Monday, 30 September 2013

My response to the latest nonsense from BSBV: Why it is unsafe to close A&E, paediatrics and maternity for first time mothers!

Dear Editor,

The letter (24th September) to the Guardian from BSBV staff, quoting the Birthplace Study as showing stand alone midwife led units and home births as safe if proper assessment of risk is carried out, did not include other findings of the study which we copy here. 
It is true that the study found advantages in these settings for women who had already had a baby but you will see there are risks for first time mothers.
From the very outset, BSBV staff have glossed over these risks. At one public meeting we were told there were "just a few" transfers needed. Please see the figures below -36%-45% are not a small number. Not all these transfers will be life threatening but some will be so it is important to know how long such transfers would take.
This is why we published SECAmb data, which shows that, as admitted by BSBV staff, at least 30minutes is involved if people from the area served by Epsom are taken to alternative hospitals.
This is also why we published the Royal College guidance used in the Darzi report, which states clearly that maximum transfer time is 15-20 minutes from the time things start to go wrong in labour.
Again, responses from BSBV have been to question the validity of our ambulance data, to insist it is the time taken to get to the patient that is important (not until paramedics can carry out Caesarean sections) and vague promises of "lounges" for people who have a longer distance to travel!!
The reality is that BSBV do not want to consider points, which show our area’s residents, would be at risk if we lost Maternity and Paediatrics.
We agree a lot of adult care can be safely centralised and would provide better outcomes for patients. It is hard to understand why BSBV cannot make provision for the services that are more safely provided locally.
Even worse, they don't seem to have looked at the Darzi report, which was a massive piece of research with a whole section on Maternity.
From the Birthplace Study;
“ For women having a first baby, a planned home birth increases the risk for the baby
         For nulliparous women, there were 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units, and this finding was statistically significant.
         For multiparous women, birth in a non-obstetric unit setting significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy.

For women having a first baby, there is a fairly high probability of transferring to an obstetric unit during labour or immediately after the birth.
For nulliparous women, the peri-partum transfer rate was 45% for planned home births, 36% for planned FMU births and 40% for planned AMU births

Thursday, 19 September 2013

In response to the latest BSBV nonsense!

There may actually only be 5 minutes!

BSBV response to our concerns raised at the suggestion that Epsom Maternity unit should be closed, is very alarming, as it appears to be so un-informed. (Letter to Guardian 19th September)

The Darzi Report recommendations by Royal Colleges states 15-20 minutes transfer time, when things go wrong in labour, is the maximum time before what they call “an adverse” incident occurs.

Our work shows that ambulance times, when one adds on 8 minutes response times, would mean a longer journey than 15-20 minutes.

We have had to counter BSBV suggestions, on twitter, that this only applies in hospital. This is nonsense- it applies whenever and wherever a mother gets to a point where the baby is in difficulties during delivery.

We have looked into the BSBV denial that 8 minutes is significant and would suggest they look up the recent references given below.

The majority of pregnancies are very straightforward and uncomplicated and they lead to the birth of a well baby. In a minority of instances a baby can get into difficulty. For example, one of these instances could be a lack of oxygen. In this instance a doctor would be required to intervene. The Royal College of Gynecology (source below) and the International Cerebral Palsy Task Force states that in the situation of a baby’s head getting stuck before delivery there are only five minutes before the baby gets a serious brain injury due to a lack of oxygen.

Source: RCOG Green-top Guideline on Shoulder Dystocia No. 42, 2nd edition published | March 2012 and Leung TYet al paper Head-to- body delivery interval and risk of fetal acidosis and hypoxic ischaemic encephalopathy in shoulder dystocia: a retrospective review published in British Journal in Obstetrics and Gynaecology 2011; 118:474–9
There are also, of course, the contradictions that have existed throughout the plans put forward by BSBV.
If it is only safe if there are large units manned by consultants for 24 hours how are midwife only, not co-located with an obstetric unit, safe for other mothers. Their argument is that low risk mothers will be fine and will be transferred if need be. However, 40 % of first time mothers do need transfer- (Birthplace Study used by BSBV) and some of these transfers will be for serious reasons which mean the unit should be co-located with obstetric unit for safety.

There are also issues around the waste of public money spent by the various attempts by BSBV to deny evidence to the media rather than looking at proper evidence for the Epsom area.

We agree with BSBV that a lot of specialist care is centralised but they should accept that maternity services, in the main, and children’s services, must be local. Centralised children’s units need a hub and spoke system to work so sick children can be stabilised. Don’t try and remove the spokes or the Hub won’t work!!
Jane Race
Rosemary Najim
Epsom Hospital Campaign

Tuesday, 17 September 2013

Women and children could die if unsafe journey times are ignored!

'Women and children could die if unsafe journey times are ignored', say campaigners against controversial healthcare review

12:30pm Monday 9th September 2013
By Hardeep Matharu
Women and children could die if the team behind the controversial healthcare review aiming to axe Epsom hospital’s acute services do not take information about "unsafe" journey times seriously, according to two dedicated campaigners.
Rosemary Najim and Jane Race, from Epsom, approached this newspaper to raise concerns that the increased distances people would have to travel if the Better Services Better Value (BSBV) review’s recommendations - to axe Epsom and St Helier hospitals’ A&E, maternity and children’s units - go ahead, would put women in labour and children at risk.
The recommendations in the review, which is currently on hold, would mean patients in the area would have to travel to hospitals in Surrey or London for the services instead.
A spokesman for the BSBV review said it is "unimaginable that the obstetricians, paediatricians, GPs, nurses and midwives who developed the BSBV case for change would support proposals that put women and children at risk".
But the campaigners believe that, in contrast to emergency patients who they say can be stabilised significantly through emergency treatment in an ambulance en route to a hospital, women in labour and children, who deteriorate more quickly than adults, can only be treated in hospital when complex complications arise.
Ms Najim said that A Framework for Action, a report in Lord Darzi’s 2007 review of the healthcare service, stated that doctors only have 15 to 20 minutes from a time a woman starts to experience problems in labour until an abnormality develops.
But she said that Hassan Shehata, clinical director for women and children’s services at Epsom Hospital, said pregnant women should actually be seen by an obsetrician within eight minutes once a labour starts to go wrong.
She also said that the time it takes for an ambulance to get to a patient in the first place need to be considered - a BSBV spokesman said that the "standard ambulance response time" should be eight minutes for 75 per cent of all calls, which the South East Coast Ambulance Service surpasses.
The campaigners obtained figures, from a freedom of information request, for ambulance journey times, from the Epsom area to alternative hospitals, for 'Category A' patients - those believed to have life threatening conditions - journeys which started off by 'blue light' ambulance to the home, but did not all continue as such to the hospital.
The shortest journey times to alternative hospitals, including the eight minutes standard response time, all exceeded 20 minutes, with the longest journey lasting for 54 minutes. The campaigners say this can only worsen if the recommendations go ahead.
Ms Najim and Mrs Race also said that figures obtained from Epsom and St Helier hospitals trust showed that, between January 1 and February 1 of this year, just 7.2 per cent of children and 63 per cent of acute medical patients were brought to Epsom’s A&E by ambulance - meaning that a large number of patients currently drive to the hospital and would face even longer journey times than the fastest ambulance journeys to get to alternative hospitals.
Mrs Race said: "BSBV says it’s done the work, but it hasn’t.  All of these PR campaigns need to stop. 
"The BSBV models are unsafe and it’s up to the CCG to see this now."
A spokesman for the BSBV team said: "It’s important to emphasise that it is the time taken to reach patients that is most important. 
"Once paramedics are on the scene, they are able to administer emergency care and stabilise patients for transfer to hospital. 
"The time taken to reach patients will not change under the BSBV proposals." 
He said that this includes emergency patients as well as women in labour and sick children.
The spokesman said that, under the proposals, "most women would go to their nearest available major acute hospital".
He added: "Clinicians working on the proposals acknowledged that some mums-to-be would have to travel further to give birth, but for high-risk women they agreed it was no longer acceptable to run a lower-quality service during evenings and weekends."
The spokesman said that the 15 to 20 minutes time cited in Lord Darzi’s review by Ms Najim is for emergency transfers from a midwifery-led unit or a home birth to a consultant-led unit.
But, he said that BSBV has acknowledged that women will have to travel further if the recommendations take effect and are "proposing we create additional space at the units for a lounge to allow women to arrive earlier during labour".
He said: "Currently women who arrive at a maternity unit when in the early stages of labour are given a series of options to choose from. 
"If they live nearby, they can go home for a few hours.  Otherwise they can stay in the waiting room. 
"If more women had to come from further away it may be that hospitals would require some additional space to relax given it would be more difficult for them to go home.
"Women in labour may be asked to come in slightly earlier in labour if they live further away - this already happens now."
When asked about concerns relating to children, the spokesman said the BSBV proposals aim to "improve quality and safety".
He said: "We do not currently have consultant paediatricians available round the clock in all our hospitals. 
"If a child becomes seriously ill, a consultant has to travel from home by their own transport to treat them.
"Travel to the nearest acute hospital by ‘blue light’ ambulance would take no longer than 20 minutes and less than this in most cases.
"The clinicians felt that they could not staff five children’s units adequately to guarantee safe services."
He added: "We know that in implementing the proposals there would have to be a huge amount of communication with local people to help ensure that they went to the best place for their specific needs. 
"This may well be Epsom Hospital, which under the proposals would have an urgent care centre."  
But the spokesman said that women in labour would be "unlikely to go to an urgent care centre", but that it would be able to treat children.
Journey times to hospitals, including eight minute standard response time, from postcodes KT18, KT20, KT21, KT22 and SM7 between December 15, 2012 and January 14, 2013:
Shortest: 8 minutes
Longest: 30 minutes
Shortest: 16 minutes
Longest: 36 minutes
Shortest: 23 minutes
Longest: 35 minutes
Shortest: 25 minutes
Longest: 32 minutes
Shortest: 32 minutes
Longest: 54 minutes
Shortest: 26 minutes
Longest: 30 minutes
(Source: Data obtained via Freedom of Information Request by the campaigners from South East Coast Ambulance Service)