Scottish Government

Health in Scotland 2002

The Future of Maternity Services

There is wide variation in the location and levels of intrapartum care throughout Scotland, reflecting the disparate population and needs, which are significantly changing. The present configuration of intrapartum care is unsustainable.

During 2002, the Deputy Minister for Health and Community Care set up a Short Life Expert Working Group on Acute Maternity Services (EGAMS) with stakeholder representation to consider the intrapartum care aspects of implementing A Framework for Maternity Services in Scotland 2001 (Framework). The Group was tasked to develop a model specification, that would provide appropriate intrapartum care by appropriately trained staff in a safe and sustainable fashion.

EGAMS noted the declining birth rate and population especially in children and reproductive age women, the mix of central urbanised and dispersed rural population, the reduction in family size and the older age of mothers in pregnancy. Developments in clinical practice in maternal and fetal medicine have resulted in a more complex case mix in specialist units. Increased intervention and invasive treatment, increased antenatal and neonatal screening programmes, advanced neonatal care and community based management have all resulted in a significant change in maternity need. Expectations of mothers have changed in terms of accessibility, choice and involvement in the decision-making process. Workforce issues of multidisciplinary specialist training, junior doctors' hours, the European Working Time Directive, clinical governance, recruitment and retention have made it increasingly difficult to provide an appropriately trained maternity workforce in all locations of care, especially rurally.

EGAMS considered the

• Present configuration of Scottish intrapartum care within the three Levels of Care within the Framework

• International approaches

• Evidence supporting community midwifery units

• Risk Management processes

• Required workforce skills, competencies, roles and responsibilities in each Level of Care and the present educational provision

• Workforce issues

The Group identified innovative approaches to intrapartum care and developed consensus criteria for intrapartum management in each defined Level of Care. An appropriate programme for education and training was developed alongside a local and regional planning framework to deliver intrapartum care within an explicit network structure depending on the level of need and risk of the patient.

In conclusion, EGAMS agreed that the pattern of the present service provision was unsustainable. The Group developed Key Core Principles for intrapartum care within the context of the Framework including patient-centred local care, choice and involvement, a safe and clinically effective incremental approach to care while managing risk, delivered by an appropriately skilled workforce and planned within a local and regional context. EGAMS made a significant number of recommendations for intrapartum care .

The comprehensive EGAMS Reference Report will enable NHS Boards to plan and provide innovative approaches to safe and sustainable intrapartum care to meet the changing maternity needs of the Scottish population.

Pregnancy and Newborn Screening Programmes

There is a commitment in Our National Health: A plan for action, a plan for change that the NHSScotland will refresh and update its screening programmes, focusing on the health of women and children. In line with this commitment, advice was issued to the service in 2001 (HDLs (2001) 34, 51, 52 and 73) about the following pregnancy and newborn screening developments

• Improvements to organisational aspects of pregnancy screening for Down's syndrome and newborn screening for phenylketonuria and congenital hypothyroidism

• Introduction of newborn hearing screening programme

• Introduction of newborn screening for cystic fibrosis

• Introduction of pregnancy screening for HIV

Progress has been made by National Services Division (NSD) and NHSScotland in 2002 in the development of an appropriate infrastructure for the new pregnancy and newborn screening programmes. It is expected that newborn screening for cystic fibrosis will begin in February 2003 and pregnancy screening for HIV by April 2003. The two newborn hearing screening pathfinder sites have been established and screening in these areas is expected to commence in early 2003.

Developments to date include

• Patient information leaflets - new general pregnancy and newborn screening leaflets have been developed, to be available by February 2003

• Training - three training roadshow events have been held around Scotland for health visitors and midwives involved in pregnancy and newborn screening. A training manual for midwifery staff is being developed by NSD

• Consent for Screening - in future the signature of expectant mothers will be required when seeking consent for screening tests during pregnancy, to confirm that they have received appropriate information to enable an informed decision. A signature will be required for newborn screening tests from one of the new parents or guardians. If they choose not to be tested or have their child tested they will be required to sign a form which indicates which test(s) they are declining and that they understand the significance of this decision. Consent will also be required for the storage of the residual blood spot specimens, the forms to be available by April 2003

• Quality standards for pregnancy and newborn screening programmes are being developed by National Health Service Quality Improvement Scotland (NHS QIS) and are expected to be available by Summer 2003

• A letter to the Service in December 2002 about the development of Managed Clinical Networks for paediatric cystic fibrosis services.

Newborn Screening for Cystic Fibrosis

In 2001 the UK National Screening Committee endorsed proposals for the introduction of a standardised newborn cystic fibrosis screening programme. The SEHD accepted the Committee's endorsement and issued advice to the Service (HDL(2001)73) in October 2001. For most patients, where there is no family history of cystic fibrosis, diagnosis is made in infancy or early childhood but a significant number are missed in the first few years of life.

The predicted incidence is between 20 and 30 new cases a year. Over the last 10 to 20 years there have been improvements in the treatment, and the life expectancy of cystic fibrosis patients rose from 31 years in 1997 to 40 years in children born now. The screening programme will offer detection of cystic fibrosis shortly after birth, allowing treatment to begin earlier so that the complications associated with cystic fibrosis may be less severe, leading to a better quality of life and longer life expectancy.

At present in Scotland all newborn babies should have a dried blood spot specimen (Guthrie card) taken around the sixth day of life. Newborn screening for cystic fibrosis will be introduced using the Guthrie card. It is anticipated that the diagnosis of cystic fibrosis using this screening method can be made in approximately 90% of cases.

Neonatal Transport

Following recommendations in the Report of the Review of Acute Services (1998) the Working Group on the Transport of Critically Ill and Injured Children in Scotland considered the diverse arrangements around the country for neonatal transfer. This Group submitted its report on Neonatal Transport in Scotland in 2002. It concluded that the existing arrangements were unsustainable and under increasing pressure, due to factors including enhanced health and safety requirements, constraints on working hours and medical input, difficulties in recruitment and retention of specialist staff and changes to neonatal bed staffing ratios.

The SEHD accepted the report's findings and Ministers asked three Regional Service Planning Groups to implement recommendations in this report and to establish by April 2003 regional transport utilising the regional planning and commissioning framework set out in HDL (2002) 69. NSD will work with the relevant Trusts to ensure that robust interim arrangements are implemented.

The Health of Scotland's Children

In many ways, there has never been a better time to be born in Scotland. Infant mortality is at its lowest ever and life expectancy at its highest. Figure 3.8 shows that the number of children in Scotland dying before their first birthday has fallen from over 20 per thousand in 1971 to fewer than five per thousand today. Compared with the Scotland of even 30 years ago, the opportunities to live in a warm house, eat a healthy balanced diet and receive a good education have never been greater.

However, these headlines conceal some very uncomfortable realities, for there are large numbers of children in Scotland today who are not given the best start in life and for whom the chances of developing to their full potential are slim. Poverty continues to blight many children's lives, with over a quarter of Scottish children living in low-income households. It is much more difficult to provide these children with the safe, healthy, stimulating and supportive environment they need to develop to their full potential.

At present, about a quarter of Scottish babies are exposed to the toxins in cigarette smoke during pregnancy. Smoking is damaging to the baby and evidence is growing that maternal smoking during pregnancy can result in serious health and behavioural problems developing in later childhood and adulthood ^{10 11}.

Given the known damaging effects of alcohol on the fetus, the increase in the amount of heavy drinking by young women is also worrying. With the increase over the past 20 years in drug misuse, especially of heroin, tranquillisers and, more recently, cocaine, many fetuses are being exposed to these drugs and to drug injecting related viruses. The disruptive effect on parenting is another powerful reason for redoubling efforts to prevent drug and alcohol misuse.

The benefits of breast feeding are clearer than ever - protecting against childhood infections ¹², improving intelligence ¹³ and reducing the risk of childhood obesity ¹⁴. Breast feeding reduces the mother's risk of breast and ovarian cancer ^{15 16}. Despite this, in 2000, less than 50% of Scottish babies were breast fed at two weeks and only about 15% at nine months. Breast feeding rates are especially low among young mothers living in disadvantaged areas, with only about 10% of babies of teenage mothers in the most disadvantaged areas being breast fed at all ¹⁷ (Figure 3.9). Mothers who smoke are half as likely to breast feed, irrespective of their socio-economic circumstances.

Breast feeding is only one aspect of children's diet and nutrition where there is considerable room for improvement. The continuing high consumption of sweets, biscuits and sugary soft drinks, together with insufficient fluoride and poor oral hygiene, largely explains why so many Scottish children already have dental caries by the time they go to school - 65% in Greater Glasgow, for example ¹⁸.

There has been an increase in the number of children who are overweight. The proportion of Scottish 9-11 year old boys who are overweight rose from 5.4% in 1984 to 12.7% in 1994 and of girls from 9.9% to 16.7% ¹⁹ and the upward trend is continuing. Children who are overweight are more likely to remain overweight or become obese as adults, with serious consequences for their health. Already, a higher proportion of adults in Scotland are obese than in any other country in Western Europe ²⁰. Thus, there is a need not only to continue to improve the quality of the children's diet but also to address the quantities consumed.

It is also important that children are physically active and enjoy movement and active play. Concerns over safety, the attractions of the television and computer games and a decline in school sports have combined to create a more inactive generation, more likely to become overweight and develop heart disease, osteoporosis or other problems when they become adults. This trend must be reversed.

Immunisation

Immunisation has been one of the greatest public health successes, protecting millions of children from the scourge of infections such as smallpox and polio. In Scotland, rates of immunisation against diphtheria, polio and whooping cough remain at over 95%. However, parental questions about the Measles, Mumps and Rubella (MMR) vaccine have led to a fall in the uptake ²¹. In 2002, the publication of the report of the MMR Expert Group and the Executive's commitment to providing parents with the factual information they need about MMR, contributed to ongoing efforts to build public confidence in MMR. The common goal is to ensure that children in Scotland are protected against these serious infections.

Vaccine uptake rates

Over 96% of children aged 24 months in the first three quarters of 2002 had received three doses of vaccines against diphtheria (D3), tetanus (T3), pertussis (P3), polio (Pol3) and Haemophilus influenzae type b (Hib3) (Figure 3.10). The uptake of meningococcal serogroup C (MenC) vaccine, introduced in 1999-2000, was over 95% in the same age group. The uptake of Measles, Mumps and Rubella (MMR) vaccine was lower at 87.3%-88.6%, but the figures for Scotland continue to compare favourably with those for elsewhere in the UK (Figure 3.11). Pre-school vaccination uptake rates indicate that around 95% of children received fourth doses of diphtheria, tetanus and polio vaccines by their sixth birthday and over 90% received a second dose of MMR.

Disease Epidemiology

There were no reports of diphtheria or poliomyelitis in Scotland in 2002, continuing to represent long term successes in immunisation. There were two notifications of tetanus in young adults, with unclear vaccine histories, who were admitted to infectious disease units. This emphasises the need for vaccination, as the presence of the organism, Clostridium tetani, in soil makes eradication impossible. The number of notifications for whooping cough (pertussis) has remained almost unchanged, although the number of laboratory reports has increased slightly (Table 3.7). An acellular pertussis booster for pre-school children was introduced into the routine childhood immunisation schedule from January 2002, as there is evidence that infants too young to be protected through immunisation may be catching the disease from older siblings, or possibly parents.

The number of notifications for measles, mumps and rubella increased in 2002 (Table 3.7). However, it must be emphasised that notification is on the basis of clinical suspicion and may not be taken as a sufficiently accurate measure of the true number of cases occurring. The high level of publicity has contributed to the increase through awareness and levels of reporting. There were four laboratory reports for measles, all of which were linked to virus imported from other countries. There were 64 laboratory reports for mumps, 81% of which were from Dumfries and Galloway. Ages indicate that most (88%) of the cases were born before 1983 and therefore too old to have been offered MMR vaccine. There have been similar mumps outbreaks in teenagers and young adults in other parts of the UK. There were seven laboratory reports of rubella, all in adults (five men and two women).

Twenty-four laboratory reports were received for invasive Haemophilus influenzae type b (Hib) disease in 2002 (Table 3.7). The continued increase in cases is reflected throughout the UK and is under investigation, through collaboration in enhanced surveillance.

Table 3.7: Vaccine preventable disease: notifications and laboratory reports, Scotland, 2001 and 2002

While the childhood diseases and malnutrition of the past are all but conquered, creating a Scotland in which every child has the best possible start in life remains an immense challenge, but one surely deserving of effort.

Child Health Support Group

The Minister for Health and Community Care established the Child Health Support Group (CHSG) in 2000 to improve child health, provide expert advice to Ministers and support NHSScotland to strengthen child health and health services.

In its first two years, the CHSG has successfully raised the profile and priority of child health services locally and nationally and has played a crucial part in sharing expertise and advice about best practice across the country. The Group has comprehensive information about child health services in Scotland and has developed a national template for Child Health Services now being used by NHS Boards to plan and commission their services.

The Group has revised its remit and workplan for the next two years and identified five areas for development:

• Promoting social justice through better integrated and high quality services for children

• Supporting regional planning groups in reviewing specialist paediatric services

• Promoting high quality community based child health services, including work with NHS QIS to develop standards for child health

• Championing and developing child and adolescent mental health services

• Promoting the Patient Focus, Public Involvement agenda for children and young people in NHSScotland

References

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