How far is too far?

Abstract

Any change to local hospital services is unlikely to win instant acceptance, but plans to close the obstetric department at an Oxfordshire hospital have stirred up particularly strong feelings, as Adrian O'Dowd reports

Many acute trusts in England are currently considering reconfiguring some of their services. All over the country battle lines are being drawn as patients and doctors fight to save local hospitals, and in one case the dispute has become so intense that the health secretary has been called in to make a judgment.

One of several changes proposed by Oxford Radcliffe Hospitals NHS Trust is to close its consultant led obstetrics department at the Horton General Hospital in Banbury and replace it with a midwife led birthing unit, which would be the country's largest such unit. The trust argues that change has come because of long held concerns over the long term safety and sustainability of medical staffing of children's services at the Horton. It claims the changes overall will cost the trust an extra £593 000 (€893 000; $1.2m) annually, alongside a capital programme of £7m investment at the hospital, but those opposed to the changes have questioned the figures and believe cost cutting is playing a part in the trust's motives.

These plans have led to strong opposition, as shown by a four month consultation held last year, a petition opposing the changes signed by more than 15 000 people, and a statement condemning the move signed by 86 general practitioners.

In response to concerns, the trust set up two clinical groups (including general practitioners, consultants, and midwives) to consider the proposals in more depth. A stakeholder group including representatives of patient, community, and public bodies, however, rejected the clinical groups' support for the trust's proposals, saying they “represented a significant downgrading of access to services and a worsening of choice for women and children.”

The Oxfordshire joint health overview and scrutiny committee then considered the arguments, concluded the changes were not in the best interests of local people, and referred the issue to the health secretary.

Local concerns

The argument centres around the safety and efficiency of a midwife led unit compared with an obstetrics led unit because, should the change go ahead, the new unit will be 26 miles from the nearest consultant unit at the John Radcliffe Hospital.

The issue of distance was highlighted recently by a study in the Emergency Medicine Journal which found that the further seriously ill patients had to travel to receive emergency care, the more likely they were to die.¹

A local campaign—Keep the Horton General—has been launched and local MPs are also involved. A debate on the future of smaller general hospitals will take place on 10 October in the House of Commons, led by Conservative MP for Banbury, Tony Baldry, who will raise his concerns about plans for the Horton as well as national changes.

Richard Lehman is a general practitioner who has worked in the area for more than 20 years and says, despite the findings of the two clinical groups, there is appreciable opposition to the proposed changes from local clinicians.

“The trust's proposals would have gone through a year ago had it not been for a lengthy, strongly worded statement of opposition from local GPs, in which we unanimously characterised these proposals as unsafe and inhumane,” he says.

If the changes were to go ahead, he says: “We would be faced with the impossibility of recommending the local midwife led unit when we are convinced it is unsafe.”

Dr Lehman says there is little evidence to prove the safety of midwife led units, and there will not be any accurate figures for outcomes in such units until 2009, when the National Perinatal Epidemiology Unit study is due to report.

Feelings are running high over this issue, he adds, saying: “This is not a matter of local sentiment and convenience, but an issue of fundamental safety common to all localities at an hour's remove from a major hospital.”

Melanie Every, Royal College of Midwives' regional manager for the south, rejects the accusation that midwife led units are not proved to be safe.

“There is no hard evidence that they are unsafe either,” she says. “There is a lot of evidence that women's labours progress better with one to one care from a midwife that they know. You are much more likely to get that in a midwife led unit.

“For Horton, the proposals need to ensure that women have real choice so that those women who want to have a consultant led service can have that and that you've got the appropriate back-up services if you do need to transfer women from a midwife led unit to a consultant unit.”

The Horton is not an isolated situation, she says, adding: “A number of areas of the country are looking at concentrating their consultants' services on one site for all sorts of reasons, but mainly to do with a shortage of paediatricians and making sure they have a high quality service on one site for those neonatal babies that really need it. Therefore, the other sites are likely to be midwife led.”

Horton symbolises many other ongoing debates in the country, says Jim Thornton, professor of obstetrics and gynaecology at the City Hospital in Nottingham. Professor Thornton is about to publish the findings of a study of the national situation on reconfigurations for the campaigning pressure group Doctors for Reform.

“The Horton closure is typical,” he says. “Despite the fact that England already has much larger maternity units than other west European countries, we have discovered plans, at various stages of development, for consultant maternity unit mergers in nearly all strategic health authorities. They affect units of all sizes.

“If they are all followed through, England will have a few consultant units delivering fewer than 3000 women per year and many delivering two or three times that amount.”

Peter Fisher, a retired consultant in general medicine at the Horton hospital, who is now president of the NHS Consultants Association, is also worried about the safety of the changes being proposed at the Horton.

“The major risk (and psychological trauma) would be in those cases needing emergency transfer in labour from a Banbury midwife led unit to Oxford,” says Dr Fisher. “We now have a situation where the trust claims that its proposals would carry less risk than the current services might in two years' time. Whereas virtually everyone else takes the view that the proposals carry unacceptable risk.”

The Oxford Radcliffe trust is adamant that it is doing the right thing and expects that a full review will be instigated now that the health secretary has referred the issue to the Independent Reconfiguration Panel, which provides advice on changes in NHS service. The panel will report back early in the new year, and if it supports the trust board's decision to approve the proposals the changes will be phased in over 12-18 months.

A trust spokesperson said: “It's not been driven by a desire to drive down costs. It was driven by concerns about clinical safety. All we are doing is moving the obstetricians to another of our hospitals. The obstetrics service remains, it simply moves from one site to another.”

The issue is far from settled.