Douglas Noble on maternity care

douglas nobleFive days in hospital for the delivery of our first child was a sobering reminder of the harsh realities of life (our newborn had a post-natal stay on ITU), the inner workings of the NHS system, and on several occasions a personal reminder of just how far we still have to go to realise high quality care. 

It’s the little things that get to you.  Almost universally no-one introduces themselves; they could be anyone, and in fact on one occasion a member of staff, rather than introducing themselves, declared, “It’s okay. I’m not just off the street. I work here.” Phew. 

Several times I noticed a phenomenon I’d always been aware of, but never quite managed to reconcile.  Indicate patient preference for one course of action and the clinical picture and results are spun to fit that scenario. We did finally see a consultant (after 36 hours, argh…) who was, unfortunately, floored by a question about comparing relative risks of different management plans. 

As evidence-based medicine lay on the floor weeping, I resorted to continuously sampling the doctors with a straightforward survey of one unvalidated question: “What would you do if it was your wife and baby?” The straw poll was successful and correlation of agreement was generally good.  Management was then based on the expert consensus, with a notable vested personal interest, but one I was willing to accept. 

There were some bastions of hope. After we noticed one cleaner in particular, who seemed to spare no amount of elbow grease, she declared resolutely to us that she cleaned every bed and ward because, “I’m saving babies’ lives.”  Enlightened!  And it wasn’t just the auxiliary staff. One consultant watching me coming back to the bedside, having seen me put something in the clinical waste bin, insisted I washed my hands. He kept his eyes on me like a hawk until he had seen the liquid soap ooze from the dispenser.  Commitment to hygiene was reassuring, if somewhat creepy. 

One of the most frustrating aspects of the NHS is the variation in levels of care. One parent experiences a world class service, whilst others struggle to see a consultant promptly as an in-patient. A report from the National Childbirth Trust this week on a survey of almost 1300 new mothers revealed that approximately 50% did not get the quality of service they needed. It’s this variation that presents one of the largest challenges in reforming NHS services. Although the system described in the recent White Paper has the potential to raise the standard of care overall, it also risks exacerbating the gap between best and worst. Strenuous efforts need to be made not just to improve quality of care, but to reduce these inequalities.

Douglas Noble has worked in surgery, emergency medicine, public health and for the WHO . From 2006 to 2008 he was clinical adviser to the chief medical officer for England.