• Flawed system for funding fetal medicine leading to “morbidity and mortality” among women and babies, doctors warn
  • London units have identified multiple cases of “avoidable harm” because of change in referral patterns
  • Specialist units losing money as less than 10 per cent of bills for referrals being paid

Babies are “dying unnecessarily” because of a flawed system for funding specialist units, senior doctors have warned.

Ultrasound

The costs of fetal medicine frequently exceeds the money hospitals receive through the maternity tariff

fetal ultrasound pregnancy monitoring

HSJ can reveal that consultants at specialist units in London have circulated a letter highlighting “multiple cases” where women and babies had been subject to “avoidable harm” as a result of the funding system for fetal medicine.

Fetal medicine is highly specialised and involves the diagnosis and treatment of complications that may arise in unborn babies.

Following the Health Act 2012, it was expected that fetal medicine services would be commissioned nationally by NHS England as a specialised service with its own dedicated budget.

However, in 2014 NHS England said rather than having its own budget, the services would be funded through the money allocated for general maternity services.

Under the “maternity tariff”, hospitals receive a payment to cover the cost of care at three stages of a woman’s pregnancy: antenatal, delivery and postnatal.

Where complications arise requiring a referral to a specialist fetal medicine unit, the unit is expected to recoup its costs from the district general hospital by billing them for the referral.

However, because of the highly specialised nature of the service, the cost of procedures frequently far exceeds the money local hospitals receive through the tariff.

According to fetal medicine doctors in London, this has resulted in a perverse incentive for local hospitals to “hold on” to patients rather than making a referral. The doctors claim this has caused harm to patients, including the deaths of unborn babies.

Where a referral is made, bills for procedures are often not being paid because the local hospital cannot afford it, which has resulted in the specialist units haemorrhaging money.

In summer last year leading consultants at London’s specialist units set out their concerns in a letter to the capital’s strategic clinical network.

While the letter focused on the situation in London, the concerns it raises apply to the whole country.

The letter argued that NHS England should “urgently review” the commissioning arrangements because they were causing a “significant risk to women and babies”.

“We have identified multiple cases where women and babies have been subject to avoidable harm as a direct result of these commissioning changes,” it said.

According to the letter, the units warned NHS England in 2014 that the changes would “lead to women being screened for fetal anomalies but not receiving care in centres with the expertise to improve outcomes for this small cohort of women”.

“No action was taken and the units were reminded of the need to recoup their costs from the referring organisations,” it added.

The units followed NHS England’s guidance and started billing the referring hospitals, but the letter revealed that “less than 10 per cent of payments have been received”.

The letter said there was “significant evidence” hospitals were “delaying referral to tertiary centres and attempting to provide care locally without appropriate expertise or infrastructure”.

“This mismanagement is leading to morbidity and mortality amongst women and their babies,” it added.

The letter listed eight anonymised cases from across England where patients have been mismanaged and in some circumstances experienced harm as a result.

The first case was given to illustrate the “the emotional costs endured by parents when a district general hospital substituted early tertiary referral with ineffective follow-up appointments”.

The case involved a woman who was scanned by a local hospital, but the sonographer was unable to obtain adequate views of the fetal anatomy. Instead of being referred to a tertiary centre, the woman was booked in for another scan some weeks later, but the sonographer was again unable to obtain adequate views. She was then referred to a consultant in the hospital with an interest in ultrasound scanning, who later made a diagnosis of “fetal hydrops” – an abnormal build-up of fluid in the fetus – over a month later. She was then urgently referred to a tertiary centre and seen within 24 hours, but a scan revealed the baby had died. A post-mortem confirmed it was a “preventable death” from a disease that could have been managed in the womb.

“Sadly this is just one example of a baby dying unnecessarily,” the letter said.

As well affecting care, the letter claimed that the current system fundamentally threatens the financial sustainability of fetal medicine services.

“It is unreasonable and not sustainable to continue to offer a highly specialised tertiary service without reimbursement for costs incurred,” the letter said.

The authors argue fetal medicine should be centrally funded by NHS England as a specialised service.

An NHS England spokesman said: “Clinicians and their teams should always seek to ensure that women get the best and most appropriate care for them, with good governance of units and collaborative commissioning across networks being central to achieving this.

”Clinicians will shortly have the opportunity to suggest improvements to the tariff system for 2017-18 through the annual consultation run by NHS Improvement and NHS England.”

Exclusive: Babies 'dying unnecessarily' due to flawed funding system