Critics of the Manchester maternity review are in denial, says Leila Williams of NHS Greater Manchester

Scythe matters

Death at the age of 75 appears to influence future heath budgets.

But, for biological reasons which may be difficult to explain, are any number of adults destined to die sooner, say at 59 or 60, regardless of their chosen diet and exercise regime? And if the Grim Reaper occasionally refuses to follow statisticians’ normal distribution, will financial support to councils allow for such variation?

Neil Richardson, NHS Kirklees

In denial

Sarah Davies and Heather Rawlinson are entirely right to make the case that celebration of outcome improvement for mothers and babies following the maternity reconfiguration in Manchester should await the actual evidence of service quality over the next few years.

However, the successful completion of this very challenging and complex reconfiguration is at the very least a cause for considerable satisfaction

The Making it Better changes in Greater Manchester were driven by the forcibly expressed views of local clinicians that 12 inpatient maternity and paediatric units for a population of three million people was unsustainable. Clinicians were very clear that too many of the units did not have the critical mass of workload necessary to support the midwifery staffing levels, specialist expertise and 24/7 medical staff availability which is necessary to deliver the improved outcomes that we all want to see.

Those who continue to make the case for maintaining 24/7 medical staff cover and increased consultant presence at smaller maternity units (delivering between five and eight women a day - with most delivered by the midwives) are seemingly in denial of the fact of the existence of the European working time directive, the need for obstetricians to maintain their skills by concentrating on complicated pregnancies in units with a big enough workload to justify 24/7 medical staffing, and limited resources.

The maternity unit in Salford was indeed highly regarded but the objective of the MIB changes was to replace 12 units (of variable strength and quality) with eight units which all provide a high quality and sustainable service to the whole of the Greater Manchester population. Eight units for a population of three million living in a densely populated conurbation of 40 miles by 40 miles is hardly a radical centralisation of services.

Before it was decommissioned the Salford unit was delivering 3,000 babies and, given a resident population of 240,000 and three bigger maternity units within an eight-mile radius, it was never likely to achieve the workload of, say 6,000-7,000 deliveries per year. This is the number necessary to support 24/7 consultant presence on the labour wards which, along with large co-located midwife led units, is likely to become the standard model for hospital maternity care. Women may have the option of home delivery and in some areas, standalone midwife units, but at present there is little evidence of significant demand for either.

As of now women in Salford can still have their antenatal care at their local hospital and have the choice of a home delivery and a standalone midwife unit (also at their local hospital). For those women (the vast majority) who prefer to deliver their baby at a consultant unit they have the choice of three units within a distance of only five miles from almost anywhere in Salford. All these units have state of the art facilities, 98 hours per week consultant presence on the labour wards, and midwifery staffing levels which enable one-to-one care for women in labour.

This means that Salford women, along with all other women in Greater Manchester, continue to have easy access to what are now the best equipped and best staffed maternity services in the country.

Providing validated evidence that outcomes for women have improved will take time. The whole basis for the Making it Better project is the strong belief of the clinical community that improvements in outcomes and ultimately safer services depend initially on creating units with the critical mass to support the depth of skills and expertise required for the very best care and outcomes.

Leila Williams, director of service transformation, NHS Greater Manchester

Where there’s muck there’s brass

Gary Cohen makes some very pertinent points in his interview and that is by reducing, recycling and isolating infectious waste, NHS trusts can make significant savings. As a clinical waste management company we see easy-to-recycle, “domestic” materials like paper, glass and plastic bottles all too often ending up in clinical waste bags which by law have to be disposed of by incineration to meet infection control requirements.

Simply by segregating these types of materials from truly infectious items , trusts will reduce clinical waste handling costs and improve their environmental performance. It takes just one infectious item to deem a whole bin of recyclable material as clinical waste, meaning stringent segregation is critical for the environment and the finances.

Brendan Fatchett, executive director, SRCL