Mike Nesbitt
Strangford · Ulster Unionist Party · Northern Ireland
“Think public service, wisdom, generosity and courtesy. Think integrity, insight and curiosity, the lack of which is a key criticism of the two public inquiry reports of recent days.”
“I spoke during Members' statements earlier about the untimely passing of the Western Trust's chair, Dr Tom Frawley CBE. I repeat my condolences to his family, his friends and his many admirers.”
“I absolutely share the Member's ambition to see people living in the community. The trusts provide a range of evidence-informed programmes for individuals who are awaiting assessment. For children and young people, early intervention teams deliver proactive needs-led programmes that are neurodiversity-affirming and trauma-informed.”
“Thank you, Mr Speaker. The Western Trust has assured me that it has undertaken a comprehensive early engagement exercise with stakeholders, involving all political parties, local businesses, service users, community groups, the Patient and Client Council (PCC), local media, community planning partners and Departments, including mine and D…”
“The role played by social workers in delivering safeguarding and family support interventions is complex and challenging. The work frequently pivots on multidisciplinary collaboration, with parents and carers positioned as partners in the formulation and delivery of safeguarding and support plans.”
“I fully recognise the impact of the current delays on individuals and families. The situation has arisen due to a combination of factors, including funding that falls short of objectively assessed need and previously missed opportunities to reform health and social care delivery.”
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“Again, perhaps there are two things. I apologise if Committee members feel that they were not given early enough sight of the report. However, I do not see this being the be-all and end-all of the discussion. I would welcome the Committee's taking a detailed look at the Renfrew recommendations. As regards implementation, I can assure the Member that Professor Renfrew, whom I met this week, is an impressive expert in the field. There is no point commissioning a report if you do not look closely at its recommendations. Basically, with the couple of exceptions that I mentioned, we accept those recommendations. It is an incredibly important area. Members are aware of the genesis of commissioning that report. We have got to get this right. I am not going to sit and just ignore those recommendations. I want the best possible service.”
“<BR /> <BR />The second point is that, yes, the Member can say that we cannot just say that it is all a problem for the Southern Trust, but the fact of the matter is that, if the Southern Trust chooses to make a decision and call it a "temporary decision", I cannot stop it. I can tell the trust that I do not like it, and I can express my displeasure, but it is entirely in the trust's gift, if it is a temporary measure, to make that move.”
“I thank the Member for her question. There are two aspects to the answer. What can we do? We have to talk, because we have to understand why the Southern Trust is in the situation that it is in. We need to understand what it intends to do about it. Once we understand the issues — I understand them to relate specifically to the workforce — we have to then question whether the Southern Trust can rearrange its workforce in a way that meets the demand and cures the problem. If not, can we look elsewhere? Are there other trusts or areas that we can look to to, as it were, fill that gap?”
“It should never be as a result of service collapse, and I do not want to see service collapse with regard to Daisy Hill and maternity services. Meetings continue at the highest level this week to look at the available options to resolve those issues, but I hope that the Member gets the sense that I am not happy.”
“I thank the Chair of the Committee. I will, if I may, focus on Daisy Hill and the issues within the Southern Trust, because those are the most pressing ones. From my point of view, the Southern Trust was late in alerting the Department — certainly, in alerting me — to the current issues. It has never been my intention that Daisy Hill would not deliver maternity services, so it is not part of any plan. The Member knows that I have published a paper about viewing our hospitals as a network to deliver better outcomes, which is a kind of preview of the idea that we may need to reconfigure and that not every hospital will deliver every service. However, I again emphasise that Daisy Hill should be offering maternity services. Furthermore, any reconfiguration must be planned and managed.”
“Yes, we need buildings, equipment and medicines, but there is nothing without the workforce, and I am very much focused, with senior colleagues, on ensuring that we improve the retention and, indeed, the recruitment of staff, including midwives.”
“I thank the Member for his comments. On his question, as recently as yesterday, I had a meeting with a large number of officials — we are talking about not just midwifery but nursing and allied health professionals; the gamut of healthcare delivery sections — and they have gone away to see how we can improve the recruitment, the training and, particularly, the retention of staff. <BR /> <BR />I cannot be specific, but I can tell you that it is very much on not only my agenda but the agendas of many senior officials in the Department. Funding is a big issue, but I have always said that the budget is not the be-all and end-all of healthcare delivery, and the workforce is vital.”
“Finally, I can assure you that improving services for pregnant women and new mothers and babies is and will continue to be an immediate priority for me and my Department. I trust that the information that I have provided to Members today in the statement gives some assurance of the priority that I am giving to the issue.”
“I am determined to ensure that all midwifery services and care in Northern Ireland are safe, respectful and compassionate, and that women and their families feel heard, valued and supported.”
“I see this as being a high priority and would like to see the partnership established as soon as possible. <BR /> <BR />I agree with Professor Renfrew that how we care for women and babies is a measure of our society and that pregnancy, birth and the early weeks of life are fundamentally important for each woman, baby and family. At the heart of this matter is the clear message that we must listen to women. I have listened: I hear them, and I agree that improvement is needed. The birthing process is a vulnerable and intimate time for women, babies and their families. It is essential that they are provided with safe, respectful, kind, evidence-informed, multidisciplinary and individualised care across the continuum and in all settings.”
“It will incorporate the work and functions of the existing maternity quality improvement collaborative, which is a facilitated group of clinicians from across the region that is largely focused on regional agreement on protocols and clinical issues, and the clinical groups of the neonatal network. The programme board will draw membership from senior officials from my Department, the Public Health Agency and the health and social care trusts. Final proposals for the partnership and programme board are being developed. Members will appreciate that there will be a funding requirement associated with that and with the implementation of the consolidated regional action plan, and I hope that my Executive colleagues will be supportive of that.”
“<BR /> <BR />Given the fact that there are interdependencies between maternity and neonatal services, I will establish an interdisciplinary maternity and neonatal partnership with a programme board governance structure to lead the development, implementation and oversight of evidence-based, safe and quality maternity and newborn care and services in order to maximise the contribution of those services to maternal and newborn health. That will also include the implementation of a consolidated regional action plan. <BR /> <BR />The partnership will include representation from my Department, the Public Health Agency (PHA), health and social care trusts, primary care and service users.”
“<BR /> <BR />All the work that I have outlined will form part of a consolidated regional action plan, which will be fundamental to improving maternity and neonatal services and outcomes for mothers, babies and their families in Northern Ireland. It will also help to inform the future strategic direction for maternity and neonatal services. It is important that the challenges facing maternity and neonatal services and the implementation of the consolidated regional action plan are approached collaboratively across the region, ensuring, as far as possible, that care is consistent and equitable no matter where it is accessed.”
“<BR /> <BR />My Department has endorsed the National Institute for Health and Care Excellence (NICE) guidance on caesarean sections, which describes the benefits and risks associated with caesarean birth and vaginal birth and provides guidance on the care of women and babies before, during and after caesarean births. Health professionals have a professional and legal duty to discuss the benefits and risks of different care options with women, taking into account their individual circumstances, concerns, priorities and plans for future pregnancies, and they should support women's decisions on how they would like their baby to be born.”
“Midwives have a critical contribution to make to both of those priorities. <BR /> <BR />Professor Renfrew's report highlights the increase in caesarean births in every part of the United Kingdom and Ireland over the past 10 years and the fact that those rates are out of step with similar countries internationally. The reasons for the increase may include a number of factors, such as an increase in the number of complex pregnancies due to a range of factors, including older maternal age and underlying health conditions, as well as maternal choice. While the rate of caesarean births has increased, it is in line with other UK countries. The priority must remain to provide the most appropriate care for mothers and their babies, taking account of their individual needs and personal choice.”
“More than half of pregnant women require specialist care during pregnancy or delivery, or following the birth, and one in 10 newborns also requires specialist care, which is provided by a range of professionals who work as a multidisciplinary team. The proportion of women requiring specialist care has increased significantly over the past 10 years. For example, around one in eight pregnant women in Northern Ireland now has some type of diabetes, and one in 20 has high blood pressure. That means that women require specialist care from multidisciplinary teams. Other health inequalities also have a major impact on pregnancy outcomes, so it is essential that we continue to prioritise initiatives that not only enhance the quality of care at all levels but address health inequalities across Northern Ireland.”
“I recognise, however, that, in recent years, the wider system has struggled to refresh and transform services at the pace required to enable them to cope with the changing needs of pregnant women. As a result, many staff members have experienced exhaustion and burnout, and they must be better supported in that vital role. <BR /> <BR />While birth rates in Northern Ireland and the rest of the United Kingdom have fallen in recent years, maternity care has become more complex, with an increasing proportion of women having health problems, which increases the risk of adverse events for them and their babies.”
“It is important to recognise that, while the vast majority of women will have a safe birth and a positive experience, many of those who contributed to the report did not. We must acknowledge the failings that the report has highlighted in many areas and be clear that there must be improvement and a prioritisation of those services. Caring for women and babies must be a top priority for our future. It is, after all, one service that each and every one of us requires. <BR /> <BR />With the support of dedicated maternity professionals, pregnancy and childbirth is a relatively uncomplicated process for most. Northern Ireland has key strengths in its maternity services. It has a skilled and dedicated workforce that is committed to providing high-quality care.”
“There are, however, no plans to resume births at the three units at present. Before any community midwifery hubs offer facilities for labour and birth, all essential requirements outlined in the report must be met. The immediate focus must be on the stability of maternity and neonatal services. The future configuration will need to consider the key requirements outlined by Professor Renfrew, the wider health and social care population needs, demographic trends and system capacity. <BR /> <BR />I am conscious that the content and findings of the report may be met with elements of concern about the safety of maternity services in Northern Ireland, particularly for pregnant women and those who are planning a pregnancy.”
“The eight requirements seek to reconfigure and transform that service model. <BR /> <BR />In addition, Professor Renfrew states that at least one community midwifery hub should be available in all HSC trusts and that the sites of the free-standing midwifery-led units should be developed and reconfigured as community midwifery hubs in a phased programme to ensure safe, quality care for all. I believe that it would be premature at this point to make decisions on the future of the free-standing midwifery-led units transitioning to community midwifery units or on the recommendation that one should be available in each trust area. <BR /> <BR />In the meantime, antenatal care will continue to be provided at Lagan Valley Hospital, Downe Hospital and the Mater Hospital, taking into consideration Professor Renfrew's eight requirements.”
“Professor Renfrew advocates a rethink on how we provide those care options for the women of Northern Ireland, and he outlines eight key requirements that need to be met for those options to be safely provided. Those key requirements provide a framework to strengthen and connect the whole maternity system. <BR /> <BR />The evidence, coupled with the feedback that Professor Renfrew heard from the women and staff whom she engaged with, is that safe, quality care for all women and babies requires Northern Ireland to ensure that community and hospital options for care and pregnancy, birth and the postnatal period are available. The report recognises that the old model of service delivery and the terminology used created the potential for free-standing midwifery-led units to become disconnected from the maternity service.”
“At this time, I am unable to commit to part of the fourth recommendation, which is that service users and advocates should receive remuneration for the time that they spend participating in stakeholder and engagement events. While the feedback that was provided by service users and advocates is invaluable, I am unable to commit to payments under that recommendation at this time. There is a policy in place, however, to provide reimbursement to service users and advocates for issues such as travel expenses, subsistence and childcare where appropriate. <BR /> <BR />One recommendation that I have partially accepted in principle refers to the future of free-standing midwifery-led units. I want to explain this point very carefully. It is important that women have safe options to give birth outside of labour wards, if that is their preference.”
“Whilst it is recognised that some of the actions required to address the critical priorities will require regional coordination, trusts have already been asked to take immediate action in a number of areas to address those critical priorities. <BR /> <BR />Having considered Professor Renfrew's report and the assessment carried out by my officials, I have accepted the report in principle, with caveats on some recommendations that will present particular implementation and funding challenges and will need further consideration. However, the recommendations in the professor's report provide us with an opportunity to strengthen and improve maternity services for women and babies and for the dedicated staff who provide the services.”
“That is about ensuring that women receive adequate pain relief and essential care for themselves and their babies. <BR /> <BR />The second is improving:”
“The report identifies three issues as critical priorities. The first is improving:”
“That includes ensuring that midwives are represented at senior management levels, tackling silo working and developing an open learning culture at every level of the system. <BR /> <BR />It recommends:”
“that ensures respectful, personalised care and genuine involvement. <BR /> <BR />Next, it advocates:”
“<BR /> <BR />The report contains 32 detailed recommendations that are aligned to seven interrelated key conditions. Those conditions are themed under five areas: safe quality care in midwifery units and at home for home births; regional strategic developments; safe quality care and services in all settings; monitoring and review of information and data; and building for the future. <BR /> <BR />In summary, the report advocates:”
“I also recognise that Professor Renfrew's engagement identified a level of adverse experiences reported by some women and families, as well as stress and distress being reported by all staff groups who participated in the review, especially midwives. It is important to acknowledge that the number of individuals engaged with during those events represents a small proportion of the overall maternity population in Northern Ireland. The number of women engaged with represents 0·5% of the total number of women who gave birth in 2023. The number of midwifery staff represents around 10% of the total number that were recorded in March 2023. Nevertheless, the messages were clear and consistent from those women and staff. The system must, and will, listen to their concerns.”
“Professor Renfrew is clear that our maternity and neonatal staff are committed and determined to provide the best care that they can. In her report, there are examples of good-quality care across Northern Ireland, including: the appointment of a consultant midwife in each health and social care trust and the roll-out of a new model of care; continuity of midwifery care, which means that women receive support from the same midwifery team during and after pregnancy; and the establishment of a weekly, multidisciplinary clinic in the Western Health and Social Care Trust to enable teamwork in the development of individualised pathways for pregnant women who experience gestational diabetes.”
“<BR /> <BR />My Department received the final report during the summer and has had the opportunity to consider it fully. It will be available to view on my Department's website from today.”
“In developing her report, Professor Renfrew and her secretariat team carried out extensive and widespread engagement with maternity service users and advocates, holding face-to-face and virtual listening events with women, families and professionals across Northern Ireland. I am incredibly grateful to the professor for undertaking the review, which assists the Department in strengthening midwifery services and care across Northern Ireland. I acknowledge the effort of all the participants who contributed to the report — those with professional and expert input and, particularly, the women and families who were willing to share their own experiences, no matter how difficult or traumatic, to assist change and provide improvement in our maternity services.”
“To address the issues identified by the coroner in April 2023, my Chief Nursing Officer commissioned Professor Mary Renfrew, an independent expert in the field of midwifery with professional experience outside Northern Ireland, to carry out a comprehensive and independent review that would help inform a consistent approach to the provision of midwifery services throughout Northern Ireland. The terms of reference for the review were based on the areas identified by the coroner that I mentioned. The broad scope led Professor Renfrew to undertake a comprehensive review of midwifery services and care in Northern Ireland, including all its interdependencies within the overall maternity service. That included a review of the evidence base and models of care across the region and internationally.”
“<BR /> <BR />Regarding midwifery services, the oversight group established a work stream to consider issues highlighted in the coroner's report, which recommended that the Department should:”
“The Department accepted the report's recommendations in principle, with the caveat that the implementation and timescales may differ from those suggested by the RQIA due to the need for additional funding and the ongoing work on maternity and neonatal safety. <BR /> <BR />Other areas of work ongoing include reviewing progress with the implementation of relevant National Institute for Health and Care Excellence (NICE) guidance and developing a gap analysis of the implementation of all relevant reports and recommendations that have been endorsed by my Department. Although work is ongoing and improvements are required, it is important to say that, to date, no material safety concerns have been identified in that suite of work.”
“That group is made up of senior officials from my Department and the Public Health Agency (PHA). A broad programme of work is ongoing, with an immediate focus on improving governance and safety across maternity and neonatal services. The programme includes a comprehensive independent review of midwifery services led by Professor Mary Renfrew that I will come to shortly. <BR /> <BR />My Department also asked the Regulation and Quality Improvement Authority (RQIA) to carry out a review of the governance arrangements in place to support safety in maternity services in Northern Ireland. That report was published in May of last year. The RQIA report made 23 recommendations to strengthen the governance, systems and processes that support the delivery of safe, effective care in maternity services across Northern Ireland.”
“As you will be aware, concerns about the safety of maternity services across other parts of the United Kingdom have come to light in recent years. In November 2022, the coroner for Northern Ireland contacted my Department with concerns around her findings following an inquest into the death of a baby who was stillborn after being transferred from a free-standing midwifery-led unit to a consultant-led maternity unit. As I deliver the statement, my thoughts turn to the family of the baby who tragically died. My condolences go out to them and to all those affected by such a tragic loss. <BR /> <BR />In light of the concerns, my Department established a maternity and neonatal services safety oversight group in January 2023 to receive assurance on the safety of maternity and neonatal services for the population of Northern Ireland.”
“Maternity staff work closely with women to enable them to make an informed choice about where to have their baby. For babies who, unfortunately, require additional support at birth, that is provided by one of the neonatal units around the region, which are all aligned with the seven maternity units. Those units take care of some of the most vulnerable members of our society. My Department has been overseeing a major programme of work on improving maternity and neonatal safety, and I will now update Members on that.”
“I must acknowledge that services have needed to adapt and change over recent years. The impact of COVID-19 meant a downturn and new ways of working for some services. I recognise that that was a difficult time for everybody involved: expectant mothers, their partners and maternity staff. However, having emerged from that difficult period, we now have an opportunity to rebuild and transform service delivery to adapt to current demands, with a new focus to improve maternity and neonatal services. <BR /> <BR />Women in Northern Ireland can give birth in one of the seven consultant-led maternity units staffed by midwives, doctors and other members of the multidisciplinary team; in an alongside midwifery-led unit; or at home, supported by midwives.”
“However, I also recognise that, for some, that is not the case. Whilst, unfortunately, some situations are outside our control, we must do all that we can to make sure that maternity and neonatal services provide the best care. Therefore, improving maternity and neonatal services is an immediate concern for me and for my Department. <BR /> <BR />Maternity and neonatal services are made up of various areas that work together to provide support to women during pregnancy and in the early months after birth. They include community midwives, antenatal clinics, multidisciplinary teams (MDTs) in consultant-led maternity units, midwifery-led units and post-partum support such as health visitors, community midwives and GPs, as well as hospital neonatal units that care for sick babies.”
“Mr Deputy Speaker, given the nature of the subject matter, with your indulgence, I suspect that the statement may exceed the normal duration. <BR /> <BR />I welcome the opportunity to update Members on maternity and neonatal services, including the report by Professor Mary Renfrew entitled 'Enabling Safe Quality Midwifery Services and Care in Northern Ireland'. <BR /> <BR />Pregnancy is, of course, a normal life event. For some, it can be a more challenging experience, but it is mostly a time of joy and new beginnings. The vast majority of women have a safe birth and get to go home with their healthy baby or babies. I acknowledge and thank the staff across our health service in hospitals, GP surgeries and communities who make that possible every day through their dedication to pregnant women and babies, often in challenging circumstances.”
“<BR /> <BR />My Department will set out an ambitious body of work to address the challenges faced by children and adults with learning disabilities, enjoined through a revised approach to transitions. A point was made about police intervention and how inappropriate that was. It seems to me that that reflects the fact that, sometimes, when we have a really difficult challenge, we go for the easy solution, not the right solution. I assure the House that I want to be in the business of right solutions.”
“<BR /> <BR />My Department fully recognises the scale of the challenge in services for people with learning difficulties. It is further recognised that several challenges that have been identified are long-standing and cannot be viewed in isolation. To put it into context, we need three things: the infrastructure, properties and places where residential and respite care can be offered; the funds to run it; and a workforce that is appropriately trained and committed. At least two of those things — the infrastructure and the workforce — cannot be magicked up overnight. The funding in the middle is an enormous challenge, but it is one that, I am happy to say, departmental officials have risen to at pace. I commend them for that.”
“However, the recent BBC 'Spotlight' programme on short breaks has helped to focus minds and outline an immediate body of work that will be progressed in the days and weeks, rather than the months and years, ahead. <BR /> <BR />This week, I will meet the families involved in the programme, with the support of the Children's Law Centre and the National Autistic Society. I have been presented with a series of costed options on the way forward. As Ms McAllister alluded to, that is something that I was expecting last week and got. I have spent significant time considering those options in the intervening days. I can tell the Member and the House that, depending on the outcome of one more meeting, which is tomorrow, I shall make my announcement.”
“<BR /> <BR />In summary, the service model outlines my Department's vision to recalibrate services and better support unpaid carers while providing the building blocks for robust forward planning. It is my hope that we will launch a public consultation in the coming months. <BR /> <BR />While the motion focuses primarily on adult services — it would be expanded by amendment to include children — it would be remiss not to provide an update on short breaks for children. As part of the exercise commenced in 2023, significant work has been progressed to outline the way forward for Health and Social Care services. A framework for children with disabilities has been developed and is being implemented. Improvements across services will require years of sustained investment and workforce development.”
“Earlier this month, Professor Bengoa and I visited a Shared Lives service delivered by Positive Futures. It is an example of a different type of short break, where members of the public can be trained and supported to provide day breaks and overnight stays for adults with a learning disability. Self-directed support also provides flexibility to families, but I am aware that the administrative burden can be excessive. In September, my Department, in collaboration with Impact and the Association for Real Change, appointed a regional post to expand the use of managed budgets. That represents a better way to provide families with choice and control, with the administrative burden resting on the trusts. Both Shared Lives and managed budgets are central to how we will diversify and expand respite and family support in the years ahead.”
“That will involve increasing the level and diversity of short-break services, with consideration being given to modernising existing services and environments to better support those with more complex needs. The model will be underpinned by a robust regional needs assessment, ensuring that the level of residential short breaks reflects the population size, living arrangements and needs of carers and families. It is clear that the level of that service will need to increase, but we also need to diversify the breaks provided.”
“<BR /> <BR />In Health and Social Care, the learning disability service model aims to produce a regionally consistent service for adults, with an emphasis on supporting need at an early stage in the community. The model aims to ensure that the needs and views of families and carers are fully understood and that accessible support is available. It will ensure that families and carers will be offered the flexible, practical and emotional support that they need to support individuals to live in the community and have a meaningful life.”
“That thread is critical to ensuring that adult services can appropriately forward-plan for children who are entering adult services in the future. <BR /> <BR />On transitions for people with learning disabilities, I take this opportunity to pay tribute to the efforts of Alma White, the lead campaigner for Caleb's Cause Northern Ireland. I met Alma recently and was moved by her enthusiasm and the energy that she brings to improving transitional support for her son and for other children with special educational needs. I have committed my support to Alma and to working with the Department for the Economy as it explores options for legislative change. While we need to be mindful of what can be achieved in the remainder of this mandate, we should not be deterred from exploring opportunities to deliver better outcomes.”
“It is important to note that that is not a criticism of the staff delivering the services. I fully recognise their hard work and dedication. Since the first day of my appointment, I have visited several learning disability services delivered by trusts and the independent sector. Each time, I have been amazed at what can be achieved through creativity, innovation and hard work. <BR /> <BR />It is important to give Members a brief update on the work of the learning disability strategic plan. In March last year, the Department established a task-and-finish group to finalise a service model for adult learning disabilities and a framework for children with disabilities. The golden thread to progressing those products is a renewed and regionally consistent approach to transitions.”