I was very pleased to have the opportunity at the 9 May iHV conference to present the broad findings of the World Breastfeeding Trends Initiative (WBTi) 2016 UK assessment of the state of support for breastfeeding, using the metaphor of a river. The WBTi UK Steering Group is keen to raise awareness of its 2016 report so that the findings can be used locally and nationally for change. National Breastfeeding Celebration Week provides an opportunity to be proud of what has been achieved but it is also important to be mindful of what still needs improving in supporting and protecting breastfeeding.
Any efforts to improve a situation require a thorough assessment of the current situation first. A WBTi assessment considers ten policy and programme indicators, drawn from the 2003 WHO Global Strategy on Infant and Young Child Feeding. Each indicator is scored on how well it is implemented, and gaps and recommendations are identified. The Steering Group collaborates with a core group of representatives of relevant organisations, such as professional organisations, charities and government departments, to achieve consensus on the various elements of the report. Nearly 100 countries have carried out this process so far.
UK score out of 10
National policy, programme and coordination
Baby Friendly Initiative
Implementation of the International Code of Marketing of Breastmilk Substitutes
Healthcare systems (primarily health professional training)
Infant feeding and HIV
Infant feeding during emergencies
Monitoring and evaluation system
In the metaphor, the mother’s breastfeeding journey is represented by stepping stones across the river. The stepping stones stand for the people who provide the mother with direct support, such as family and friends, midwives, maternity support workers, health visitors, peer supporters, breastfeeding counsellors, and lactation consultants. The Health Visitor’s role is crucial as the service is universal and she can both signpost as well as give direct support.
The river itself is the flow of intermingling influences on the mother’s infant feeding decisions – these start in her infancy at the head of the river and include the later factors categorised as the WBTi indicators. A dam represents the legal protections – in the UK these include protection from formula advertising for babies under 6 months (Indicator 3) and maternity leave and protected breastfeeding/ expressing rights at work (Indicator 5).
The riverbanks represent other Indicators, such as the extent of national leadership (Indicator 1), health professional training (Indicator 5) and data collection on breastfeeding rates (Indicator 10). A weak riverbank that looks stable is particularly risky and is like a trusted health professional with inadequate knowledge and skills.
Strengthening the dam and riverbanks would mean that the mother is much less likely to be knocked off the stepping stones, so much more likely to achieve her breastfeeding goals. To have greatest impact, there needs to be concurrent improvement on the different Indicators, otherwise there will still be too great a flow of negative influences over the stepping stones.
Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.
Today is International Women’s Day, which was first held in 1911. The idea had been proposed at the second International Conference of Working Women, held in Copenhagen in 1910. The Day symbolises the struggle for equality, particularly in the workplace, but is also an opportunity to celebrate women’s achievements. You can read more about its history here: https://www.internationalwomensday.com/About
The theme this year is #BalanceforBetter, summarising that a better world has a better gender balance. While considerable progress has been made (for example, it was only in 1948 that women at Cambridge were given formal recognition of their degrees, and the percentage of girls in primary school in the world has risen from 65% in 1970 to 90% in 2015*), there is still a gender pay gap and women are in the minority in business and politics.
Balance requires removing conscious and unconscious bias about people; bias that results from assumptions being made about their capabilities. Alongside removing bias there needs to be support to meet specific needs individuals may have so that opportunities really are accessible – practical support includes items such as ramps and particular computer software. Thus, on the one hand, it’s essential not to assume differences that don’t exist so that women, men and intersex people of equal merit have equal opportunities.
On the other hand, it is important to respect real differences such as biological differences. Female employees who are breastfeeding need breaks for expressing or feeding, a suitable place to do that and facilities such as a fridge for storing expressed milk. If those were a legal requirement in the UK employers would be expected to provide them. Indicator 4 of the World Breastfeeding Trends Initiative is about maternity protection and the 2016 UK report assessed how well the UK is doing and made recommendations.
The media have been reporting today on the lack of legal protection in the UK for women to express milk or breastfeed when back at work. This is one of the reasons women cited for stopping breastfeeding in the U.K. National Infant Feeding Survey.
Media coverage of WBTi’s findings on gaps in Maternity Protection in the UK
The media seized upon our findings on the lack of maternity protection, in particular the lack of any statutory rights for mothers to breastfeed or express milk at work. There are resources to support employed mothers, and resources to guide best practice for employers (from Maternity Action and from ACAS), but mothers have no rights in law beyond basic health and safety.
Valentine’s Day saw the launch of the Medway ‘ Grow My Brain’ campaign at the Medway Maritime Hospital, which I was fortunate to attend. Hospital midwives, health visitors, public health commissioners, local authority councillors and members of the press also attended. Dot Smith, the Head of Midwifery opened the launch by explaining how this campaign is aimed at helping parents interact with their unborn children from conception into early childhood. She said that Jo Maynard, the Infant Feeding Co-ordinator at the hospital had the initial idea and was supported by her colleague, Trude Mc Claren, Midwifery Lead in the Birth Centre, to draw the images. Jo then explained that although midwives have been talking to parents about brain development for some time, these messages are often not remembered when parents are asked about them in audits. Scott Elliott, Head of Health and Wellbeing Services, Public Health, Medway Council described how local users were consulted through focus groups, which were often of men, on their views of the animations and images. Jo explained that simple interactions with the baby inside and outside the womb stimulates the hormone oxytocin in both the parents and the babies, which helps bonding with the baby and feelings of calmness, stimulating cell connections in the baby’s brain. The aim of the campaign is to reinforce these messages and make them relevant to parents and families so they feel able to interact with their small children, build relationships and help their brains develop.
The materials were released today on the ‘A Better Medway’ website and consist of six 20 second film clips, showing parents how they can interact with their unborn and new born babies in the first 1,000 critical days after conception. This vital time in a baby’s brain development is when emotions such as love and trust develop and may impact on the child’s future personality, educational achievements, future physical and mental health and job prospects. Each film begins with a child’s voice, still in the womb saying ‘grow my brain’ and what parents can do to relate to the unborn baby then there is a ‘pop’ (the birth!) followed by a message about different activities that parents, grandparents, siblings and others can do to help this happen. The messages of ‘love’, ‘talk’, ‘play’, ‘keep me close’, ‘sing to me’, ‘read to me’, and ‘dance with me’ are demonstrated in the animations in the films, on posters and stickers.
The plan is to promote the films to families through every health professional contact, when stickers can be put on notes, through Social Media and to have planned spikes in marketing at key times such as National Book Day for the ‘Read to me’ and Strictly Come Dancing for the ‘Dance with me’! Scott suggested that success of the campaign will be realised by the volume of social media posts, coverage by the media, numbers of staff trained breastfeeding audits, case studies especially dad’s stories on the website and the Medway Citizens’ Panel feedback.
This inspiring, novel campaign could have a far-reaching impact on building warm, close relationships between children and their families. This could optimise the brain development of the future generation of Medway and improve its future physical and mental health.
Just as a partridge can find support and protection in the branches of a pear tree, each breastfeeding dyad needs a society that provides a supportive structure; to achieve this needs coordination at national level through having a national policy, a strategic plan and effective implementation of that plan (WBTi Indicator 1).
Jeremy Hunt, when Secretary of State for Health, declared that
“The government is implementing the vision set out in the WBTi UK report. The Maternity Transformation Programme seeks to achieve the vision set out in the report by bringing together a wide range of organisations to work in nine areas… this includes promoting the benefits of breastfeeding by
Providing national leadership for breastfeeding celebration week;
Publishing breastfeeding initiation data;
Publishing breastfeeding profiles; and
Improving the quality of data on breastfeeding prevalence at 6-8 weeks after birth.”
A national assessment of UK breastfeeding policies and programmes, “Becoming Breastfeeding Friendly,” has now begun across England, Scotland, and Wales, led by the national governments and public health agencies and the University of Kent. Importantly, this initiative requires government commitment to implementing the resulting recommendations.
Another positive development since the WBTi report in 2016 is that in April 2018 Public Health England created a one-year Midwifery Adviser post for a seconded health professional whose responsibilities include breastfeeding, funded by the National Maternity Transformation Programme.
Day 2 – two turtle doves
This fits very well with Indicator 2 as it assesses the extent to which maternity-related services are Baby-Friendly accredited and the standards support loving relationships. Since the WBTi report, percentages of UK accreditations have increased as follows (2016 figure in brackets):
maternity services 62% (58%)
health visiting services 67% (62%)
universities: 43% (36%) midwifery and 17% (15%) of health visiting courses
childrens’ centres 16 (0)
neonatal units 6 (0)
Births taking place in fully accredited hospitals:
The WBTi recommendations call for “implementation and maintenance of Baby Friendly standards in all healthcare settings” in England and Wales. New maternity plans in December 2018 from the Department for Health and Social Care include “asking all maternity services to deliver an accredited, evidence-based infant feeding programme in 2019 to 2020, such as the UNICEF Baby Friendly initiative.” We would urge the government to extend the expectation of Unicef Baby Friendly accreditation as a minimum in community settings and Health Visiting Services, in neonatal units, and in midwifery and health visitor training programmes.
Day 3 – three French hens
The French hens are believed to symbolise the virtues of faith, hope and charity. Indicator 3 assesses the extent of implementation of the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolutions. There is faith, that incorporating the Code and resolutions in a country’s laws improves protection for all babies from commercial interests, as the experiences of individual countries like Brazil shows. There is hope that the Code and Resolutions will one day be implemented in UK law. Charity includes helping the vulnerable, such as babies.
Relatively recent changes include the World Health Assembly passing resolution 69.9 in May 2016, welcoming the new World Health Organisation 2016 guidance which clarifies that the Code applies to all milks and commercially produced foods marketed as suitable for infants and young children up to 36 months. A new Implementation Manual for this WHO guidance is also available.
In addition, the First Steps Nutrition Trust is now taking on the role of secretariat to the Baby Feeding Law Group (BFLG), a coalition of UK organisations working in maternal and infant health who work to bring UK law into compliance with the International Code. The WBTi UK Steering team is a member of the BFLG.
Day 4 – four calling birds
Indicator 4 assesses the protection and support provided by workplaces for employees who are breastfeeding. Four organisations helping to improve the situation include:
WBTi UK, which made several recommendations in its report, including that tribunal access is available to women in all income brackets.
Gold is associated with precious things, and colostrum is known as “liquid gold.”
Indicator 5 assesses both the extent to which care providers are trained in infant and young child feeding and how supportive health service policies are. There are five professions which work most closely with mothers, infants and young children: midwives, obstetricians, paediatricians, health visitors and GPs. If they value breastfeeding and have the training to support mothers effectively they can serve as a golden chain of support.
The midwifery standards are currently undergoing a thorough review and there will be a consultation in February 2019.
Members of the WBTi team have been supporting the work of revising and updating professional standards, and a working group led by Unicef Baby Friendly has now formed to take this work forward.
Day 6 – six geese a-laying
In the song the geese symbolise the six days of creation.
Indicator 6 covers community-based support. So many mothers stop breastfeeding before they want to that it is really important to create an integrated system of support to avoid mothers falling into gaps between services. Six key aspects are:
Basic support: Health visitors and other health workers trained to a minimum Baby Friendly standard provide basic but universal help with feeding.
Additional: A peer support programme with trained peer supporters provides ongoing social support.
Specialist: For more challenging situations, mothers need to be able to access specialist help, for example from certified lactation consultants and breastfeeding counsellors.
Matt Hancock, UK Secretary of State for Health and Social Care since July 2018, launched his prevention vision on 5 November.
His other priorities are to advance health technology and provide better support for the health and social care workforce. He sees prevention as having two aspects. Partly it is about keeping well physically and mentally, to prevent ill health, but also about the environment around people, their lifestyle choices and how existing health conditions are managed. The aims are for the average person to have 5 more years of healthy independent living by 2035, and to reduce the gap between the richest and poorest. At present there is a large discrepancy in spending with £97 billion (public money) spent on treating disease and £8 billion on prevention across the UK!
The proposed actions in the vision are:
“Prioritising investment in primary and community healthcare
Making sure every child has the best start in life (our emphasis)
Supporting local councils to take the lead in improving health locally through innovation, communication and community outreach
Coordinating transport, housing, education, the workplace and the environment – in the grand enterprise to improve our nation’s health
Involving employers, businesses, charities, the voluntary sector and local groups in creating safe, connected and healthy neighbourhoods and workplaces”
It states there is strong evidence that prevention works and recognises that a healthy population is both vital for a strong economy and for reducing pressure on services like the NHS (almost 10% of the national income is spent on healthcare). Average life expectancy is now 81 years, helped by:
advances in healthcare
changing attitudes so there is less stigma with some conditions
improvements in the environment, at home, work and in neighbourhoods
antibiotics and mass vaccination
public health programmes.
However, there are major challenges in the huge discrepancies between areas – ‘A boy born today in the most deprived area of England can expect to live about 19 fewer years in good health and die nine years earlier than a boy born into the least deprived area.’ (p.7)
Improvements will depend both on encouraging individuals to choose healthy lifestyles and manage their own health, and expecting local authorities to take the lead in improving the health of their communities. The challenges of smoking, mental ill health, obesity, high blood pressure and alcolol-related harm are mentioned, along with the benefit of having a more personalised approach to health.
The section on ‘Giving our children the best start in life’ (p.20) mentions healthier pregnancies, improved language acquisition, reducing parental conflict, improving dental health, protecting mental health and schools involvement, but infant feeding is not mentioned at all!
However, in the Parliamentary debate on the vision (Prevention of Ill Health: Government Vision) on 5 November, Alison Thewliss MP made the case for supporting breastfeeding by investing in the Baby Friendly Initiative to bring all maternity and community services up to the minimum standard. Matthew Hancock’s reply sounds positive: ‘The earlier that we can start with this sort of strategy of preventing ill health the better, and there is a lot of merit in a lot of what the hon. Lady said.’
‘Prevention, Protection and Promotion’ at Public Health England
Earlier in the year (March 2018), Professor Viv Bennett, the Chief Public Health Nurse, and Professor Jane Cummings, the Chief Nursing Officer, came together to launch a campaign on the ‘3Ps – Prevention, Protection and Promotion’, which is about actions to improve public health and reduce health inequalities. Breastfeeding is mentioned in the Maternity Transformation Campaign and Better Births and there appears to be increased govenment commitment to the key role breastfeeding plays in improving public health.
Directors of Public Health have a key role
The DHSC paper expects Directors of Public Health to ‘play an important leadership role’ (p.15). As an example, the Annual Report of Croydon’s Director of Public Health, published in mid-November, We are Croydon: Early Experiences Last a Lifetime, focusses this year on the first 1000 days of a child’s life.
It includes three breastfeeding recommendations:
Reset targets for increasing breastfeeding rates at 6 to 8 weeks and 6 months across the Borough and within particular localities
Achieve level 3 of the UNICEF Baby Friendly award
Turn Croydon into a breastfeeding friendly Borough, so women feel comfortable breastfeeding when they are out and about
How can progress on prevention occur unless it starts at the beginning – with infants? Will other Directors come up with similar recommendations?
Make London a ‘Baby-Friendly’ city
The Mayor of London, Sadiq Khan, aims to “make London a ‘Baby-Friendly’ city” in the London Food Strategy. This strategy aims to increase the health of all Londoners from infancy onwards, including supporting and normalising breastfeeding across London Transport and across government buildings and workplaces, and encouraging all London boroughs to become Unicef UK Baby Friendly-accredited in maternity and community services.
The UK government is due to publish a Green Paper on Prevention in 2019 to set out more detailed plans and, together with the NHS Long Term Plan, which is due to be published soon, is relevant to a future with better health for all.
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The gripping film ‘Tigers‘ is based on the true story of former Nestle salesman Syed Aamir Raza, who took on the baby milk industry, with the help of IBFAN, when he realised the tragic impact of his work.
The World Breastfeeding Trends Initiative (WBTi) UK team has arranged a screening of ‘Tigers’ at the Lexi cinema in Kensal Rise on Wednesday 5thDecember at 10.45am, to mark the 2nd anniversary of the WBTi report on the UK.
The Lexi is situated in Kensal Rise, north-west London, and is the UK’s first social enterprise independent boutique digital cinema, donating its profits to charity.
Following the 90 minute screening, there will be an opportunity to discuss issues raised by the film, and a discussion on issues in breastfeeding support in the UK raised by the WBTi report.
The WBTi project brought together nineteen of the main organisations and government agencies working in maternal and infant health, to assess the state of infant feeding policies and programmes the UK, and to collaborate to produce recommendations for action – 46 in all!!
One innovation in the UK report was our inclusion of mothers’ perspectives, and the incredible way that breastfeeding mothers have supported the whole project, through social media, volunteering, and bringing the report and recommendations to the attention of their local commissioners and MPs. The WBTi Steering Group is keen to acknowledge the crucial role of mothers, and we are delighted to dedicate this anniversary event to all of you!
Economic systems, however, do not acknowledge the contribution of unpaid work like caring for a baby. The irony is, that if breastfeeding rates rise and formula sales go down, GDP is lessened. Similarly, an increase in formula sales increases GDP! Australian economist Julie Smith has highlighted this, for example in her article Breastfeeding and the Measurement of Economic Progress.
The First 1000 Days of Life (from conception to the age of two years) are a critical window in a baby’s development. The 1000 Days concept was first widely used by the World Health Organisation and UNICEF, and there are currently numerous campaigns building on that theme.*
A focused briefing on the the role of breastfeeding on infant brain growth and emotional development can be found here.
Breastfeeding: cornerstone of the First 1000 Days
Human babies are born extremely immature compared to other mammals; they are completely dependent on their mothers for milk, comfort and warmth.
“A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breasts, and security in the knowledge of her presence. Breastfeeding satisfies all three.” ~ Grantly Dick-Read
Scientific research has continued to underscore the vital role that breastfeeding and breastmilk play in the development of the human infant. See our WBTi blog series for this year’s World Breastfeeding Week, from 31st July – 7th August 2018 for a review of the myriad ways that breastfeeding influences human development.
Breastfeeding: more than just food
This is the title of a series of blogs by Dr Jenny Thomas which focuses on some of the ways that breastfeeding contributes to immune development and more. Beyond physical health and development, however, breastfeeding also plays a key role in the healthy mental and emotional development of the infant. Breastfeeding provides optimal nutrition for the first months and years of life, alongside suitable complementary food after six months, but it also supports the development of the child’s immune system and protects against a number of non-communicable diseases in later life as well.
The impact of breastfeeding on maternal and infant mental health and wellbeing.
Breastfeeding can help strengthen mother and baby’s resilience against adversity, and can protect infants even when their mothers suffer from postnatal depression. It supports optimal brain growth and cognitive development. Unfortunately, if mothers don’t receive the support they need with breastfeeding, this can significantly increase their risk of postnatal depression. A summary of evidence can be found here.
It is essential that policy makers, commissioners, and researchers understand the evidence and importance of breastfeeding, so that women who want to breastfeed get any support they need. The WBTI report outlines major policies and programmes that national infant feeding strategies need to include; other research on the psychological and cultural influences on mothers’ infant feeding decisions will help policy makers to develop sensitive and sound policies and programmes to support all families.
In the end, it will be essential that families themselves are heard, in order to create the support systems that our society needs.
*Unfortunately a number of infant milk and baby food companies have jumped on the “1000 Days” bandwagon too, despite the fact that breastfeeding is the centrepiece of the original 1000 Days concept, and replacing breastmilk with formula or baby food actually removes that fundamental building block from a baby’s development.
Helen Gray MPhil IBCLC is Joint Coordinator of the World Breastfeeding Trends Initiative (WBTi) UK Working Group. She is on the national committee of Lactation Consultants of Great Britain, and is also an accredited La Leche League Leader. She is a founding member of National Maternity Voices. She represents LLLGB on the UK Baby Feeding Law Group, and serves on the La Leche League International special committee on the International Code.
World Breastfeeding Week 2018 (link) ends today. Kate’s six daily blogs for it have helped to explore in a UK context the key themes of nutrition, food security and poverty reduction which underpin the strapline Breastfeeding: Foundation of Life.
Breastmilk is uniquely tailored to the needs of the baby receiving it. The most critical time for epigenetic changes is from in utero to age 3 years so gene expression may be significantly affected by the nutrition the baby receives. Early nutrition also influences the development of the gut microbiome; vaginal birth, particularly at home, skin-to-skin contact and breastmilk help to seed the infant’s gut microbiome from the mother’s microbiota, and oligosaccharides in breastmilk are food for beneficial bacterial species. A healthy gut microbiome helps to programme the immune system and lessen the chances of the person developing non-communicable diseases (NCDs).
Breastfeeding ensures food security, including in times of crisis, as even malnourished mothers can breastfeed and the baby thrive. There is no reliance on external supplies, equipment or hygienic conditions for preparation. Breastmilk is the most locally produced food possible.
Breastfeeding is a low-cost way of feeding babies. The mother may be hungrier and eat more so then there is an additional cost, but a minimal one compared to formula-feeding a baby, which in turn can increase poverty as there is less income available for the rest of the family.
In addition, and Kate has given details, not breastfeeding increases the health risks of both babies and mothers. This has consequences for society as it leads to increased healthcare costs.
The 4 objectives are to:
Inform people about the links between good nutrition, food security, poverty reduction and breastfeeding.
Kate described how she has incorporated it in her Year 7 teaching about reproduction and led a school assembly on it. Despite others’ misgivings, the reality was that the boys responded maturely.
Anchor breastfeeding as the foundation for life.
Engage with individuals and organisations for greater impact.
For example, in April 2018, the World Breastfeeding Trends Initiative (WBTi) UK Steering Group organised a conference with the iHV (Institute of Health Visiting) at the Royal Society for Public Health; the conference summary has just been published.
Galvanise action to advance breastfeeding as part of good nutrition, food security and poverty reduction.
This needs education about breastfeeding in schools, workplaces, health professional training, parliaments……, with practical actions to improve support for mothers wherever they are and to encourage people to be supportive. The WBTi UK report in 2016 identified specific gaps, and recommendations to address those gaps.
Feature photo credit: Adobe Stock
Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.
I recently had a very interesting conversation with a friend who breastfed in America. Her initial observations of breastfeeding in the UK is that it is a lot more open and society a lot more accepting of mothers doing it. It’s interesting because, despite our generous maternity leave in comparison to The States and the legal status that a mum can breastfeed everywhere (not in place in every state in the U.S.A!), our rates remain some of the lowest in the world. So what is it? There are many articles and books discussing the matter. But more often than not, the “blame” lies with society. Society’s perception that bottle feeding is the normal. Why does every baby doll kit come with a bottle?! Why are we instilling in our children from a young age what is not biologically normal? Not that we should be looking for who or what to blame. We should be looking for solutions to ensure that the parents of our children of the future world are able to make informed decisions about how to feed their child. There are several places where we should be focussing. For example with our government, ensuring that we follow the World Health Assembly International Code (WHO 1981) and subsequent resolutions.
An area of great interest to me is ensuring that the children of our current generation are fully informed and educated on the matter. Incorporating this into the national curriculum would be amazing. But until that time, I can take heart by teaching it in the year 7 reproduction topic that I teach. I can teach the whole school by doing an assembly on it. Which in fact was what I did with two of my esteemed colleagues, who are equally passionate about breastfeeding and supporting mothers. When I tell friends and family I did an assembly on breastfeeding, they were amazed and in awe of the “brave” activity I did. Brave because I teach in an all boys’ school. But why brave? Breastfeeding isn’t just a female topic. It isn’t just a mother topic. It is a whole society topic. The whole of society should be educated and care about it. Interestingly, the management at the school supported the idea that this was indeed a “very brave” things to do. In actual fact, the boys received the information very maturely and it led to some great conversations and learning around the topic.
If we could improve society’s perceptions of breastfeeding and improve our breastfeeding rates, what impact would this have on society? As we’ve seen in these WBW blogs, one of the key benefits of breastfeeding is a reduction in illness in both mother and baby. Also of importance is the economics of breastfeeding based on these improved health outcomes. They are quite eye-opening. A 2012 report commissioned by Unicef UK showed that investment to increase and sustain breastfeeding rates will provide a rapid financial return on investment (Unicef 2012).
Kate Butler is a Secondary School Biology teacher by day and mother to two boys (aged 2 and 4) day and night. She trained as a breastfeeding peer supporter in 2013 and since then has set up local peer support meetings in her local area and joined the committee of West Herts Breastfeeders to support with fundraising and event management. West Herts Breastfeeders is a community based mum to mum peer support group that supports breastfeeding families with their breastfeeding journeys in the community and within West Hertfordshire Hospitals NHS Trust.