NHS reflects on delivery of key priorities

NHS Chief Executive David Nicholson thanked NHS staff for their hard work improving care for patients this year, including reducing healthcare associated infections and waiting times, and extending GP opening hours. Launching his third annual report at the annual NHS Chief Executive’s Conference, Mr Nicholson said that while the NHS had delivered what it said it would over the year, it had to go further and faster to improve the quality of services for patients. 

The report states that whilst the NHS has 11 per cent growth in funding over the next two years, which will be locked in on recurring basis, it would need to prepare for leaner times after that. This meant the NHS would need to deliver efficiency savings in the order of £15 billion over the three years after 2011, to address pressures in the system, and this can only be achieved through the improvements in quality and advances in innovation envisaged in the Next Stage Review.

Mr Nicholson said the leadership of the NHS had delivered on what they had promised for patients in 2008/09 and he was confident that they would continue to deliver improvements in the future.
In 2008/09, the NHS:

• met the commitment to treat all patients within 18 weeks from referral to hospital treatment five months early
• reduced MRSA infections by 62% below the 2003/04 baseline – exceeding the target of 50%
• provided extended opening hours at 71.% of GP practices – exceeding the target set by the Prime Minister of 50%
• employing an additional 1,195 midwives by the end of 2009 against a target of adding 1,000 to the 2006 baseline
• exceeding the Gershon efficiency savings target of £6.47 billion, with the NHS delivering £7.88 billion of savings

Public confidence in the NHS rose to the highest levels on record during the year and staff morale also remained at record highs.

The effectiveness of relaxation classes for childbirth questioned

New research to be published in BJOG: An International Journal of Obstetrics and Gynaecology reports that specialist pre-pregnancy preparation for women and their partners, emphasising practical training in breathing, relaxation and massage techniques, and aimed at promoting ‘natural’ childbirth, produced no measureable outcome benefits over the standard classes offered at antenatal clinics in Sweden.

 

1, 087 first-time mothers and 1, 064 of their partners took part in the study by the Department for Woman and Child Health at the Karolinska Institute in Sweden between January 2006 and May 2007.  They were recruited from across Sweden and randomised into two groups to attend specifically-tailored antenatal classes.

 

The ‘natural’ group focused on teaching the women and their partners psychoprophylaxis (relaxation, breathing and psychological coping techniques).  The standard care group were provided with information about childbirth and parenting, modelled on the standard Swedish antenatal education programme.

 

Researchers hypothesised that participants in the ‘natural’ group would have lower rates of epidural analgesia, a more positive overall experience of childbirth, but higher levels of parental stress, as the classes did not prepare them for parenthood.  The main outcome measures were therefore the use of epidurals during labour, and the recorded experience of childbirth and parental stress.       

     

Researchers found that the experiences of childbirth and stress were similar in the two groups.  The epidural rate was 52% and the spontaneous vaginal birth rate 66% in both groups.  The caesarean section rate was 20% in the ‘natural’ group and 21.5% in the standard group.  The instrumental delivery rate was 14% in the ‘natural’ group and 12% in the standard group.  There were also no statistically significant differences between the groups in the satisfaction of the childbirth experience or postnatal parental stress (measured at three months). 

New Social Security Regulations aimed at lone parents announced in Northern Ireland

The Minister for Social Development, Margaret Ritchie, this week introduced new regulations for approval which would provide opportunities for paid work to more lone parents and intends to support them in creating a better standard of living for themselves and their families.

 

 

The purpose of the regulations, which were approved following a short debate, is to implement new arrangements for lone parents with older children who claim income support solely on the grounds of being a lone parent. Instead of continuing to receive income support until their youngest child turns 16, parents who are able to undertake paid work may claim jobseeker’s allowance when their youngest child reaches 12; by 2010, they will be able to do so when their youngest child reaches the age of seven. With support and assistance, those parents will be required to look for paid work that is appropriate to their individual situation.

To ensure a smooth transition, the changes are being phased in, starting with lone parents of children who are over the age of 12. Lone parents who have a disability or health-related condition that limits their capability to work may be able to claim employment and support allowance. The regulations do not apply to lone parents who are entitled to income support on other grounds, such as those who are in receipt of carers allowance or those who foster. Lone parents who have a child for whom the middle or highest rate care component or disability living allowance is payable will remain eligible for income support.

To ensure further that the change does not compromise children’s welfare, the regulations designate lone parents as a vulnerable group so that the jobseeker’s allowance hardship regime may apply in certain circumstances.

The regulations also include transitional protection for lone parents who receive income support and are full-time students; lone parents who are undertaking a work-related qualification; lone parents who are undertaking work placements in the Department for Employment and Learning’s Steps to Work programme; and lone parents who are on an approved New Deal for lone parents scheme.

Lone parents in those categories will remain entitled to income support until their youngest child reaches the age that is in force at the time at which they commence their studies.

To provide opportunities to prepare and support lone parents for the change, the regulations include the introduction of mandatory, quarterly work-focused interviews in the last year in which they are eligible for income support. The changes that are set out in the regulations form part of a package of ongoing welfare reform and are intended to contribute to the strategy to eradicate child poverty.

Advice for toddlers and young children to avoid rice drinks due to risk of exposure to inorganic arsenic

Following research published by the Food Standards Agency (FSA) looking at levels of arsenic in rice drinks, the Department of Health (DH) has advised that all toddlers and young children should avoid the consumption of rice drinks in order to minimise their exposure to inorganic arsenic.

The research was from a survey of total and inorganic arsenic levels in 60 samples of rice drinks available in the UK. Rice drink (also known as rice milk) is a blend of filtered water and rice and is usually marketed as either a ‘dairy free-alternative to cows’ milk’ or a ’low-fat drink’ and are usually often consumed by those who wish to avoid dairy foods. Some toddlers and young children who are allergic to cows’ milk and soya drink are currently advised to use calcium fortified rice drinks.

A DH statement notes that arsenic occurs naturally at low levels as organic and inorganic forms in a wide range of foods. Most arsenic in the diet is present in the less harmful organic form but the inorganic form is known to cause cancer. Low levels of inorganic arsenic were detected in rice drinks (12 μg/kg of rice drink). None of the samples tested in the survey were above the legal limits. The Committee on Toxicity has not been able to set specific thresholds of exposure (tolerable intakes) for inorganic arsenic, and has advised that exposure to arsenic should be as low as reasonably practicable.

However, the DH say that toddlers and young children may be particularly vulnerable, because of their proportionally higher milk intake and are likely to have higher dietary exposure to inorganic arsenic per kilogram of body weight. In the statement it also says that a toddler or young child consuming about half a pint of rice drink a day, (instead of cows’ milk) is likely to double his total dietary exposure to inorganic arsenic. Therefore, as a precaution, the DH advises against the substitution of breast milk, infant formula, cows’ milk or soya drink with rice drinks for toddlers and young children aged 1-5 years.

The Department’s advice is that:

• All toddlers and young children (aged 1-5 years) should not be given rice drinks in order to minimise their exposure to inorganic arsenic.
• This is a precautionary measure to minimise children’s exposure to arsenic. Parents who have given their children rice drinks should be reassured that there is no immediate risk of harmful effects but in order to reduce further exposure to inorganic arsenic, they should stop giving rice drinks to toddlers and young children.
• Parents of toddlers and young children with diagnosed allergy to cows’ milk and soya drink who are currently consuming rice drinks should be advised of suitable alternatives such as fully hydrolysed infant formula or oat or almond drinks. Growth and development of these children should be monitored and parents should receive specific dietary advice to ensure that their nutritional needs particularly of calcium are met through a diversified diet.

Parents of toddlers and young children who are lactose-intolerant or who have galactosaemia should be advised to give their infant lactose-free formula.

Further details of the FSA survey of rice and rice products is available on www.food.gov.uk

Over one in five children in Scotland lives in poverty

Approximately 21% of children in Scotland are living in poverty, according to a report released this week by the Joseph Rowntree Foundation (JRF). The report noted that despite earlier progress over the last decade in reducing child poverty – reductions were greater in Scotland than in other UK regions – levels have stalled since 2004/05 and are now fairly similar to the rest of the UK.

The report, Child poverty in Scotland: Taking the next steps, discusses progress made to end child poverty in Scotland. It states that the Scottish government could do more to reduce child poverty in Scotland. A wide range of policy measures are recommended to get progress back on track, from increasing the availability of affordable childcare to encouraging the Scottish government to look seriously at defining and paying a living wage.

Later this year, to mark ten years of devolution, the JRF will publish research into whether devolution has helped the poorest in society.

New guidelines for childbirth launched in Scotland

Women with low-risk pregnancies are to be offered more choice and control over giving birth, as a result of new guidelines published today. The Keeping Childbirth Natural and Dynamic (KCND) guidance for doctors and midwives will ensure midwives are the lead carers for women who have safe, low-risk pregnancies and births – the majority of women giving birth in Scotland.

Public Health Minister Shona Robison launched the guidance today as she opened Perth Royal Infirmary’s Women’s Clinic and Midwife Unit.

She said:

“Pregnancy and birth are normal and natural. Most women have a straightforward, uncomplicated pregnancy and labour and don’t need intense medical intervention. Having a midwife as the main carer is totally appropriate for them, and it’s also the best way to ensure that a woman is in control of her own pregnancy and care options. Scotland leads the way in putting women at the heart of care and supporting normal births. Most health boards already work this way, but the introduction of these guidelines will ensure the same high standard of care everywhere. Women whose pregnancies are assessed as being higher-risk will have their care led by an obstetrician and all women will continue to have the choice of where and how their pregnancy will be cared for.”

The KCND clinical guidelines have been prepared by NHS Quality Improvement Scotland. This work included a three-month consultation. They represent the latest phase in the implementation of the programme, which was introduced in 2007.

In addition to the guidance for maternity care professionals, NHS Health Scotland have been asked to produce information for patients to ensure pregnant women remain as well-informed as possible about their care.

Keeping Childbirth Natural and Dynamic (KCND) programme

Welsh children poorest in UK and getting poorer

The Welsh Liberal Democrats released research this week using the recently released Households Below Average Income (HBAI) statistics showing that the risk of children living poverty is greatest in Wales and has risen more than any other part of the UK.
 
The figures reveal that:

 

• Welsh children have a 27% chance of living in poverty, equalled only by the North East and well above the UK average of 22%.
• This is 2 percentage points higher than the previous year’s figures. This rise is equalled only by the North East and the East Midlands.
• The overall risk of child poverty across the UK has remained stable over this period.
• When housing costs are taken into account, the risk of a Welsh child living in poverty rises to 32%.

 

Commenting, Jenny Willott, Welsh Liberal Democrat MP for Cardiff Central, said:
 
“A child born in Wales today has more than a 1 in 4 chance of growing up in poverty, the highest in the country. Even more shocking is that the risk of a child living in poverty in Wales is actually increasing, and by more than almost anywhere else in the UK. The reality is that Labour only just dented child poverty in Wales. With the recession kicking in, the small progress that had been made is being rapidly undone. The Government’s target of halving child poverty in 2010 is totally fanciful. But the long-term and more important goal of eradicating child poverty by 2020 is now in serious doubt.”
 
Notes:
 
Child Poverty is measured as children living in households with less than 60% of contemporary median income, before housing costs.
 
The HBAI statistics can be found at: http://www.dwp.gov.uk/asd/hbai/hbai2008/pdf_files/full_hbai09.pdf

Minister questioned on number of Caesarean Sections in Northern Ireland

The Minister of Health, Social Services and Public Safety was this week questioned on the number of Caesarean sections performed in the past five years.  He noted that in 2003-04 there were 5,487; in 2004-05, 5,564; in 2005-06, 6,412; in 2006-07, 7,196; and in 2007-08, 7,149. 

He also stated that the decision to deliver a baby by Caesarean section, either electively or as an emergency, is based on the clinical judgement of an obstetrician, who takes account of the medical condition and circumstances of both mother and infant.

Mrs McGill, who asked the question noted concerns about the increasing number of Caesarean sections, particularly in the North of Ireland, and asked if the Minister agreed that the new Public Health Agency should inform people, particularly young mothers, about the implications of having a Caesarean? “Should the Public Health Agency, for example, inform young mothers that there is an 80% likelihood that their babies could develop childhood asthma as a result of their having a Caesarean section?”

The Minister responded that although there are concerns that rates are on the high side, “the number of Caesareans performed in Northern Ireland is approximately the same as the UK average, and is less than, for example, that in the Irish Republic and other countries. There is a huge range in the number of incidences across Europe, from around 15% in eastern Europe to 33% in Portugal and 38% in Italy. Our section rate is sitting at 28%, and, certainly, I want to get that number down. However, the decision to carry out a Caesarean section is based on a clinical judgement made in discussion with the prospective mother.”

He did note that a patient safety forum has been established which will promote a safety culture, share best practice, support organisations in implementing evidence-based interventions and measure patients’ safety and that they are considering other ways in which to get out messages about Caesarean sections.  However, he did not envisage the Public Health Agency playing a key part in that, as it has a different role in health promotion. “However, there is a strong push across the Health Service to provide the type of information that allows clinicians and mothers to make informed value judgements.”

The maternity unit at Craigavon Area Hospital was highlighted for its good work, particularly in pressured times due to the increase in the number of births from just under 3,000 in 2004 to a provisional figure of 3,800 in 2008. “Those figures illustrate the steep rise in the number of deliveries at the hospital. Much of that rise is due to the mothers’ preference for Craigavon Area Hospital because of its excellent reputation. It has highly professional staff, and its obstetricians and midwifery unit work together.”

The proposal to establish a midwifery-led unit at Lagan Valley Hospital was also questioned. “It means that less-routine cases, including Caesarean sections, will, in all likelihood, be transferred to the Royal Victoria Hospital. What negotiations are ongoing to enhance the budget and resources of the maternity unit there to enable it to deal with women who have to undergo surgery, including Caesarean sections, or other acute interventions?”

The Minister said that he has requested a business case to be provided for the establishment of a midwifery-led unit at Lagan Valley Hospital. “In Belfast, the Jubilee Maternity Hospital continues to work within its capacity, and it will receive investment to ensure that that remains the case. Investment will be made in Craigavon Area Hospital, whose maternity unit is also a unit of choice for mothers in the Lisburn area. In the south-east, the maternity unit at the Ulster Hospital is a unit of choice, and that will be the case for the new unit in Downpatrick when it comes into operation shortly.” However, he also said that he anticipated that he would receive a positive business case indicating the substantial use of a new midwife-led mater.

British Heart Foundation: Risks and benefits of folic acid must be carefully weighed

In response to a study, published by BMJ online, linking the fortification of food with folic acid with a decline in the number of babies born with heart problems, Ellen Mason, cardiac nurse at the British Heart Foundation, said:

“Pregnant women are advised to take folic acid because it is proven to reduce neural tube defects such as spina bifida occurring in an unborn baby if taken within the first 12 weeks of pregnancy. There is also some evidence to suggest it may prevent some congenital heart defects forming. A problem for women who have an unplanned pregnancy is that they may not take folic acid supplements during that time.  This Canadian study shows that when folic acid was added to flour and pasta the number of babies born with certain severe heart conditions was reduced. While the decrease in babies born with heart conditions during this time is statistically significant, many children were still born with congenital heart disease. This must be taken into account when considering the benefits of routinely introducing folic acid to flour and pasta in the UK. Especially because routine introduction could pose a risk to some elderly people as potentially dangerous vitamin B12 deficiency can be masked by high intake of folic acid.”

Issued in response to ‘Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada’ by Raluca Ionescu-Ittu et al. Published online by the BMJ. BMJ 2009;338:b1673 doi:10.1136/bmj.b1673

Question on the development of policy on nutrition for children

Dawn Primarolo MP this week responded to a question on who is responsible for the development of policy on nutrition for children between the ages of one and three years; and what guidance on nutrition for such children the Government provide. The Minister of State for Health noted that the Department of Health (DH) is responsible for the development of policy on nutrition for children between the ages of one and three years. She noted that the policy is evidence based, drawing on the recommendations from the Committee on Medical Aspects of Food Policy (COMA). She also confirmed that the Scientific Advisory Committee on Nutrition (SACN) is currently reviewing evidence on the influence of maternal, fetal and child nutrition status, including growth and development in utero and early childhood, on the development of disease later in life.

In taking this work forward, the Committee is considering the evidence around maternal, fetal and early life factors, including infant diet and growth. SACN aims to publish their final report later this year. She also said that as part of its ongoing work, the Committee’s Sub-group on Maternal and Child Nutrition is also planning to update the COMA report Weaning and The Weaning Diet.