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. 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

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 <.9991-1.992-2.993-3.994-4.995-5.996-6.997-7.998+Total 19733101215825130000527 19961471046328310000341 200316 ??? 275649279201*1* 186

10. <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.

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

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

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 MEETING Risk Management and Medico-Legal Issues In Women’s Health 25 to 26 April 2007