ourNHS

Smaller maternity hospitals can be safer - is government willing to pay for them?

Will Cameron's intervention reprieve Stafford Hospital's well regarded maternity unit? Or will it remain under threat as 'too small', heralding an uncertain future for over 50 more maternity units across the country?

Diana Smith
5 March 2014
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Image: Jon Ovington

David Cameron insisted on a last minute addition to the Health Secretary’s statement on Stafford hospital last week. The Special Administrator brought in to sort out the Trust’s financial issues made a range of recommendations, mostly nodded through. But Jeremy Hunt ordered NHS England to look again at the possibility of retaining a consultant-led maternity unit so that women can continue to have babies at the hospital. The Prime Minister told parliament “that is what I want to see”.   

The Prime Minister’s unexpected intervention matters a lot. The results of this review will set  the “direction of travel” for maternity care in this country.

If all the review does is retrace the steps of the Special Administration 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 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.  

Births dropped below 2,500 a year. So the Administrator declared that it was too small to remain a consultant-led unit. On the other hand, they also made clear that a midwife-led unit would be unaffordable. Unsurprisingly no provider bid to run a maternity service, and the proposals put out for consultation said there would be no more births at Stafford.

The public reaction to this was predictably strong. 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.

In response the Special Administrator modified their proposals to say there should be a midwife-led maternity unit.

But the selected provider seems unenthusiastic, 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.

In the background, maternity - like other services - is facing a debate between centralisers and localisers, with an increase in midwife led maternity units and some favouring the concentration of specialist, consultant-led care in a small number of large units.  

There are 56 other maternity units with fewer than 2,500 births. Will these guidelines be used to downgrade or close them, I asked. The answer came. Guidelines would not apply to existing units, unless they are in administration.

This might sound reassuring to other smaller hospitals until you recognise how many of them are currently in deep financial trouble. It is only a matter of time before many other hospitals are also subject to the administration process, where closure and downgrade decisions are made on costs.  

It’s doubtful whether the 'tariff' the government pays for maternity units actually covers the costs.  The tariff operates as a clumsy tool to bring about changes in the health service. It drives hospitals into deficit if they do not make financially driven cuts that ignore health needs and public wishes.   

Centralisation of care into huge maternity units is favoured because it is the most cost effective option. These decisions are dressed up as being based on “clinical excellence”.

The Royal College of Obstetricians and Gynacologists recommend the development of a networked maternity service where services are “localised where possible” with a back up of specialist units “for the infrequent but complex high-risk cases”. This is a vision I believe the public would accept.  

The first outing of the Administration process, at mid Staffs, gave little attention to the existing service. The exemplary record of the existing maternity unit was dismissed as irrelevant. The Administrator did not talk to the staff or public before drawing up their proposals, instead relying in the “direction of travel” set by the CAGs. 

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 because the care they need is now further away, who is deemed responsible for this?  Is it just seen as a sad accident, with the public essentially now carrying the risk of the increased distance from hospital?

Elsewhere in Europe large centralised maternity units 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.

The decisions about Mid Staffs were justified by the use of highly aspirational figures, driven to some extent by the NHS Litigation Authority - for whom medical errors in childbirth are the most expensive claims for compensation. Specialist care for high risk births requires a high number of consultant hours, which is currently unaffordable for smaller units. Does this mean we simply close the services, regardless of local wishes and the clinical opinion that larger centralised units, too, can be risky?

The underlying problem is there are not enough midwives or obstetric consultants to go round.   

The minutes of the Clinical Advisory Group set up to advise the Administrator show a body feeling its way and uncertain of its role. Meetings were strongly guided by Sir Hugo Mascie Taylor from the Special Administrator, and included prominent advocates of centralisation like Professor Terence Stephenson from the Academy of Royal Medical Colleges. Are such voices representative of medical opinion, or are they drawn from those clinicians who already accept a centralising agenda?

I am encouraged that the Commissioners are doing what the Special Administrator failed to do and are talking to the staff in the hospital as a result of the Prime Minister’s significant last minute intervention.

David Cameron knows that maternity units matter. Accountants and a few eminent clinicians have a powerful voice in the future of the health service, but politicians from all parties are alert to the danger of forcing these changes through against the wishes of communities.

This is also what is should worry MPs voting on the ‘hospital closure clause’ next week, that proposes dramatically broading the Administration process even to hospitals not in any difficulties. 

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 - and that women elsewhere will get the same chance.

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