Mary Reid

When we put the hospital on the spot over maternity services yesterday evening we didn't realise that the issue was going to feature as the front page story in the Comet today.

One of my rôles is Vice Chair of the Health Overview and Scrutiny Panel. This is unique among all the Council Committees, because the councillors have the task of scrutinising non-Council services provided by the NHS. The Committee sends a standing invitation to representatives from NHS Kingston (the renamed Kingston Primary Care Trust), Kingston Hospital and South West London and St George's Mental Health Trust, and their most senior staff attend.

Back in January last year, the Healthcare Commission judged the maternity services at Kingston Hopsital to be 'least well performing'. I blogged about my concerns then with links to the official reports.

A report was placed on the Health Overview Panel agenda in March 2008. At that meeting I was unhappy with the response from Kingston Hospital, especially as they did not send someone along who could answer our questions properly. We were unable to see any progress towards an action plan to deal with the shortcomings. We were even told that one of the figures was provided in error by the hospital to the Inspectors - a worry in itself.

The key issue then was inadequate staffing levels, since that has a knock-on effect on all the other indicators. The hospital said that it had reduced the staffing ratios from 1:43 to 1:38.  No-one could quite explain how these ratios worked - clearly one midwife to 43 women, but was this per month, per year, or what?

I asked for the Hospital to prepare a new report to the Health Overview Panel which would explain exactly what steps the Hospital was taking to improve maternity services for local women. And I wanted to make sure that next time they sent someone along who could answer our questions.

We waited.

Finally, we were promised a presentation this January. And when we saw it, we realised that we had been fobbed off once again with something that did not address the concerns that had been raised by the Healthcare Commission. Instead we were shown a PR exercise which covered general aspirations for maternity care, not hard action.

I was pretty unhappy with this, and insisted that we must be given a proper report. Kate Grimes, the new Chief Executive of the Hospital, was attending Health Overview for the first time, and she undertook to provide us with what we were entitled to.

And that is what happened yesterday. At last we received the Action Plan that addresses the issues raised by the Healthcare Commission about maternity services.

It took 17 months to see that document.

I wish I could say that I am now confident about the quality of the service, but I'm not.

The report states that the staffing ratio had now dropped to 1:34. However, 'The Hospital hoped to continue to improve this ratio to the nationally recognised standard of 1:28'.  I queried the word 'hoped' - shouldn't it have been 'planned' or 'intended'?

I was then told that the 'nationally recognised standard of 1:28' was not a standard, nor a target, but should be viewed flexibly. Indeed, we were told that better ratios would be expected in deprived areas. My response was that no woman deserves a lower standard of care than the nationally recognised standard, whilst those who are the most disadvantaged should be receiving a standard above that.

I made it clear that the Panel was very disappointed, and we requested an update report in six months time.

It seems that the midwives themselves are sufficiently anxious about this problem to do some whistle-blowing. They wrote a letter to the Comet, which I have seen today. Had I seen it yesterday I would have read it out to the Panel. As it happens, the Comet did not publish the letter but turned it into their front page news item. So I am giving it in full here:

Dear Editor,

We are writing out of absolute desperation in the hope that the press will be able to assist in highlighting the shocking staff levels that have become common place in many hospitals, but particularly at Kingston Hospital, Surrey.

Numerous incident forms and complaints from staff about conditions within the maternity unit have had no effect and substandard staffing levels are becoming more and more frequent; some shifts having as few as three midwives on the labour ward.

We urgently neeed more staff to cope at Kingston and nobody seems to be taking us seriously.

Kingston NHS Trust has decided to increase the number of women booking at the hospital from 5,000 women to 7,000 women per annum. Last year we delivered approximately 6,000 babies, which stretched our services to the limit. Extra staff were recruited, but unfortunately these were off-set by staff leaving or retiring.

To compensate for the increased numbers we opened six extra beds on one of the postnatal wards; and have introduced a new discharge policy to encourage women to go home after two hours following the birth of their baby, if stable. [It was] stated that under no circumstances were we to convey that there was a bed shortage, but explain to these women that home is the best place for them to be.

However, despite these initiatives the beds are continually blocked, women have to wait in the reception area for a bed to become free, sometimes they are in strong labour and clearly require pain relief. Women being induced on the antenatal ward have to wait sometimes two days or more for labour beds, occasionally they have to labour on the antenatal ward because there is nowhere else for them to go.

The labour ward is like a conveyor belt, as soon as you deliver one baby you are informed of another admission. After a birth the mother needs time to bond and feed her baby, invariably she needs suturing, assistance with bathing, the written records need completing and then the information is duplicated for the computer records. Yet the main priority is to transfer your woman as quickly as possible and at the same time you are being told to admit the next person.

When the room is vacated all blood spillages to the bed and floor are cleaned by maternity staff before the domestic staff will enter, the room is then quickly prepared for the next person. Sometimes there is help from a maternity assistant but this isn't always the case as their numbers are equally low.

The Malden Suite is a mix of low risk women in labour and postnatal women. The turnover of cases is rapid and with labouring women being given priority it is difficult to give mothers and babies the support they need.

The postnatal midwife is focused on discharging women as quickly as possible to free up beds. Therefore other women on the ward requiring examination are rarely given the attention they deserve.

We are also seeing an increase in our re-admission rate, where perhaps women or babies have been sent home too soon. To alleviate staff shortages some community staff are asked to work in the unit and postpone their visits until the next day. The midwife on call for home births may continue her shift through the night on the labour ward, which means women wanting a home birth have to be transferred to hospital instead.

Over the last 15 years the role of the midwife has changed and we have taken on tasks that were once performed by Drs e.g. administering intravenous drugs, inserting IV cannulas, suturing post delivery and now, some midwives are trained in performing the paediatric examination. However, the midwives staffing ratio has not increased to compensate for the extra tasks performed.

We work 12.5 hour shifts and are entitled to an hour's break during this time. However, on some shifts we are not getting any break and others just 30 minutes. Sometimes we can't go home at the end of the shift as there is no-one to replace us.

Staff on the antenatal, and both labour wards have to wait sometimes 8 to 9 hours to be relieved for a break.

We are not allowed hot drinks in the unit and had to figt for permission to drink water. Breaks are taken in a small room off one of the ward areas so that staff can be called back to assist when necessary. In contrast the managers meet collectively for their breaks where they go over to the restaurant. In an email to a union rep [it was] stated that if staff had a problem with time management she would work with each individual to address the problem. Staff don't want to miss breaks. They do so because the unit is unsafe to leave.

What has angered staff is that one midwife of retirement age wanted to reduce her hours to work one day a week, she was told that this wouldn't be cost effective as the Trust would have to pay for her mandatory training days; the experienced midwife has since left. How many other prospective staff wanting part-time work have been turned away? We need all the help available no matter how limited.

To reassure women still to come to Kingston, a recent poll of women, remarkably gave us favourable results in terms of staff attitude and care. I think this shows the level of dedication from staff who are highly skilled, conscientious and professional; and in an emergency work well as a team. Whilst some will see this letter as scaremongering, I think it is important that these circumstances are made public with a view to obtaining change and assistance. We cannot continue working in these conditions indefinitely. The Trust has a duty to provide a safe environment for women to deliver in and to protect the welfare of its staff. This is not the case at present.

Unfortunately names of employees cannot be divulged as it would lead to disciplinary action and possible jobs at loss,

Yours sincerely,

Concerned midwives of Kingston, NHS Trust.

Kingston Hospital has responded, thus:

Communication Channels

We are very disappointed that these members of staff have not raised these issues with senior management directly before speaking to the press about their concerns. Our Chief Executive is committed to, and promotes an open culture at the hospital. She writes to all staff every week, holds monthly open staff forums and regularly asks for feedback. We also have a very clear and well publicised whistleblowing policy which enables staff to raise issues anonymously and every concern raised is investigated thoroughly. We are very concerned that these members of staff have not used these well established channels.

Workload

We are a busy maternity unit. Last year there were 5,694 deliveries (5,802 babies) and this year we are aiming for a small reduction. This means sometimes there will be pressure points of increased activity, but these will be planned for. It is true that on occasions the labour ward is very busy. It is widely recognised across the whole organisation that the midwives, support staff and doctors all work incredibly hard and are very committed to providing the highest quality of care possible, in what is at times a busy and demanding environment.

Staffing

Like most maternity units we do have some vacancies. There are currently 130 midwives in post and we are funded for 157, which means we have 27 vacancies. This is in line with the national average and we cover these vacant posts with some of our own staff who are willing to work additional hours and with agency staff where necessary. We disagree that we are not taking the issue of staffing seriously. We have recently received extra funding from our local primary care trusts and are currently recruiting an additional 30 midwives and 40 midwifery support workers, whom we hope to have in post in the very near future.

The best way of measuring staffing levels is to explain it as a ratio of how many births there are per midwife. The ratio of births to midwives has reduced significantly over the past few years at Kingston Hospital.

In 2007/08 (the most recently published figures) we had a ratio of 38 births per midwife (1:38). This was as high as 1:43 in 2006 but has now reduced to 1:36.

The unit is currently going through a consultation on an alternative model of care which will be better for women. There is a government drive to improve maternity services nationally and this new model of care will offer local women more choice about where and how they have their baby.

This work will also enable us to reduce our midwife to birth ratio to 1:30.

Bed Shortage and safety

The process for women in labour arriving at the maternity unit is that they are seen by the receptionist in the reception area whilst they are booked in. The majority of them will have telephoned in advance, the team will be expecting them and will have prepared a delivery room for them. There will be some occasions when women may have to wait for a room to become available either because of the number of women in labour or because a room is being cleaned and prepared. The lives of women and babies are never put at risk.

If the unit is deemed to be operating unsafely then it would close to all further admissions. This is not a frequent occurrence. The last time this happened, due to bed shortages, was in 2006.

Number of deliveries

Between April 2008 and March 2009 there were 5,694 deliveries. This financial year we are aiming to deliver 5,600 women. There have previously been discussions to consider expanding the service to 7,000 deliveries per year but a decision has been made to maintain our current levels.

Discharge

It is true that it is the Trust's policy to encourage women to go home within 2-6 hours of delivery if they have had a straightforward birth, both they and their baby are healthy and there is no reason for them to remain in hospital. Each situation is assessed individually. This is in line with best practice across the NHS and is not linked to freeing up beds. We know that many women want to get home as soon as possible after having their baby and home is the best place for them.

Induction

Sometimes women waiting for an induction will experience a delay in being admitted. This is because high risk women are induced first and emergencies, such a caesarean sections, have to take priority in addition to those being admitted in labour. If an induction is delayed, it will not happen without a full clinical assessment. This is an area where we are working hard to improve.

Experience

We know that many women are happy with their experience of the maternity services at Kingston Hospital. This is reflected in the surveys that are undertaken, but also in the many personal thank you letters and cards that we receive. However, we do sometimes receive official complaints and informal feedback on occasions women are dissatisfied with the care they receive. Each of these is investigated and lessons learnt are taken forward.

Staff Breaks

When the unit is very busy, it can be difficult for staff to take their break at the allocated time.

However, every attempt is made to enable them to do this and it is seen as a priority by the managers.

Changing role of a midwife

It is part of normal midwifery (and nursing) duties to clean up blood and other bodily fluids. We would not expect this to be part of the domestic cleaning role. This is reflected across the NHS as a whole.

The role of a midwife has changed and they are taking on more responsibilities as part of an intended career path as they increasingly develop additional skills with training. Some specialist posts have been created at the Trust to take on specialist tasks such as a paediatric examinations etc and they have been fully trained in these roles.