As I commented earlier this week a powerful consensus of clinicians and patients’ groups is emerging all arguing, for reasons of safety, for much greater centralisation of some hospital services.
The argument made by the RCOG, as with the other Royal Colleges, starts with the clinical case for safety. The case is based upon the difference in safety outcomes that occur when a specialist is in charge and when they are not. This is not to say that all births should take place through a specialist but it is to say that a service that has a specialist at hand is safer.
The problem for the maternity services is that having a baby is, for most mothers, not something that can be planned down to the nearest hour. 50% of all births take place ‘out of hours’. That is outside of the office hours when all units have a specialist present.
This 50% of births is an unsurprising figure. But it is alarming if you analyse patient safety incidents by 4 hourly time periods. The time spans during which the greatest number of incidents of fetal distress occur are between midnight and 4 am and between 8pm and midnight.
If this is the time when there is no specialist at the unit there is a problem.
As the report says,
“ The lottery of time of birth for women and their babies should not be accepted as the status quo by commissioners, policy makers, providers and by women themselves” (para 109)
The offer that the NHS makes to the public is one of security – not of a lottery.
In one sense the Royal Colleges are used to making the case that their members add safety but what is radically different about this argument, and some of the others being made by the Royal Colleges is that they do not conclude this argument by saying that there need to be more consultants. They recognise that there needs to be a change in the way in which specialists work – with much more team working.
“Responding to financial restrictions in the health service will require more efficient use of staff and innovative ways of working, particularly where investment in an individual, such as an obstetric and gynaecological specialist is substantial.” (para 118)
This therefore is not a ‘bid’ for more specialists. There is recognition that there is no more money, meaning that we need an argument for using the staff we have in a very different way to create better safety.
“The NHS more than ever requires a flexible obstetric and gynaecological workforce with the ability to respond to change. In order to improve patient safety and women’s experience, it needs a workforce of highly effective generalists with a smaller number of highly specialised individuals to care for those women with very complex needs.” (para 168)
and this need for change will not simply happen without changes in the locations that people work,
“All tomorrow’s specialists will need to work in teams with different responsibilities, it will be necessary for employers to reflect this contractually. As more specialists enter the workforce, and a greater proportion of care is delivered by this group, the service will need to develop different ways of medical staff working together in order to provide the comprehensive care over the 24 hours necessary. This may lead to further negotiations on increasing flexibility within the consultant contract for these different levels and types of work.” (paras 254 and 255)
Therefore the argument goes
- Babies come at inconvenient times and you need 24 hour cover by specialists
- This will need a much more flexible, team based, workforce
- This will need changes in the nature of the contracts with some staff working for networks and not just one set of buildings
- It will be necessary to concentrate those teams into a smaller number of specialist units
The main argument against this is that it is hard to bring about the safer centralised unit.
Sooner or later the failure to do this hard work, and leave maternity as a lottery for mothers and babies, will be seen as the scandal that it is.
A personal note
Throughout the three and half years of writing this blog I have consistently argued for a more plural approach to providing services for NHS patients. I have argued for a larger number of private and third sector organizations for the NHS to choose from in providing health care and supporting services for NHS patients and staff.
Throughout this period the only private sector company that I have had any governance relationship with has been the company that I set up to trade as a management consultant – Paul D Corrigan Ltd of which I am a director.
I am now going to join the board of a small number of health care organizations. To ensure transparency I will announce each time I do this on this blog.
To that end I announce today that I am about to become a non-exec director of Quality Practice. This is an organisation that will work to improve the best of GP practices by setting up a network of those best practices to work together to create rapid improvement.
“Quality Practice is a national federation of high quality practices with members drawn from the UK’s best General Practices: a national network of practices that is committed to excellence and to driving up the quality, development and sustainability of General Practice.
Quality Practice, through its’ community of excellence, reduces variation and makes the practice’s high quality of care, its’ competitive advantage for the patient’s benefit. Through its national scale and expert resources, Quality Practice enables its’ members to compete effectively with multi-million pound businesses and Foundation Trusts, to draw in new income. Unity promises strength in numbers to deliver shared support services, group purchasing, representation and influence.
Practice ownership in Quality Practice Ltd brings shared commitment and shared rewards without loss of the boutique character of the individual general practice.
Quality Practice aims to set the bar to which others aspire, to deliver the best of health.”