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 < Total *1* 186

< , , , >4,000 England %2%8%13%56%21% Belgium %60%17%6%4%0 Germany %39%27%11%5.7%0 France %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 ,000-1,500>1,

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 Percent95% CI Finland %25-39% Spain %35-54% Netherlands %41-56% Belgium %44-58% Denmark %45-57% England %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 at delivery 2 DGH (four consultants) 9,000 deliveries over 3 years (750 assisted) Anon BMJ 1999 Normal6 Forceps/vacuum19 Breech2 Emergency Caesarean26

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

Medico-legal claims UK and Europe No data

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”

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

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

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

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

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