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Archive for February, 2010

 

Back in the middle of 2009 I was referred by my G.P to a London teaching hospital. After many trials and tribulations I finally saw the consultant, the decision was made to schedule surgery, the exact nature of which would be based upon the results of further scans and tests. I fairly bounced my way home, at last I could look forward to resolution.

I’ve spent the 2 years, since my previous surgery, in discomfort and, by the end of the day, in pain. I’ve put up with it and carried on regardless but increasingly it has been affecting more and more of my day-to-day life. As long as I believed that my op would be only a few weeks away I was prepared to ‘grin an bear it’ but last week my gritty determination crumbled. I had the tests and scans back in December, I had a further appointment last week where. after a 2 hour wait, I was called in. The doc, not the consultant, duly reviewed my scans and told me the plan, fairly simple operation with a reasonable recovery time, yeah! ‘When, when?’ I grinned and, after a brief discussion with the nurses, he told me, ‘ Probably June’.

I slouched home and then spent 10 minutes blubbing. How I wish that the hands of the clock did rotate at a visually disturbing rate, I just want things sorted soon, quickly. In 2 words the doc had made my symptoms escalate from bearable to unbearable. By the evening I’m really tired and extremely uncomfortable, on-calls are now more stressful. It’s not just my usual disinclination to get up in the middle of the night and drive to a previously unknown destination for an unspecified length of time but also a fear that I may not function at 100% when I get there. I mulled the situation over and decided to go and have a chat with the occupational health department. Dream on, what occupational health department, they have been re-branded, Workplace Health. No longer are they there solely for NHS employees, no, workplace health (WPH) are there for NHS, plus they are also providers to the public and businesses. I found this out when I misguidedly phoned them to arrange an appointment, another faux paux as there are no direct referrals, my manager has to refer me. I am now firmly off  into the land of Alice, for years I have inhabited a workplace where, if you had a work-related health query you would chat about it to occy health, you certainly didn’t have to spread word of your personal, health problems around. Right, in Wonderland I have to go to my manager, tell her what ails me and let her decide if I do need to see them. Manager then has to do a referral and then Workplace Health will triage (their word, not mine) me and arrange an appointment accordingly. I’ve done it all, I even made sure that HR were there when I spoke to my manager, I’m really dotting i’s and crossing t’s nowadays, I’m losing faith in people’s motives. HR advised me to phone WPH a week later if I hadn’t heard anything as she felt that I should see them sooner rather than later but I’m generous, I left it 10 days before I phoned them. They cannot find my referral, I have 2 copies, 1 sent by email and the other by snail mail but they haven’t received it in any form, not even by pigeon post. No referral, so no appointment. WPH want a new referral, I’ve sent them one of my copies.

It’s really difficult not to become extremely frustrated by all this paper-trailing, waiting and black holes that referrals disappear into. I can’t believe that I am unlucky enough to have this only happen to me, twice. I don’t expect an instant service, I know that the hands of the clock move slowly within the NHS, but I do expect that once paperwork has been sent that people can at least find it and that when they can’t they at least take ownership of the problem, not turn the poor unfortunate person who has been referred into a human ball being bounced backwards and forwards.

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Reclaiming Birth

A date for those interested in improving maternity services, March 7th.

Reclaiming Birth

What is Reclaiming Birth about?

Reclaiming Birth is a campaign by NCT, AIMS, ARM, IM UK and Albany Mums about the standard of maternity services throughout the UK. We want parents-to-be to have the best opportunity to start family life in the optimum way. Our concerns cover a range of issues:

Many women and their partners are left alone in labour and get little support from overstretched midwives. Parents-to-be often don’t have access to the services and support they need for the birth of their baby to be a safe, positive and life affirming event.

This will only change when there are more midwives, more women being able to birth in free-standing midwifery units (Birth Centres) or at home and more midwives carrying their own caseloads and looking after parents-to-be from conception to birth and postnatally.  Few parents-to-be currently have any of these options.

See you there!

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I’ve had time for musing today and yesterday as I’ve driven between my visits and here’s what I’ve come up with –

  • I really don’t like the drop in clinic. No surprises there. I feel that I’m short-changing the women and that I’m missing out on aspects of the women’s welfare. The clinics are good for the women as they are given an appointment time so they are not left wondering when a midwife will appear at their home, other than that I can’t see a positive for them. For me; I get depressed when I see the long appointment list; it’s difficult to give truly individualised care within an appointment system and in an environment which is alien to both the woman and myself. In most cases the woman is accompanied by her partner/husband and he will come into the room with her, making himself comfy on a chair. This spectator aspect can stultify the midwife and woman relationship, I am not seeing or hearing the real woman, I am receiving the information and impression that the woman wants her husband/partner to receive.

Following on from the drop-in clinic muse I began to wonder if anyone had followed-up on outcomes for women whose care was provided within clinics compared to those whose care was provided my a ‘named’ midwife, in their own home. This lead me to considering the holistic approach, which named midwifery should favour, and if it is beneficial and gives rise to increased positive outcomes.

  • Yesterday I visited a woman, her husband and 15 month old son to book her care in a new pregnancy. I knew this family through the previous pregnancy so there were many questions I didn’t need to ask, in fact it was less like an ‘interview’ and more like a social catch-up. When I left I was remembering her last pregnancy, all normal, in fact at 36 weeks I booked her for a home birth. Things change though an when I took the home birth bag round a week later I thought S looked puffy. I asked her if she was swollen, she showed me her hands and feet, slightly oedematous, but her face looked different. I asked her husband what he thought, he looked at S and agreed that she was slightly puffy. I took her blood pressure and it was slightly higher than usual, nothing unduly worrying though, a trace of protein in her urine, no headache, flashing lights, everything within acceptable limits, but I was still uneasy. I sent her in to our day assessment unit and within a few hours she was being induced for pre-eclampsia. This disease of pregnancy generally, but not always, shows itself with high blood pressure and lots of protein in the urine, if I had relied solely upon these diagnostic determinants I wouldn’t have suspected PET. I’m not super midwife, I’m just a midwife who knew her patient.

Midwives talk about ‘intuition’ and frequently recount stories like the one I’ve just written down. Examples of when we have been unable to robustly support why we have concerns but feel strongly enough to push for a second opinion or diagnostic tests. I know that if I have a ‘feeling’ about something then I don’t ignore it, I have been proved right too often. It would be interesting to see if community midwives working a named midwife caseload have a higher early detection rate for pregnancy complications or even just better outcomes for pregnancy. I wonder if any research has been conducted on this?

  • Research. Is it beneficial? How, why, when and where does it affect practice? It does if it shows that it improves outcomes. It does if it is shown to be economical. What about if it improves working lives, and here I’m talking midwives, is any research being done on this area? 

‘A happy worker is a productive worker’. Come on midwives, are you happy workers? What woud impove your woking life and the care you can provide, we all know increased numbers would be a huge fillip, but what else? What research could highlight practice which would beneficial to you? Please leave any suggestions in the comments section.

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One of those days

At the weekends we operate a ‘drop-in’ clinic, drop-in, hmm, well that’s wrong for a start as it is a clinic which has a pre-booked, appointment system, it’s held at the local birth centre where 2 community midwives staff it, today was my turn to be one of the midwives. It was depressing looking at the appointment list, 20 women and babies, 1 stretch and sweep, 1 blood pressure check and 1 antenatal examination with a query of oligohydramnios ( low levels of amniotic fluid). The midwife I would be conducting the clinic with announced that she had an appointment at another hospital right in the middle of the busy clinic, I was somewhat stressed at this revelation but luckily a colleague revealed that she not required elsewhere so she could come and lend me a hand. Just over halfway through the clinic the midwife running the birth centre announced that the woman she was caring for in labour required an ambulance transfer to the obstetric unit 15 miles away,and were there any offers to be the escort. Luckily the midwife who had gone off to an appointment arrived back at this time so there were 3 of us to choose from. Ambulances, well-equiped, often life-saving but also great wallowing vehicles so many passengers find that they suffer from a susceptibility to travel sickness therefore volunteers are often quite difficult to find. I thought about it, I’ve never been sick during a transfer, Hubby was playing golf quite close to the obstetric unit and would be finishing about the time I would need rescuing from the unit, the ambulance takes us there but then leaves us to get a taxi back, so I offered to accompany the woman. The ambulance driver asked if we should blue-light and siren, we decided on a calm drive but lights and noise through traffic and half an hour later we arrived at the obstetric unit. Mission accomplished successfully.

Hubby arrived from golf, unfortunately he had a golfing chum with him who we had to drop off before continuing to the birth centre. We had to drive past the top of our road so I asked if we could just pull into our drive so I could run in and get a biscuit, it was 3.45 pm by then, I hadn’t eaten since 7.45 and was ravenous, we then drove the 9 miles to the unit and Hubby dropped me off. I went in, helped with the last appointment, tidied up and went to leave, no car keys. Right, I had them to get in and grab a biscuit. I remembered taking them out of the front door, perhaps I had left them in Hubby’s car. Quick phonecall, no the keys weren’t there. I scoured the birth unit, we all scoured the birth unit, looked in the emergency transfer bag, no car keys. Phoned Hubby again and asked him to drive over with my spare key. By now he was convinced that I had left the keys in the front door and someone had taken them. I wasn’t so sure, I felt sure that I had had them with me when I went back into the birth centre. I was worried though, car keys, house keys, office keys, children’s house keys and Mum’s keys were all on my key ring, massive loss. I needed to pick up the entonox from our office, but it was locked, and I didn’t have the key.  B****r.

One last search and there, peeking out from behind a clinical waste bin, my keys. Yeah! I phoned Hubby, not a happy man as he was nearly back with me. Whoops.

Now I’m sitting here, jumping every time the phone rings as I’m on-call for community and the birth centre, at least it’s stopped snowing though, and I’ve got the entonox.

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E-mail I received today

I am contacting you on behalf of the MHRA (Medicines and Healthcare products
Regulatory Agency), the government agency responsible for ensuring medicines
and medical devices work and are acceptably safe.

I would like to invite you to take part in our online discussion around the
MHRA’s proposal on making information about medicines available online, and
would love to have your voice added to the conversation.

Please take a look at the online dialogue here:
http://www.medinfodiscussion.org/

This will be a big decision for the MHRA and they want as many views as
possible on it – is it a good idea? What difference, if any, would such a
resource make to you? How would you use a resource like this?

You can read, rate and add ideas to the discussion until 8 March 2010,
during which time we hope to hear from as many people as possible, ranging
from health professionals and patients to members of the public.

Would it be possible to disseminate this information on your website and in
any press/newsletter outreach?

Thanks in advance for taking part, and please forward this message widely –
the more people taking part, the richer discussion we will have! Please get
in touch if you require any further information.

Many Thanks

 Jenny Hardy

Delib (Working with MHRA on the discussion.)

Online Opinion Research and Public Consultation

www.delib.co.uk

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Play

Boys in a box

Two weeks ago my 10 month old Vax carpet washer packed up. I phoned the number on the handle, spoke to a lovely man about my problem, exchanged chit-chat about grandchildren and then arranged for my defunct cleaner to be picked up. On Thursday it was returned to me in a large cardboard box, I was happy to have my Vax back, the boys were delighted to have a box to play in, hours of fun.

Today I have been a domestic goddess, well my version anyway. I have made 3 puddings for a family meal tomorrow, a lemon meringue pie, an apple cake and, a new to me recipe, toffee apple crumble. This crumble has apples( obviously), lemon juice, golden syrup, flapjacks and fudge, I think that tomorrow I may be a cursed Nanny, all that sugar!

Work? Well I’m just not thinking about it, it’s too depressing, demotivating, demoralising and many more de- something or others.

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Midwife Muse’s roll call of causative factors so far –

  • PCT’s for with-holding government monies
  • Groups who place the majority of their emphasis on THE BIRTH, and lobby accordingly, putting antenatal and postnatal care on the back burner
  • Trusts for employing too many managers

Fittingly the midwives come last, that’s the usual position we appear to occupy in any planning, so why alter the status quo? Why are we to blame then? Well we will do what we always do when change is foist upon us, we will grumble, get stressed, some of us will even rant, in private but ultimately we will comply. When I used to work in the unit the obstetricians, generally the registrars, would keep coming out with jokes which were always based upon how bolshie midwives are, ‘What’s the difference between a rottweiler and a midwife? A rottweiler eventually lets go.’ That may be true in the one-on-one clinical situation, when we are being an individual woman’s advocate, but as a group, when change is being imposed, our contracts being re-written or some other attack on our ability to provide the care we KNOW that we should provide we capitulate and fail to work together to resist or modify the changes.

My crystal ball is showing me that once again we will moan and have a brief, vaguely supportive interaction with our union, incidentally that won’t get us anywhere (prediction), a couple of us will leave, another couple will retire, half of us will apply for other jobs, perhaps midwifery related but the majority of us will just end up going along with a change we are intensely unhappy with.

Midwives are their own worse enemies. We are already working above our capacities, both within the maternity units and in the community but we don’t ‘work to rule’, we can’t, but we should. The managers are not ignorant of the ridiculous workload and the number of extra, unpaid hours the staff put in, in fact I do believe that the managers join in sometimes, so we are all colluding in the farce which will allow these changes to go through, these changes which will definitely affect the coal-face midwives, the women and babies.

For a profession whose members are portrayed as fierce we are badly misrepresented, we are actually shrinking violets.

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In Part 1 I identified the PCT’s role in affecting how midwifery care is provided in the community and then, in Part 2, I talked about how I believe that user and pressure groups, focusing their lobbying on the birth, has adversely influenced funding for other areas of maternity care.

Managers, and other higher grades. They are not dissimilar to metal coathangers really, turn your back on them for a while and they have replicated themselves, Southampton have managed a 85% increase in their numbers in 4 years.  Maternity services are not about to be out-shone by the other departments where the number of managers has risen 3 times as fast as the number of nurses.

Locally, 10 years ago we had 2 separate maternity units, each unit had 3 managers, including their Head of Midwifery, I’m quoting here from personal experience, but I doubt that my experience is different from many others. Anyway, within 5 years 1 Head of Midwifery had gone, this happened when the 2 separate units came under the umbrella of 1 Trust, but 2 more manager posts and 1 consultant midwife post had been created, so minus 1 but plus 3. When the 2 maternity units later amalgamated into 1 building it was imagined that a manager may lose their job but that didn’t happen, blink twice and there are 11. They don’t all have the title ‘manager’, there are ‘specialist’; ‘consultant’; ‘modern matron’ and ‘head of’ but, basically, they are all managers, I’m not including 9 ‘team leaders’ here as they are a sort of hybrid who manage but are predominately clinically based, unlike the afore mentioned menagerie. So, in summation, over a 5 year period 6 managers have become 11 whilst the number of midwives have increased by 6 therefore 1 more midwife has been employed on the coal face compared to managers. Managers are Band 8, clinical midwives Band 5 and 6. A look at current pay scales shows the difference in wages, bottom Band 5 = £21,000 pa, the same for Band 8 = £38,000 pa, that’s nearly a two for one situation, or scrub the Band 8 and that’s a saving of £38,000 + employers NI and pension contributions, that must take it well over £40,000, nearly what they are saving in mileage costs and stopping weekend/bank holiday working by ALL community midwives.

There, no consultation required. No cutting of domiciliary visits. Just get rid of ONE manager.

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Previously in ‘The Demise of Community Midwifery :-

The PCT’s, in some areas, are with holding the government monies which were supposedly ring-fenced for the improvement of the maternity services. The result is that the maternity care providers, the hospital trusts, have increased consultant availability, improved facilities and employed (in some cases) more midwives in line with recommendations but the promised monies have not been forthcoming from the PCT’s, so they are now having to make cut-backs.

Next on my list of ‘those responsible’ are the ‘user’ and ‘interest’ groups. Within maternity care the focus, their focus, is on the birth itself. Fair enough, that is what is most important, a healthy baby and Mum. Childbirth is not an isolated event though, there are 40 weeks leading up to the birth of a healthy baby, the antenatal period. Traditionally this care is provided in a variety of ways but, within the NHS, the majority of care options will involve a midwife to a greater or lesser extent. G.P’s may also be involved, if the G.P is registered as providing maternity care s/he will receive extra funding from the PCT for each of his pregnant women, regardless of how much input s/he actually has and, surprise, surprise, the PCT’s are still paying G.P’s this.

Back to the interested parties and why I point a finger at them. They lobby, they lobby for women’s choice. Women’s choice in where they give birth. Nothing against this, in theory, but everything against it when it appears that they place more emphasis on this than on antenatal and postnatal care and so this is where the money and focus is. Wonderful for a woman to give birth in a friendly, tastefully decorated, home-from-home room, littered with birthing balls, fully equiped with a birthing-pool and aromatherapy diffusers. Is it still wonderful though if, after the birth of her choice to a healthy baby, baby fails to thrive, develops jaundice and is, eventually, readmitted to hospital for IV fluids and phototherapy? This happens now, how much more often will this happen when community midwives no longer visit? G.P’s will see an increase in visits by, or to, newborns and their Mothers. Why the Mothers? Well, wounds become infected. Presently a midwife will visit, suspect an infection, take a swab and then phone the G.P to request that a prescription be issued for antibiotics. The infection will be caught early and the wound will, in most cases, heal well. If an infection is not treated promptly then it will ‘break down’ leading to a longer healing period or a readmission to hospital for re-suturing. I’m not even going to discuss the effect that reduced domiciliary visits will have on breastfeeding rates, all at a time when WHO are emphasing the importance of community support. Much is written about the detection of postnatal depression, as a community midwife I may suspect that a woman is likely to suffer PND, but serious PND generally shows after I have finished visiting. My role in this is to ensure that women know where to access help and to not  be ashamed, as many women are, of admitting that she is suffering from depression. Then there is an illness which does present whilst community midwives are visiting, puerperal psychosis, yes, it is rare but when a woman does begin to suffer from it early detection is beneficial as this illness can have tragic outcomes, as recognised in Why Mothers Die.

The essence of my argument with the ‘interest’ groups, who concentrate so single-mindedly on the ‘birth day experience, is ‘what point an ecstatic birth if, as the result of poor follow-up care, the mother and/or baby are unnecessarily ill, or die?’ It is wonderful that there are groups out there who apply pressure to government and care providers to improve care within the maternity services. Come on though, widen your focus from the glamour, headline catching time of birth and acknowledge the importance of good care before and after birth

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Maternity funding still not being delivered, British midwives claim

Millions of pounds of government funding intended to improve maternity care is still not reaching front line services, midwives say. Despite a rising birthrate, nearly a fifth of the heads of midwifery said that their budget had been cut, and almost a third had been asked to reduce their budgets. Last year the Government promised £330 million of extra funding for maternity services, but this has not been ring-fenced.

The results, from a survey across Britain by the Royal College of Midwives (RCM), come as the Health Secretary is due to speak at the union’s conference in Manchester. Andy Burnham will today announce a new “Start4life” campaign highlighting the importance of breastfeeding and healthy eating from infancy.

The RCM said that 5,000 more midwives were needed to provide safe and quality care to new mothers. Ann Keen, a health minister, said that it was up to NHS trusts how to invest the additional money. “Where funding is not reaching maternity services I call on Heads of Midwifery to challenge their PCTs,” she said. “We recognise there are concerns around staff morale and attrition rates and we are working with the Royal Colleges and the NHS to address these areas”. From Times Online November 27,2009 & Socialized Medicine

When I first worked on the community we all wore a uniform, when we were instructed to be in ‘mufti’ I was uneasy, I liked the fact that that as soon as a door was opened to me I was identifiable as ‘the midwife’. It’s been nigh on 10 years since I donned my uniform, other than odd days when I have been irritated by edits from above advising us to dress like office workers, so I protest by squeezing into my uniform, after all I’m not an office worker, I need to wear outfits which allow me to drive comfortably, plod across muddy fields, crawl around floors and lean over birthing pools. Do I miss my uniform now? No. That’s the thing about change, at first it’s disturbing but eventually it becomes normality.

There, aren’t I the philosopher, quite rational really. Well that stops now, a change is looming which has me seriously concerned, a change which doesn’t just affect how I dress as a midwife but how I deliver care as a midwife. So, what is the association with the quote from ‘The Times’ and my disquiet? My Trust is one of those affected by the PCT with holding government funding intended for maternity services, and what can be done about it? Nothing apparently, and the result, oh the result is fine and dandy, for the PCT, they keep the money but the providers of maternity services, well they have to make cutbacks. Does that suggest that maternity care will be improved?

The cutbacks, or evisceration, are fairly comprehensive. Our antenatal clinics will be moving out of  G.P surgeries and into Children’s Centres. Actually this is a suggestion within ‘Maternity Matters’ , I was going to put a link here, but fittingly the ‘website was unavailable’ since a quick read would reveal quite how loosely the recommendations (promises) are being implemented, the culling continues further though. Women will only receive a home visit from a midwife the day after they return home with their newborn, after that, well its back to the afore mentioned Children’s Centres. Sorry, I fibbed, not all women will have to travel to these centres, those assessed as requiring more ‘assistance’ will have a home visit. Oh, I forgot to say, no visits on a weekend, no clinics either. We won’t be able to do that, well midwives are expensive at a weekend, so it will be a skeleton service, so skeleton that there will have to be 2 midwives ‘on-call’ for the weekend as, if there is a homebirth, there will not be any midwives left. Incredibly cost-effective really as those 2 ‘on-call’ will only be paid £15 each to put their lives on hold for 24 hours, over a weekend, and be at the Trusts beck and call. Real value for money.

Am I blaming the PCT? Yes, but there are also other culprits, they will be in Part 2.

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