Maternity Mergers: Impact on Patient Safety & Care Quality

1. Trust/maternity mergers A threat to patient safety? Jim Thornton, Nottingham Doctors for Reform

2. Advantages of larger units • Easier staffing • Increase consultant hours • Smoothing peaks and troughs • Decreased need for neonatal transfer • Training opportunities • Savings on running costs • Permits choice

3. Disadvantages • Less convenient for patients • Increased capital/reorganisation costs • Co-ordination/communication difficulties • Fewer staff at peak activity times • Impersonal • Reduced choice/competition

4. Shared care unit 6000 births MLU 1000 births Shared care unit A 3,500 births Shared care unit B 3,500 births Choice? Two meanings

5. Size v. quality Better quality No. of deliveries

6. Optimum size • Midwifery/normal labour – small • Obstetrics/abnormal labour – medium • Neonatology – large

7. Best for who? • Patients • Providers

8. The evidence • Comparative studies of different sized units • Unit size in different countries • Other inter country comparisons • Reports on mergers

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

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

11. 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

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

13. 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

14. Substandard care • Euronatal Working Group - Ricardus 2003

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

16. 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

17. 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

18. Special enquiries into maternity services • Northwick Park, London • New Cross, Wolverhampton • Ashford and St Peter's, Surrey Two followed mergers

19. Merger process • Politically unpopular with general public • MLU often created • ? Genuine need • ? Sop to the public

20. Trust merger process in general • Important unintended side effects • Interfered with service delivery • No improvement in staff recruitment or retention • Projected financial savings rarely achieved Fulop et. al. BMJ 2002 325: 246

21. Conclusions • Mergers may improve neonatal care. • Little or no evidence that further mergers will improve obstetric care. • Potentially dangerous

22. Spare onwards

25. 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

26. Joint RCOG/ENTER MEETINGRisk Management and Medico-Legal Issues In Women’s Health25 to 26 April 2007