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 <.9991-1.992-2.993-3.994-4.995-5.996-6.997-7.998+Total 19733101215825130000527 19961471046328310000341 200316275649279201*1* 186

4. <500500-9991,000- 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.

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 <500 dels.500-10001,000-1,500>1,500 3933145

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 Deaths evaluated Substandard care Percent95% CI Finland1635232%25-39% Spain1024544%35-54% Netherlands1577648%41-56% Belgium1889651%44-58% Denmark26013351%45-57% England21511554%47-60%

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 Normal6 Forceps/vacuum19 Breech2 Emergency Caesarean26

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