Save Our Hospitals: Consultant says babies could die

On 'Fit for the Future' maternity service proposals:

a commentary

West Sussex Primary Care Trust has published proposals under the title of 'Fit for the Future' which will determine the structure of healthcare in West and East Sussex for a generation. Many of these proposals pertain to the maternity services. This paper analyses the stated reasons underlying the proposals, the background data relating to maternity care in West Sussex and the potential effects of the proposals on the provision of maternity care.

Summary

West Sussex PCT has proposed a radical reorganisation of the delivery of maternity care in West Sussex; if enacted, these proposals are likely to have a deleterious effect on the provision of maternity care to the population of West Sussex.

The need for change: the stated reasons behind the changes including the European Working Time Directive and increasing senior medical cover on the labour ward are misleading.

Statistics & Data: the data presented by West Sussex PCT is misleading, out of date and flawed.

Deprivation: the proposals run counter to national recommendations for the provision of medical services close to those who most need them.

Clinical Support: the proposals are opposed by senior clinicians on grounds of safety.

Clinical risk: the proposals are felt to be so flawed as to represent a genuine threat to the well-being of mothers and their babies, in effect a "blueprint for disaster".

Fit for the Future proposals for the maternity services in West Sussex:

a commentary.

Introduction

Two of the plans proposed for West Sussex suggest the closure of the Worthing Maternity unit which is the largest in West Sussex and only slightly smaller than the Brighton unit which is the largest unit in East Sussex.

The PCT states that these changes are being introduced to modernise maternity care and improve services. This is being done on grounds of finance, to meet EWTD requirements and to improve senior cover on the labour ward all of which appear desirable. However, the reality is far removed from this and the current proposals are liable to lead to increased maternal and perinatal mortality.

The PCT is planning for an MGH with c.4000 deliveries in West Sussex. This assumes that deliveries can be packaged and women transported to deliver wherever the PCT decides.

The need for change

EWTD

EWTD requirements are stated as a driving force behind the proposals. Yet, this is artificial and determined by the government. Virtually every other country in the EU determines and interprets EWTD differently typically dividing work into service and training and usually only including the service commitment as part of the EWTD hours. However, despite this, the Worthing maternity unit is already de facto compliant with the 48 hour EWTD requirement. There has never been a problem with recruitment at junior or middle grade level in the maternity unit due to the high quality of training afforded. Hence EWTD cannot be justified as an excuse to change the service.

Labour ward cover

The ability to provide senior cover on the labour ward is cited as a reason to move to larger units as per the PCT proposals. Worthing currently provides 40 hours of resident consultant cover for the labour ward. In addition, many of our middle grades also possess a CCST or CCT further enhancing the quality of senior care on the labour ward. The paper Towards Safer Childbirth recommends that units delivering more than 4000 babies p.a. should provide 168 hours of resident labour ward cover in order to provide adequate safety. There is currently a shortage of qualified obstetricians, exacerbated by a shortage of trainees, and this is further worsened by the RCOG recommendation that consultants should cease to provide out of hours emergency labour ward cover after the age of 55. Thus any suggestion that labour ward cover will be enhanced under the current proposals is entirely misleading.

Statistics/data

Most of the statistics produced by the PCT are out of date and so flawed as to be potentially dangerous. This problem pertains to delivery numbers, place of residence and travel times.

Delivery numbers

In its consultation paper, Fit for the Future, West Sussex PCT has insisted on using anachronistic data pertaining to delivery numbers in the county from three years back. In effect, despite clear advice to the contrary, it continues to use data which is inaccurate and which grossly underestimates the number of babies delivered in the county. Along with most hospitals in the country, those in West Sussex have experienced major increases in delivery numbers over the course of the past three years. Indeed, at Worthing the increase has been in the order of 18%. In its consultation paper the PCT acknowledges that delivery numbers may change by 2016. However, the variance postulated in the consultation paper was exceeded even before the consultation paper was published. Based on annual data it is expected that c. 3,000 babies will be born in the Worthing maternity unit during the course of the 2007 calendar year; this is c.400 more than the figure which appears in the consultation paper. Unfortunately, the delivery numbers at other West Sussex hospitals have also been similarly underestimated thus rendering impossible any accurate assessment of patient need associated with the proposed reorganisation of services. In making the potentially unattainable seem achievable the PCT has sown the seeds for potential disaster as neither facilities nor staff are likely to be adequate following any reorganisation. The PCT has claimed that it used the most up-to-date audited figures available; it is difficult to comprehend why it could not have relied on the maternity registers in the various hospitals which go to inform official data. As such, the PCT, with minimal effort, would have been able to obtain the accurate current data necessary for comprehensive planning. Why it has deliberately chosen not to do so is disquieting. Nor is there any likelihood of a decrease or even stabilisation in delivery numbers due to the planned increase in housing in West Sussex.

Place of residence

Fit for the Future has estimated where patients are likely to go if the Worthing maternity unit were to close. The PCT suggests that 1510 of Worthing's 2587 deliveries (the actual value is 3000) would deliver at St. Richard's and that only 874 of the same 2587 would deliver at Brighton. The PCT does not stipulate where the remaining 203 babies would deliver. Again one may struggle to comprehend just how these estimates were derived or by using what formula. There follows a breakdown by postcode of the mothers who delivered at Worthing during the six months January to June, 2007. This is, of course lower than the number of babies delivered.

WORTHING DELIVERY NUMBERS AND SOURCE

JANUARY TO JUNE 2007

EAST of WORTHING

POSTCODE LOCATION NUMBER OF DELIVERIES

BN1 Brighton 25

BN2 Brighton 11

BN3 Hove 89

BN5 Henfield 12

BN41 Portslade 46

BN42 Southwick 41

BN43 Shoreham 116

BN44 Steyning 36

BN21 Eastbourne 1

BN7 Lewes 1

BN27 Hailsham 2

BN9 Newhaven 1

BN15 Lancing 136

TN22 Uckfield 1

RH10 Crawley 1

RH11 Crawley 1

RH12 Horsham 26

RH13 Horsham 29

TOTAL

575

AVERAGE PER ANNUM

1150

CENTRAL WORTHING AREA

POSTCODE LOCATION NUMBER OF DELIVERIES

RH14 Billingshurst 4

RH20 Storrington/Ashington 54

BN11 Worthing 205

BN13 Worthing 135

BN14 Findon 167

TOTAL

565

AVERAGE PER ANNUM

1130

WEST OF WORTHING

POSTCODE LOCATION NUMBER OF DELIVERIES

BN16 Rustington 92

BN17 Littlehampton 125

BN12 Goring 68

PO22 Bognor 3

BN18 Arundel 1

TOTAL

289

AVERAGE PER ANNUM

598

These figures clearly demonstrate that of Worthing's deliveries, 40% originate in Lancing and to the east of Lancing, 20% from Goring and to the west of Goring and a further 20% from the central belt. Women living just to the west of Goring are equidistant from St. Richard's and Brighton Hospitals and it would be reasonable to expect that most of the women who reside to the west of Goring would choose to deliver at St. Richard's Hospital. It is equally certain that that 40% of women living to the east of Lancing who reside an average of 6 miles from Brighton and 26 miles from Chichester would choose to deliver at Brighton. Women in the central area living on average 11 miles from Brighton and 21 miles from Chichester would be expected to deliver at both hospitals with the majority opting to travel to Brighton. Why so? Distance predicates that most women would wish to deliver at the nearer hospital. The PCT argues that their statistics show that women are prepared to travel to avail of a good quality service. This is true but only up to a point for while Worthing, as per the above data, accepts several hundred women a year from within Brighton's nominal catchment area, nonetheless, many of the women concerned live just as close to Worthing as they do to Brighton. If one judges the matter rightly one would just include those women living in BN1, BN2 and BN3 postal areas who would appear to have transferred to Worthing from Brighton by choice. Yet, things are not so simple: Many of these women live no more than 8 miles from Worthing - a distance far removed from those which women may have to travel following the proposed changes; more tellingly, many have delivered at Worthing by necessity due to the frequent closures of the Brighton maternity unit.

In fine, the PCT's assessment of where women who now deliver at Worthing would go in the event of the units closure in intrinsically flawed, unrealistic and in planning terms downright dangerous. Similarly, clinicians in East Sussex have stated that they anticipate a much higher number of mothers to be redirected to Brighton from Princess Royal and Eastbourne Hospitals than those estimated by the PCT. Consultant estimates of the likely patient flows to Brighton are as follows:

Worthing: 2000-2200

PRH: 1000-1500

Eastbourne: 700-1000

With Brighton numbers currently at c.3500, the Brighton unit would have between 7000 and 8000 deliveries.

This in itself is not a recipe for disaster as long as the scale of the problem is appreciated, the will is there to surmount it and the finance available to enable it. Regrettably, these three factors are lacking.

As per its consultation paper the PCT estimates that Brighton will have 5227 deliveries under the current proposals for a closure of Worthing. The ultimate result would be that instead of having to deal with c. 5227 deliveries as postulated by the PCT, the Brighton unit would, having been prepared for this number in terms of facilities and staffing, find itself faced with having to cope with almost 2,000 more deliveries than its structural and staffing facilities would warrant. One needs to recall the eventualities at Northwick Park generated under similar circumstances (vide infra).

Perinatal data

One of the postulated reasons behind the proposed change is the improvement in perinatal outcomes. Yet the changes are poised to wreak havoc on a system of care which currently operates at the highest standard. This could not be exemplified any better than at Worthing:

the CEMACH report of April, 2007 documents Worthing as having the 14th lowest stillbirth rate of any hospital in the country and this despite treating a moderately high risk population; the same report documents Worthing as having the 13th lowest neonatal mortality rate in the country.

The report 'Mothers and babies - trends in West Sussex ( a 20 year survey ) published in 2001 by the West Sussex Public Health Observatory has demonstrated that over a 20 year period, Worthing, of all West Sussex hospitals, had the lowest percentage of low Apgar scores and the lowest incidence of fetal distress.

The effects of deprivation

Current evidence all supports the contention that health outcome is significantly affected by social deprivation. While this applies to healthcare in general in West Sussex where the life expectancy of the most deprived is 13 years less than the most affluent, it applies equally when it comes to the provision of maternity services. The Confidential Enquiry into Maternal and Child Health is published annually. In its April, 2007 report it identified maternal age under 20 as being a leading cause of perinatal mortality. It also identified social deprivation as being associated with a twofold increase in perinatal mortality.

In West Sussex we are fortunate in having long term data pertaining to social deprivation and maternity care. The report 'Mothers and babies - trends in West Sussex (a 20 year survey) published in 2001 by the West Sussex Public Health Observatory has identified the following:

of all of the wards in West Sussex, 8 of the 10 highest teenage pregnancy rates are in Worthing Hospital catchment area. The same report identified that of all the local authority districts in West Sussex, the three highest for maternal smoking are Arun, Adur and Worthing respectively.

The report further comments on birthweight: "National data demonstrates the relationship between infant mortality and birthweight - the higher the birthweight, the lower the mortality rate - except for very large babies. Birthweight also reflects the health experience of the mother during pregnancy, as maternal illness, poor nutrition, smoking and excess alcohol consumption are all major factors associated with low birthweight. In addition, maternal alcohol consumption and drug abuse remain major health problems in pregnant women delivering at Worthing and the number of women delivering at the hospital who are unable to speak any English is rising.

It is abundantly clear that in order to reduce the effects of deprivation, health services including hospital care must be readily accessible by the same deprived populations for whom lack of transport may further exacerbate the problems of healthcare access. As such, major facilities must be situated close to the centres of deprivation. Such an approach is supported by all of the recommendations from professional organisation such as the Royal College of Obstetricians and Gynaecologists as well as from statutory bodies such as CEMACH and governmental reports such as 'Every Child Matters'. Indeed the government has just recognised the importance of deprivation on maternal well-being and in doing do is to give a grant of two hundred pounds to every pregnant woman to try to ensure adequate nutrition during pregnancy. How anomalous then, that West Sussex PCT should propose options which would involve the closure of the Worthing maternity unit, the largest in West Sussex, and the one which deals with the most deprived populations in the county. Both of the proposals of Fit for the Future which would see the closure of Worthing maternity unit close run directly contrary to accepted recommendations and good practice and would result in the removal of established services from the most deprived and vulnerable groups in West Sussex.

Effect on specialist services

The suggestion by the PCT is that a major hospital would have more specialist services to offer and that women would need to travel to London less than at present. What the PCT has entirely failed to assess, let alone acknowledge, are the specialist services already available at Worthing both in Obstetrics and Gynaecology including tertiary referral services. In obstetrics these include fetal and maternal medicine, combined clinics for diabetic women and high risk pregnancies. In gynaecology they include urogynaecology and minimal access surgery. Indeed Worthing is recognised as a national centre for the surgical management of advanced endometriosis by the BSGE and has produced world-leading results in this area receiving tertiary referrals from the UK and abroad. There are also established cancer networks operating between Worthing and Brighton Hospitals which have produced excellent results for patients. All of these services risk fragmentation under the current PCT proposals.

Fit for the Future proposals and the Healthcare Commission enquiry into maternal deaths at Northwick Park

In 2005 the Healthcare Commission launched an investigation into a series of 10 maternal deaths at Northwick Park which occurred following a merger between Northwick Park and the Central Middlesex maternity units. The number of babies delivered at Northwick park increased from 3537 in 2002 to 5028 in the financial year 2004/05. Northwick Park catchment area includes Brent which is one of the most deprived areas in the UK. Indeed, the Healthcare Commission has recommended that the lessons learned from Northwick Park should be taken into account in future mergers of services. Unfortunately, there are many similarities between the Healthcare Commission's analysis of the underlying problems which led to the Northwick Park tragedy and the plans being drawn up by West Sussex PCT in the event of a closure of the Worthing maternity unit. These include:

- Maternity services will not have the necessary systems or staff with appropriate skills to manage high risk cases

The PCT has failed to consult clinicians about the appropriateness of the proposed model. Rather than doing so, it has asked clinicians to determine what would be required to manage a maternity unit catering for c.4,000 deliveries p.a. Clinicians were denied the opportunity to comment on the suitability or safety of this particular model for the needs of the women of West Sussex

- Poor planning in relation to the transfer of maternity services

The PCT has published statistics which are out of date or grossly inaccurate making the attainment of the impossible appear achievable. The planning of the PCT in relation to delivery numbers, place of residence and likely patient flows is so flawed as to make realistic planning impossible. This is the kernel of the problem from which would grow many of the dangers which follow

- Inadequate planning for provision of facilities

As described above, any plan for the provision of facilities to delivery just over 5000 babies at the Royal Sussex County Hospital is unrealistic and fails to take in account current delivery numbers, the residence of women or, indeed, patient choice

- Inadequate provision of midwives with reliance on locums and agency

Problems are inevitable as for the planning for the provision of facilities. In addition, there has been no assessment, formal or informal, of the likely compliance of midwifery staff with the proposed changes (vide infra)

- Inadequate provision of consultants and junior staff with reliance on locum and agency staff

Problems are inevitable as for the planning for the provision of facilities. In addition, there has been no assessment, formal or informal, of the likely compliance of medical staff with the proposed changes (vide infra)

- Hospitals care for deprived populations

Worthing Hospital currently cares for a high risk population and has developed services to accommodate these needs. The current proposals risk the fragmentation of these services and the removal of specific services from those with the most and specific needs. Thus, the proposals run contrary to the recommendations of governmental agencies and relevant professional bodies

- Services unprepared for a higher than anticipated number of deliveries

It is self-evident that, based on the gross inaccuracies inherent in the PCT statistics and data, services will be inadequate to meet the needs of pregnant women in West Sussex

- The merger of Northwick Park and Central Middlesex Hospitals saw many staff refuse to transfer their employment and going elsewhere. There has been no consultation with any staff or survey of any kind in order to determine what they would do in the event of transfer or termination of services at the hospital where they work. There is no reason to expect that what happened at Northwick Park would not happen at Worthing also.

- Refurbishment plans were insufficient

Inaccuracies and omissions in current data and unit capacities make any realistic planning impossible

- The concerns of staff were ignored

The concerns of senior medical staff have been ignored and the activity of the CRAG group for maternity deliberately restricted to the determination of what would be required to manage a delivery unit for 4000 babies p.a. The concerns and reservations of clinicians do not appear in the consultation document.

Conclusions

Proposals have been put forward by West Sussex PCT for the reorganisation of maternity services in West Sussex. Two of the three options which it has proposed involve the closure of the Worthing maternity unit. The stated reasons driving the change are invalid at least in the context of Worthing. The process lacks clinical support. The data used by the PCT to plan the changes is intrinsically flawed and unreliable as a basis for service development. So similar is what is now happening in West Sussex to the situation which underlay the Northwick Park tragedy, that the process may be described as a blueprint for disaster.

Bibliography

'¢ A Blueprint for the Future. RCOG, 2000.

'¢ Healthcare Commission enquiry into 10 maternal deaths at Northwick Park, 2005

'¢ Learning from Litigation. Manchester: Victoria University of Manchester, 2004. Available from http:/www.mbs.ac.uk/research/public-policy-management/projects-publications.aspx

'¢ Medical Workforce in Obstetrics and Gynaecology. 17th Annual Report. RCOG, May, 2007.

'¢ Modernising Maternity Care - a commissioning tool for England. Department of Health 2006.

'¢ Mothers and Babies - Trends in West Sussex 1980-1999. The West Sussex Public Health Observatory, 2001

'¢ Our Health, Our Care, Our Say. 2006. Dept. of Health, London:TSO.

'¢ Perinatal Mortality 2005. CEMACH 2007

'¢ The European Working Time Directive and Maternity Services. RCOG 2004.

'¢ The Future Role of the Consultant. RCOG Working Party Report, December 2005