Plans to strip British public hospitals of maternity units

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

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

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

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

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

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

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

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

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British obstetrics bad and talk of improvement unconvincing

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

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

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

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

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

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

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

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

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

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

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Questions not even a doctor should answer

Politics invade Australian medical schools

You might think that medicine is the one field that prides itself on making decisions based on objective evidence. Wrong prognosis. When it comes to selecting medical students, our finest universities are in the subjective business of social engineering. And that experiment appears to be failing dismally.

According to a study published on Monday in the Medical Journal of Australia, the present method of choosing medical students - a combination of written tests and interviews aimed at finding the best critical thinkers and problem solvers - is a poor predictor of how students will perform during their medical course. The gurus running the medical schools like to describe the process of turning a fresh-faced 18-year-old student into a fully fledged doctor as a complicated business. It is also an expensive business. Given that our tax dollars go into producing most of those doctors, that makes the method behind choosing who makes the cut our business.

This latest study appears to confirm concerns raised in The Australian last year from some inside the profession that good old-fashioned class envy and its twin sister, social engineering, are behind an interview process that pushes some of the most academically gifted students away from medicine. Being a son or daughter of a medico is now a handicap.

So too is going to a private school, said former deputy chancellor of The University of Adelaide, Harry Medlin. “I personally believe that to select medical students predominantly on their skills in an interview is a horrendous thing to do,” added John Horowitz, director of cardiology at two Adelaide hospitals.

Others voiced similar concerns. Like all pendulum swings, the move away from academic merit is turning out to be plain dumb, no matter how good the intentions pushing the pendulum. In trying to refute the claim, Lindon Wing, chairman of the Committee of Deans of Australian Medical Schools ended up confirming the bias.

In a letter to this newspaper last year, Wing defended the selection processes by pointing out “that medical doctors are among the most represented profession among parents of medical students in Australian universities. In some institutions, students whose parents are medical doctors number close to 20 per cent.” There. We have enough of the progeny of the bourgeoisie - 20 per cent is plenty. For Wing, it would be irrelevant if the age-old drive of human nature for children to follow their parents’ footsteps into a calling meant that 50 per cent of the qualified candidate pool were doctors’ children. Instead, the deans of the nation’s medical faculties centrally plan what they think is the best demographic make-up of medical students. And once they fill their pseudo-quota for doctors’ offspring, it wouldn’t matter how smart or well suited to medicine a doctor’s child was. When the quota is full it’s time to start engineering some results more to the planners’ liking.

And working out just who they like seems to involve asking the young students questions about gay marriage and the Iraq war. Many in the medical schools busily tried to defend the status quo, arguing they carefully train interviewers so that bias is not an issue. Reading some of the experiences on a website that provides feedback from those who sat through interviews suggests bias is indeed an issue.

One student from the 2003 intake in Queensland advised other interviewees: “Don’t expect medically orientated questions. Mine were about reconciliation, forest clearing, stem cell research, war in Iraq etc.” Other students were asked about their views on capital punishment and IVF for gay people. Students are a canny lot. The smarter ones know what interviewers want to hear. Here’s a sample. One student who secured a place in medicine in 2005 advises that a question about hobbies is a “disguised volunteer-work question”. Not wanting to look coached, the student says: “I did not list volunteer work first. I mentioned that I play soccer, guitar and working with kids.” Another student remarked that the interviewers “particularly delved into my volunteer work”.

It’s all being done, say medical schools, in the name of finding a cohort of future doctors able to reason and communicate. But as one leading Sydney specialist told The Australian: “If I had been asked, as an 18-year-old, whether I thought Australia should go to war in Iraq, I might have answered, Well, is the beer any good in Iraq?” This distinguished doctor says he may not have made it through the interview process. For the record, he is a dab hand at heart and lung transplants, is a top-notch communicator and his views on Iraq are now more advanced.

Now, as far as cartels go, you’d be hard pressed to find one more tightly knit than the medical fraternity. So, when doctors start criticising their own, you know something is awry in the nation’s medical schools.

Reinforcing the PC madness, it’s all about diversity, say those running medical schools. But what’s to stop interviewers, deliberately chosen for their diversity, imposing their own diversity filters on the interview outcomes?

Of course, raising questions about the interview is immediately sniffed at by those supporting the status quo as nothing more than nostalgia for old-fashioned elitism. It’s true that relying on objective academic results to allocate scarce resources is not the perfect solution. But it’s better than leaving the decision of who will make a good doctor up to the whims of two or three people on the basis of a 45-minute interview.

Refreshingly, even before this latest study, some medical administrators admitted the lack of evidence to suggest that interviews are producing a better calibre of students.

Ken Donald, former head of the University of Queensland’s medical school, told The Australian that introducing interviews was an “interesting experiment” but it was time to rethink the admission process because “people who perform poorly in the interview sometimes turn out to be the best in the class”. The corollary is also true: those who score highly in the interview are not necessarily the best performers down the track.

“I have a bit of sympathy with the assertion that unless the interviewers are well trained and the interview is well structured, there is the potential to misjudge liars, cheats, psychopaths etc,” adds Donald. “There is no good evidence anywhere in the literature, even in the published papers on this, that the interview, at least the one we have been using, is reliable as a predictor of performance,” he said.

Now, Queensland University’s medical school is reviewing the interview process. Abandoning interviews will restore fairness. No longer will talented young students be denied opportunities because the interviewers didn’t like their politics, or their parents’ background. But there is another more fundamental reason to dump interviews. They don’t work. Central planning never does. Would someone please tell the doctors.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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