Wednesday, 5 March 2014

Maternity services - what does the future look like?

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.


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.





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