COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Maternal Deaths at Antrim Area Hospital

4 December 2008

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill

Witnesses:
Ms Norma Evans )
Dr Peter Flanagan ) Northern Health and Social Care Trust
Mr Glenn Houston )
Miss Bronagh Scott )

The Deputy Chairperson (Ms O’Neill):

This evidence session is with the Northern Health and Social Care Trust. I welcome Ms Norma Evans, the chief executive, Dr Peter Flanagan, the director of medical governance, Miss Bronagh Scott, the director of emergency, primary care and older people’s services/executive director of nursing, and Mr Glenn Houston, the director of women and children’s services. I invite you to make your presentation, after which members can ask questions.

Ms Norma Evans (Northern Health and Social Care Trust):

I propose to talk for approximately 10 minutes, and then I will take questions. The Northern Health and Social Care Trust has already shared a number of documents with the Committee, and I do not propose to repeat the information contained in those. I had intended to go over some of the findings, but as Breedagh has already gone into them in detail, I will not do so. Thank you for inviting us. I welcome the opportunity to brief the Committee on what is happening in maternity services in the Northern Trust.

I wish to say a little bit about the context in which we are working, particularly in relation to the three completed reviews. As Breedagh said, the Northern Trust was established in April 2007. As chief executive, I quickly became aware of the ongoing inquests into two perinatal deaths and the unfortunate death of Mrs Brown. I am very conscious that Mrs Brown’s family are in the Public Gallery today. Privately, I have offered them my absolute apology, and I offer that again publicly. I am also conscious of the impending inquest, and, therefore, I will take care to restrict my comments. Although my comments on the findings will be brief, I do not want them to appear callous to anyone. However, given the context in which the trust is trying to manage its maternity services, it is important that I make them.

In April 2007, the Northern Trust took over responsibility for Antrim Area Hospital and the Causeway Hospital. Given the difficulties being faced, particularly by the Antrim hospital, we considered how best those could be addressed. The coroner had commissioned several detailed reports from expert witnesses on the deaths of Mrs Brown and the two infants to inform his determination, which is specifically about the cause of the deaths.

However, I felt that we had a responsibility to commission reviews to help us to understand — as an organisation, a trust and a hospital — what had happened as far as we could determine, and, particularly, what we could learn from those tragic events. Sadly, by the time that we commissioned the reviews, there had been another death in December 2007.

Having decided to commission the reviews of the maternal deaths, the senior management team, the trust board and the maternity services management team felt that, as a new trust, it was important not simply to examine the tragic circumstances of the deaths but to review maternity services in their entirety. As a new trust, it was important to uncover any problems and learn the necessary lessons. It was also important that any changes that we needed to make were informed by a clear evidence base.

After wide consultation with colleagues in the Department of Health, Social Services and Public Safety and the Regulation and Quality Improvement Authority, we initially decided on a Northern Ireland-based review team. However, taking into account the seriousness with which we took the task, the smallness of Northern Ireland and advice from our colleagues, we opted to commission two entirely external reviews, one on the two maternal deaths and one on maternity services generally.

It is important that I clarify our intention in commissioning those reviews. It was not to try to determine the causes of the deaths, because the coroner would legitimately do that, but to determine what we could learn about the services that were being provided. As many of the people who were managing the services were completely new to the trust, it was important that we had a baseline from which to determine what we needed to do and what we needed to change.

I will address some of the findings of the review of maternity services, and I am grateful to Breedagh for taking the Committee through the report so carefully. It is important, however, that I try to achieve a balance on behalf of the trust and its staff, who have gone through a difficult period. It has been extremely difficult for them to cope with some very negative publicity. That, to a large extent, combined with staffing pressures, has contributed to the difficulties that they are experiencing.

Yesterday, I talked to some of the senior midwives in the maternity unit. They told me that they spend some time trying to reassure mothers who are worried about whether it is safe to book in to hospital, and Antrim Area Hospital in particular, to have their baby. It is important to examine the headline figures, as confirmed by our independent review. When measured against headline figures, the performances of Antrim Area Hospital and the Causeway Hospital are in the top 25% of trusts in the United Kingdom.

With great respect to the Brown family — and this is not meant to cause them any distress — more than 30,000 babies have been delivered in Antrim Area Hospital since it opened almost 15 years ago. There have been two maternal deaths at the hospital since it opened. The confidential inquiry information into maternal and child health states that the UK average for maternal deaths, measured over a two to three-year period, is between 13·7 and 13·93 for 2000-05.

The Northern Trust delivers 4,500 babies annually. If we were to transcribe the UK average outcomes on maternal death, it is possible that we could have up to three maternal deaths every five years. Therefore, I ask the Committee to consider the implications of that UK average on over 30,000 births in Antrim Area Hospital alone and compare that with two maternal deaths in Antrim Area Hospital and none at the Causeway Hospital, which opened in 2001.

It is unfortunate that mothers are under the impression that it is unsafe for them to have their babies at Antrim Area Hospital. Yesterday, midwives told me that they had to spend time speaking to mothers on the telephone and at antenatal clinics to reassure them that it is not unsafe for them to have their babies at the Antrim hospital.

On the issue of perinatal mortality, the report also makes it clear that the mortality rate at Antrim Area Hospital is significantly lower than the Northern Ireland average and that the Northern Ireland average is significantly lower than the UK average. Again, there is no evidential base for the perception that Antrim Area Hospital, in particular, is unsafe for mothers or their babies. That is not to detract from the tragic circumstances that have occurred between 2005 and 2007.

Post-partum haemorrhage rates, Apgar scores at birth and stillbirth rates — other indicators that are normally used to determine the quality of services statistically — at Antrim Area Hospital and the Causeway Hospital are also below the Northern Ireland average and the national UK average.

In the review, it is very clear that rates of intervention for Caesarean section at the Causeway Hospital are lower than the UK national average but that rates of intervention for Caesarean section at Antrim Area Hospital are higher than the national average at between 27·2% and 30·6%. If the averagerate of intervention for Caesarean section in Northern Ireland is 33%, Antrim Area Hospital’s rate is still higher than we want it to be. I will not go over the reasons that they are higher, because those reasons have already been very well versed by Breedagh. Interventions for Caesarean section in the Antrim hospital are higher than the Northern Ireland average, whereas interventions for Caesarean section in the Causeway Hospital are lower.

The induction of labour rate at both hospitals is higher than the Northern Ireland average. One issue that arises from those figures is that the mother’s length of stay can then be extended. Indeed, that is what the ‘Value for Money Audit of Maternity Services’, which was published in 2006, found. Breedagh has already explained the review very clearly, so I will not repeat what she said; however, it concluded that the trust generally has very good results, despite being at the lower end of the Northern Ireland funding range.

The review also identifies that recent events and their consequent negative reporting, and the suspension of midwives linked to the coroner’s cases, has had a profound effect on the morale and confidence of even the most experienced staff. Certainly, that feeling, which midwives have clearly articulated, is palpable on the wards. They are distressed because they feel that the services that they provide are being portrayed as unsafe.

Breedagh has already taken us through the detail of most of the review team’s recommendations. Those were: the need for a strategy for maternity services; the need to develop multi-professional meetings and training; the need to develop dedicated risk management staff and resources; and the need to have well-designed and easy-to-use incident reporting systems. Those needs are clearly articulated in the recommendations. The trust has accepted those recommendations in full, and they have been put into an action plan, which was updated on 27 November; members have received a copy of that action plan.

We are absolutely committed to this matter, and we provide the trust board with a monthly report on the progress that we have made against the action plan. That is done in a traffic-light system: we have to report what has been achieved, what has still to be achieved and what is on its way to being achieved. We are happy to answer detailed questions that members may have about our progress against the action plan.

The Deputy Chairperson:

Janet Brown and Joanne Moore cannot be brought back, but we can learn from what happened. The most important issue for the Committee is that lessons are learned, taken on board and fully implemented. I fully intend for the Committee to monitor the report that you have provided. I note that there is nothing in the report that has been fully achieved. Rather, everything in the report is a work in progress. I want the Committee to be given a regular update on the progress that is being made. It is incumbent on us to monitor the report and take it forward. We must also ensure that midwives receive the support that they need.

I have met you before in relation to the case of Janet Brown. Even since ‘Insight’ was broadcast, I have been contacted by a number of families who have complaints about how the trust dealt with them after an incident. Has the trust taken that on board? Have you implemented any new procedures for communicating all the information that families need?

Ms Evans:

There is a complaints process that is very well used. The trust receives a very low number of complaints about maternity services. Any complaints that we do receive are treated very seriously and fully responded to. Sadly, complaints usually concern serious issues.

Last night, one midwife was at pains to show me a complimentary letter that was sent by a lady who gave birth to a baby boy last week. I have given each Committee member a copy of that letter. Every patient is given a comments sheet when they are leaving the unit. They are asked to return that sheet two days later so that they do not feel under pressure in the ward to state that they were really well looked after.

I do not disagree with many of Breedagh’s comments. However, midwives’ morale is being seriously compromised by the pressure of the work and by the pressure that the ongoing coroner’s inquest and PSNI investigation is putting on their colleagues. It is a deeply distressing situation for any professional to be in, and they are vulnerable. We have tried to provide support, and the Royal College of Midwives has given excellent support. The circumstances are exceptional, and it is not surprising that morale has been affected.

The midwives to whom I have spoken are completely dedicated to their patients and absolutely determined to provide the best possible care. They complain that there are not enough midwives and that they do not have enough resources. As the Committee will understand, the trust cannot spend money that it does not have.

We are dependent on our commissioner to fund the additional posts and developments that are required. We work collaboratively with the commissioner — in a tight context — in an attempt to secure additional resources. However, the comprehensive spending review savings round dictates that the trust has to save £44 million over the next three years. The implications of that affect every part of the trust, although the commissioner has responded with some generosity by funding the posts that Breedagh outlined. Glenn can provide more detail on that from a managerial point of view.

The Deputy Chairperson:

Yes, that would be helpful.

Mr Glenn Houston (Northern Health and Social Care Trust):

I am the director with responsibility for women and children’s services in the Northern Trust. I came to the trust on 1 April 2007. My portfolio of responsibilities includes maternity services in the community, in Antrim Area Hospital and in the Causeway Hospital, together with a wide range of other related services.

When I was appointed, it was clear that I needed an assistant director who would take the lead for obstetrics and gynaecology in the trust, and we quickly appointed an experienced midwife to that role. We also have a clinical director, who provides the medical lead for the medical staff team across the trust. I am pleased to say that we have a full complement of consultant obstetricians and gynaecologists at Antrim Area Hospital. As well as an assistant director who takes the lead for maternity service across the entire trust, we have a head of midwifery, who is responsible for the day-to-day management of the midwifery service in the community, at Antrim Area Hospital and at the Causeway Hospital. When we received the report’s recommendations, we decided to appoint a number of middle managers: three or four have already been appointed and are in post, supporting the head of midwifery. They now work with the head of midwifery and medical staff to develop that vision for maternity services across the trust.

The Deputy Chairperson:

Why has the risk management strategy not yet been devised and implemented?

Mr Houston:

Across the trust, we have a robust governance and risk management protocol. Where there is an incident of clinical risk, staff are required to report it, using that protocol. We regularly monitor the number of reports that are made using that protocol, and we use it for learning purposes.

A key driver in the report is the issue of risk and governance. As Ms Hughes explained earlier, that was why one of our earliest decisions was to appoint a midwifery lead for governance and risk: that person has already been appointed and is in post. To complement that appointment, we are also appointing a specialist midwife who will take the lead in practice development. Those two appointments will assist us to make the culture change that is referred to in the report as being necessary for developing and strengthening our arrangements for risk and risk management. The most important issue is to make services safer for patients.

The Deputy Chairperson:

If, for example, there were a serious adverse incident tomorrow, would all the staff in the trust be fully aware of the procedure of who should report to whom and what should happen?

Ms Evans:

Yes, they would.

The Deputy Chairperson:

With respect to what Breedagh said about the need for a change in focus towards midwifery-led services and the development of the pathway services, as opposed to medical intervention, how far has the trust developed that?

Miss Bronagh Scott (Northern Health and Social Care Trust):

I am the director of nursing and midwifery in the trust, so I am responsible for ensuring that professional issues for midwives are addressed.

I wish to commend the midwifery staff of the trust to the Committee. They are very committed and dedicated. I talk to them regularly, and they are determined to raise their morale once more and send out the message to the public that the trust’s services are safe to use. They need support in that.

Traditionally, in our legacy organisation, the United Hospitals Trust, there was a medicalised approach to maternity services. The changes that we have made in the Northern Trust, and the new people that we have appointed, will help us to push through midwife-led initiatives. A key post is the midwife consultant: we are considering that post carefully and developing it in conjunction with Queen’s University Belfast. The creation of that post will see the appointment of an expert midwife who will be able to concentrate on the normal pathway for maternity services and pregnant women. The appointee will also assist with the development of required skills among existing staff and will establish services that provide a more focused, midwife-led approach to care.

All that will require a significant culture change in the development of our staff, particularly with confidence building. However, that post is key to achieving that change because it will focus on the normal pathway and will be a clinical-practice-level post rather than a management post. With support from Queen’s University, the post will help us to move towards a more midwife-led culture in the unit.

We are also working closely with our commissioners. Previously, there has not been a strategic lead in the Province for midwifery-led units, and it has been only in recent months that we have heard of a drive to create such units. We wish to discuss that matter with our commissioners in the future.

Mr Houston:

As part of the action plan, we have established a multidisciplinary forum. That forum will drive the changes needed to get us to the point where we have fully achieved each of the eight objectives that are set out in the action plan.

In the previous evidence session, Ms Hughes spoke about the importance of having local maternity services committees, and I am keen to see the development of a local maternity services committee in the Northern Trust. That committee would work with the trust and help to make the type of changes that are required in order to reduce intervention rates, which is a key challenge in the independent expert’s recommendations.

That must be done over time. It will require close collaboration between obstetricians and midwives, and the trust will have to work effectively with its colleagues in the Royal College of Nursing at departmental, board and regional board level.

Mrs Hanna:

Glenn and Bronagh have already answered some of my questions about how the report recommendations will be implemented.

The review is good for all the trusts, and it is very much needed. However, it is sad that it has had to come about as a result of these tragedies. Nevertheless, it is important that it is in place.

I take on board what you have said about the morale and confidence of midwives, and I can understand that that is a real concern. We need the midwives; they are professionals who must be supported.

However, we must take heed of the statistics. Inevitably, when a tragedy occurs, it raises many concerns on many issues. I take on board the statistics that you have provided to the Committee, and it is important that they have been spelt out.

I look forward to seeing the practical development and outworking of better teamwork. When I worked as a midwife — although I have not practised for some time — we worked in silos, and the current situation is probably worse than it was in my time. Nowhere is co-operation and teamwork more important than in midwifery. Pregnancy is normal and healthy for most women and should be treated as such.

It is important that the new posts of consultant midwife and head of midwifery have been created and that someone is examining risk management. I will watch the expected roll-out with interest and also the actions of the other trusts.

Ms Evans:

The trust — from the chairman and the trust board down — is absolutely determined that the action plan will be implemented.

The Deputy Chairperson has indicated that she has concerns that some of the objectives have been only substantially achieved, and I understand that concern. However, it is important to clarify that the trust had already moved on some of the recommendations, because we were clear that something must happen. The trust received the report only this summer, and it was endorsed by the project board only in September. We have set what we hope are realisable time frames.

A lot of training and culture change is involved. Many staff are employed in the maternity services of Antrim Area Hospital and the Causeway Hospital — probably in the region of 200. It takes time to make sure that they are all trained to the appropriate level. If that was done quickly, it might not be done properly. I assure the Committee that there is an absolute determination to follow that through in its entirety.

Mrs Hanna:

As you said, the top and bottom line is safety. Sadly, that will not bring those babies back, but we can learn from the experiences.

Ms Evans:

Absolutely. That was the fundamental principle on which we commissioned the three reviews — a determination to learn and to ensure that what happened will not be repeated.

The Deputy Chairperson:

Breedagh mentioned cardiotocograph (CTG) training, and I note that the report states that some of that has started. Is that training for other staff as well as midwifery staff?

Mr Houston:

Yes, it is.

The Deputy Chairperson:

How far through the trust will that training be provided?

Mr Houston:

Currently, 285 people are registered with the K2 training programme; 60 have completed that training, and there are probably another 100 who are well advanced. The aim is that everyone will have completed that K2 training by the end of March 2009.

Miss Scott:

That is only one aspect of training; other CTG training is also taking place. Every midwife in the Northern Trust completed CTG training in the past year. Face-to-face training is also being undertaken in the Beeches Management Centre.

The Deputy Chairperson:

The Chief Medical Officer advised that all midwives should receive that training, but the point was made that it was not only midwives who needed training.

Mr Buchanan:

Following the closure of the maternity unit at the Mid-Ulster Hospital, Antrim Area Hospital took the biggest percentage of influx of patients from areas such as Magherafelt and Cookstown. Does that leave a shortage of midwifery staff in Antrim Area Hospital, or are you confident that there are enough staff to deliver the service that is required? We talked about low levels of morale and confidence — perhaps what happened had an impact. If there is pressure on the workforce because there are not enough people to deliver the service that is expected, that will also add to low morale, and it will lower confidence levels.

We also talked about the £44 million of efficiency savings that the trusts are required to make. Will that have a knock-on effect on front-line midwifery services, or will those savings be made in the overly bureaucratic sections of the trust?

Ms Evans:

As a provider trust, we can never have enough staff. No matter how many staff we have, we can always find ways to improve the quality of the services that we provide. There is a constant debate between us and the commissioner about securing more resources. I was not personally involved when the maternity unit at the Mid-Ulster Hospital closed in 2006, but I know that there were very active debates with the Northern Health and Social Services Board. A significant proportion of the resources that was associated with the midwifery and obstetric services in the Mid-Ulster Hospital transferred to Antrim Area Hospital.

In the document that we provided to the Committee, table 1 details the effects. Glenn understands those better than I do, so I will let him speak about them.

Mr Houston:

There was a significant increase in the number of mothers who used, and who continue to use, Antrim Area Hospital as a result of the closure of the maternity unit at the Mid-Ulster Hospital. At that time, there was a debate about where those mothers would choose to go. The feeling was that the majority would probably go to Antrim Area Hospital, some would go to the Causeway Hospital and some would go to Craigavon Area Hospital. Almost two years on, that pattern has emerged. It has had a significant impact. As well as the fact that the underlying birth rate has increased across Northern Ireland, there has also been an accelerated increase in the number of women who book into Antrim Area Hospital.

We have undertaken an exercise, using the Birthrate Plus methodology, which compares the funded establishments of midwives across the trusts with the recommended Birthrate Plus national standards. Ms Hughes referred to that earlier. There is a shortfall, not so much in the hospital but in the community. In the hospital, the shortfall is no more than two whole-time-equivalent midwives.

Members have copies of a table that compares staffing levels across Northern Ireland and shows how Antrim Area Hospital compares with hospitals in the other four trusts. The table indicates that there is no huge or significant under-resourcing at the Antrim hospital compared with other hospitals. However, on the basis of that exercise and the recommendations in the report, we have made a robust submission to the Northern Health and Social Services Board for additional investment in maternity services. One response from the board concerns the two specialist posts: the lead for practice development and the lead for risk and governance.

We strongly wish to set up a properly staffed foetal or maternal assessment capability at Antrim Area Hospital. I am pleased to tell the Committee that the board has responded positively to our initial approach: we expect to appoint three additional midwives to help to develop that capability. That facility will be for women who attend daily, who have some concerns, have consulted their GP and have been referred straight to the hospital. The benefit of that is that it does not require midwives to leave other duties on the wards or in the labour suite to attend to those women.

Ms Evans:

Although Birthrate Plus is helpful and generally shows how many staff are needed for each mother and for the number of deliveries, it must be remembered that patients tend to stay in Antrim Area Hospital for longer than is recommended by the national average. Also, the context is one in which midwives are not particularly well supported by administrative and clerical staff and by other auxiliary grades. Midwives in the Antrim hospital do not have many healthcare assistants or midwifery assistants. Breedagh and I have discussed this issue; she would say that raw statistics may show that there are sufficient midwives, but are they doing the right things? Are they being managed and directed in the right way?

We need more staff in Antrim, although not a huge number. We have tried to identify the number of whole-time-equivalent staff who are off on sick leave. Four staff are off work: two were suspended as a result of the coroner’s decision on the inquest in December 2007 and are currently the subject of a PSNI investigation; and two will be involved in the coming inquest. Therefore, we are missing four experienced senior midwives.

I was in the maternity unit yesterday, and staff told me that, in the past few months, seven midwives had been on maternity leave. We have tried to cover those maternity leaves, but as Breedagh has already said, there are not enough midwives to replace them. Sometimes, the only way that we can continue to deliver the service is by asking midwives to work additional hours, which they do willingly and never let us down. However, midwives should work 37∙5 to 40 hours a week, with proper rest and recreation. To ask them to do otherwise jeopardises patient safety. Midwives become tired and do not get proper meal breaks. We understand and accept that. I remind the Committee that, as a result of the comprehensive spending review, we have no choice but to find £44 million between now and 2010-11: however, we will not cut front-line midwifery-care-delivering staff.

The reference to over-bureaucratisation is interesting. The report indicated that, under the previous regime, in all the trusts, insufficient concern was given to management and administrative staff who are needed for risk management and incident reporting, and who process the information that emanates from those activities, analyse it and look for trends. That is the type of task that is undertaken by administrative and clerical staff.

However, it is clear to me that, in the maternity unit in Antrim Area Hospital, there are significant periods of time when midwives do not have the administrative and clerical staff to support them. Those midwives have to undertake administrative duties, such as entering patient information onto the system and keeping accurate records of observations. Some of that is appropriate work for midwives, and some is not.

We are determined to continue to work with the commissioner in order to secure resources and to address not only the number of midwives but ways in which we can use them better and give them more support. As far as possible, midwives should be doing their own duties rather than having to undertake others.

The Deputy Chairperson:

When do you expect those changes to be implemented?

Ms Evans:

Those changes will be implemented as soon as we secure the necessary additional resources from our commissioner, the Northern Board. Under the financial regime of the Health Service, I am not permitted to spend money that I do not have from a recurrent source. The Northern Board has been working closely with us and has met representatives from the Royal College of Midwives.

The perception is that we are over-bureaucratised — to use your word. It is always more difficult to get resources for hotel services staff, IT staff and administrative staff than it is for medical staff; doctors and nurses will always generate more sympathy. However, if there is not a balance in resources, those scarce highly skilled professionals will be diverted into duties that are not required of them.

We are heavily involved in working with the Northern Board on that issue, but, because of concerns about the number of midwives, the board’s priority is to provide us with midwifery support. As Glenn indicated, that means five additional posts.

I apologise for interrupting Bronagh to say all that.

Miss Scott:

You covered most of what I intended to say.

We are working with midwives, particularly at ward manager level, examining how they and their staff are working. In Northern Ireland, traditionally, the midwife assistant role has not existed. The Chief Nursing Officer has undertaken work on a regional level to develop that role.

Midwives must examine how they work and identify aspects of the job can be done by others. Staff can then be trained to carry out those duties, freeing the midwives to concentrate on a purely midwifery role. That work has begun and will continue among our staff while we are in negotiation with our commissioners.

Breedagh said that the trust did not look at the impact, or the necessary staffing, after the transfer of services from the Mid-Ulster Hospital to Antrim Area Hospital. I assure the Committee that work was done at the time. A modified Birthrate Plus exercise was carried out, which told us the number of staff that would be needed when services were transferred.

At that time, we were in robust negotiations with our commissioner about holding on to those resources and putting them into the community and Antrim Area Hospital. As a result of that, when the transfer was made, the full Birthrate Plus exercise, which has already been mentioned, set out exactly what staffing levels should be. That modified exercise took place because we did not have the time to conduct the full Birthrate Plus exercise, and we recognised that it would need to be repeated when the services were transferred.

Mrs McGill:

Norma, did you say that there are currently seven midwives on maternity leave?

Ms Evans:

No; I said that I was in the maternity unit yesterday and that staff said that there had been seven midwives off on maternity leave; I think that one or two of them have returned. Midwifery tends to be a female profession so it is reasonable to expect that there will be maternity leave. The difficulty is not one of resourcing; it is one of finding midwives to enter the service on a temporary basis. In a current recruitment exercise for permanent posts, we have two applicants for four advertised posts. The problem with advertising a temporary post is that, as Breedagh has said, there are no midwives in Northern Ireland who are not working if they want to. Refresher training for older ladies who wish to return to work having had their families are among the incentives being offered. The trust is happy to consider limited hours. In an effort to secure cover in areas where staff are under pressure, the trust happily offers any support that it can to any midwife who wishes to work.

Mrs McGill:

That seems to be a massive gap — seven staff being out on maternity leave.

Ms Evans:

There were seven out at one time, but there would have been an overlap. Some would have been coming back, but, at one stage, the point was made that seven staff were missing from the department. However, two or three have now come back, and the difference in having them back was commented on, because they were experienced midwives.

Mrs McGill:

The point that I am making is that the absence of seven midwives at any one time, even a short time, seems a lot to me. That appears to be a massive gap.

Ms Evans:

It is, unfortunately, something that is terribly difficult to predict and put contingency arrangements in place.

Mrs McGill:

I accept all that, but I am making the point that it seems a lot, and it would clearly put pressure on other staff. How is that level of absence managed on the ground? There have been comments about support staff, but that seems to be in the very early stages of development. Is that the case?

Mr Houston:

Among the decisions that were made earlier this year was the need to recruit people permanently in order to bolster cover over and above the trust’s establishment figure to cover sickness absence and maternity leave. Additional posts have already been advertised.

To reinforce what the chief executive has said, it is difficult to recruit people on temporary contracts for that purpose; therefore, the risk of appointing people on permanent contracts must sometimes be taken in the knowledge that, in any year, some staff will be on maternity or long-term sick leave. Cover must always be provided; therefore, the trust tries to make provision for that within what it considers to be a reasonable limit.

The Deputy Chairperson:

Claire’s point is that with staff morale low, pressure mounts on midwives for a combination of reasons. It is a wonder that the sickness absence is not much higher because of that pressure.

Ms Evans:

I assure the Committee that the trust is doing its very best; it must cope with the fact that some colleagues are off in very difficult circumstances or on maternity leave.

I must also say that, because of perceptions about the service, a midwife is in a seller’s market and can get a job just about anywhere in Northern Ireland. Antrim is 20 minutes up the road for opportunities to be a midwife in Belfast. I postulate that that in itself has an influence on where people choose to work. However, I spoke to a senior midwife yesterday who had been working in Belfast but had returned to Antrim Area Hospital because she lives in Ballyclare, and she said that she was absolutely delighted to be back in Antrim. She acknowledged the stress and the difficulty but confirmed that she was working in a wonderful unit with extremely committed staff.

There are problems and difficulties that we all accept must be addressed. In fairness, we are talking about midwives, but the report also highlights some of the difficulties that medical obstetrician–gynaecologists face. There are seven of them to cover 23 outpatient clinics. Therefore, as well as providing cover in the ward and in the delivery suite, they also have to provide outpatient clinics to women.

Our trust’s geography is one of the largest in Northern Ireland, going from Larne, through Carrickfergus, Newtownabbey, Antrim, Ballymena, Magherafelt, Cookstown, Pomeroy, Draperstown and all the way up round the coast. Those consultants are delivering outpatient clinics to ladies who require antenatal care, which also puts them under pressure. From an antenatal point of view, our geography is quite challenging, particularly where it is led by obstetricians, and the review has recommended that we examine that.

If experienced midwives were recruited, they could take on antenatal care for healthy women in the early stages of pregnancy, and the consultants could be used only to see the women who are at higher risk. That would mean that there would be more opportunity to get the training, the skills and the leadership from the obstetricians in the hospital on the ward. We are trying to address all those issues, and the most important point is that they have been identified in the review. We know what we have to do, and we are determined that we will do it.

Mrs McGill:

You mentioned the size of the geographical area. Are you making the case that it is too big?

Ms Evans:

That is a matter of opinion. The reality is —

Mrs McGill:

I represent the same constituency as Mr Buchannan, and he made an effective point earlier — as he often does. It is the same argument that we have been making in Omagh for a considerable time.

Ms Evans:

With the greatest respect, I do not think that I am necessarily saying that the area is too large. Two fully functioning maternity units are within the geography of the Northern Health and Social Care Trust — one in the Causeway Hospital and one in Antrim Area Hospital. However, I was saying that, if antenatal care is organised so that it is mostly obstetrician-led, one must make it convenient for one’s population. There is a choice: a trust either makes the patient travel to the obstetrician or it makes the obstetrician travel to the patient.

The history in the Northern Trust area has been that the clinics have, by and large, been in local areas, meaning that there would be one in Magherafelt, one in Larne, one in Carrickfergus, and so forth — in our main centres of population. The point that the review is clearly making is that that does not have to be the way that a trust delivers antenatal care. Breedagh has already referred to the potential for reform and modernisation, where midwives begin to take a much more prominent role in looking after fit, healthy women who will proceed to deliver healthy babies perfectly normally. There may not be the requirement for the obstetricians to be involved to that extent, which would free them up to provide more leadership and support in the hospital, looking after the higher-risk mothers and those who require medical care rather than nursing care. It would improve significantly the confidence and status of midwives. It would also give many women a greater choice over how they are looked after during their pregnancy. That was the point that I was making rather than anything vaguely political.

The Deputy Chairperson:

It all comes back to the pathways for care and to the fact that midwives are saying that they are more than able, and more than willing, to move in that direction.

Norma, the Committee would like a commitment from the trust to have regular updates on the recommendations in the review and how they are being implemented.

Ms Evans:

That is fine. The Committee Clerk can indicate how the Committee would like that information, how frequently and in what format, whether it wants a written report or wants us to come back at regular intervals, which will not be a problem.

The Deputy Chairperson:

A written report will be fine, and the Committee will come back to you if it has any further questions. An inquest is staring next week, and the Committee reserves the right to come back to you after the inquest. It is hoped that the inquest will deal with the issues, but, if not, the Committee will come back to you to take the matter further. Thank you for attending the Committee today.