The case for retaining full maternity services in Salford Sept 2010 Page 1
Keep Hope Maternity Open Campaign Group
http://www.keephopematernityopen.com
The case for retaining full maternity services in Salford
The case for retaining full maternity services in Salford Sept 2010 Page 2
Foreword, Lisa Kean, Chair of the Salford Maternity Forum
In July this year, Andrew Lansley ordered that the decision to close Salford maternity and neonatal services be reviewed, stating that decisions on service change must now meet four strengthened criteria. These criteria are that proposed changes must: focus on improving patient outcomes, consider patient choice, and be based on sound clinical evidence, as well as having support from General Practitioners (GPs). The Salford Maternity Forum has therefore commissioned this report which examines the case for retaining services at Salford, based on the first three criteria.
We are now sending this report to all GPs in Salford, as we believe it sets out a compelling case for retaining Salford‟s excellent maternity and neonatal services. We believe that it is not too late to reverse this wrong decision and ask for your support in achieving this, for the sake of Salford people now and in the future.
The case for retaining full maternity services in Salford Sept 2010 Page 3
Summary
1. The „Making it Better‟ (MIB) consultation was biased from the outset, as the Children, Young People and Families‟ Network team ignored a report they themselves had commissioned from TMS consultancy just prior to the consultation. This report in February 2005 stated unequivocally that Hope Neonatal Unit should be retained.
2. The proposals were based on the assumption that the birth rate was declining, whereas in Manchester and Salford the birth rate is projected to increase. Staff in local maternity units are currently struggling to cope; St Mary‟s, for example, was forced to close on 39 occasions last year. In its most recent report the North West LSA (the midwifery statutory supervisory body) has expressed concerns regarding future capacity if the reconfiguration goes ahead. Reduced capacity, with pressure on staffing and beds, will result in a less safe service for the majority of mothers and babies.
3. In 2008 Salford was designated the eighth best performing Trust for maternity care in England by the Health Care Commission. It has also achieved Level 3 in the Clinical Negligence Scheme for Trusts (the highest safety level, which means reduced insurance premiums). Maternity and neonatal care at Salford is therefore currently recognised as safe and effective, with lower intervention rates than in the surrounding hospitals. These enviably low intervention rates, achieved through sustained effort and teamwork, will be jeopardised by the closure. If intervention rates were to rise, care for Salford women would be not only less safe, with long term public health implications, but also more expensive.
4. The closure of Salford maternity would mean less choice for women in Salford. Even if a stand- alone midwifery led unit were to be retained, this would only cater for the healthiest women (around 500-600 per year).
5. The closure of Salford maternity and neonatal services would mean that women and their families would have to travel further, incurring greater expense and inconvenience than currently, and running an increased risk of giving birth before arriving at hospital. Salford has a high level of non car owners. The closure of an excellent unit serving a deprived population will result in perpetuation of the „inverse care law‟– those who need it most have the poorest care.
6. Bigger is not necessarily better when it comes to maternity care; evidence from this country and Europe suggests that smaller maternity units (supported by excellent networks for transfers to neonatal intensive care units for very low birth weight babies) have higher staff retention and better outcomes.
The case for retaining full maternity services in Salford Sept 2010 Page 4
The ‘Making it Better’ review
The „Making it Better‟ reconfiguration programme (MIB) was set up in 2004 by the Children, Young People and Families Network, to carry out a public consultation on reconfiguring children‟s, maternity and neonatal healthcare services across Greater Manchester. This then expanded to take in East Cheshire and High Peak and Rossendale, a review area with a population of around 3.1 million people. In July 2005, the Network published a discussion document, Making It Better (MIB). More than 120,000 copies of the document and 400,000 copies of an information leaflet were distributed. According to the MIB team, around 242,000 people had their say on the proposed changes during a 4-month public consultation and more than 55,000 formal written responses were received.
The discussion document suggested the creation of eight „Centres of Excellence‟ for maternity and children's services, with neonatal intensive care provided at three large specialist units. Option A, which had been identified by the team from the start as the „preferred option‟ was finally chosen at a meeting of 13 PCTs on 8th December 2006. Option A proposed Centres of Excellence at 8 sites: Royal Albert Edward Infirmary in Wigan, Royal Bolton, Royal Oldham, St Mary's, Stepping Hill, Wythenshawe, North Manchester General and Tameside General; with Neonatal Intensive Care Units at St Mary's, Royal Oldham and Royal Bolton Hospitals.
Background to the decision to withdraw services from Hope
Consultation had been going on in Greater Manchester for some years regarding neonatal and paediatric care. By early 2004 the Greater Manchester Neonatal Network Board (GMNNB) had reached broad agreement on the future location of neonatal intensive care services. Their recommendation to the Children, Young People‟s and Families Network, who were to be tasked with consulting about the reconfiguration, was to retain St Mary‟s and have 2 other designated neonatal intensive care sites: ROH, Bolton and either Stockport or Wythenshawe.
It is not clear to us why Hope, the only other NNU accredited by the Royal College of Paediatrics and Child Health, was omitted as a designated neonatal intensive care site at this point. In response to the GMNNB‟s position and prior to their MIB consultation, in June 2004 the Children, Young People and Families‟ Network commissioned a report by Teamwork Management Services (TMS) ‘to make recommendations on how neonatal intensive and high dependency care should be configured in future, to improve the outcomes of care for babies, as well as explore the potential impact for parents, families and staff’. TMS was a leading clinical management and business strategy consultancy which specialised in redesigning health services. Their detailed report was published on 14 February 2005. It stated that the preferred option (1) would be to reconfigure these neonatal services onto 3 sites, adding ‘in terms of which sites should provide specialist neonatal care it is sensible to build on the existing, well-established and accredited units at St Mary’s and Hope hospital. There is no evidence from the service user, clinical or commissioning perspectives, or published audits available to this review, that either of these established services should be moved from the two existing hospital sites’ (p17). The Report therefore unequivocally recommended that Hope should be one of the designated sites.
The case for retaining full maternity services in Salford Sept 2010 Page 5
What happened to this report? It is not mentioned in any of the MIB statements in the public domain. This suggests that prior to the public consultation the Children‟s Network Board, following the GMNNB, had decided that Hope would not feature as an option for intensive and high dependency neonatal care - despite the fact that it was the only other RCPCH accredited unit apart from St Marys. One of the requirements for lawful consultation is that at the formative stage the team must have an open mind on the outcome. This background clearly demonstrates bias. Further, employing a consultancy is costly; this ignored report must surely constitute a waste of public money and put into question the motives of the Network Board in purposely excluding Hope from their proposals. Membership of the Network Board itself may have affected its ability to make objective decisions on these matters. It is interesting that the team then did not return to TMS for analysis of the responses to the MIB discussion paper but instead chose a different company, Tribal Consulting. This consultancy analysed the responses and came up with new options but none of these included Salford Royal, and therefore there was very little chance of maternity and neonatal services being retained at Hope. Hope was only included in the initial options as Option C after lobbying by local MPs.
The MIB consultation had a neonatal bias, focussing largely on the care of very low birth weight babies (1% of the total) at the expense of the wider issues for all mothers and babies. Anthony Emmerson, neonatologist and lead clinician for the GM Neonatal Network has been quoted in MIB press releases as saying: ‘It's about moving forward and improving outcomes for these tiny infants (Bury Times Thursday 30th August 2007) … we believe (the changes) will help to save the lives of up to 30 more babies every year’ (MIB press release 24 August 2007). The public consultation questions focused on the care for sick babies and children. This created bias as parent‟s responses to questions about how far they were prepared to travel for care of their sick baby (a rare occurrence) were interpreted to also mean they would be happy to travel the same distance for maternity care.
Although the MIB team has been self-congratulatory about the size and scope of the consultation, calling it the largest ever response to a health consultation in the UK, the community of Salford was in the main highly critical of the proposals. In Salford there was a large protest rally supported by local MPs and Salford Council. A petition against closure was signed by over 26,000 residents of Salford. Salford Council Health Scrutiny Committee referred the decision to the DH Independent Review Panel (IRP). Midwifery educationalists, supervisors of midwives and many clinicians expressed concerns about the proposals and about the consultation process itself to the Network Board and to the IRP, which unfortunately upheld it in June 2007.
In July this year, Andrew Lansley outlined new, strengthened criteria that he expects decisions on NHS service changes to meet. They must focus on improving patient outcomes; consider patient choice; have support from GP commissioners; and be based on sound clinical evidence (DH 2010).
He ordered that the decision to close Salford maternity be reviewed according to these criteria; this review is currently ongoing.
The case for retaining full maternity services in Salford Sept 2010 Page 6
The case for retaining full maternity and neonatal services in Salford
Health and well-being at birth have far reaching implications for health throughout life. Optimal maternity care should be that which aims to be effective, do the least harm and which takes account of women's experiences (NCT 2010). If maternity services were audited with this in mind then priority would be given to those units with low intervention rates, low caesarean rates and a high normal birth rate because these would the ones associated with reduced physical and psychological morbidity. These would also prove to be the units that were most cost-effective due to the PbR tariffs.
Reconfigurations leading to centralisation of services are often cited as justified as being cost effective and as a means of improving patient safety. The MIB reconfiguration can be challenged on this basis as it appears to have been predicated on consultant rotas meeting the Working Time Initiatives rather than being quality and safety driven (see MIB end of project report 2010). In August 2007 Andrew Lansley said of the Manchester MIB consultation: "It was clearly driven by pressures from the European Working Time Directive [to limit doctors' working hours] and it failed to adequately reflect how access to services impacts the overall quality of care. Our contention is that with suitable support, good risk assessment and a neonatal critical care transport service, more of the existing locally based obstetric units can be maintained."(BBC News 24 August 2007) We agree with this view.
If the hospitals affected by the review are analysed for the latest statistics (Drazek 2009) then it is obvious that Salford is both safe and cost-effective and in fact performs better on all indices than its neighbouring units (Fig 1):
Salford (3100 births)
Bolton (4400 births)
St Mary’s (4700 births)
North Manchester (2900 births)
Caesarean section
18%
23%
21%
23.3%
Instrumental
11%
8%
14%
10%
Inductions
11%
24%
25%
21.4%
Stillbirths
16
33
42
16
Closures
1
3
39
N/A
These figures show that maternity care offered at the proposed sites of St Mary‟s, North Manchester and Bolton will not be better than that at Salford Royal – indeed it is likely to be less effective. A focus on safety is necessary as litigation costs are very high, so care provided should be appropriate to the risks of the population. Salford Royal maternity unit holds a Level 3 certificate for CNST, the highest level, which means the Trust pays reduced insurance premiums. The unit is held in high esteem by local women and is often chosen by women who live out of the area which is also an indicator of its reputation as a safe and supportive place to give birth.
The case for retaining full maternity services in Salford Sept 2010 Page 7
The MIB document was based on the premise that the birth rate was falling: “The birth rate
nationally is falling so there will be fewer children and young people in the future” (p18) and
this meant that there was not a need for all the current maternity units to be retained. The
latest available statistics from ONS (2008) show that this assumption was mistaken. ONS
predicts that the population of fertile females is set to reduce in all areas in Greater
Manchester apart from Manchester, Salford and Trafford (Fig 2). With the establishment of
Media City at Salford Quays the Salford childbearing population is likely to increase beyond
that currently projected.
ONS 2008 based population Projections - GM Districts - Change in the
Number of Fertile Females (Aged 15-44) 2008-33
-5
0
5
10
15
20
Bolton
Bury
Manchester
Oldham
Rochdale
Salford
Stockport
Tameside
Trafford
Wigan
District
Change - Fertile Females (000s)
Fig 2
The reconfiguration of maternity services across Greater Manchester will reduce bed
capacity. This will impact on safety as women will be more likely to be diverted away from
their hospital of choice. We judge that the new unit at St Mary’s will be barely able to
meet the needs of its own population let alone that of Salford. Indeed the Local
Supervising Authority Annual Report to the Nursing and Midwives Council ( Drazek 2009)
has expressed concern about future capacity in Greater Manchester, stating: The temporary
closures… are of particular concern in view of the reconfiguration of maternity services
across Greater Manchester and the fact that this will significantly reduce capacity and bed
numbers further’(p63).
The network board has said that "flexibility" has been built in but has not given details of
what this means for women. Does it mean being discharged after 2 hours to „free up‟ beds, as
some units are doing, to reduce bed occupancy? Or women not being cared for on a labour
ward until they reach 6cm dilatation? Both these scenarios are currently occurring in other
The case for retaining full maternity services in Salford Sept 2010 Page 8
units due to pressure on beds. These are not safe practices and are not contributing to positive experiences for women and their families.
MIB placed a strong emphasis on reducing health inequalities and yet perversely has voted to close down the very unit in the area most in need of locally based services. Moving maternity and neonatal care out of the City will cause already disadvantaged families more hardship. Salford scores highly in all deprivation indices such as unemployment, reliance on social housing, reduced life expectancy, low birth weight and low car ownership. Specifically, 39.2% of Salford residents do not have access to a car as opposed to 26.8% of England‟s households. 12.5% of Salford residents are lone parent families against 9.5% of England‟s households (LINK 2009).
The proposal to retain only a stand-alone Midwifery Unit will result in only the healthiest, low risk women able to give birth in Salford, while women with complications will have to travel further. Ill health is higher in more deprived populations such as Salford therefore the reconfiguration will result in perpetuation of the „inverse care law‟ (Tudor Hart 1971) – those who need it most have the poorest care. Increased mortality and morbidity are recognised to be a consequence of poverty. Salford has a level 3 accredited unit for a very good reason - the residents of Salford need one!
In 2008 Local Involvement Networks (LINKs), were set up to give communities a stronger voice in how their health and social care services are planned and delivered. Local residents of Salford have identified and voted three top priorities for their first work plan: Access to local health and social care services. Promotion of healthy lifestyles Healthcare service provision (LINK 2010)
For 2010 – 2011 one of the top priorities identified by Salford residents was the need for access to LOCAL hospital services (LINK 2010). It is clear that Salford is a city that wishes its services, which include maternity and neonatal services, to remain located locally and to be of a high standard.
Public transport links to the proposed „super centres‟ from Salford are poor and not family friendly. The plans will unquestionably increase travelling times, put pressure on the ambulance service and possibly deter women from attending. Low car use amongst its population means that women will be less likely to easily access services or afford to travel to Manchester or Bolton. The MIB team did examine distances from Salford to other units but distance analysis is a crude measure and does not take into account aspects such as rush hour traffic, city congestion and public transport links. The MIB plans do not include plans for increased emergency support such as airlift for urgent maternity/neonatal cases at times of severe congestion/gridlock. In Liverpool, currently the largest maternity unit in the UK with around 8,000 births per year, 553 women gave birth unattended in 2008-9 (Drazek 2009). The reasons for this have yet to be examined but can be supposed to be down to geography and difficulty in accessing the service.
Large centres equal increased levels of management where the focus of care (i.e. care of women) may become lost. It is well recognised that midwives do not work well within these units and that care becomes fragmented (Ball et al 2002). Safety becomes an issue then as
The case for retaining full maternity services in Salford Sept 2010 Page 9
highlighted by the Healthcare Commission Report (2006). Bigger units mean that women are more likely to be left alone in labour and less likely to have the same midwife caring for them during labour (Statistics from Birthchoice UK). Large units also tend to stifle dissenting voices. For example, Liverpool Women‟s Hospital was found by the Health Care Commission in 2007 to have had 20% of staff suffer bullying, harassment or abuse from managers or colleagues and it failed to investigate serious claims of abuse. Such working environments are not conducive to woman centred care. Recruitment and retention of staff becomes difficult which adversely effects care (Ball et al 2002). It is not yet evident whether all Salford staff will transfer to the other units. Some have already left and others have cited a preference to taking early retirement rather than transfer site. This equals a loss of experience and skill sets, which has worrying implications, as the riskiest times for services are post merger. This is demonstrated by the Healthcare Commissions enquiries into maternity services at Ashford and St Peter‟s Hospitals and Northwick Park as well as the independent inquiry into maternity services at Wyre Forest Birth Centre. These reports illustrate problems of management and staff morale arising as direct or indirect consequences of mergers. Furthermore the loss of midwifery skills and experience which will follow as a consequence of the closure of Hope will impact upon the sound training of future midwives, consolidation of skills, and retention, with the risk of further increasing intervention rates.
Although the question of whether there is any association between the size of maternity units and the quality of their clinical care has never been systematically evaluated, the Healthcare Commission report (2006) into Northwick Park Hospital challenges any assumptions which may have been made about the safety and quality of care in very large units (Macfarlane 2008). The sustainability of very large units needs to be addressed. Large units are known to have frequent closures due to staffing pressures. St Mary‟s closed on 39 occasions last year and this is before Salford is scheduled to close. If this level were to continue women would be turned away more frequently with all the increased risk and anxiety that this entails. Closures put women at greater risk of complications.
Other European countries use improved neonatal transport networks to achieve excellent outcomes and their mortality rates are lower than ours (Bosanquet et al 2005). Their largest units care for no more than 4,000 births per year, supported by excellent networks for transfers to neonatal intensive care units for very low birth weight babies.
Salford has a long standing history of excellence in maternity care and has been a thriving referral centre for women with complications of pregnancy (including neurological and renal problems) due to the excellent regional specialist services provided by Salford Royal Foundation Trust. It is not clear where pregnant women requiring this specialist input would be cared for in the future. The acute trust has a team of highly skilled and committed staff which in turn has meant it has an enviable recruitment and retention rate. The team strives to be innovative and has been the forerunner in many aspects of care, which have been disseminated and recognised both nationally and internationally. The people of Salford need and deserve to retain this service.
The case for retaining full maternity services in Salford Sept 2010 Page 10
Report compiled by:
Sarah Davies, Senior Lecturer Midwifery University of Salford, Salford resident
Heather Rawlinson, Midwife, Salford resident
on behalf of the Keep Hope Maternity Open Campaign Group, 8th Sept 2010
REFERENCES
Ball, L., Curtis, P., Kirkham, M. (2002) Why do Midwives Leave? Women's Informed Childbearing and Health Research Group, University of Sheffield
BBC News (2007) Johnson backs maternity closures http://news.bbc.co.uk/1/hi/england/manchester/6961877.stm Accessed 6th Sept 2010
Bosanquet N, Ferry J, Lees C and Thornton J (2005) Maternity services in the NHS. Reform. http://www.reform.co.uk/Research/Health/HealthArticles/tabid/80/smid/378/ArticleID/596/reftab/69/t/Maternity%20services%20in%20the%20NHS/Default.aspx Accessed 5th Sept 2010
Commission for Health Improvement (2003) Maternity services – Ashford and St Peter’s Hospitals NHS Trust. London: Commission for Health Improvement,.
Department of Health (2010) Health Secretary outlines vision for locally led NHS service changes. Statement, 21 May 2010 http://www.dh.gov.uk/en/MediaCentre/Statements/DH_116290 Accessed 6 Sept 2010
Drazek, M (2009) North West Local Supervising Authority. Annual report to the
Nursing and Midwifery Council on the statutory supervision of midwives &
midwifery practice 2008-2009. NHS Northwest
http://www.northwest.nhs.uk/document_uploads/lsa/LSA%20Annual%20Report%2008-09%20%20final.pdf Accessed 6th Sept 2010
Greater Manchester Children, Young People and Families‟ NHS Network (2010)
A Network Approach to Achieving EWTD Compliance. End of Project Report
Health Care Commission (2006) Investigation into 10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London NHS Trust, between April 2002 and April 2005. London: DoH
Health Care Commission (2007) National NHS staff survey. Brief summary of results from Liverpool Women’s NHS Trust http://www.cqc.org.uk/_db/_documents/AH_NHS_staff_survey_2007_REP_sum.pdf. Accessed 6 Sept 2010
LINK (2009) Salford Annual Report. 2008 – 2009. Unlimited Potential, Salford
LINK (2010) Salford Annual Report. 2009 – 2010 Unlimited Potential, Salford
National Childbirth Trust (2010) Normal birth as a measure of the quality of care. London, NCT
South West Midlands Strategic Health Authority (2004) Maternity Services at Wyre Forest Birth Centre. Report of an independent inquiry under Section 2 of the NHS Act of 1977.
Tudor Hart J (1971) The inverse care law. The Lancet 27 February 1971
