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The centralisation of maternity services in Europe

The centralisation of maternity services in Europe. Jim Thornton, Nottingham Doctors for Reform. NHS maternity services. Compared with rest of Europe Centralisation Midwives Consultants Standards. Size of maternity units UK (000s of deliveries per annum). Department of Health 2004.

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The centralisation of maternity services in Europe

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  1. The centralisation of maternity services in Europe Jim Thornton, Nottingham Doctors for Reform

  2. NHS maternity services • Compared with rest of Europe • Centralisation • Midwives • Consultants • Standards

  3. Size of maternity units UK (000s of deliveries per annum) Department of Health 2004

  4. Sizes of maternity units Europe Wildman et al 2003 & Natl. stats.

  5. Largest maternity units • England • Liverpool 8,084 deliveries • Belgium • 2,641 deliveries • Germany • Humbolt, Berlin 3,000+ deliveries • France • Jeanne de Flandre, Lille 4,000+ deliveries

  6. Evidence for large units 1 • Hesse, Germany - neonatal mortality • “Small” units 3 X “large” ones • Heller et al 2002

  7. Evidence for large units 2 • Norway - low risk pregnancies • Lowest combined perinatal and neonatal mortality in units with 2-3,000 deliveries per annum • > 3,000 dels. = 30% higher death rate. Moster et al. 1999

  8. Substandard care • Euronatal Working Group - Ricardus 2003

  9. Medical presence at delivery • Very low in UK compared with rest of Europe • Midwives v nursing assistants • Good? • Why?

  10. NHS Consultant presence at delivery • Normal delivery – almost unknown • Complex delivery – rare • Complex Caesarean (pl. pr., full diln., <32w, obese, abruption) • Consultant present in 21% • Natl. Caesarean Section Audit. Thomas 2001

  11. NHS Consultant presence at delivery 2 • DGH 1996-9 (four consultants) • 9,000 deliveries over 3 years (750 assisted) Anon BMJ 1999

  12. NHS Consultant presence on delivery suite • 40 hours per week • 80/207 maternity units in England and Wales RCOG 2005 • Clinical Negligence Scheme for Trusts level 2 (incl. 40 hours cover) • 18/151 participating units CNST 2004

  13. Medico-legal claims UK and Europe • No data

  14. Special enquiries • Healthcare commission report (Kennedy) • Northwick Park, London • New Cross, Wolverhampton • Ashford and St Peter's, Surrey “birth more dangerous than it should be” “bad management rather than lack of funding to blame” “too much poor practice” “deficient organisation, shortage of midwives, dirty toilets, lack of communication”

  15. Campaigning groups • Holland • Grass roots and strong but no campaigning • Germany • Doctor initiated, weak, and not campaigning • England • Grass roots, strong and vibrant and campaigning for better care. Tyler 2002

  16. NHS Consultant staffing • 1303 w.t.e. England & Wales (2005) • 207 Units - 6.3 per unit • 635,000 births - 487 per consultant

  17. Conclusions • NHS maternity care more centralised than rest of Europe • More midwife involvement • Less consultant involvement • Possibly worse care

  18. NHS planners solution • Increase consultant hours of labour ward cover • Enforce the new consultant contract

  19. Doctors for Reform solution • Shift power from doctors to patients (and their agents) • Increase providers • Competition and patient choice • Money follows patients

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