of us to achieve the gold standard in maternity services? Most definitely, we do.

To achieve the vision in “Maternity Matters”, we have made it clear that, in addition to the introduction of those 1,000 midwives, other measures will have to be taken in local health economies where the work force is not at the appropriate level to deliver that guarantee of choice to women. We have made it absolutely clear to primary care trusts in local health economies that they will have to commission additional midwives if they do not have a sufficient baseline number of midwives; they will have to consider all the professionals who contribute to the maternity experience and get them working together; and they will have to entice back to the NHS some of the midwives who have left.

The hon. Member for St. Ives and other hon. Members talked about the roles and responsibilities of the Department vis-à-vis the local NHS. I find it staggering that, time and again, we hear rhetoric from both main Opposition parties about maximum devolution, localism, local determination and being in the best place to respond to the needs of local communities, but that we are then criticised for not commanding and controlling every decision from offices in Westminster and Whitehall. It is a complete intellectual contradiction.

From the centre, we can make resources available, specify the outcomes that we expect, put maternity high up the NHS annual performance assessment framework, give the Healthcare Commission the power to inspect to ensure that maternity services are adequate and ensure that the local health service leadership understands that maternity must have a new priority and that strategic health authorities commission and develop services to deliver “Maternity Matters”.

The hon. Member for St. Ives says that the Government appoint people to run health organisations. Does he not realise that the independent NHS Appointments Commission is a source of great angst to many Government Members?

The hon. Member for Enfield, Southgate (Mr. Burrowes) made a very personal contribution, and I congratulate him. The slogan that comes to mind is, “Cameron fails to deliver, Labour ends triumphantly,” but perhaps the hon. Gentleman would not necessarily accept that.

During the debate, hon. Members made several points about reconfiguration, but let us be clear that, whatever decisions are made locally, every woman must have access—through real choice—to a consultant-led service, a midwife-led service or a home birth. Wherever they live, in whatever part of England, such access is absolutely central to the “Maternity Matters” guarantee that will be in place by the end of 2009. Any decision about reconfiguration in Banbury or anywhere else must lead to a scenario in which any woman has access to such choice.

I say to the hon. Member for Banbury (Tony Baldry) that if the scrutiny Committee refers the decision—I do not think that it has been made, by the way—to the Secretary of State, she would of course consider the weight of evidence from a variety of sources in her determination about whether to send it to the independent configuration panel. I shall write to the hon. Gentleman about the membership of the working party and why there is no transparency in that respect.

I say to the hon. Member for Cheltenham (Martin Horwood) that change in some areas—in many areas—may be necessary for safety, quality and choice. Politicians should be frank and honest about that. However, not all proposed changes are right, and frequently, local communities do not like the proposals, which is why Parliament has laid down clear processes, so that local communities and commissioners have the right to say, “A proposal in our area does not best meet our needs.”

I say to my hon. Friend the Member for Stroud (Mr. Drew) and the hon. Member for Billericay that we are working with independent midwives to resolve the insurance issue.