So what is going on with Maternity at the end of 2017?

We write this from the standpoint of the campaign to Save Liverpool Women’s Hospital but in reality it is a much wider issue

Liverpool Women’s hospital is a large maternity hospital which also provides gynaecological care and a range of other services .

In this analysis of the issues facing NHS users, we are focussing on the maternity aspect but start with the wider context. This sia first draft of an article we are likely to amend

Context

The UK is a very rich country. Far poorer countries spend a greater proportion of their wealth on health.

The NHS was founded and ran for decades as a service

funded directly from taxation,

publicly provided,

free at the point of need,

providing the best available treatment

and

as a comprehensive service so the overwhelming majority of the population used it as their health care.

What is happening now?

1. The NHS does not get enough money from the government. The UK uses less of its annual wealth (GDP) to pay for health than other advanced countries do. This is policy not accidental.
2. The NHS is a very cost efficient way of organising health care but these efficiencies cannot compensate for the overall lack of funds
3. Large parts of the NHS funds from the government are diverted from patient care to pay for Capital building costs through PFI
4. Staff have worked way beyond their stated duties to stop the service crashing, but this is unsustainable long term. It is damaging for staff and patient care. Staff wages and pensions have been deliberately held back
5. The internal NHS market created under Labour Government has also proved very wasteful of money and of staff time. The creation of Trusts to run hospitals has made vital cooperation between hospitals very expensive and distorted staffing patterns.
6. Attempts by hospitals to share services have themselves been complicated by privatisation, and the breaking up of services into so called discreet parts, for example bloods.In Liverpool one service covers the city but it is a stand alone company.
7. The structure created by the 2013 Act of Clinical commissioning Groups and bundling services into commissioned packages has proved very expensive
8. The use of private companies to deliver services has been more costly than NHS delivering in house, and scarce money has gone to private companies to make profit.
9. Staff planning has been disastrous. Not enough doctors, nurses, midwives have been trained, and the reliance on overseas recruitment for doctor’s nurses and other health care workers is now especially in the Brexit situation, caused serious problems. The withdrawal of bursaries is likely to make this worse. There are not sufficent midwives coming through to replace those retiring and leaving the profession
10. The plan for the NHS is called the Five Year Forward View, but even this is not a steady picture but one that is ever changing
11. There has been fluctuations in medical fashion between local general hospitals, specialist hospitals and big acute hospitals, The conversation about which is the correct model has been largely within professional circles without popular democratic involvement and has been circumscribed by available resources and dominant political views.
12. A propaganda point that we need fewer beds has proved woefully wrong.
13. Staff training appears to be coming more specialised and less general/ holistic
14. A new system is being developed which, it appears, might remove the trust CCG model and replace it with Accountable care systems. We use the term “it appears” because nothing has gone through Parliament ot other democratic processes, but that is the way it looks now.
15. The ACO system is designed for private profit, for rationed service not patient care
16. The parallel crises in funding for social care and elder care are also impacting on and being impacted on by NHS problems
17. The crisis in Local Authority funding is caused by the years of Austerity.
18. The ACOs appear to be bringing all three sectors into one underfunded and for profit umbrella
19. Co-payment is being suggested so people will pay more for less services. Free at the point of need is at risk.

So where does maternity fit into this?

Maternity is the most frequently used service in the NHS

Maternity is commissioned by CCGs

The maternity tariff, the money paid by the government to providers of maternity care is insufficient to provide the service our babies deserve

There is no future for the human race without babies. Babies are a huge source of joy to the world.

UK maternity services are certainly better than prior to the NHS, better than the USA but not as good as the best in the world, in terms of outcomes for maternal mortality and health or for the numbers of stillbirths and babies born with health issues

There is a shortage of midwives, obstetricians and neo natal nurses and linked professionals. Those we have are over-worked, in some cases to burn out. The replacement by newly trained staff cannot match those leaving.

The plan for Maternity is called the Maternity Review.

The maternity review describes enhanced choice for mothers in the kind of place they give birth, yet across the country places to give birth are being closed. Four hours travel in labour is seen to be safe. Closures of maternity provision is rampant.

For profit providers are being brought into the maternity service; locally one to one midwives are the private pioneers

The model for maternity supposedly employed in the NHS is set out in the Better Births

Huge priority is given in the words of the maternity review to mothers’ choices but that is in strong contrast to the reality of maternity unit closures across the country. You can choose if you want extra maternity classes but not to give birth in your own town!

Maternity vanguards, or women and children’s vanguards, do not answer to local structures but are super-imposed on them.

There is an ongoing problem of resources in the system and units temporarily closing to mothers in labour is becoming common. Such closures are short term while the mothers already there are delivered. What happens to the mothers in labour turned away is another story.

https://www.ifs.org.uk/uploads/publications/bns/BN215.pdf

“MUs also face pressure from daily fluctuations in demand. This is an inevitable feature of maternity service provision. Occasional closures are probably unavoidable, unless the NHS is prepared to operate with excess capacity for much of the time. However, the patterns we observe in closures by day of the week and month of the year suggest that, in some instances, closures could be foreseen and avoided through improved planning. Whether the costs of that improved planning and additional resources exceed the costs to mothers in labour of units closing is another question”.

The women in labour turned away face major problems

Prof Mary-Ann Lumsden, vice president of the Royal College of Obstetricians and Gynaecologists (RCOG), said the UK remained a safe place to give birth. “However, the pressures on maternity services are growing, which could compromise the experience for women and their families. Stretched and understaffed services also affect the quality of care provided to both mothers and babies,” she said. “Unit closures may be due to insufficient midwifery, obstetric or paediatric staff, as well as inadequate capacity. If the UK governments are serious about improving the safety of maternity services, these staffing and capacity issues must be addressed as a matter of urgency.”Lumsden said it could be distressing for a woman in labour being turned away from a hospital, although stressed that closures were “relatively unusual”. She said units worked as part of a network that could help provide alternative care at a nearby hospital – “though this is less than ideal”.The RCOG has produced recommendations on how units can have medical staff available at all times in the face of changed working patterns, reduced trainee availability and financial constraints.

For profit maternity providers, commissioned by the NHS but nor supervised within or employed by the NHS, are operating locally and nationally.

There are 4 major kinds of maternity provision around actual delivery of the baby;

• The Obstetrician/ Consultant led services in hospitals
• Midwife lead units alongside Obstetrician led services
• Stand alone midwife units
• Home births

Some home births are assisted by NHS midwives, some by midwives employed by for profit companies and some independent self employed midwives.

A few wealthy women give birth in private hospitals like the Portland in London

Liverpool Women’s Hospital

There is a determination to close one hospital in Liverpool as an infamous Panorama programme made clear.

LWH has and will have a problem financially until the maternity tariff is improved

The Merseyside Women’s and Children’s Vanguard appears to have the ability to make decisions not made by either the Liverpool Women’s Hospital or the Clinical Commissioning Group.

The Sustainability and Transformation partnership (?)for the Merseyside and Cheshire Region also impacts on decisions about maternity care, linking to the Vanguard

Issues to do with national staffing planning and consequent shortages, funding structures, Trust structures and the internal market impact on the LWH’s ability to employ consultants in all the fields they would like. Long term lack of investment in the neo natal unit and City wide problems with organisation of blood services all present problems

Current thinking seems to be that the Women’s hospital should be co- located with an acute hospital and the children’s hospital but given that Alder Hey Children’s Hospital and the Royal are new build hospitals such expenditure seems unlikely.

The Royal site which is favoured by the CCG and the LWH board is miles from the children’s hospital. We think its important that babies in intensive care are close to their mothers. We want to neo natal intensive care to stay at Liverpool Women’s Hospital. We are less keen on the idea of babies still needing care being discharged earlier from neo nate units

The Royal is also in a traffic hot spot, likely to get worse in terms of traffic as the Clatterbridge unit and the life sciences buildings come into operation on the site

The precious safe space element of the women’s hospital is largely ignored yet violence against women and children is a feature of our society and sadly of pregnancy.