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Consulting professionals and managers about the NHS.
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A professorial view on the economic oportunity – for business. This runs against the trend.
The only problem is that no government, including ours, can afford all the technological advances equally. The fact is that the value of our economy (stockmarket value) has diminished by 37.5% since 2007. The decline has been accellerated by Brexit. See “Why the stockmarket is disappearing- Large companies such as ByteDance, OpenAI and Stripe are staying private” in the Economist 18th April 2024 and 18th Jan 2024 “A golden age for stockmarkets is drawing to a close” – Share prices may be surging, but even AI is unlikely to drive a repeat of the past decade’s performance. Leaving the EU and the EFTA area cannot be helping.
Times letters 6th May 2024: Economic medicine
Sir, The OECD figures suggesting that next year the UK economy will be the worst performing in the G7 (report, May 2) strengthen the case for an ambitious industrial strategy to boost sectors that could act as engines for economic growth.
Medical technology is an example. Despite being half the size of biopharmaceuticals in terms of jobs, med tech contributes £13.5 billion to the UK economy annually, against biopharma’s £15 billion. Its annual growth rate between 2016 and 2020 was 19 per cent — far higher than biopharma’s 3 per cent. But the med tech sector’s vitality has been in spite, not because, of government policy. Regulatory uncertainty, scarce funding, and ineffective NHS procurement processes make it difficult for med tech inventions to develop into viable businesses.
We have no shortage of talented people in this country, and we boast some of the best universities in the world, so bringing academic expertise together with industry should be an easy win. But countless good ideas go to waste. Imperial College London is investigating how to improve the competitiveness of the UK economy. A central theme is the need for more flexible regulatory environments that can align with key markets such as the EU and US. With the right strategy and investment, we have an opportunity to generate economic growth and cement the UK as a world leader in technology and innovation.
Professor James Moore Jr
Bagrit & RAEng chair in medical device design, Imperial College London
Exit Interview: MP resigns from Tory party over NHS “stretched close to breaking point”
If the medical profession are going to shape Labours 10 year NHS plans, which doctors will they ask? The BMA and most of my froends are divided. There is however a 70% , and increasing, majority in favour of rationing: not having everything for everyone for ever everywhere for free. This means excluding some treatments. The debate on reducing social security support and sick pay is a similar one. The ethics are around the choice between a paternal state and autonomous, resilient self sufficient individuals and societies. Jacqui Wise for the BMJ reports 4th May 2024: MP resigns from Tory party over NHS “stretched close to breaking point”
Dan Poulter, a consultant psychiatrist and former health minister, has resigned from the Conservative Party over the state of the NHS and accused the government of putting political ideology before pragmatism over doctors’ pay. In a shock resignation on 28 April the MP for Central Suffolk and North Ipswich for 14 years said he would sit as a Labour MP until the general election and then would stand down.
Poulter said he had made his decision after spending more than 20 night shifts over the past year working as a mental health doctor in a busy accident and emergency (A&E) department. He told BBC Television’s Sunday with Laura Kuenssberg programme, “I found it increasingly difficult to look my NHS colleagues in the eye, my patients in the eye, and my constituents in the eye with good conscience.”1
In an article for the Observer newspaper Poulter said, “Throughout the small hours, my clinical colleagues and I cared for many patients suffering from serious psychosis who would routinely be waiting several days, rather than hours, in a windowless room in A&E for a mental health bed.”2 He added, “The chaos of today’s fragmented patchwork of community addiction services—making A&E the default location for people to get treatment and help—has added pressure to an already overstretched service. The mental toll of a service stretched close to breaking point is not confined to patients and their families. It also weighs heavily on my NHS colleagues, who are unable to deliver the right care in a system that simply no longer works for our patients.” Poulter said he believed that the Conservative Party no longer valued public services. “It is abundantly clear to me that the Labour Party alone has the will and the trust to restore and reform the NHS.”
Poulter, who served as a health minister under the UK’s coalition government from 2012 to 2015, said he was deeply concerned about the failure of the government to implement vital reforms to mental health law and to the 1983 Mental Health Act, many of which were contained in the 2018 independent review of the act by the psychiatrist Simon Wessely.3
Writing in the Observer, Poulter said that in particular he was “dismayed by the failure to address racial disparities in the use of mental health laws and to reform aspects of mental health law relating to the care of people with learning disability and autism.” He added that community services have been hollowed out, leaving the system poorly equipped to prevent crisis admissions and deliver the transformative care in the community that patients with mental ill health needed.
He also accused the government of failing to tackle NHS staff’s longstanding concerns over pay at a time of a cost-of-living crisis and increasing staff recruitment and retention challenges. “Political ideology has been put before pragmatism and meeting the needs of patients—who are the real losers from the strikes,” he said.
In January Poulter spoke about the parlous state of the NHS at the launch of the BMJ Commission on the Future of the NHS (bmj.com/nhs-commission).45 The commission identified years of constrained funding, workforce shortages, and high demand among an ageing population as some of the key pressure points on the health service and called on the government to declare a national health and care emergency.
Commenting on Poulter’s decision, Nigel Crisp, an independent member of the House of Lords and lead author of the commission’s first report, said, “The Conservative Party has changed massively in recent years and left many good people behind, Dan included.” He told The BMJ, “I am not surprised he feels so strongly about the state of the NHS. An incoming government should declare a national health and care emergency and get the country mobilised behind it.”
2014: A first debate in West Wales BMA – on rationing – wins a majority in favour
TAKING STOCK Rammya Mathew: We can’t miss the backdrop as the UK becomes sicker
The absense of truth seeking behaviour in all 4 dispensations.
Medical continuing education is not complete without many more post mortems.
Matt Dathan reports in the Times 2nd May 2024: Grieving families let down by ‘unacceptable delays’ in coroners’ courts – Chief coroner blames underfunding as number of cases waiting more than a year for a verdict rises 25 per cent to a record high
Thousands of bereaved families are being let down by “an unacceptable level of avoidable delay” in coroners’ courts across the country, the chief coroner has admitted. The number of cases waiting more than a year for a coroner’s verdict has increased by more than a quarter to a record high of 6,149, according to new figures.
Judge Thomas Teague, the chief coroner of England and Wales, said the delays were not only preventing families from complying with their loved one’s beliefs and last wishes but also compounding families’ grief. Th
e registration of a death cannot be completed until the coroner’s investigation concludes and it can also delay burial and cremations, affecting the grieving process, he added. Teague attributed the unnecessary delays to “chronic underfunding” of coroners’ services, a shortage of pathologists and the “residual effects” of the Covid-19 pandemic. Writing in his annual report for 2023, the chief coroner called on the government to take urgent action to “address the fundamental problem of resourcing”.
The report was published last week but has since been removed from the Ministry of Justice (MoJ) website after being published “in error” and was not supposed to be in the public domain until after the local elections due to purdah rules which bar certain civil service announcements that may affect voting behaviour in the run-up to polling day.
The report will be republished on the MoJ website later this month, government sources said. Labour blamed government inaction for betraying bereaved families.
Emily Thornberry, the shadow attorney-general, said: “All across the justice system we are seeing these same pressures and backlogs, and as the chief coroner says, it is ordinary families who are being let down as a result. We cannot go on with a government that just sticks its head in the sand, and pretends these problems do not exist.”
Under the 2009 Coroners and Justice Act, coroners’ offices across England and Wales are required to complete inquests within six months of the date on which a death is reported to them, or “as soon as reasonably practicable” afterwards. To monitor compliance, they must report to the chief coroner all investigations that have not been completed within a year. In the report, obtained by The Times in full before it was removed, Teague reported that as of April 2023, 6,149 cases had been outstanding for more than 12 months. This is up by more than a quarter on the previous year when 4,812 cases had taken more than a year and four times higher than the figure for April 2017 (1,508).
In 2017 there was only one coroner area in England and Wales — the City of Manchester — reporting more than 100 cases waiting over a year. However, in the latest annual report the number of areas reporting outstanding cases of more than 12 months rose to 18 from 14 in 2022. While 29 areas saw their number of cases outstanding for over 12 months fall in 2023, 52 saw their number increase, and in 24 areas, their total rose by at least half.
Writing in his 2023 annual report, Teague described 2023 as a “difficult year” for the coroner service as many areas were “still struggling to eradicate the backlogs that built up during the Covid-19 pandemic”.
Changes to medical practice that have led to greater numbers of natural deaths being reported to coroners have also caused delays. Teague said the financial crisis had also “severely affected the ability of many local authorities and police services to resource the coroner service appropriately”. He wrote: “Under-funding of the service remains a serious and pervasive problem. “Although delays can never be completely eradicated because of the need for coroners to wait for external investigations and processes to conclude, I must report that there is currently an unacceptable level of avoidable delay within the coroner service.”
Addressing the impact that the delays can have on bereaved families, Teague wrote: “Coroner cases should be conducted without delay — the posthumous duty of the family to the deceased includes ensuring that the body is disposed of with dignity and in accordance with the deceased person’s beliefs, that the death is registered, and that the estate is dealt with as the deceased person would have wanted.
“Where a death has been reported to a coroner, the family cannot arrange for their loved one to be buried or cremated until the coroner has released the body. “The registration of the death is also delayed until the coroner’s investigation concludes. There is therefore a tension between the coroner’s duty to investigate and the family’s need to fulfil their obligations to their loved one. “This tension is particularly acute where the deceased person held religious beliefs that are incompatible with delayed burial.”
He added: “Delays within the coroner service not only prevent some families from complying with their loved one’s beliefs, but also compound families’ grief and impact on the reliability of the evidence available to coronial investigations. Avoiding unnecessary delay must therefore be a key priority for the coroner service.”
A government spokesman said: “We are taking decisive action to ease the burden on grieving families and reduce any delays they may face when laying loved ones to rest. This includes changing the law to make it easier to establish if a death is from natural causes without the need for a post-mortem, reviewing pathologists’ fees and investing billions to help local services recover from the impact of the pandemic. We will respond in full to the report in due course.”
NHSreality posts on “post mortems”, the absense of truth seeking behaviour, and the restrained Coroners.
Ministry of Justice – GOV.UK (Where the report will be released this May.
RAAC and collapsing Hospitals. An allegory for the all 4 “NHS” dispensations
It is interesting that since the original RAAC reports in 2023 it seems that we knew about the timebomb in our school and hospitals and other public buldings since 1993, and our politicians and administrators at high levels in government were unwilling to tell us the “hard truths” – as usual. We could replace these hospitals wityh open spaces, parks and parking places for the next generation of hospitals. (In plastic and cardboard) . Our collapsing ceilings in multiple buildings are an allegory we should all take seriously. It will have to be bottom up if the conservatives stay in office! If you dont provide caring environments for your staff, and indeed, you dont care, you cannot expect them to stay in the UK. Its a world market in medical jobs. “Nobody cares how much you know antil they know how much you care”. The staff will no longer be gagged.
6th July 2023: Inverclyde Royal Hospital inspection raises ‘poor conditions’ concerns | The Herald
23rd September 2023: BBC News: More than half NHS Scotland buildings not inspected for Raac
14th December 2023 Dennis Campbell in the Guardian: Hospitals ‘falling to bits’ as NHS in England faces record £12bn repair bill – Government needs to find more than £2bn for urgent maintenance to prevent catastrophic failure, report shows
Meaningless targets – even plastic and cardboard missen hut hospitals may not be within our means.
Rachel Davies in 12th September 2023 in The Evening Standard: RAAC hospitals: Full list of NHS buildings with unsafe …
Alice Thompson changed her mind on assisted dying. So can our MPs,
Its time to think that the naysayers might be ina minority, and they might be wrong. It has noticably taken many votes and much discussion to get to this point in new legislation on dying choices. The comparison with other countries is valid: in some up to 67% die at home. The charitable funding of hospice care is part of the problem… not because it is charity money (We have to ration care) but because it is unequal and unfair depending on where you live. In richer areas the opportunity to look after more people at home is reduced because of the nindset that inpatient hospice care is better and expected. Unfortunately this is true for individuals but not for the population. There is an added issue in that in my area, and many others, several charities compete for funds and fundraisers leading to reduced efficiency of those funds in totality. It might be that if more money was given from government to those hospices that increased the proportion cared for at home, the expectations would change. The choices around assisted dying are hard, and harder as we get nearer our end. But they must be OUR choices, and we should not be forced overseas to make them.
The Times letters 2nd May 2024: End-of-life care
Sir, The campaign for assisted dying is a missed opportunity to talk about fixing our social care and palliative care systems so that proper end-of-life care with appropriate pain relief is available for all. It is to be hoped that others follow Alice Thomson’s lead (Comment, May 1) and change their minds.
Canon Dr Chris Sugden
Oxford
Alice Thompson April 30th: Why I changed my mind over assisted dying – My father’s dementia was dreadful to watch but right-to-die laws in Canada and the Netherlands are a slippery slop …. (• Don’t assume we will get assisted dying right)
…..Our children used to roll their eyes at our right-to-die conversations, insisting that they wanted both their parents and pets to be kept alive as long as possible. But whenever my husband and I read about people being charged with attempted murder for helping a loved one to end their excruciating pain, we agreed the system was barbaric. Only this week the former mayor of Winchester was in court for putting a pillow over his nonagenarian mother’s head to end her suffering. Neither of us wanted to die in a Swiss clinic far from home……
A majority in Britain now want assisted dying. (80% in the Times on line poll) An Ipsos Mori poll last year found 65 per cent in favour. Many of those I respect most, from Dame Esther Rantzen, who has terminal cancer, to Jonathan Dimbleby, whose brother died with motor neurone disease, to my fellow columnist Matthew Parris, want a new legal right-to-die.
A recent House of Lords bill set out how a law might work. It proposed that terminally ill adults certified as being mentally competent by two doctors could apply to a High Court family judge to end their lives. However, a debate in parliament this week showed the difficulties of defining such terms.
I don’t think Britain is full of granny killers nor do I want the terminally ill to have to starve themselves to death, but I don’t trust our politicians to get this legislation right — or future parliaments to hold the line. What would start as a choice could become an expectation.
Sir Keir Starmer has made changing the law a priority for a Labour government, promising a free vote. But this moral conundrum is already turning into another part of the culture war with activists on both sides becoming increasingly shrill and uncompromising. I worry that we will lose sight of the need to be compassionate and humane.
Increasingly, I would prefer us to prepare for better deaths. Only 3 per cent want to die in hospital, yet more than 50 per cent do, with only 17 per cent ending their days at home where they can be surrounded by family and friends. Hospices are another alternative. In Spain, two thirds of adults die in their own beds, often aided by pain relief. This is achievable with better social care.
My husband disagrees. The sooner assisted dying becomes law the better, he says. He wouldn’t want to be kept alive with multiple complex conditions and sees little joy in eking out his final days to postpone death rather than extend any meaningful life. Both of us want to promote individual choice, but I don’t want to hasten anyone else’s death.
Letters |May 3rd 2024: Assisted dying and improving end-of-life care
Sir, Alice Thomson emphasises some of the complex and deeply personal issues around assisted dying against a background of an ageing population, worries around loneliness, being a burden, chronic illness, the cost of care and other matters that may put pressure on individuals (“Why I changed my mind over assisted dying”, May 1). Despite an increasing number of people seeking assisted dying once it has been established, these individuals remain a tiny proportion of those who die each year.
Thomson points out that more than 50 per cent of people with an end-of-life condition die in hospital even though only 3 per cent of people state that to be their preferred place of death. Good end-of-life care should be provided by the hospice service, with an emphasis on quality of life. However, a recent all-party parliamentary group report on end-of-life care found that the integrated care boards that supply health funding locally were “not fit for purpose”, which was echoed in a parliamentary debate last week.
We need excellent — and properly funded — end-of-life care across the country for 24-hour care by all hospices, not just some. Skilled palliative care is the chosen path for most of us but we must get assisted dying right for the few who choose it.
Professor Stephen Spiro
Vice-chair of trustees, St Luke’s Hospice, Kenton, Harrow
Sir, Alice Thomson is to be applauded for her courage in changing her mind, given the ever-widening selection criteria in the Netherlands and Canada. Clinical experience indicates that many patients also change their minds, after an initial request of “Please help me to die”, if they are given the opportunity and the time to discuss their fears of dying. Patients who have assisted suicide no longer have the chance for a change of mind.
Dr David Jeffrey
Former palliative care doctor; senior lecturer, Three Counties Medical School, Worcester University
Sir, I am a retired NHS surgeon and a Swiss citizen. I have always believed in assisted suicide the Swiss way. The Swiss law on assisted suicide was passed in 1942 and enacted the next year: the country “got it right” from the start and the law has not changed since. The only change has been that individual cantons can (and have) chosen to impose on hospitals the duty to allow it to take place in hospital. In the canton of Vaud (where I grew up and trained) this is done by Dignitas or Exit, not the team caring for the patient. The process has been working well there for nigh on 80 years now.
Michael Dusmet
Ret’d thoracic surgeon, Richmond upon Thames, Surrey
Sir, Alice Thomson emphasises the downsides of assisted dying in societies that have it: expansion from terminal illness to someone with depression, the possible inclusion of children, and much else. But it need not be like this. Proper rules, carefully supervised, can control assisted suicide. There will be controversies and even mistakes. But we should not let the perfect get in the way of the good.
Paul Larsmon
Burbage, Wilts
Sir, The crux of Alice Thomson’s article is in her last sentence: “I don’t want to hasten anyone else’s death.” But what if the person concerned wants to hasten their own death? It is morally wrong and patronising to deny that person their wish.
Rachel Wildblood
London SE21
Update letters 6th May: Help at the end
Sir, Further to Alice Thomson’s article (“Why I changed my mind over assisted dying”, May 1), I believe the hastening of death for the terminally ill has been around for a long time. My mother, who was in a care home in her nineties, became constantly dehydrated. She was hydrated several times and eventually those in her care decided on denial of food and drink, and she soon passed away. Several years later my sister, who had cancer, asked her doctor “to make her comfortable”. Morphine was administered and she died that night. Both were helped to die.
Bernard Jackson
Harrow, Middx
Sir, I have never really understood the slippery slope argument referred to in Alice Thomson’s article. It seems to boil down to this: we cannot afford to do what is right today because it may lead us to do what is wrong tomorrow. Applied generally, this argument would inhibit us from doing pretty much anything at all.
Richard Oerton
Cannington, Somerset
If the NHS workforce includes the politicians, then yes, its future depends on their honesty and altruism!!
There are many stakeholders in the 4 health services. The workforce is certainly the greates tasset, but they dont feel they are. The patients have to want to use the services: they dont. The politicians have to use it themselves, and they dont. The King and the royal family dont either. Yes, if the workforce leaves the services will fail, but it is in the hands of the politicians to change the systems to ones that are sustainable, fair, transparent and honest in that everyone knows what is NOT available. The new NICE guidelines on Storke for example, mention levels and frequency of physiotherapy that are not possible given for a decade given current capacity, and only informed and affluent families can afford what is recommended. It looks as if IT strategies will be different as “Palantir gets £480m data contract” from NHS ENgland. In Mental Health inpatient care is often miles away from patient’s homes. Remember that “Its the complexity stupid” (BMJ Leader – Kamran Abassi) and that unintended outcomes of changes always need to be expected and anticipated. The unintended consequences of breaking up the NHS into 4 dispensations being one of them. The miners of Tredegar no longer have the same life chances as the bankers of London. Notes from one dispensation to another are not automatic downloads, and in England GPs dread the arrival of a person from Wales as the notes have to be entered manually.
And why is it that letters are still sent out for appointments rather than offering e-mail or test options, and why are the 4 dispensations the last users of Fax in the country?
The future of the NHS depends on its workforce BMJ 2024;384:e079474 : M Dixon-Woods mary.dixon-woods@thisinstitute.cam.ac.uk
Achieving a high quality, sustainable NHS is currently challenged by major workforce problems. Staff are the most significant element of NHS expenditure1 and its most important asset in providing care for NHS patients, but stewardship of the workforce is not optimised at policy or service level. Based on knowledge of the field, the literature, and listening to patients and staff, we identify three key interlinked areas in which action is urgently needed: configuring the workforce, improving conditions and working environments, and enhancing career and training pathways. We propose what might be done to tackle the current challenges, emphasising that workforce stewardship needs to be highly intentional about diversity, inclusion, and equity and needs to be done collaboratively with staff, patients, and the public.
Configuring the workforce for the future of the NHS
Staff shortages
The future of the NHS depends on having the right numbers of staff in the right roles, at the right times, and in the right locations. At present, the NHS simply does not have enough staff to deliver on its goals and commitments: it has fewer doctors, nurses, and managers than peer countries. By June 2023, there were over 125 500 vacancies in hospital and community health services in England.2 Over 1 in 10 nursing posts were unfilled, with mental health and community nursing especially affected.2 Although the overall number of doctors in hospital and community services has increased to 134 000, representing an additional 39 000 medical staff since 2010,2 the NHS is currently short of nearly 11 000 doctors (a 7.2% vacancy rate). The vacancy rate in clinical professional roles is compounded by difficulties in recruiting and retaining high quality staff in other roles, including administrative, managerial, scientific, and technical staff, as well as estates and ancillary staff. These groups make up nearly half of the workforce and are essential to the NHS but receive much less recognition than their clinical counterparts. Despite the essential nature of their work, some are disparaged in policy and media discourses as somehow not “frontline.”..
Remeber “Its the complexity stupid” Why hospital capacity is more complex than bed capacity(BMJ Leader – Kamran Abassi) BMJ 2024;385:q883….. and Video
Its easy and somewhat commonplace to liken healthcare to a widget factory, to boil it down to inputs and outputs; to capacity, productivity, and efficiency. I was reminded of this at last week’s international quality and safety forum, jointly hosted by BMJ and the Institute for Healthcare Improvement. The event was held at the ExCel, London’s homage to the austere corridor world of Blake’s 7—and the site of a Nightingale hospital at the height of the covid pandemic. The Nightingale hospital was assembled in rapid time and added to hospital bed capacity.
But that extra bed capacity went unused, because hospital capacity isn’t just about beds. It also requires, for example, trained staff and appropriate equipment. Counting the number of beds alone, it turns out, isn’t especially useful in determining hospital capacity, particularly in intensive care. Kevin Fong and colleagues, in a sobering piece that should be widely shared with anybody sceptical of the pandemic’s impact on health services (doi:10.1136/bmj-2023-075613), describe hospital capacity as a “complex property of a complex sociotechnical system.”1
The same magical thinking—that bed capacity somehow conjures the staff, equipment, and expertise to accompany it—is the logical hole in political plans to use the private sector to reduce waiting lists (doi:10.1136/bmj.q858).2 Beyond ideological objections, plans to engage the private sector are bedevilled by data gaps across a broad range of metrics, from workforce to patient outcomes (doi:10.1136/bmj-2024-079261).3
Critics attacked the NHS when the pandemic was most severe for crying wolf over being overstretched because the bed count exceeded bed usage. Yet the service was overstretched, care was compromised, and staff reported mental health symptoms at a rate of 47%, similar to that among Afghan war veterans. Despite the extraordinary efforts of staff, on the background of a depleted health service coming into the pandemic (doi:10.1136/bmj.q760),4 intensive care capacity was exceeded, with knock-on effects on routine services and care.
It isn’t hard, therefore, to understand the lasting damage to patient care and staff welfare. A third of UK doctors are considering leaving in the next 12 months to work abroad (doi:10.1136/bmj.q856).5 Around four million people in the UK are out of work, and around the same number are living with a work limiting health condition (doi:10.1136/bmj.q734).6 When relations between health and employment (and employment and health) have rarely seemed so critical, a decision by the NHS to review its practitioner support service and close it to new referrals seemed extraordinarily insensitive. The decision was overturned within 24 hours after a public outcry (doi:10.1136/bmj.q874).7
This undermining of healthcare staff is now a system failure within the NHS and government. What the public needs is a healthy, satisfied workforce, in the best possible shape to meet the population’s health and wellbeing needs (doi:10.1136/bmj-2024-079474); a workforce that can fill the gaps in our knowledge and practice on the primary prevention and complications of the growing burden of atrial fibrillation (doi:10.1136/bmj-2023-077209 doi:10.1136/bmj.q826), implement the new advances in the diagnosis and management of type 1 diabetes (doi:10.1136/bmj-2023-075681), narrow the gender health gap (doi:10.1136/bmj.q787), and find solutions to the perplexing challenge of social care (doi:10.1136/bmj.q783), even in Northern Ireland, where, despite an integrated health and social care system, community and social care remain deprived of resources (doi:10.1136/bmj.q704).891011121314
Healthcare isn’t a widget factory. It’s a complex sociotechnical system, growing more complex by the day with the impact of new technologies such as machine learning on medical science and clinical practice (doi:10.1136/bmj-2023-07806316 doi:10.1136/bmj.q749 doi:10.1136/bmj.q721).151617 Inputs and outputs matter. As do capacity, productivity, and efficiency. When you’re struggling to make sense of medicine and healthcare, remember: it’s the complexity, stupid (https://en.wikipedia.org/wiki/It%27s_the_economy,_stupid).18
Ignoring a 2013 report has led to the crisis in Maternity, Neonatal, (and other) care as politicians fail to act because they cannot grasp the complexity of medicine. Since 2019 there have been 15 chairpersons of the health and social care committee!
You need to be in medicine for 20 years to become experienced. You need to have begun training 10 years previous to become really useful, How can politicians be tought the importance of long term planning, and of Primary Care in making the 4 health services the efficient filters that they use to be 20 years ago. Living with uncertainty is impossible without trust and continuity of care. Using time as a diagnostic tool is not recieved wekk in a litigous society, and will only come back if we have no fault compensation. Without these strengths GPs are deprofessionalised and we are heading for a private based and regresive (unequal and worsening) system. Ignoring a 2013 report has led to the crisis in Maternity, Neonatal, (and other) care as politicians fail to act because they cannot grasp the complexity of medicine. This follows for General Practice. They just dont seem to care! They even get rid of the best chair persons, Sarah Wollaston 2019, and ensure frequent change in what needs a long term perspective, from the Health and Social Care committee of the House of Commons. Since 2019 there have been 15 chairpersons of this committee!!!
Matthew Limb in the BMj: Government criticised over failure to implement patient safety recommendations Cite this as: BMJ 2024;384:q727 and on ITV News 22nd March: Government ‘failed’ to act on patient safety recommendations, post-Lucy Letby report finds
The government has failed to implement a number of recommendations over major patient safety issues, according to an independent panel. The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”. As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010. These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress.
The recommendations on maternity care and leadership came from the 2013 report that followed a public inquiry into patient deaths at the Mid Staffordshire NHS Foundation Trust, as well as the 2015 report from the Morecambe Bay Investigation, which highlighted serious failings at the University Hospitals of Morecambe Bay NHS Foundation Trust leading to the deaths of mothers and babies.
The panel gave the government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good.
The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”.
“Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added. The panel did recognise the impact the Covid-19 pandemic may have had on implementing recommendations. Professor Dame Jane Dacre, chair of the expert panel, said: “Nine or more years have passed since these recommendations were accepted by the government of the day.
“We are concerned about delays to take real action to implement them and rate overall progress by the government on this serious matter as requiring improvement.” The report added the aim of using “evidence-based scrutiny” is to “feed back to those making promises so that they can assess whether their commitments – or in this case, the implementation of recommendations the government has accepted – are on track to be met”.
Steve Brine, chairman of the Health and Social Committee, welcomed the report, which he said was “commissioned in the wake of the deep concern around the Letby case which gave rise to calls for another statutory inquiry”. Letby was convicted of murdering seven babies and attempting to murder six others, with two attempts on one of her victims, at the Countess of Chester Hospital’s neonatal unit between June 2015 and June 2016. Senior judge Lady Justice Thirlwall is leading the inquiry into how the nurse was able to carry out murder and how the hospital handled concerns about her.
Mr Brine added: “The Health and Social Care Committee has now launched its inquiry into leadership, performance and patient safety in the NHS. The work of the panel will provide valuable insights and an important foundation in support of our forthcoming public evidence sessions.”
Publication of the panel’s findings comes after NHS Whistleblowers, a group representing hundreds of current and former doctors, midwives and nurses, asked to contribute to the Lucy Letby inquiry.
They have instructed Hudgell Solicitors to represent them, arguing there is a need to look at problems across the entire health service, not just in one trust. A spokesperson for the Department of Health and Social Care said patient safety was “paramount”, adding that it had “made significant progress to improve care, including publishing the first NHS Patient Safety Strategy”. “We recently announced the first phase of Martha’s Rule which will give patients or family members in 100 NHS sites the right to a rapid review of their care if they are concerned their condition is worsening,” they said.
“We have also established an independent body to investigate and learn from serious patient safety incidents, and we have made progress in improving maternity services, reducing the stillbirth and neonatal death rate by 23% and 30% respectively since 2010.”
Current enquiries and reports from the Health and Social Care committee of the House of Commons.
Our children are more important than our elderly. Lets say so with approval of new RSV vaccine.
Time to listen to our paediatricians – but then we have reached the time in our development when we no longer need to “listen to experts” (Mr Gove) In 2022 the antibody treatment was approved. In 2023 the use of the vaccine in the elderly was approved, and in 2024, slowly and reluctantly, the government of England might approve. Will Wales, Scotland and Ireland dispensations be able to afford it? No NHS applies! Rationing does... The RSV vaccine needs an advertising campeign on TV to encourage breast feeding and vaccinations for mothers and infants.
RSV: Paediatricians call on government to expedite infant vaccination programme BMJ 2024;384:q727
Jacqui Wise in the BMJ March 2024: The Royal College of Paediatrics and Child Health has called on the UK government not to wait until after the upcoming general election to approve an infant immunisation programme against respiratory syncytial virus (RSV), so that babies can be protected next winter.
In June 2023 the Joint Committee on Vaccinations and Immunisations (JCVI) recommended developing an RSV immunisation programme for infants and for older adults.1 It issued a fuller statement reiterating the advice in September 2023.2 But the government has yet to make a final decision on rolling out an RSV immunisation programme.
A letter signed by more than 2000 paediatricians and healthcare professionals says that the sooner a full RSV vaccination programme is implemented the more effective it will be and that it “could save child health services reaching breaking point.” It says that the UK risks falling behind other countries, such as Spain, that have already introduced RSV vaccination programmes.
The open letter addressed to the UK health secretary, Victoria Atkins, says, “You can act now to relieve pressure on health services this coming autumn and winter as well as help prevent infant and child mortality. We call on you to approve an RSV vaccination programme urgently.”
The royal college added that it must be made clear about how funding will be made available for such a programme in Scotland, Wales, and Northern Ireland, as well as England.
Procurement and delivery
In the UK the RSV epidemic peaks each December and causes around 33 500 hospital admissions in children under 5 every year. It is linked to 20-30 childhood deaths a year. Rolling out an RSV vaccine to infants could result in 108 000 fewer GP consultations, 74 000 fewer emergency department visits, and 20 000 fewer admissions solely in children aged under 1, the letter says. These figures are based on modelling by the JCVI.2 “Every year our child health services grind to a halt with high levels of RSV and other winter bugs. We now have an opportunity to turn the tide on this trend,” said Camilla Kingdon, president of the Royal College of Paediatrics and Child Health.
An RSV immunisation programme “would be an absolute game changer,” she said. “We simply cannot have another winter like the last. The chancellor and health secretary are staring a no-brainer in the face—they must heed the advice of doctors. Together with 2000 of my colleagues, I urge them to seize this opportunity and not wait until after the upcoming election. RSV won’t wait.”
Ian Sinha, consultant respiratory paediatrician and member of the Asthma + Lung UK Council of Healthcare Professionals, said, “The lack of government action following the JCVI’s recommendation for a vaccination programme is a blow to children and young people in the UK, who already have worse respiratory outcomes than those in other rich countries.
“We need swift and decisive action now to ensure there is time to implement this programme in the autumn. Delaying further will complicate procurement and delivery, leaving thousands of infants needlessly vulnerable to this dangerous infection next winter.”
Maternal immunisation
Nirsevimab (Beyfortus), a long acting monoclonal antibody for passive immunisation against RSV infection, was licensed by the UK Medicines and Healthcare Products Regulatory Agency in November 2022. A study of more than 8000 infants showed that nirsevimab, developed by Sanofi in partnership with AstraZeneca, reduced RSV associated hospital admissions in infants by 83%.34
Abrysvo, a bivalent maternal vaccine developed by Pfizer, was also approved by the agency in November 2023. It is intended for use by pregnant women to protect their infants, as well as for adults over 60. Last year experts called for further analysis of trial data and post-approval monitoring of the maternal RSV vaccine after the drug company GSK’s trials of a similar product were halted over a rise in preterm births and neonatal deaths.5
The JCVI has said that it has no preference whether a maternal vaccination or a passive immunisation programme should be chosen to protect infants from RSV. It indicated a preference for a year round offer for a passive immunisation or maternal immunisation programme, to help ensure high uptake and because it would be simpler to deliver than seasonal campaigns.3
A spokesperson for the Department of Health and Social Care said that the government was working with the UK Health Security Agency and NHS England to explore the potential for an RSV vaccine programme for infants and older adults and that a decision would be made in the coming months.
Editor’s note (25 April 2024): We added a sentence to explain that the predicted numbers in the seventh paragraph were based on modelling.
www.theguardian.com › society › 2023RSV vaccine for older adults approved by UK medicines …
Ethan Ennals in the Mail: Government urged to roll out virus jab for babies or face sick infants
www.bbc.co.uk › news › health-63572228Antibody jab approved for common winter virus RSV – BBC News
At least we are talking about it: death and advanced directives
The BMA has changed position on the subject of death by assisted dying/design along with most of the public (Esther Rantzen leading). There are other countries who have initiated the change, and the fears of overuse and abuse seem ill founded. Indeed, many of those who register an interest never follow it through – probably because they have good care and pain relief. The Lords, led by Baroness Findlay will try to stop it, but lets hope she fails.
There are risks, and all of these need addressing. However, if the Isle of Man, Scotland and the channell islands are in favour and implementing laws, it would be both unreal and unfair for the UK to behave differently. Indeed, not implementing a choice would be illiberal, and encourage more a more regressive society, as those with the means will still go abroad. Dr Green for the BMA ethical committee spoke very well on the subject on the Today Program on radio 4 at 08.10 this morning. He points out that many patients are in palliative or terminal care with hospices, either home based or, more expensivly, hospice inpatient care.
The funding of hospice care is rationed – approximately 90% is from charitable donations. Dr Green does not want to confound the two issues (palliative care and assisted dying) but given that the former is not state funded, there is bound to be large differences in service and outcomes between rich and poor areas.
Ducking important debates has been part of our recent history. The media led society is dominated by the money and capital behind our papers and radio and TV stations, as well as the e-media. This has applied to education (no debate since Mr Blair), crime and punishment, defence, and health. Honesty is the hardest word.. (Billy Joel) NHSreality has pointed out that oncologists are still offering treatments without joint consultations with palliative care and /or GPs. Thus decisions are taken without a full consideration of the potential harm, shortening, and quality of life. Today the house of commons will debate assisted dying, but the supportive mechanisms to make it work fairly and with considerationare not in place.
NHSreality on Oncology and Overtreatment
Frances Gibb March 14th in the Times : Assisted dying reform in spotlight
Stephen Bleach Times letters editor: Our readers back compassion on new assisted dying rules – The letters we receive about the trauma of watching loved ones die in agony convince Stephen Bleach it is time to change the law
Assisted dying is a delicate and sensitive issue. Some people are strongly in favour of it becoming legal in the UK, as it is already in a growing number of countries. Others feel strongly that it should not. Everybody, however, should agree that this is not an issue to be swept under the carpet indefinitely, and today The Sunday Times is launching a campaign to legalise assisted dying in this country.
For too long, indeed for six decades since the Suicide Act of 1961, a view has been allowed to take hold, and dominate the discourse, that the public is split equally on the question of assisted dying. But much has changed in the 60 years since the act banned assisted dying. Our lives, our hopes, our expectations have been transformed beyond recognition. Medical advances and healthier lifestyles are allowing many of us to live longer than ever.
Our ageing population provides a glimpse of a healthy future in which many of us will live happy, fulfilling lives well into our nineties and beyond. But that positive change, which we should all welcome, should not also mean that the end of life, when it comes, has to be an ordeal. We all wish for a peaceful, painless and dignified death. The law on assisted dying denies that to too many people.
The notion that assisted dying is an incredibly thorny issue with equal numbers — and arguments — on either side is simply wrong. Two years ago the largest poll conducted on assisted dying found that 84 per cent of people supported a change in the law. The survey showed they would be in favour of allowing terminally ill, mentally competent adults to have an assisted death, provided there were strict safeguards.
Yet two years later nothing has changed. Hundreds of terminally ill Britons are forced to live out their final weeks, days and hours in cruel, painful, distressing circumstances.
Nor should campaigners against assisted dying be allowed to get away with the canard that unscrupulous children or other relatives would use a change in the law to take advantage of the frailty of elderly people with good recovery prospects. Strict safeguards — for instance in the form of judicial oversight and two independent doctors — would prevent this from happening. And, if anything, children are more inclined to push doctors to keep a distressed elderly parent alive when the kindest thing would be to let them die peacefully.
Before the pandemic, on average one Briton every week travelled to Switzerland for an assisted death — a process that costs £10,000 on average and often means people die prematurely because they need to be strong enough for the journey. Anyone who assists in arranging an assisted death overseas or accompanies someone to Switzerland for this purpose risks being prosecuted for “assisting a suicide” in England and Wales.
A further 300 terminally ill people end their own lives in England every year on average, and more people suffer every day as they die in distress even with access to the best end-of-life care.
Today we report the harrowing case of Charlie Kentish, a former army private who served in the Second World War and was diagnosed with terminal cancer three days before his 94th birthday. He begged for help to end his own life but, because of the law, his pleas went unheard. He spent his last few months unable to swallow, unable to socialise, unable to live life on his own terms. He was found dead in his garage after taking his own life.
That this is still going on in the 21st century is distressing and should be a cause for alarm. That is why we believe a change in the law is the right way forward. We are not alone. Baroness Meacher’s private member’s bill to legalise assisted dying will have its first reading in the House of Lords this week.
We have a long and proud history of campaigning, particularly when it comes to matters of health. The Sunday Times spent many years campaigning for compensation for the victims of the thalidomide scandal, and more recently exposed the opioid crisis that erupted in the UK.
All of these campaigns have a common thread, which is to challenge the consensus and take on vested interests, whether it be for children forced to live with serious birth defects, the millions struggling with addiction to dangerous painkillers or those dying from terminal conditions and suffering to the end. We believe passionately that everyone should be entitled to dignity in death and choice at the end of life, regardless of status. This country’s legislation, passed 60 years ago, denies people these basic rights. It is time the law changed.
My nightmare giving birth — and Britain’s maternity scandal. Standards are fallling and will fall further.
In my own family a relation has had a delivery with traumatic problems. After an instrumental delivery and a long labour no rectal examination was done. A fouth degree tear was missed. A life was “changed” because the correct diagnosis was only made 6-8 weeks later at post natal examination. The mother after birth has often got a numb perineum and undercarriage, and is exhausted. She cannot inform the midwife or doctor if all is in place as before, Only an examination will do, and omitting this is nothing other than neglect. Retiring midwives with vast experience are leaving things in the hands of much less experienced people. (Birth rate falling, and age of muns increasing, so more surgical interventions).
My nightmare giving birth — and Britain’s maternity scandal – Every year 25,000 British women meet the criteria for post-traumatic stress disorder after giving birth. Hannah Barnes investigates what’s going so badly wrong
When my husband and I left for hospital on a Friday afternoon, we had no idea what would happen. The next few hours would change my life. For good and bad. It had all started with a cervical sweep the day before. I was 40 weeks and 4 days pregnant and, frankly, I’d had enough. My pregnancy had been uncomplicated in terms of my baby — she was healthy throughout, albeit had spent much of her time in the back-to-back position. But I had found the nine months increasingly difficult. From around 20 weeks I’d suffered from pelvic girdle pain, which, for me, meant increasingly agonising pain in my lower back. Walking and other everyday movements became difficult. The only place I felt vaguely comfortable was in water. Swimming was a relief.
Women are offered a sweep to help induce labour. A midwife inserts their finger and sweeps around your cervix. It’s about as basic as you can get. They’re trying to separate the membranes of the amniotic sac that surround the baby from your cervix. This then releases hormones, which may help start your labour. “Some women find the procedure uncomfortable or painful,” NHS guidelines say. I found it excruciating.
“Oh,” the midwife said, as I lay in a rather compromised position. “I might have broken your waters.” This didn’t make sense to me. I’d always assumed that when my waters broke, I’d know about it. Apparently not always, and I was instructed to call the hospital if contractions hadn’t begun within 24 hours as I was now potentially at risk of infection.
• New mothers being driven to suicide, senior midwife warns
• I was so frightened giving birth on NHS ward
They didn’t start. And I did what I’d been asked. The voice on the phone was chirpy — everything sounded fine, stay at home, we’ll be seeing you soon enough. Half an hour later, my phone rang. “Where are you? You’re meant to be at the hospital,” the woman said angrily. I needed to come in immediately to be examined.
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It was late Friday afternoon and it was busy. We took the last of the beds in maternity triage. And my waters broke in earnest. That solved the mystery, I suggested. No, I was told, and the water birth I’d hoped for was out of the question — too risky.
Strong and regular contractions started immediately. We were moved to a glorified cupboard that had been turned into a makeshift holding room. I was denied any pain relief because it was “too early”, and told that someone would bring me some paracetamol when they came to “examine” me.
It seems obvious when you think about it, but I had never been told what being “examined” meant. Nor thought about it. It sounds medical. But it’s literally a midwife sticking their fingers inside you. I was 3cm dilated. Plenty of time to go, apparently. It was 9.30pm. I felt sick and in enormous pain. Both were dismissed — until I vomited everywhere. And lost control of my bowels. This would happen several more times over the coming hours. I felt utterly ashamed. Again, it’s common — but I hadn’t been told.
I continued to ask for pain relief and continued to receive none. An hour later, I was 7cm dilated — in full labour — and finally received some paracetamol. There was no space on the labour ward. In just another half an hour, I was fully dilated and ready for the baby to come out. No one seemed to know what to do. The midwives were panicking. And that made me scared. This was my first baby. I didn’t know what to expect. We were rushed to the ward. Already, nothing had gone the way I wanted, or the way it had been talked about at National Childbirth Trust (NCT) classes. Eventually, I was given gas and air to ease the pain. But only for about 20 minutes. Apparently it was “distracting” me too much and I needed to push.
Two hours later there was still no baby and I was in agony. A doctor arrived, took a brief look and said cheerily, “You’re going to be fine. You’re going to get that baby out.” And then he left. My maternity notes state, “PLAN: continue pushing.” I have no idea what this refers to — like so many of my notes. There was no plan. If there was, it wasn’t one I had agreed to. Finally, after another hour the decision was made that the doctor would use a ventouse — a suction cup that sits on your baby’s head — to help deliver my baby. Apparently I consented to this, but I have no recollection of doing so. And I’m ashamed to say I didn’t know what was being asked of me. My doctor didn’t use the word ventouse. He used “Kiwi”, which is a type of ventouse. At the time, I didn’t know what either were.
I remember screaming in pain and then my daughter finally being born. She was placed on my chest for less than a minute. I was examined, told I had a fourth-degree tear that must be repaired and that I needed to sign a consent form for surgery straight away. “Look at the state of her,” my usually mild-mannered husband said. “How can she possibly sign a form?” I couldn’t. The writing on that form is barely legible, but they would not proceed without it.
I had no idea what had happened. I lay in an operating theatre in pain, silent tears rolling down my face. I was frightened. The anaesthetist was amazing and stayed with me while I was repaired. I am so grateful for that, at least. But I also feel guilty about it. It was half past three on a Saturday morning and she was the only anaesthetist on duty at the London hospital. Other women may well not have received the pain relief they needed because of me. “Will I be able to have any more children?” I asked as I stared at the ceiling.
After surgery I was moved to the high dependency unit (HDU) and reunited with my daughter. I finally held and fed her for the first time. That morning is a blur. My notes tell me we stayed in the HDU for five hours before being moved to a ward. It was there that I attempted to understand what had happened to me. I was in pain, barely able to move and soaked in blood. I asked various midwives to explain what had gone on. They repeated that I’d had a fourth-degree tear, but I didn’t know what that meant. One line, in scribbled handwriting, stands out when I look at my notes: “We don’t have any written info about fourth-degree tears.”
Eventually, a midwife appeared with some information they’d printed off after googling it. As I read it, I sobbed. I was 35 years old and thought my life was over; that I would be incontinent. And still no doctor came to explain. The medic who’d delivered my daughter was eventually marched to my bedside more than 48 hours later.
I am perhaps unusual in that I’ve always wanted children. We had done what many middle-class suburban couples did at that time and attended NCT classes. The underlying message of these was: try to avoid a caesarean section at all costs. “Natural” births were best, and even better just to breathe through it. No need for pain relief. I remember in our penultimate class bringing up the subject of tearing during labour. I had seen a TV feature on it that week and it struck me as important. “If most of us are going to tear to some degree, it would be really helpful to talk about that,” I remember saying. “It would be good to know how best to care for ourselves afterwards, that kind of thing.” The answer was no, there was no need. Instead, we proceeded to get on all fours and “moo” like cows and then practise putting nappies on a doll. Up to nine in ten first-time mothers who have a vaginal birth will experience some sort of tear. The least invasive kind involves only the skin from the vagina and the perineum — the area between a woman’s vagina and anus. These tears usually heal quickly and without any treatment. Second-degree tears involve the muscle of the perineum and require stitches. Third and fourth-degree tears are the most serious. These involve not just tearing of the skin and muscle of the perineum but the muscle of the anus. In fourth-degree tears, the injury can extend into the lining of the bowel. These deeper tears need proper surgical repair under anaesthetic.
I don’t really have any happy memories of the first few days or weeks after we left the hospital. I was completely in love with my baby, but I felt shellshocked. I couldn’t process what had happened and there was no one who offered to help me. A different midwife was sent to our house every couple of days to weigh our daughter. I had no milk the first few days and she had lost a fair bit of weight. Even when my milk came in, I found breastfeeding painful and difficult, in large part because it hurt so much to sit down.
I cried quietly every day for several months. Often it would come completely out of nowhere. I’d be talking or watching television and I would just start to cry. Several midwives wrote in my notes in those early weeks the same phrase: “Mum is anxious.” I don’t think I was. I was traumatised. Several weeks later, I was told that I was “lucky” by the midwife examining my stitches. Apparently the doctors had done a “wonderful” job at repairing me and it looked “beautiful”. I now know that I was fortunate to be repaired properly and immediately after the birth. But the last thing I felt — then or now — was lucky.
After several months I desperately needed to have some control over my life again. I had never felt so helpless, lost and infantilised. But my overarching feeling was anger. I wrote to the chief executive and chair of the hospital to complain and was invited in for a debrief. The head of midwifery was lovely, apologised and followed through on her promise to try to prevent other women facing the appalling lack of communication I had. The hospital now has a specialist perineal health clinic too.
But the attitude of the consultant obstetrician whom I met with my husband floored us both. It was about six months after the birth, but I was still under the care of a consultant urogynaecologist. (I subsequently had two further operations: the first 14 months after giving birth to remove an undissolved stitch that was causing pain but hadn’t been spotted, and another six months after that.) My urogynaecologist had told me not even to consider giving birth vaginally again. The risk was too great, he explained. If I tore again, there was a 30 per cent chance I couldn’t be repaired and I’d be incontinent. The obstetrician said the opposite — don’t rule it out! I saw red. “How dare you,” I growled. I remember saying that he would never be so cavalier about a man’s body.
Every year, about 25,000 women who give birth — approximately 4 per cent — are so distressed that they meet the diagnostic criteria for post-traumatic stress disorder. That makes birth one of the biggest causes of PTSD in the UK according to the Birth Trauma Association charity – probably coming second only to sexual abuse and rape. Hundreds of thousands more women are traumatised. This is a major health crisis. And yet it is barely discussed.
“Birth trauma is a broad term, but generally it’s overwhelming distress that leads to a detrimental impact on well-being,” explains Susan Ayers, professor of maternal and child health at City University in London. Estimates “range massively”, she says, but having conducted research into birth trauma for almost 30 years, Ayers puts it at about a third. “If you ask women whether they thought they or their baby was going to die or be severely injured, then it’s around 19-20 [per cent] in the UK. But if people just ask women, ‘Was your birth traumatic?’ some of those estimates are up to 50 per cent.”
“I’M BEATRICE’S MUM,” EMILY SAID, introducing herself to a committee of MPs in March. “Beatrice died during labour at full term in May 2022.” Emily is one of a number of brave women who have shared their traumatic birth stories with the all-party parliamentary group (APPG) on birth trauma, during the first parliamentary inquiry into this issue.
“As soon as my labour started,” Emily explained, “I knew it wasn’t right, wasn’t normal.” The details are harrowing: a series of obvious but missed red flags and an attitude from medical professionals that can only be described as cruel. The midwife who shrugged her shoulders when Emily’s waters were meconium-stained; the consultant obstetrician who laughed at the “slimy” feel of that meconium while her hand was still inside Emily.
“The ultrasound scanning machine was brought in and showed that Beatrice’s heartbeat had stopped,” she explained. “At that point I begged, pleaded like I’ve never pleaded for anything in my life for a caesarean, and that consultant obstetrician refused. She said no. And she left.”
“It’s destroyed my life,” Emily says now. “I’m not the person I was before.”
This inquiry has been led by the APPG’s co-chairs, the Conservative MP Theo Clarke and Labour’s Rosie Duffield. They received more than 1,200 written submissions after asking women to share their experiences; that number doubles if you count the letters and emails they’ve been sent informally.
• Time to cut the blame game amid another NHS childbirth scandal
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“The thing that’s really struck me is there seems to be a taboo around talking about the risk of childbirth,” Clarke tells me when I sit down with both women in Westminster. There shouldn’t be, she adds. “Something we’ve heard from a number of the mothers coming to speak to us is that there’s such a focus on the baby post-delivery, they almost forget there’s a second patient in the room, and that’s the mother.”
“I was constantly told by GPs that I had nothing wrong with me,” one mother, Sarah, told the MPs. She experienced a major tear that doctors and midwives failed to diagnose. “I was discharged two days later with [an] untreated tear, which very quickly led to enormous amounts of pain, incontinence, faecal incontinence and thinking I was going mad.”
“It’s very painful,” explained Jenny, who also experienced a serious tear that was left untreated, “but the long-term consequences of an unrepaired tear are that I had to give up my job. I’ve suffered PTSD, anxiety, depression. My activities are restricted. My life is impacted in that I have to meticulously plan my day around toilets.”
Another mother, Neera, lost three litres of blood and required more than ten hours of life-saving emergency surgery the day her daughter was born. The haemorrhage had not been picked up by staff. She said she is fortunate to have had the “means and support” to access mental healthcare over four and a half years of her five-year-old’s life. “I have personally spent over £6,000 and received more than 50 hours of mental health support,” she told parliament.
The women who have spoken to politicians as part of the inquiry had different medical experiences. But there were obvious similarities. Their concerns and their pain were dismissed. They were not treated with respect or, in some cases, like human beings. They felt helpless, angry and scared. “Nobody really cares about women,” says Kim Thomas, CEO of the Birth Trauma Association. “What we tend to find with most of these stories is there’s failure after failure after failure. Lots of things go physically wrong… and that continues afterwards in the postnatal period with really poor care.” Almost all women seeking out the charity say their experience was made much worse by the way they were treated during labour. “The number of stories we hear of women being shouted at by midwives or laughed at by midwives is quite extraordinary.”
Birth doesn’t have to be this way. And it isn’t for many women. But women, in England in particular, could — and should — be having better experiences than they are.
Let’s start with serious tears. The number one risk factor is being a first-time mum. There’s nothing much that can be done about that. But the next is having an instrumental vaginal delivery — and in particular one that uses forceps. “Data indicates that we use more forceps than other parts of Europe,” says Dr Ranee Thakar, president of the Royal College of Obstetricians and Gynaecologists (RCOG). While rates in several European countries hover at around 0 per cent, a 2023 study of assisted births in 13 high-income countries found England used forceps in a higher proportion of births — about 11 per cent — than any other.
There are cases where forceps must be used. When babies are premature, suction would cause too much damage to the head. But that’s doesn’t explain the discrepancy. “It’s education,” Thakar explains. “We should be trained to do both [forceps and ventouse], so that we provide the best care to women and use the right instrument for the right baby and the right mother.”
The risk of a severe tear when forceps are used is at least twice as high as with ventouse: 8-12 per cent compared with 4 per cent. Women should be told this. The recent parliamentary inquiry heard other suggestions that might explain why forceps use in England is so high. The consultant gynaecologist and obstetrician Dr Nitish Raut explained that when poor outcomes of childbirth become part of litigation, the question, “Why were forceps not applied earlier?” will be asked. Although they can cause injury to mothers, forceps are the most effective instrument for getting a baby out. If a doctor tries and fails to deliver a baby with the less invasive ventouse first, a record will be made at the hospital trust. It was suggested by others that this might also be pushing some doctors straight to forceps use even when they might not be necessary.
“Training is a really key part of everything here,” Posy Bidwell, deputy head of midwifery at South Warwickshire Foundation Trust, told MPs. “If we can train people, we can prevent these injuries happening. Many midwifery students wouldn’t know the impact that these injuries are having on women.”
Newly qualified midwives did not know enough about perineal damage, and yet they’re providing one-to-one care to women. Current training did not seem to see it as a priority: while several aspects of maternity care are mandatory each year, suturing and perineal protection are not.
• See the latest from The Times Health Commission
Neither doctors nor midwives appear to be taught how to routinely examine women after they have given birth either. Where this was once part of mandatory medical training, doctors are no longer encouraged to do it, Raut explained.
England is short of as many as 2,500 midwives, the Royal College of Midwives (RCM) estimates, although people are wanting to train and join the profession. Donna Ockenden, who is reviewing maternity services at Nottingham and who previously did so at Shrewsbury and Telford Hospitals NHS Trust, cautions against being too optimistic, however. The focus needs to be on retention. “Two midwives don’t equal two midwives,” she told parliament, “of we are losing midwives with 20, 30, 35 years’ experience… and they’re then being replaced by a more junior workforce, who are not being supported in those early days of their career.”
In the past decade and a half, the UK has seen several NHS maternity scandals — in Morecambe Bay, Shrewsbury and Telford, and East Kent. In all these cases, some of the poor care provided to mothers and their babies was because of a push towards “normal” or “natural” birth and a desire to keep caesarean section rates low. The RCM ended its campaign for “normal births” in 2017, but its legacy persists. Some NHS trusts still talk about them today. A culture of cover-ups and a lack of care remains in others. Just last month, the Care Quality Commission found that staff at Great Western Hospital in Swindon had been downgrading third and fourth-degree tears, “which meant they were not investigated as thoroughly as they should” have been. The c-section target was only officially dropped in 2022. Does RCOG now accept that it was a mistake? “It’s difficult for me to say years later whether it was a mistake or not,” Thakar tells me. “I think there was a general trend at the time to put figures to caesarean section rates. But now we know that, we don’t do that.” It was now right that women were offered a choice; she insists she hasn’t seen an attitude against caesareans more recently.
Aside from any physical and psychological impact, traumatic births are costing the country billions. According to figures from NHS Resolution, the arm of the Department of Health and Social Care that handles litigation, 62 per cent of the total clinical negligence cost of harm in 2022-23 (£6.6 billion) related to maternity. Of the £2.6 billion spent on clinical negligence payments that year, £1.1 billion (41 per cent) related to maternity. (As the fact-checking service Full Fact explains, the cost of harm differs from the amount actually paid out in compensation: the former includes an estimate of claims expected in the future arising from incidents in that financial year.) The year before, maternity services accounted for 60 per cent of the total clinical negligence cost of harm (£13.6 billion). NHS England spends about £3 billion a year on maternity and neonatal services.
There is such a long way to go. The government is well behind on its long-term target of halving the rates of stillbirth and neonatal mortality by 2025; the death of mothers within 42 days of the end of pregnancy is at its highest rate in almost 20 years. And while only a handful of trusts have been subject to official investigations, there are signs that poor care is happening across the country. Only half of maternity units in England are rated good or outstanding; one in ten is inadequate. That is a damning indictment of the way so many women are cared for.
One crucial area of improvement does not cost money at all. It requires a shift in attitude to one where women are treated with respect, listened to and allowed to make informed decisions about their bodies and babies.
When I first heard of parliament’s inquiry into birth trauma, it was never my intention to share my experience. Doing so has been upsetting and uncomfortable. But as I sat listening to other women talk about how giving birth had affected them so profoundly, it felt dishonest to stay quiet. Difficult births are not something we should feel ashamed of — much as I know many women will have been, myself included.
A longer version of this article was first published in The New Statesman
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