Monday, 3 March 2014

The future of maternity units and the last minute review at Stafford.

We are having a review of the possibility of retaining a consultant led Maternity service at Stafford Hospital – so what does that mean?

The Secretary of State for Health essentially nodded through the TSA (Trust Special Administrators) recommendations on the future of Stafford hospital, but with one puzzling addition; The announcement of a review by NHS England into the possibility of retaining a consultant led maternity unit at the hospital. The Prime Minister has made it pretty clear that he would like this to be provided.

This small last minute addition to the recommendations matters. It matters a lot. The results of this review will determine the “direction of travel” for maternity care in this country.  

For those of us watching the process carefully it is puzzling. We do not know what the review is intended to achieve.  The first question is what is the scope of the review and how will it be conducted.

If the review simply retraces the steps of the TSA process then it is very likely that it will reach the same conclusion, and in doing so it will put at threat a large number of smaller maternity units throughout the country.  If it goes back a step further and questions in some detail some of the assumptions behind the TSA recommendations then it is possible that a review may reach a conclusion that is in line with the wishes of many communities, and the many politicians that represent them.   

To understand the question it is useful to back track on what has happened here. Stafford has been running a small maternity unit for many years. Its results and its reputation are good and it has years of detailed data to back this up. This is something that the TSA did not really take into account at all.

The numbers of people 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.  It is very hard to judge if the numbers of women choosing to have their babies in Stafford at this very particular point in the hospitals history is a fair reflection of the potential demand from a growing population.

The numbers fell below the number of 2,500 births a year which has been elevated by the TSA process to a magical number.

The model that the TSA put forward to potential service providers pointed out that the unit was below this number, and this was sufficient to ensure that no providers made a bid to provide a consultant led maternity service. Initially the TSA took the view that there should be no more births at Stafford. They modified this in response to the public demand, leading to the offer of a midwife led maternity unit, which is better than nothing, but is not popular with the service provider and may not meet with the approval of the public. The heightened sense of risk that clearly now exists in Stafford may mean that Stafford women will remain nervous about what may appear to be a risky option. They are unlikely to have the detailed information to allow them to make a fully informed choice.

It is worth taking a look at where this magical 2,500 came from.

The NMC did research which looks at maternity units and came up with an aspirational figure of the numbers of consultant hours that should ideally be available to maternity units of different sizes.   Larger units should move closer to having 24/7 consultants, though most including the unit at Stoke which will now be the main option for Stafford women does not and probably will not have 24/7 consultant cover.

The NHS litigation authority took the aspirational figures from the NMC and came to the conclusion that level of consultant cover was a key element in safety. 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 NHSLA elevated the aspirational 2,500 figure to the number of births that hospitals should have in order to provide the number of consultant hours necessary to satisfy the NHSLA requirements.

The NHSLA figures were used by the Clinical Advisory Groups (CAGs) set up by the TSA in order to set up the model that was submitted by the TSA to service providers.

The membership of the CAGs is something that perhaps the review needs to revisit.  Were the CAGs an entirely objective and representative group of clinicians, or did the majority of them already accept the centralising agenda that seems to be the fashionable “direction of travel”.  I would also like to know to what extent the members of the CAGs expected their advice to be used in the way that it was? The minutes of the CAG meetings indicate a division of opinion.

One of the questions that I asked as a part of the HEIA Health equalities impact assessment group is what would the impact of the 2,500 rule have on the many hospitals that currently have less than this number of births. I was told that this would not apply to them as they were existing units, and the Mid staffs unit because the hospital was being dissolved counted as a new unit.  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 an administration process.

I also had questions to ask about the tariff for maternity. Does this actually cover the costs? Or is maternity a loss making service for a hospital to offer.

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 units. The good or even 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.

As the attention of the people of Stafford turned to the fate of the Maternity and Paediatric units the issue of travel times and maternal safety became a major focus of attention. 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 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 will be a test for the CCG. The CCG has I believe done its best to rise to the public interest in Health in Stafford and to begin the task of working with the public to create the right solutions for the future. The CCG stress that they are the commissioners, and they have also indicated that a “creative solution” to the current  problem may be available.  I am with them on this. I am also 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.

The last minute intervention of the Prime Minister in the Stafford situation matters. He is a politician, and he therefore knows that the opinion of the voters matters. Maternity units matter.  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.   I hope that the review that the Prime Minister has backed will take a close look at what we actually want from our maternity units. .





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