Rebecca Evans AM, Assembly Member for Mid and West Wales, has asked the Welsh Health Minister to address a series of specific concerns following his statement relating to maternity services in the Hywel Dda University Health Board area.
In the Assembly Chamber on Tuesday, following the delivery of the statement, AMs were able to question the Minister on plans to centralise specialist baby care in Glangwili Hospital, Carmarthen, and the replacement of the special care baby unit at Withybush Hospital, Haverfordwest, with a mid-wife led service. The service in Bronglais will continue as it is now while a review of health provision in mid Wales is undertaken.
The Minister’s statement followed receipt of a report from an independent expert panel which recommended the way forward subject to what it called a “safety net” being put in place.
Mrs Evans raised issues including safety concerns, the impact on Glangwili Hospital, developments at Morriston Hospital, and lessons from Powys.
Safety concerns
Mrs Evans voiced specific concerns about the safety of the proposals for pregnant women who, following assessment under established clinical guidelines, are deemed to be ‘not at risk.’
Mrs Evans said: “Minister, I think that most people accept the evidence, which suggests that standalone midwife-led units for low-risk women are safe. That was made clear in the recent Maternity Clinical Reference Group’s position paper on midwife-led care, and the Cochrane Library review, which found that maternity care delivers better outcomes for low-risk women under a midwife.
“However, what really, really frightens people about these proposals are those rare cases where a woman who has been identified as ‘not at risk’ suddenly develops unexpected complications. So, according to the evidence, Minister, how often would you expect women to find themselves in that situation, under the new system? What solid reassurance can you offer them about their safety and that of their baby?”
She went on to ask for more detail of the “safety net” which the expert panel said must be put in place, and sought information about the proposed “phased implementation” of plans.
The Minister said: “Rebecca Evans is absolutely right to point to the very recent Cochrane Collaboration review of maternity-led services. Not only did it conclude that midwifery-led services had advantages over other forms of provision, but it also concluded that the risk level of births in midwifery-led units could be raised safely and successfully. So, there is more scope within these units for more births to be conducted in the future.
“The Member asked me about the safety net that the panel set out. I have already mentioned two aspects of it [robust emergency transfer arrangements and strict accordance with midwife-led unit guidance].
“At Withybush, while the midwifery-led unit is being established and matured, a level of consultant obstetric cover will remain in place. I expect that to be there for at least the next 12 months. It will provide the safety net to make sure that, should midwives come across cases that, in those early establishing days, they do not have the confidence or competence to deal with, there will be consultant obstetric cover available to them.
“At Bronglais, the existing provision will continue during this safety-net period, and certainly into the period during which the piece of work that has been set in hand to look at the future of services across that middle part of north Wales will have a chance to consider this issue and to report on its work.”
Impact on Glangwili Hospital
Mrs Evans raised the potential impact of the proposals on Glangwili Hospital, asking about the clinical and physical capacity of the hospital, and accommodation for parents.
Mrs Evans said: “I must also ask you, Minister, about the impact of the proposals on Glangwili hospital.
“Specifically, are you satisfied that Glangwili has the expertise for a level 2 unit, or are we looking at another difficult and protracted round of recruitment?
“Does the hospital even have the physical capacity to deliver anything more than it already does? I cannot see that there is much spare physical space in the hospital, or much room for it to expand. The expert panel refers to the need to for additional labour ward, theatre, antenatal and postnatal capacity. Are you sure that there is the capacity there to do that?
“In your previous statement, you said that you would expect the level 2 unit to comply with all modern standards, including parental accommodation. Is that still your intention? What investment would be needed to make that happen, and what would the timescales be?”
The Minister responded: “This will require additional expertise at Glangwili. The panel was in favour of Glangwili because it believes that recruitment there will be more successful. It will require physical capacity at Glangwili as well. I expect the level 2 unit to be built to modern standards. There is money in the Welsh Government capital programme next year set aside against exactly this development.”
Developments at Morriston Hospital
The Independent Expert Panel, which provided advice to the Minister, has said that the proposal for a purpose built obstetric and neonatal unit at Morriston “also has to be considered” because it “has the potential to attract mothers from the Eastern Carmarthen area.”
Mrs Evans said: “The development of neonatal services at Morriston would also impact on services at Glangwili. Is there a danger that Morriston might make a level 2 unit at Glangwili unsustainable in the long term?”
The Minister responded: “Regarding Morriston, it is possible that, in the future, there will be further developments in other parts of Wales. The panel draws attention to this. It says that we will need to keep the whole of these services under review as patterns of service change in the future. However, we have to attend to the here-and-now needs of the population of Hywel Dda, and that is what today’s decision does.”
Lessons from Powys
Mrs Evans was keen to probe the Minister what lessons he and his panel had learned from Powys. Powys does not have a District General Hospital. It has six established midwife-led birth centres. All high-risk women give birth out of county.
The Minister said: “May I take a moment to reflect on the experience that we have in Wales, in Powys, where exactly this sort of model has been in operation now since 2001?
“Over the last few years, 2,549 babies have been born in Powys using midwifery-led services. Of course, there are occasions when a woman will have opted to give birth in a midwifery-led unit and things, in an unexpected way, turn into an emergency. That has happened in fewer than 4% of those cases. Every one of those cases then requires that woman to be taken, in an emergency—and in Powys’s case, lengthy distances—to the hospital where she will get the care that she needs. In not a single one of those cases has there been a risk to the life of the child or the mother. We have the experience in Wales. We know that it can be done.”
Mrs Evans asked: “What have you learned about how geographical challenges are dealt with in Powys, and how does that impact on how the emergency retrieval service might work in Pembrokeshire?”
The Minister said: “What have we learned in terms of those transfers? We have learned that they can be carried out successfully, because they are carried out successfully every week of the year, and in some challenging terrain as well. This can be done.”
A&E and the Ambulance Service
Due to the limited time for questioning in the Chamber, Mrs Evans has also written to the Minister to seek clear assurances that the proposals will not negatively impact specifically on A&E, and has asked him to respond to concerns about the impact that proposals might have on an already stretched ambulance service.
