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On 29 Mar 2014, at 19:19, Macfarlane, Alison <[log in to unmask]> wrote:

It looks like the argument is that as the Lewisham obstetric unit was apparently saved by 'shroud waving, we need some research to 'prove' that freestanding midwifery units are unsafe. If they had applied the NICE guidelines and the results of Birthplace, the numbers of women eligible to choose midwife led care would have been higher, but that would have still left plenty who needed the obstetric unit.


From: Tony O'Sullivan <[log in to unmask]>
Sent: 29 March 2014 01:07
To: Macfarlane, Alison; Anna Athow; Martin Rathfelder; Caroline Molloy
Cc: Brian Fisher
Subject: Re: blog by john lister on 'London's NHS at a Crossroads' report
 
This is an important debate which will be recurring again and again. Hope you don't mind my joining in. I'm a paediatrician at Lewisham Hospital and Community combined services and we've just been through all this. 
The context in which we defend the NHS is highly political and some arguments are used for political motives. The TSA for South London Healthcare NHS trust at one point discounted the option of reducing the full integrated maternity unit (4200 births in 2012) to a midwife-led unit on grounds that it was not viable. ( He had decided to shut down Lewisham Healthcare NHS Trust's acute and maternity services as the economic solution to financial problems in the neighbouring trust.) Selecting 'low-risk' pregnancies in an inner city environment amongst the highest in deprivation, obesity, diabetes, non-English speaking, late booking, teenage pregnancy, substance abuse, STD rates etc is a dangerous concept. Removing first pregnancies and other risk factors, the TSA estimate was 10% and our most experienced obstetrician estimated 12%. That is 420-500  births, generously 1.4 births per day. That was costed as requiring a subsidy from the CCG of £1m per year as it would not be cost effective. 
When the decision to close Lewisham was pre-determined on financial grounds, and £1m seemed small fry, the TSA brought back this proposal after his team had ruled it out. It was a surprise proposal in his Final Report January 2013. This was clearly for political not best and safe clinical practice reasons, nor for patient choice.
Whilst I agree with Alison that in general, abstracted from specific contexts, midwife-led units cannot be said to be unsafe, in general; in practice in specific settings, and in the absence of relevant data, it is clearly a step backwards to downgrade the existing integrated maternity unit, remove on site obstetric care and diminish choice. Advocates for this were politically motivated to see through a hospital closure that was unlawful and unjustified. 
It comes down to risk analysis and the risk of delivery in Guildford or Maidstone is different from the risk in inner city London. Risk would have to be compared between Lewisham with a combined unit against Lewisham as Midwife-led alone. The TSA was loose and free with his lack of facts and modelling of transport times eg should a woman suddenly haemorrhage in labour in the midwife unit, and be required to go by ambulance to Woolwich or Kings. Ruth Cochrane eloquently spoke of this at our Commission of Inquiry before we won in court at Judicial Review

We have to be careful about what we argue for clinically, and be aware of the social context and indeed the political context. At a time when NOT one unit in London was offering 24hour obstetrician presence in Labour Ward ( and Lewisham was above average in consultant cover) the TSA was arguing that this was a reason to close Lewisham's obstetric unit. 

We forced the government to back down.
Not against change, but if has to be for the better and demonstrably so.

Tony O'Sullivan

From: Martin Rathfelder [mailto:[log in to unmask]] 
Sent: 27 March 2014 11:00
To: Brian Fisher
Subject: Fwd: Re: blog by john lister on 'London's NHS at a Crossroads' report

 

 

-------- Original Message --------
Subject:
Re: blog by john lister on 'London's NHS at a Crossroads' report
Date:
Thu, 27 Mar 2014 10:53:14 +0000
From:
Macfarlane, Alison <[log in to unmask]>
Reply-To:
Macfarlane, Alison <[log in to unmask]>
To:

Dear Anna,

 

That may have been written before publication of the Birthplace study, a large prospective study which didn’t show that ‘alongside’ midwifery units are safer than freestanding units. https://www.npeu.ox.ac.uk/birthplace  The point is that that freestanding units are set up with arrangements for transfer when needed and the consultant unit has to be still open for them to transfer to. Also, midwives who have always worked in consultant units may not have the confidence and skills to work in a freestanding unit, let alone develop the type of care they can offer. It isn’t difficult to find examples where so-called freestanding midwifery units have been set up as a sop in the aftermath of the closure of an obstetric unit and have failed. Kidderminster is a prime example.

 

At the other end of the scale, recent research from Epicure shows that the tiny minority of extremely preterm babies do better if they are transferred antenatally to units with a level 3 neonatal unit, but that doesn’t mean that all babies should be delivered in maternity units with such a high level of neonatal intensive care.http://fn.bmj.com/content/early/2014/03/06/archdischild-2013-305555.full.pdf+html

 

Maternity and neonatal services have been trying to develop networks in order to offer appropriate care with good arrangements for transfer if needed. This involves collaboration between a range of units rather than competition between a small number of huge units, so it is completely undermined by current government policy under the HSC Act.

 

Alison Macfarlane

 

From: Anna Athow [mailto:[log in to unmask]] 
Sent: 26 March 2014 18:56
To: Macfarlane, Alison
Cc: [log in to unmask]
Subject: Re: blog by john lister on 'London's NHS at a Crossroads' report

 

Dear Alison, 
When they came to remove the consultant led obstetric unit at Chase Farm, which has about 4000 deliveries a year and an excellent record, there was the sop of the possibiity of a midwife led unit, to salve the blow.
  ( The same sop is being suggested at Mid Staffs incidentally as it is being dismantled. )

 

The Chase Farm midwives themselves wrote a critique of this proposal and said it was not safe. The problem is that even with the best antenatal sifting, every now and then the expected normal delivery is not normal and requires emergency obstetric care.
In their view, these midwife led units should only exist within running distance of a proper consultant led obstetric unit.  I think they are rigat even with the best antenatal sifting, every now and then the expected normal delivery is not normal and requires emergency obstetric care.
In their view, these midwife led units should only exist within running distance of a proper consultant led obstetric unit.  I think they are right.
 bW
 Anna
On 21 Mar 2014, at 11:45, Macfarlane, Alison wrote:

It was unfortunate that the article in the Evening Standard article on this report led on maternity services with an unsubstantiated claim that midwife-led maternity units are unsafe. In particular, it claimed that freestanding units were unsafe compared to midwifery unit on the same site as obstetric units. This is what the RCOG wants to believe, contrary to evidence from the Birthplace Programme https://www.npeu.ox.ac.uk/birthplace This showed that, for women without complications, planning to give birth in a midwifery unit is as safe for the baby as giving birth in an obstetric unit, and has lower rates of intervention for the mother and is more cost effective. Most midwifery units have a different philosophy of care from obstetric units This has been shown in a considerable body of recent research on midwifery units, including a freestanding midwifery unit in Tower Hamlets. It is completely wrong to describe them as ‘downgraded’ maternity units.

 

While we could do with more midwifery units, they are obviously not for women with complications who need obstetric care. Plans to withdraw and centralise obstetric care are a separate issue. There has been no research to compare obstetric units by size and no evidence that larger obstetric units are better or safer than smaller ones. Given a series of enquiries about problems in huge centralised units, surely it is time some research was done, given threats of centralisation. It is a pity the report didn’t call for this research, instead of attacking free-standing midwifery units.

 

Alison Macfarlane

 

From: Caroline Molloy [mailto:[log in to unmask]] 
Sent: 21 March 2014 08:51
To: [log in to unmask]
Subject: blog by john lister on 'London's NHS at a Crossroads' report

 

Of interest even to non-Londoners!

 

 

yours
Caroline

 

(ex-Londoner)

 

-- 
mobile 07931 302507 / tel 01453 753700
@carolinejmolloy

 



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