Present:
Dr J Hendron (Chairman)
Rev R Coulter
Mr T Gallagher (Deputy Chairman)
Mr J Kelly
Mr A McFarland
Ms M McWilliams
Ms S Ramsey
Mrs I Robinson

Apologies: Mr P Berry
Ms C Hanna

In Attendance:
Mr G Martin (Committee Clerk)
Mr D Harkin (Assistant Clerk)
Mrs K McFerran (Executive Support)
Mr G Neill (Administrative Support)
Dr J Thompson (Assembly Researcher)

Dr Hendron took the Chair at 2:00 pm.

Private Session

1. The Chairman reported briefly on the productive meeting that he had yesterday with the Comptroller and Auditor General (C&AG), Mr John Dowdall, which the Clerk recorded in a note issued to members. The main point arising from the meeting was the fact that the health service was the only area of expenditure in the transferred field where the C&AG did not have control of the audit of accounts, which are conducted by the private sector.

The Committee was strongly supportive of the proposal in the Audit and Accountability in the Public Sector in NI consultation document that the C&AG should have responsibility for the audit of health services, and will address this matter when finalising its response to the document at next week's meeting.

2. Members were copied a letter from Joan Ruddock, Chairman of Belfast City Hospital Trust, to the Minister expressing concern about the proposed funding for health in the draft Budget for 2002/03. The Committee will have an opportunity to explore the issues more fully at its visit to the A&E units of the BCH and RVH scheduled for Wednesday, 5 December 2001.

2. Minutes of the Last Meeting

The minutes of the last meeting were agreed.

3. Matters Arising

1. A copy of the NAO Report on Inpatient and Outpatient Waiting in the NHS is available. The Clerk will provide members with a brief synopsis of its main findings and recommendations.

2. Agreed: The Clerk will write to remind OFMDFM of the outstanding response to the Chairman's request for a meeting of a Committee delegation with the First and Deputy First Minister in relation to resourcing for the health service.

4. Subordinate Legislation

The Committee noted the Department's notification of a Statutory Instrument, Introduction of the Medicines (Products for Animal Use-Fees) Regulations 2001, which will take effect on a UK-wide basis from 22 November 2001.

Public Session

5. Inquiry into the Delivery of Cancer Services in NI: Oral Evidence from the BMA General Practitioners' Committee (NI)

Panel Members: Dr Brian Patterson, Chairman
Dr Brian Dunn, Member
Dr Janet Watters, Member

The Chairman welcomed the witnesses to the meeting at 2:17pm, after which the panel members each spoke to aspects of the written submission, which had been copied to the Committee. This was followed by a question-and-answer session, and the entire proceedings are recorded separately in verbatim minutes of evidence.

Ms McWilliams joined the meeting at 2:35pm.

The Chairman thanked the panel, and they left the meeting at 3:37pm.

Mr Gallagher, Mrs Robinson and Mr Kelly left the meeting at 3:07pm, 3:37pm and 3:39pm respectively.

6. Maternity Services in Northern Ireland - Presentation by Departmental Officials

Panel Members: Mr Brian Grzymek, Director of Secondary Care
Dr Paddy Woods, Medical Officer
Ms Ruth Clarke, Midwifery Adviser

The Chairman welcomed the panel to the meeting at 3:40pm, after which Mr Grzymek gave a brief presentation on the current state of maternity services in Northern Ireland, and in particular the position at the Downe Maternity Hospital, as summarised below. This was followed by a question-and-answer session, which is summarised at Annexe 1. The Chairman thanked the panel, and they left the meeting at 4:50pm.

• NI enjoys an overall very high standard of maternity care. The Department's policies are aimed at sustaining and developing services, thus ensuring safe and effective care to mothers and babies.

• Although years ago NI had higher levels of infant mortality at birth, this rate has been decreasing year on year, and we are now comparable with GB and the ROI in terms of maternity services' safety.

• Though historically in NI virtually all births were in consultant-led units, the fact is that between 75% and 80% of births are delivered by midwives without any significant medical intervention.

• Departmental policy in relation to maternity services is underpinned by delivering choice to women. This offers scope for a number of future configurations, including midwife-led units adjacent to obstetric or acute service units, but not stand-alone midwife-led units.

• One promising development has been the midwife-led unit at Craigavon Hospital, which is adjacent to the obstetric unit. It is expected that the robust process followed in the setting up of this unit will provide a model for the future development of similar units.

• The Minister will be considering a number of issues raised in the Report by the Acute Hospitals Review Group in relation to the future of maternity services. These will include the suggestion that an inpatient maternity unit would require a minimum of 2,000 deliveries for 24-hour anaesthetic and paediatric cover, which would have implications for a number of smaller units. (This is in line with the Royal College of Obstetricians view.)

• While there were a number of problems in relation to the Downe Hospital last year, the Minister instructed the Department to write to the Eastern HSS Board and Down Lisburn HSS Trust advising that they were expected to do all in their power to maintain the current maternity services arrangements.

• In response to a concern about the ability of the Downe Hospital to provide anaesthetic cover simultaneously over two sites almost a mile apart, the Board and Trust moved imaginatively to develop a sophisticated model to support a second on-call anaesthetic rota, which is reported as working well. The clinicians involved are content that the new arrangements - including the appointment of five extra theatre nurses and the offer of advanced life support training for all midwives at the unit - are sustaining a fully satisfactory service. The Minister keeps a regular watching brief to see that all is working well at the unit.

• The new arrangements have come at a price, though. The Department is now spending £500,000 more p.a. on the Downe maternity unit than in 1997.

• The question of risk assessment for maternity units dates back to 1999 following an incident at the South Tyrone Hospital relating to anaesthetic cover. The Minister had asked the Eastern and Northern HSS Boards to provide assurances for future safety, and comprehensive reviews have been carried out. The risk assessment will not be static documents but will be subject to continuous review in line with changes in clinical direction and practice.

• Although the recent adjustment to the risk assessment at the Downe Maternity Unit raised a number of concerns, notably in relation to women with excess body mass and those with previous caesarean sections, this has resulted in just one delivery on average per week going to another unit.

Private Session

7. AOB

1. Agreed: The Clerk will prepare a draft response to the consultation paper on the 'Implementation of the Strategic Review of the Ambulance Service', the closing date for which is 15 February 2002.

2. Agreed: The Clerk will prepare a draft response to the consultation paper on the 'Executive Programme for Children', the closing date for which is 11 January 2002.

3. Agreed: The Clerk will write to the Department to ascertain the current position in relation to the shortfall in the number of speech therapists, and to ask what measures, including training provision, are being taken to address the problem.

4. Members were issued with advance copies of the Specification for a New Centralised Maternity Hospital in Belfast, which had an embargo date of 11:00am on Thursday, 22 November 2001.

5. Agreed: The Committee will consider whether it should respond to the interim report on the Accommodation Review of the Civil Service when it is received at the end of the month.

8. Date and Time of the Next Meeting

The next meeting will be at 2:00pm on Wednesday, 28 November 2001 in Room 135, Parliament Buildings.

The meeting ended at 4:57 pm.

DR J HENDRON
Committee Chairman
November 2001

ANNEXE 1

17. How many obstetricians are employed at the Downe Maternity Unit now? Are there plans to extend the midwife-led service at Craigavon Hospital to elsewhere in Northern Ireland? [The Chairman]

1. There are two full-time obstetricians at Downe Maternity Unit, who are supported by four senior house officers, to cope with an average of slightly less than 500 deliveries p.a. The expectation has been for a phased roll-out of maternitymidwifery-led units attached to both obstetric units and acute hospitals, eventually leading to free-standing maternity-led units. In practice, developments have been slower than desired, though the first substantial unit at Craigavon has proved a useful robust model.

17. I appreciate the Minister said that she was aware of the concern arising from the development of high risk criteria but that every effort must be made to sustain services at the Downe Maternity Unit. However, what control has the Department over the Royal Colleges from imposing ever more stringent criteria in relation to risk assessment? [Ms Ramsey]

1. The Royal Colleges have a distinct and important role in approving medical training posts and ensuring that new doctors are provided with meaningful training opportunities to equip them with the necessary experience, confidence and understanding to eventually become consultants whatever their chosen career. Given clinical advances, though, it is inevitable that risk assessment criteria the criteria to ensure adequate training will become more stringent all the time.

The Minister has restated her intention to sustain all current clinical profiles pending a decision on the outcome of the acute hospitals review. And while she cannot give guarantees as to what the Royal Colleges will stipulate with regard to future training requirements, the Department will work constructively to phase in any changes and minimise disruption. The Department will also expect the Boards and Trusts to examine creative ways of sustaining current complements such as rotation of staff and training grades.

17. Your reference to a commitment to retain services seems to fly in the face of the recent closure of two maternity hospitals. What impact has the closure of these hospitals and the more rigorous risk assessments had on the remaining maternity hospitals in the greater Belfast area, which are reported to be coming under increasing pressure and bulging at the seams. Can they cope? Does the Mater have the same clinical cover as the Downe? I am concerned that that there is still no sign of a regional maternity strategy. [Ms McWilliams]

1. The issue of the South Tyrone Hospital was qualitatively different from the Downe. The issue of safety came out of the blue and the results of two independent risk assessments commissioned by the CMO and the Trust confirmed the risk to be genuine and therefore unsupportable. Lessons have been learnt since and there is now a more interactive relationship between the Department, Boards and Trusts to come up with creative solutions. Expenditure has increased at the Downe Maternity Unit to sustain services. The Minister has given a commitment to sustain clinical profiles at all hospitals, and changes in risk assessments processes are under continual audit.

The new risk assessment criteria were agreed on 5 September 2001. That month was abnormally busy for the Belfast hospitals, with the Royal Jubilee having 463 deliveries compared with the average of 400. Initially the new risk assessments were applied rigorously, which lead to some referrals elsewhere because hospitals were operating at their peak. Transfers have not increased since and clinicians are now more comfortable with the revised risk assessments. We are confident that the Belfast hospitals can absorb any limited spillovers. For example, the Downe Hospital is only referring an average of one delivery per week to the Belfast Maternity Units, which is unlikely to pose a great problem. The deliveries for the Greater Belfast hospitals and Downe for the first six months of 2001 are as follows:

Royal Jubilee - 2686

Mater - 618

Ulster - 1409

Lagan Valley - 660

Downe - 288

I do not have figures to hand to make detailed comparisons between the Mater and Downe Hospitals, and in any case you are not comparing like with like. However, I would have thought that the clinical cover would be greater at the Mater, which has roughly twice as many deliveries and where there is also a neo-natal cover arrangement.

You will be receiving some information in relation to the future for a regional maternity unit very soon.

17. To what extent are midwives brought into planning for maternity services? Are there specific training programmes for midwives? Do they have career incentives? Has any action been taken to train paramedics in midwifery skills? [Rev R Coulter]

1. The Department's perspective is to bring all those involved in the delivery of services into planning. The appointment of Ruth Clarke to work with the Department as a midwifery advisor on a part-time basis is a positive step forward. The approval of business cases for rebuilds all come through Estates to the nurse midwifery advisory teams. Midwives have an opportunity to get involved at Trust level with regard to planning right down to the detail of room data sheets. Mr Grzymek also attended a number of meetings with midwives to help them formulate their robust and productive response to the Acute Hospitals Review Report.

Continual professional development is alive and healthy in the area of midwifery. The Nurse in Leadership course is one of a number of creative schemes aimed at giving nurses a stronger voice and skills in interfacing with others, thus empowering them to participate efficiently and operate efficiently at the highest management levels.

NI has broken new ground in moving to an all graduate midwifery at point of registration based on a combination of academia and clinical practice. The Department will also support mainstream staff in upskilling themselves. The settlement for midwives of an automatic level of transfer from Grade E to F this year has been a welcome development.

[Ms Clarke] I know of one of my midwives who teaches skills to paramedics. The Department will come back to the Committee on the general point about skilling of paramedics in this field.

17. Have we not moved away somewhat from the patient-centred maternity services, with a vision of choice for women? Omagh and Dungannon have closed, other units are under threat from the withdrawal of training accreditation. Some may question who is actually running the maternity services and for whom? I worry about the real pressures being exerted on the main maternity hospitals by referrals from other areas. How can we plan for regional maternity services with significant movements of women outside their natural maternity catchment area?

A. It is fair to say that the Department sees patients as central. Substantial resources have been set aside for the useful development in Craigavon. Previously midwives were being trained where a consultant was always there, but we need to build up a cohort of midwives who are confident in delivery themselves. The closure of the South Tyrone Hospital has meant just an extra three deliveries per week day on average at Craigavon, which is well offset by the extra capacity and staff provided by the new unit. Falling birth rates will also ease pressures. The Department has planning tools available but strategically this inevitably involves making assumptions and working on historical data. Down Lisburn Trust and Queen's have done some work on this area with regard to the Downe Hospital.

14 November 2001 / Menu / 28 November 2001