Trust/maternity mergers

A threat to patient safety?

Jim Thornton, Nottingham

Doctors for Reform

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

Disadvantages Less convenient for patients Increased capital/reorganisation

costs Co-ordination/communication

difficulties Fewer staff at peak activity times Impersonal Reduced choice/competition

Choice? Two meanings Shared care unit

6000 births MLU 1000 births

Shared care unit A 3,500 births

Shared care unit B 3,500 births

Size v. quality

Better quality

No. of deliveries

Optimum size Midwifery/normal labour – small Obstetrics/abnormal labour –

medium Neonatology – large

Best for who? Patients Providers

The evidence Comparative studies of different

sized units Unit size in different countries Other inter country comparisons Reports on mergers

Size of maternity units UK (000s of deliveries per annum)

Department of Health 2004

< .999

1-1.99

2-2.99

3-3.99 4-4.99

5-5.99

6-6.99

7-7.99

8+ Total

1973

310 121 58 25 13 0 0 0 0 527

1996

147 104 63 28 31 0 0 0 0 341

2003

16 ???

27 56 49 27 9 2 0 1* 186

<500 500-999 1,000-1499

1,500-1999

2,000-3999

>4,000

England 2003

10% 2% 8% 13% 56% 21%

Belgium 2003

13% 60% 17% 6% 4% 0

Germany 2000

17.5% 39% 27% 11% 5.7% 0

France 2003

15% 34% 23% 12% 17%*

Sizes of maternity units Europe

Wildman et al 2003 & Natl. stats.

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

Evidence for large units 1 Hesse, Germany - neonatal mortality

“Small” units 3 X “large” ones

Heller et al 2002

<500 dels. 500-1000 1,000-1,500

>1,500

39 33 14 5

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

Substandard care

Euronatal Working Group - Ricardus 2003

Deaths evaluated

Substandard care

Percent 95% CI

Finland 163 52 32% 25-39%

Spain 102 45 44% 35-54%

Netherlands

157 76 48% 41-56%

Belgium 188 96 51% 44-58%

Denmark 260 133 51% 45-57%

England 215 115 54% 47-60%

Medical presence at delivery Very low in UK compared with rest

of Europe Midwives v nursing assistants

Good? Why?

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

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

Special enquiries into maternity services

Northwick Park, London New Cross, Wolverhampton Ashford and St Peter's, Surrey

Two followed mergers

Merger process Politically unpopular with general

public MLU often created

? Genuine need ? Sop to the public

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

Conclusions Mergers may improve neonatal

care. Little or no evidence that further

mergers will improve obstetric care.

Potentially dangerous

Spare onwards

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

Joint RCOG/ENTER MEETING

Risk Management and Medico-Legal Issues In Women’s Health

25 to 26 April 2007