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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
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