Claims about the success of the reconfiguration of maternity services in Greater Manchester are evidence light.

Just four months after the last unit closure, the centralisation of services - dubbed Making it Better (MiB) - is being hailed a success. It has been cited by Royal College of Obstetricians and Gynaecologists president Dr Tony Falconer as a model for the NHS in other areas. Surely it would be wise to wait for robust evaluation of health outcomes before making such claims?

Service concentration was deemed necessary to achieve sustainable levels of staffing to guarantee safe services but the issue could have been addressed initially by reappraising obstetrician/neonatologist/midwife training numbers, staffing and working practices. Frequent temporary closures were also cited as a rationale for centralisation, although the reason for these was usually lack of beds or midwives.

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Centralisation quickly became the “cure all” approach for maternity care, despite there being no evidence to support this. The question then inevitably became “which units must go?”.

In economic terms, MiB has never claimed to save money. The lengthy consultation must surely have been a questionable use of resources - huge public opposition was disregarded (apart from in Salford where, as a result of sustained political pressure, a freestanding midwifery led unit was retained).  

Pennine Acute Hospital Trust had to apply for extra funding to ensure new builds at Oldham and North Manchester could go ahead. Greater Manchester commissioners agreed a three year transitional top-up (from 2011) of £110 per birth. In April, Bolton Foundation Trust, which revamped its maternity unit and recruited extra consultants to cater for the rise in births, was found by Monitor to be in serious financial trouble; at the start of August Monitor intervened to replace the chair because of concerns over the trust’s ability to manage its finances.

Merger does not appear to help struggling trusts; detailed analysis of UK hospital mergers over the past 15 years by researchers at Bristol University found no financial advantages for trusts in the four years after hospital merger. Neither did the analysis find clinical advantages - although there were disadvantages for patients with regard to increased waiting times and travelling.

The proposed cut in maternity units from 12 to eight was based on predictions that births would fall. Greater Manchester has one of the highest fertility rates in the UK and, at 37,540 in 2010, births are already in excess of the number predicted by MiB for 2015. MiB accepted the optimum unit size would manage 2,700-6,600 births per year, but two units - Central Manchester and Bolton - look set to cater for well over this number.

Contrary to “spin” about poorer units warranting closure, in Greater Manchester the unit with the best outcomes (Salford) was closed. The unacceptably high number of temporary closures (diverts) was central to the case for reconfiguration; these have reduced significantly. However, since reconfiguration, the process for such decisions has been moved from clinicians to managers, whose primary remit is for budget/target accountability rather than safety.

One to one midwifery care for women in labour is still not being achieved. Healthy women are discharged home early (six hours after a normal birth and 24 hours after caesarean section). Most trusts are now contracted to provide only three postnatal visits, which leads to concerns about ongoing postnatal support. So to assess the overall impact of the changes, data is needed on maternal and neonatal readmission rates and breastfeeding rates.

Improvements in primary care should have preceded closures; instead, community midwifery services have been fragmented. Salford has been divided between four trusts so there are now four different policies for everything from safeguarding children to home births. Such fragmentation is particularly worrying in relation to marginalised women already at significantly higher risk of mortality and morbidity.

The recent Birthplace study from the National Perinatal Epidemiology Unit has shown that out of hospital birth is the safest and most cost effective care for women with no obstetric complications. Co-located midwifery led units have been established at several sites but home births have not increased. The independent reconfiguration panel recommended exploring the feasibility of freestanding midwifery units on all sites where facilities were closed but Manchester PCTs decided not to. In change management terms, the reconfiguration could be deemed a success; in terms of outcomes for mothers and babies, claims of success are certainly premature.

Sarah Davies is senior lecturer midwifery at the University of Salford, Greater Manchester, and Heather Rawlinson is a midwife in Greater Manchester.

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