David
Cameron’s answer to Joan Walley’s question on Mid Staffs at PMQs 26/06/14 made
it very clear to people in Westminster that he personally wishes there to be a
consultant led maternity unit at Stafford.
This may explain the last minute
addition to the Secretary of State’s statement on Mid Staffs. The TSA
recommendations went through on a nod but the SoS also announced a review by
NHS England, to look again at the possibility of retaining a consultant led
maternity unit at the hospital.
This strange amendment is much more
important than it may seem. The results of this review may set the
“direction of travel” for maternity care in this country.
If all the review does is retrace the
steps of the TSA process then we will end up in the same place, and this will
put at threat a large number of smaller maternity units throughout the country,
many of which are in rural constituencies.
Stafford’s small maternity unit has
run for years. It’s reputation is good. There are years of detailed data to
back this up. But, as one of the side effects of a sensational hospital scandal
the numbers of women choosing to have
their babies at Stafford began to fall when the hospital struggled through the
years of negative publicity, even though there was never any criticism of the
maternity unit.
The drop in the numbers of women
choosing to have their babies in Stafford at this very particular point in the
hospitals history is hardly a fair reflection of the potential demand from a
growing population.
Decisions about Mid Staffs are taking
place in the middle of a fierce debate between clinicians and accountants on the future of maternity services. Some clinicians favour concentrating
specialist care for high risk births in a small number of large units, but they
also wish to keep the majority of births local where possible, and are
therefore also promoting the rise of Midwife led maternity units.
2,500 births a year is seen by the
clinicians who support the centralisation of care as the bench mark. Anything
less seen as too small to be consultancy led. When the TSA invited bids from
service providers they made this point clear so it is unsurprising that no one
offered this service. The TSA then used the fact that no one was offering the
service in their public consultation, saying there would be no more births in Stafford. The public reaction to this was predictably
strong so the TSA modified their proposals to say there should be a maternity
led unit.
As there has been no consultation on
this revised proposal we do not know if it will work. The selected provider
appears unenthusiastic, the commissioners worry about costs, and the public are
still to be convinced that this is a good option. Many members of the public have well founded
concerns about transferring women who develop complications during labour from
one hospital to another.
It is worth taking a look at the
history of magical 2,500 births a year, and look at why this figure is so important
to the future of maternity services in this country.
looks at the number of maternity units of different sizes.
Fig 2.4 shows us that there are 56 units with less than 2,500 births, which it believes are generally too small to be consultant led, then it goes on to point out that geography means that some of these will need to retain consultant led units.
The argument is
that specialist care for high risk births requires a high number of consultant
hours, and that the level of consultant cover to which the profession aspires to
provide the safest possible service is simply unaffordable for smaller units.
The report also
goes on to tell us that very large units, of 6000 to 8000 births a year, have
the potential to become unsafe. They would need very high staffing levels and they would need
to work in parallel with midwife led units to reduce the size.
The report is also
looking at the serious underlying problem which is that there are not enough
midwives or obstetric consultants to go round.
The aspirational figure of 2,500 was
elevated by the NHS litigation authority into the minimum number of births
necessary to meet the NHSLA’s notion of safe consultant led care . For the
Litigation Authority medical errors in child birth are the basis for the most
expensive claims for compensation, and it is clearly in the interests of the
Litigation Authority, and the hospitals that pay their premiums, to minimise
risk.
The Clinical Advisory Group set up to
advise the Administrator is new, Studying the minutes of the meetings in Appendix 6 to the draft report shows us a body
feeling its way and uncertain of its role. The meetings were strongly guided by
Sir Hugo Mascie Taylor from the TSA, and included prominent figures such as
Professor Terence Stephenson from the Academy of Medical Royal Colleges, The
professor is clearly convinced by the arguments for centralisation. The minutes
list the participants. We maybe need to ask other clinicians if these are a
good representation of medical opinion as a whole?
The TSA gave the CAGs an estimation
of birth numbers for Stafford, (an estimation that is disputed) and the TSA also explained why costs ruled out a Midwife
led unit. The CAGs did not see any evidence from the existing maternity unit
and knew nothing about the standard of care actually provided.
The experience of Stafford has shown
us how important the CAGs are in signing off the framework for the
reconfiguration of services. Should the review take another look at the
membership of the CAGs? Are they representative, or are they drawn from those
clinicians who already accept a centralising agenda? Are the members of the
CAGs happy with the way that their advice has been used? Is the CAG the best
way of deciding the future of hospitals, where the CAG members will have very
limited knowledge of specific local issues?
56 consultant led maternity units
have less than 2,500 births. My question was
“Will these guidelines apply to them”. The answer I got was that
it would not apply to existing units, but Stafford would now be seen as a new
unit, because it is under administration.
This might sound reassuring to other
smaller hospitals until you recognise how many of them are currently in deep
financial trouble, and work out that it is only a matter of time before they
are also subject to a financially driven administration process.
Reports like High Quality Women’s
Health show that Clinicians favour the development of a networked maternity
service providing more services closer to home with the back up of a small
number of specialist units. This is a vision that I believe most people would
accept, but when the vision meet the TSA process what emerges are decisions
made primarily on costs, where centralisation of care into huge maternity units
is favoured because it is the most cost effective option.
The review needs to look at the tariffs
paid for maternity. Do these actually cover the costs? Or are hospitals being
forced to offer maternity as a loss making service?
Tariffs have been used as a clumsy
tool to bring about changes in the way the health service operates. The
unintended consequence of this is that many hospitals are being driven into
deficit and will face closure or downgrade.
Are we seeing too many decisions being made on the basis of finances rather
than health needs and public wishes, are we seeing these financially driven
decisions dressed up as “clinical excellence’.
One of the things that bothered me a
lot about the administration process here is that there seemed to be so little
attention given to the existing service. The exemplary record of the existing
maternity unit was simply dismissed as irrelevant. The TSA did not choose to
talk to the staff, instead relying in the “direction of travel” set by the CAGs
under the TSA guidance.
The people of Stafford focused attention
on travel times and the safety of mothers and
children. Studies conducted in the Netherlands show a correlation between travel
times and risk to mothers, It is undoubtedly the case that if people are being
transferred in labour to Stoke that this will be an uncomfortable and at times
unsafe process for many women. There are certainly risks involved, but this may
be a risk that does not impact on the NHS Litigation authority in the same way
as medical errors once a woman reaches a hospital does. If a mother or child
dies or is harmed in transit then who is deemed responsible for
this?
Looking at Europe we found that the
large maternity units that seem to be the preferred option to the top ranking
clinicians in this country are seen as actively undesirable. 2,500
births in Germany would be seen as an excessively large unit, and the 6,000
plus births that would occur if all Stafford births were shifted to Stoke would
be seen as unthinkable.
I think that the review backed by the
Prime Minister will be a test for the Clinicial Commissioning Board. I am
encouraged by the fact that the CCG are doing what the TSA failed to do and are
talking to the staff in the hospital so that they can better understand the
strengths of the service that is being provided now. I hope that this will help
them move towards the right solution for Stafford, which may lead to the
retention of an effective maternity service here.
David Cameron’s last minute
intervention is significant. He knows that maternity units
matter. Accountants and powerful
Clinicians have strong views on the future of the health service, but Politicians
from all parties instinctively know the dangers of forcing these changes
through against the wishes of communities.
If we are embarking on a “direction
of travel” that will lead to the closure of a number of valued maternity units
around the country we need to know that we are doing so for the right
reason. Women will hope that the review that the Prime Minister has
backed will take a close look at what we actually want from our maternity
units.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464671/ distance and mortality.
http://www.ncbi.nlm.nih.gov/pubmed/21138515 netherlands study.
In view of the difficulties experienced across all specialties,
careful consideration should be given to the need for the current number and
configuration of delivery units, the majority of which remain within a hospital
setting.
The range of delivery unit size is illustrated in Table 2.4. There
are 56 units delivering fewer than 2500 babies/year and 17 units delivering
more than 6000 babies/year. The need for some of the small units will be
determined by geography (Figure 2.1).39 The larger units will often have co-located
midwife-led units. Experience suggests that units delivering more than 8000
babies/year
will require a significant increase in staffing and facilities.
This is predicated upon a co-located midwife-led unit delivering 25–30% of the
total number of babies.
High quality
womens health care table 2.4 Size of maternity
units.
The
RCOG reports The Future Role of the Consultant31 and The
Future Workforce in Obstetrics and
Gynaecology33
set out a case for delivering services through a network approach similar to
that used for gynaecological oncology, ensuring that resources are centralised
for the infrequent but complex high-risk cases and localised where possible.
These reports state that service reconfiguration across sites and working
practices may be necessary to ensure the delivery of optimum care, since not
all hospitals will be able to provide the full range of obstetric and gynaecological
services required. Managed clinical networks are able to make more efficient
use of staff,44,50,51 but evidence on the financial impact is both scarce and
inconclusive. The primary source of evidence on the effectiveness of neonatal
networks is the National Audit Office report,37 which states that it is very difficult
to conclude whether neonatal networks have improved value for money.
http://tsa-msft.org.uk/wp-content/uploads/2013/07/TSA-Draft-Report-Volume-2-Annexes-to-main-report.pdf Page 97 draft
report Annexes. Gives list of attendees.
