Dear Mr. Kershaw,
Proposals for reorganization of maternity services at University Hospital Lewisham
As part of the review of healthcare provision in South East London, you have made several recommendations that impact on the provision of care at University Hospital Lewisham. Key among them is the recommendation to close the Accident and Emergency department at University Hospital Lewisham (UHL) and the consolidation of emergency care at the Queen Elizabeth Hospital (QEH) site in Woolwich.
This will lead the cessation of the provision of emergency surgery and acute medical admissions at University Hospital Lewisham. It is also proposed that with the closure of the A & E and the proposal to move complex elective inpatient surgery to the Queen Elizabeth Hospital, there will be no provision for intensive care beds at University Hospital Lewisham.
Against this background of the proposed extensive changes to other acute services, we wish to comment on the proposals for the provision of maternity services at University Hospital Lewisham.
The maternity service at University Hospital Lewisham caters to a multiethnic population in a borough with areas of significant deprivation. The unit delivers approximately 4000 babies a year, with just under a quarter of these births happening in the purpose built co-located midwifery led unit at UHL. The maternity population at Lewisham is considered high risk with a significant proportion of the women requiring expert obstetric input during pregnancy and birth, including high rates of teenage pregnancies and births in women over the age of 40. Using the Birthrate plus process for calculating the intensity of care required in labour, it is estimated that around 55-60% of women delivering in this unit fall into the categories indicating the highest risk. This would equate to approximately 2400 births per year.
The draft recommendations contained in your report outline 2 proposals for the reconfiguration of maternity services. These are to have a 4 site model in which the maternity unit at Lewisham would close with the expansion of the unit at Woolwich and the 5 site model where a downgraded maternity unit would be retained at Lewisham undertaking “lower risk obstetric led births”.
As a consultant body, we have serious reservations regarding the proposals to either close the maternity unit or have a downgraded maternity unit at Lewisham without adequate support from other acute specialities. We feel that these models are unsustainable and unsafe for the reasons detailed below.
1. Low risk obstetric led unit
This is a novel (and probably oxymoronic) concept that an obstetric led unit can be a low risk one. Births considered to be low risk are managed under the midwifery led model of care and births considered to be high risk are managed under an obstetric model of care.
The fundamental principles of organisation of maternity care should be quality and safety. Childbirth is inherently unpredictable and any maternity service should have the flexibility to manage the acute and often predictable emergency. Patients assume that all services provided by the NHS are inherently safe and that safety is a necessity, not a choice! (Maternity services: future of small units. RCOG, 2008).
As clinicians, we are constantly reminded that the level of risk fluctuates throughout pregnancy and birth and cannot be considered a static state. While it is possible to identify certain pregnancies as being high risk during the antenatal period, a significant proportion of the risk (and subsequent litigation) arises from events that occur during labour that were not predictable antenatally.
Unlike stand-alone midwifery units that have been well established, we are not aware of instances where maternity services have been reconfigured to have a “stand-alone obstetric unit”. The way services are configured should support choice as a principle. However, as the RCOG points out, choice may have to be influenced by the availability of services and aligned to the level of complexity and risk. As contributors to the RCOG document “High Quality Women’s Health care: A proposal for change” noted- “there will be a need to be mindful that choice needs to be realistic, balancing wants (and sometimes needs) with what is affordable and what resources can be made available”, “it’s not just about extending choice; it’s about ensuring that services are in place to deliver the best possible outcomes for women” (High Quality Women’s Health care: a proposal for change. RCOG, 2011).
We feel that this concept of “lower risk obstetric- led births” is a nebulous one and does not reflect the realities of clinical practice.
2. Redistribution of high risk cases and impact on number of deliveries at UHL
If we were to somehow manage to define what constitutes a “low risk obstetric birth”, it follows that the high risk pregnancies and births would need to be transferred to the “high risk obstetric unit”.
As we have outlined earlier, it is estimated that around 2400 births would be considered high risk. While it is possible that some of these may be managed in the “low risk obstetric unit”, the vast majority of these would need to be delivered in the high risk unit.
If all of these were to be retained within the new organization locally, this would mean a significant increase in the number of births at the QEH site. This would entail a significant expansion in the physical capacity of this site as well as requirements for additional medical staff to be present to deal with the increased births. In addition, the increased travel time to the acute site and difficulties in accessing the QEH site by public transport for these pregnant women and their family should be taken into consideration .
However, given patient flow pathways explored in the “Picture of Health” consultation, it is likely that a significant number of these patients may choose to transfer their care to either King’s or St. Thomas’s Hospital and the impact of a further increase in high risk births in these units must be taken into consideration.
The redistribution of these high risk cases would mean that the unit at Lewisham would have far fewer births than it does currently unless there is a corresponding redistribution of low risk cases locally. In addition, as the births would be low risk, they are likely to be predominantly midwifery led in the co-located birth center or on the main delivery suite.
If there is a significant reduction in the number of obstetric led births at UHL, it would make it very difficult to provide adequate and sustainable medical cover for this site in the long term.
Currently, UHL ranks highly among trainees for the quality of training that it provides. If the unit was converted into a “low risk unit”, it is possible that we would lose our deanery allocation of trainees as we would not be able to provide them with enough experience and the breadth of knowledge and skills that they require. This in turn would make it very difficult (if not impossible) to provide 24/7 obstetric cover as the unit would be reliant on locums/ speciality doctors who would be very difficult to recruit and retain for a “low risk” unit.
3. Impact on anaesthetic and neonatal staffing
Safer Childbirth (2007) states- “for any obstetric unit, there should be 10 consultant anaesthetist programmed activities or sessions per week, to allow full working hours consultant cover”. In addition, the Clinical Quality Standards for Maternity endorsed by NHS London specify that obstetric units should have access 24/7 to a supervising consultant obstetric anaesthetist who undertakes regular obstetric sessions. In addition, these standards specify that there must be a separate consultant anaesthetist for elective section lists.
These standards are difficult enough to achieve in a busy unit with adequate workload (UHL achieves this) but would not be achievable in a “low risk” obstetric unit as the workload could not justify the number of consultant anaesthetists required.
The neonatal unit/ special care baby unit at UHL is a level 2 unit but due to a long history of managing babies with surgical conditions and extremely premature infants, is commissioned to look after babies > 25 weeks gestation. Converting the UHL maternity unit to a low risk unit would mean that high risk pregnancies (including preterm births) would be managed at the QEH whose special care unit will be unable to look after these babies. This may mean that these babies (and their mothers) may need to be moved to either St. Thomas’s or Kings unless the special care unit at Woolwich is significantly expanded and upgraded to deal with these babies.
In addition, a further downgrade of the neonatal unit at Lewisham would have significant repercussions on the provision of neonatal care in the SE London neonatal network and impact on the ability to retain staff and trainees without an adequate workload.
4. Lack of support from acute services and ITU to a “stand alone” obstetric unit
We are particularly concerned regarding the proposal to establish an obstetric service without ready access to other acute services particularly ITU. Consultant- led services should have adequate facilities, expertise, capacity and backup for timely and comprehensive obstetric emergency care, including transfer to intensive care (NSF for Children, Young people and Maternity- DH, 2004).
In addition, the Clinical Quality Standards for NHS London state that obstetric units should have access to interventional radiology services as well as emergency general surgery support 24/7 (NHS London 2011). While UHL does not have interventional radiology on site, there has been an arrangement to transfer high risk patients to hospitals with interventional radiology when required.
The consolidation of emergency care, complex elective surgery and high risk obstetrics at the QEH site will have a significant impact on the demand for interventional radiology and ITU beds. Unless there are definite proposals to expand these services (given the proposals to close the ITU at UHL), there are likely to be issues with capacity at QEH, which will impact on the ability to transfer patients from the stand-alone maternity site at UHL.
In addition, the inability to obtain opinions from physicians and general surgeons in a timely manner will have a detrimental impact on the care of pregnant women admitted as emergencies to the stand-alone maternity unit. This will necessitate the transfer of these women to the QEH site to obtain the multi-professional input required to provide optimum care.
In addition, it was initially suggested that the “low risk obstetric unit” would not have a 24 hour blood bank on site and that samples would be couriered to the acute site and blood products collected from there. Any obstetric unit must have 24/7 access to transfusion services as bleeding in obstetric patients can be unpredictable and can rapidly become life –threatening. Several confidential enquiries into maternal deaths have highlighted the risks associated with not having on site transfusion services for an obstetric unit.
In our opinion, given the complex health issues of the local population and the nature of life threatening emergencies that can develop in pregnant women, we do not think that an obstetric unit isolated from other acute services is a safe or sustainable clinical service.
5. Lack of continuity of care for high risk patients
It is proposed that antenatal care would occur at both sites in the 4 site and 5 site models. The consultant obstetricians at UHL have considerable experience in management of high risk pregnancies and would expect to continue to look after these patients antenatally in both models.
However, if a 5 site approach is chosen with UHL a “low risk obstetric” site, these high risk patients would need to travel to QEH to deliver their babies. Unless there is cross site cover by consultants for intrapartum care, these women with complex pregnancies will have to be delivered at QEH without the input or supervision of the clinician who has looked after them throughout their pregnancy.
It would be difficult for the clinicians to provide cover for intrapartum care at QEH while also having to contribute to the consultant cover required for the UHL obstetric led unit. This would lead to a fragmentation of care for these high risk patients with dissatisfaction for both patient and clinician and possible adverse outcomes.
This scenario describes the exact situation which the RCOG in its report warns against- “a woman having received expert care antenatally, enters a lottery, where for lack of specialist obstetric cover, she is transferred during labour to a unit where specialist cover is available but where she is not known, and has minimal continuity of care” (Tomorrow’s specialist. RCOG, 2012).
For the reasons elucidated above, we feel that the proposal to have a “low risk obstetric unit” at University Hospital Lewisham is unsustainable, unsafe, not economically feasible and does not provide the quality improvement that the reorganization is supposed to deliver.
We believe that the only realistic option is as follows:
Maintain a consultant led obstetric service at UHL with appropriate back up from other clinical specialities with redistribution of high risk patients
In this option, the consultant led obstetric service at UHL would remain on site but would not be the “low risk obstetric unit” as envisaged in the proposal. The unit would provide the full range of obstetric services with appropriate arrangements for on call availability of physicians, surgeons, intensive care and transfusion services to support the maternity unit.
It may be reasonable to consider the transfer of care of some women with high risk maternal conditions (eg placenta praevia/ accreta or significant maternal illness) to the QEH site where there is availability of interventional radiology and specialists in other disciplines available 24/7.
As UHL has a long established fetal medicine service, under these arrangements, UHL would become the site where women at high risk for preterm births, multiple pregnancies and fetal conditions would be cared for by the fetal medicine team antenatally and remain on site in the higher level NICU at UHL for neonatal care.
This proposal has the advantage of retaining choice for the women locally, allowing the co-located midwifery led unit to continue and maintaining and enhancing the services on both sites. With this approach, the combined service would provide the whole gamut of obstetric care with slightly different areas of expertise- fetal medicine at UHL and maternal medicine at QEH.
This proposal would minimize the need for transfer between sites as well as allowing enough flexibility and capacity in the maternal and neonatal networks to deliver an excellent service locally. In addition, there would be minimal additional capital resources required to enhance capacity at the acute site to cope with additional numbers of births.
This will necessitate a rethink about the provision of support to the maternity unit at UHL from other clinical services including intensive care, without which this proposal would not be viable.
This letter is the unanimous opinion of the consultant obstetricians at UHL who have served the local population of Lewisham for many years. We ask that these opinions be given due consideration when deciding the preferred option for maternity care for our patients.
Yours sincerely,
Consultant Obstetricians and Gynaecologists
University Hospital Lewisham
References
1. Centre for Workforce Intelligence (2011). Shape of the medical workforce: informing medical training numbers
2. Department of Health (2004). National Service Framework for Children, Young People and Maternity Services: Maternity services.
3. London acute emergency and maternity clinical quality standards
4. Office of the Trust Special Administrator (2012). Securing sustainable NHS services: Draft report
5. Rowe RE, Fitzpatrick R, Hollowell J, Kurinczuk JJ (2012). Transfers of women planning birth in midwifery units: data from the birthplace prospective cohort study. BJOG; 119(9): 1081-90
6. Royal College of Obstetricians and Gynaecologists (2007). Safer Childbirth: Minimum Standards for the Organisation and Delivery of care in labour
7. Royal College of Obstetricians and Gynaecologists (2008). Maternity services: Future of small units.
8. Royal College of Obstetricians and Gynaecologists (2011). High Quality Women’s Health Care: A proposal for change
9. Royal College of Obstetricians and Gynaecologists (20129. Tomorrow’s Specialist
Dhiraj Uchil
Consultant Obstetrician and Gynaecologist,
University Hospital Lewisham
London SE13 6LH
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