PORTSEA ISLAND STAND ALONE BIRTH CENTRE PATIENT AND PUBLIC INVOLVEMENT PLAN

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1 BACKGROUND PORTSEA ISLAND STAND ALONE BIRTH CENTRE PATIENT AND PUBLIC INVOLVEMENT PLAN In 2005 the NHS in Portsmouth and South East Hampshire undertook formal consultation of patients and the public on proposals for the future of maternity services as set out in its document A Healthy Future for Mothers and Babies. The scrutiny of this process was undertaken by a Joint Health Overview and Scrutiny Committee (JHOSC). Membership of the JHOSC came from Portsmouth City Council, Hampshire County Council and the Isle of Wight Council. The outcomes of the consultation showed clear support for the retention of a stand alone birth centre on Portsea Island. This was included as a recommendation in the subsequent report of the JHOSC. An initial business case was presented to the PCT Board in February The findings indicated that a model developed on existing ways of working would not be financially sustainable. The Board agreed to undertake further work to explore the feasibility of developing a viable model for a stand alone birth unit. The findings of this study were reported to the PCT Board in November They reflected those of the initial business case. It was therefore agreed to continue to look at alternative models of care for stand alone birth units. A report to the PCT Board in May 2007 concluded that in the United Kingdom, in general, there are 3 different models for staffing birth units, namely: a midwife staffed unit 24/7 (Option 1); a midwife assistant staffed unit 24/7 with community midwifery presence and oncall midwives (Option 2); an unstaffed unit, open for deliveries only (Option 3). Each model was tested for clinical safety, staffing feasibility and financial sustainability. As part of this testing, 2 stakeholder workshops were held in January and February They were attended by maternity staff from Portsmouth Hospitals NHS Trust (7), the PCT s Professional Executive Committee maternity portfolio holder, a representative form the City Council s adolescent health project, a member of the National Childbirth Trust and a member of the Maternity Services Liaison Committee. Four service users also took part in discussions. The workshops were monitored by 2 members of the PCT s statutory Patient and Public Involvement Forum. Following this further testing of models, the PCT concluded that it was feasible to commission a stand-alone birthing unit that was midwife-led, had a midwife presence in core hours and on-call midwives covering 24/7 that was also staffed by maternity assistants (that is, Option 2). This model was also financially sustainable for the provider. Having assured itself that a feasible model of service existed, the PCT proceeded to negotiations with the current provider of maternity services, Portsmouth Hospitals NHS Trust for the delivery of the stand-alone unit. The proposals for the development, including reasons for the preferred option, were presented to members of Portsmouth City Health Overview and Scrutiny Panel (HOSP) in July Of the resolutions made at that meeting, the PCT was required to take its patient and public involvement plan to the Panel to involve patients and the public in the development of the final model for the stand alone unit. The PCT s 1

2 Patient and Public Involvement (PPI) processes will therefore focus on this development. PRINCIPLES The PCT will ensure that: decisions take into account the views of the people of Portsmouth; decisions will take into account the views of PCT, Portsmouth Hospitals NHS staff and Portsmouth City Council staff who work with mothers and babies; an explanation is given of the clinical, staffing and financial feasibility of any options suggested during this involvement process; it works with its statutory Patient and Public Involvement Forum so that the Forum may perform its role of encouraging the public s involvement in the process, advise the PCT in this work and monitor the effectiveness of the process; and it reports to the Portsmouth HOSP as required. OBJECTIVES Involvement processes will recognise the need: to be clear on what questions are being asked and the timescale for responses; to ensure information is clear, concise and widely accessible; to ensure opportunities for involvement are widely publicised and readily accessible; to provide feedback to those involved and the public at large on the numbers involved, responses received and how the final decision is agreed; and to monitor the process to ensure it remains effective and inclusive. AUDIENCE As well as involving members of the public, the PCT will need to specifically target the following: Individuals Expectant mothers Mothers of babies and young children NHS General Practices Health Visitors Maternity staff at Portsmouth Hospitals NHS Trust Portsmouth Hospitals NHS Trust Patient Experience Panel Portsmouth City Council Children s Services leads Social Services leads Local Councillor with children s services portfolio 2

3 Groups Baffins Community Centre Mumbaba Parent and Toddler Group Carers Groups Children s Sub Groups to Community Boards CWAYS (Chinese Women and Youth Society) Maternity Services Liaison Committee National Childbirth Trust (NCT) Paulsgrove and Wymering Healthy Living Centre baby sessions Portsmouth Foyer Roberts Centre St Paul s St Monica s Sure Start ABC Sure Start Somerstown Wesley Centre Friday Rascals Toddler Group Professional Associations and Trades Unions Royal College of Midwives (RCM) Royal College of Nursing (RCN) UNISON Other Interested Parties Local media eg: The News, Express FM, The Quay, Community Newspapers Sarah McCarthy-Fry, MP Portsmouth North Mike Hancock, MP Portsmouth South Prospective parliamentary candidates Portsmouth North and Portsmouth South COMMUNICATIONS TO SUPPORT THE PPI PLAN The Action Plan at the end of this document summarises the key communications tasks that the PCT will need to undertake to ensure appropriate engagement with people in Portsmouth. Appropriate materials will need to be produced to support the engagement process. These will need to be developed in accordance with national guidelines ( Toolkit for producing patient information ) and local needs. As a minimum, materials will need to be: - concise, clear and relevant - appropriate to the needs of the audience to be engaged - have a clear recognition factor (visual image will be important here) - accessible to different population groups - unambiguous, in terms of the information we are sharing, and what we expect people to do as a result - be jointly agreed, between the PCT and Portsmouth Hospitals NHS Trust The PCT will also need to consider how best to ensure that people have appropriate opportunities to access this information if they need it. It will therefore be critical to utilise effectively: - the media (The News, local radio, tv etc) need to feel involved in the process and given appropriate access to information and spokespeople 3

4 - PCT website launch of a new website will allow us to identify a specific area within it for engagement - internal and external communications mechanisms newsletters, updates and briefings to staff, partners etc - mail outs to target groups and interested parties, to include clear instruction on the reasons for the mail out and how people can respond - opportunities for poster/leaflet campaigns, embracing public (PCT premises, Portsmouth Hospitals Trust, primary care, Portsmouth City Council, PCCS etc) and private sector (shopping centres, specific large volume employers etc) Once the engagement process has been finalised and a timescale has been agreed, the communications element of the plan will clearly need to be worked up in more detail. TIMETABLE The PPI Plan will be submitted to the HOSP as requested in December The timetable will be defined following the HOSP s approval. Timing may also be dependent on similar PPI work currently led by Hampshire PCT in that organisation s catchment area. The Hampshire work is expected to go to the Hampshire HOSC at the end of November In the interim, discussions have taken place with the Chair and Vice Chair of this PCT s statutory Patient and Public Involvement Forum (31 July 2007.) Their views and advice have been taken into account in devising the action plan. In addition, the PPIF will undertake its own work to inform the process as well as monitoring that of the PCT. The PPIF will inform the PCT of their involvement mechanisms to avoid duplication and provide co-ordination. 4

5 ACTION PLAN Mechanism Target Group(s) Action 1. Publicity material: Posters leaflets (with feedback forms) Full proposal Summary proposal Feedback forms 2. Open Meeting on neutral ground (either one centrally, or one in the south and one in the north of the city) 3. Presentations and open discussion Public (via media) All groups identified under audience MPs MSLC Public RCM NCT NHS staff working in maternity and children s services Specific groups identified under Audience Health Visiting drop-in groups Teenage expectant mums (Portsmouth Foyer) Teenage mums CWAYS Sure Start ABC Sure Start Somerstown Communications lead to work with commissioners on publicity material Communication lead to draw up media engagement plan targeting media appropriately, ensuring availability of relevant spokespeople, maintaining proactive approach. Communication/PPI lead to post information on PCT website, encouraging feedback via PCT website feedback form PPI lead to work with business service team on mail outs to target groups PPI lead to work with commissioners on format of session and invitation list. Invitations to be sent out via [complete] Display material and boards to be supplied by Communications Team PPI lead or commissioners to arrange feedback forms and post box/return mechanisms PPI lead to work with commissioners and PCT NED with children s portfolio on timetable and process PPI lead to co-ordinate communication with target groups/and or appropriately advise commissioners and PCT NED 4. Exhibitions Provide display boards of information together with leaflets in reception areas as agreed internally and with PCC and PHT PPI lead to advise commissioners and/or co-ordinate arranging suitable venues for exhibitions, eg Health Centres and clinics, Child Development Centre, Portsmouth Central Library 5. Shopping Centre(s) Shoppers in: Cascades?Bridge Centre?Gunwharf Quays PPI lead to d/w shopping centre managers feasibility of engaging with the public in their areas PPI lead to work with commissioners and communication lead on: format, duration, staffing, publicity material 5

6 All feedback will be analysed and collated and included in the final report. This report will set out how feedback has informed any decision-making relating to the standalone birthing unit as well as next steps. The report will be made available to: Portsmouth HOSP Portsmouth City (Public Involvement) Forum Participants who have provided contact details Portsmouth City Council Children s and Social Services and Lead Councillor for Children s Services Leads of target groups and organisations The wider community via local media and the PCT s web site in appropriate and summarised formats The PCT Board 6

7 PORTSMOUTH CITY PRIMARY CARE TRUST FEASIBILITY STUDY FOR A STAND-ALONE MATERNITY UNIT ON PORTSEA ISLAND SEPTEMBER

8 CONTENTS Definitions 3 Introduction 4 Purpose of the Feasibility Study 6 Portsmouth City Stand-alone Model 6 National Institute of Clinical Excellence (NICE) guideline 7 Local Picture 10 Activity Analysis at the Proposed Stand-alone Unit: Method 11 Activity Projections Activity based on a Comparison with similar 12 configurations in the United Kingdom (A) Activity based on a Survey of Women s Preferred Choice 14 of Delivery (B) Activity Based on Current Birth Activity at Blake Unit, 17 Gosport (C) Activity based on Transferring Low-risk Births from a 17 Main to a Co-located or Stand Alone Unit (D) Summary of Activity Projections 19 Other Factors Influencing Stand-alone Unit Activity 19 Finances Capital 21 Revenue 22 Summary of Revenue Income from Activity 25 Revenue and Choice of Provider 27 Summary and Conclusions 30 Recommendations 31 ACKNOWLEDGEMENTS: Vicky Styles, Commissioning Manager (Children & Families) Andrew Barker, Project Assistant (Social Inclusion) Maddy Knott, Public Health Information Manager Mark Fletcher, Development Manager Staff of Portsmouth Hospitals Maternity Services All the women who took the time to answer our survey during their pregnancy 2

9 DEFINITIONS The following words or phrases have the following meanings within this document: Main Maternity Unit: This is the traditional hospital-based maternity unit staffed with consultants and midwives. These units have consultant obstetricians on staff and are able to deal with both complex and straightforward pregnancies and deliveries. These units are capable of carrying out all medical interventions in childbirth and can offer a full anaesthetic service, including epidurals. Co-located Maternity Unit: This is a mid-wife led unit that is physically located next to or on the same site as a Main Maternity Unit. These maternity units do not have consultants working in them and offer services for women who show no signs of having any difficulty giving birth naturally. Most of them are staffed entirely by midwives although, in a few, GPs with training in obstetrics also provide care. In general there are no anaesthetists to administer epidurals and no surgeons to perform caesarean sections. Midwife-led units can provide an environment in which women are given support to give birth without medical intervention or high levels of drugs for pain relief. If complications do arise during the birth, women are transferred to the Main Unit. Stand-alone Maternity Unit: This is a mid-wife led unit that is not physically located next to a Main Unit and thus can be located in a community or non-hospital location. The services offered at a stand-alone unit are the same as those offered at a co-located unit. If complications do arise during the birth, women are transferred to the Main Unit. Definitions are based on those given on the Dr Fosters website: 3

10 1 INTRODUCTION 1.1 Context There has been extensive work and consultation across the Portsmouth and South East Hampshire area on the future configuration of maternity services for local people. These are summarised in the following sections Joint Maternity Strategy and Consultation November 2004 saw the publication of the Joint Strategy for Maternity Services. This included proposals concerning the future location and purpose of the Mary Rose Birthing Unit. The Unit is a co-located maternity unit, located next to the Main Maternity Unit on the St Mary s Hospital site. As part of Portsmouth Hospitals NHS Trust s plans to develop the Queen Alexandra Hospital (QAH) site, the Main Maternity Unit will relocate from St Mary s to QAH in 2008/09. The Joint Strategy proposed 2 options for the Mary Rose Unit: - re-locate the current co-located maternity unit (Mary Rose) from its present location at St Mary s to the developed Queen Alexandra Hospital site to continue to be a co-located maternity unit, alongside the Main Unit - change the role of the Mary Rose unit to a stand-alone unit and keep it based on the St Mary s Hospital site The Joint Strategy went to public consultation during early The consultation findings were reported in June There were a number of issues identified, including the need to understand the impact on other local maternity units of either a change in role or relocation of the Mary Rose unit. There were also concerns that other options for configuring maternity services had not been considered by the Joint Strategy. Consequently, two further pieces of work were undertaken; these are summarised in the next two sections Option Appraisal Report on the Future Delivery of Maternity Services in Portsmouth and South East Hampshire The first piece of work was a joint venture between all local NHS bodies and the Maternity Services Liaison Committee. This was an option appraisal looking at further configurations for maternity services on the Portsmouth and South East Hampshire area. It specifically addressed many of the concerns raised in the public consultation. The report was published in February Out of four possible options for configuring maternity services, it found two to be viable. These were: - A Main Unit at QAH, a co-located unit at QAH plus a stand-alone unit sited within the PSEH area - A Main Unit at QAH, no co-located unit and a number of stand-alone units at locations in the PSEH area 4

11 The report noted that the option of having a co-located unit at QAH plus one stand-alone unit would adequately match future predictions of demand; however it recommended consideration of a second stand-alone unit in order to further improve access and choice Business Case for the Commissioning of Maternity Services for Low Risk Births for the Population of Portsmouth City Teaching Primary Care Trust The second piece of work was conducted alongside the Options Appraisal. Portsmouth City PCT commissioned an initial feasibility study and business case to examine the implications of establishing a stand-alone maternity unit at an accessible location on Portsea Island. The report was published in February It found that: - The most pragmatic location for a stand-alone unit for Portsmouth City residents would be on the St Mary s Hospital site - The predicted activity of 345 births to this stand-alone unit would not generate sufficient income to cover the revenue costs; there would be a revenue shortfall of 75,000 per year to the provider of the service The report suggested that a target of 500 births to the unit in order to ensure it covers its costs adequately. It drew attention to some of the assumptions made in predicting activity at the unit, explaining that these were likely to be lower than actual Consideration of Portsmouth City PCT Board Both pieces of work were taken to PCT and PHT Boards as well as other stakeholder bodies (eg Overview and Scrutiny Committee) immediately following their publication. In February 2006, the Board of Portsmouth City Primary Care Trust (City PCT) considered the initial business case for a stand-alone maternity unit based on Portsea Island. The Board noted the conclusions of the report and supported the development of a full business case for a stand-alone unit whilst conducting feasibility testing of this initial stand-alone proposal. This paper describes the work undertaken to test the feasibility of the standalone unit as proposed in the initial business case. 5

12 2 THE PURPOSE OF THIS FEASIBILITY STUDY The remit of this study is to: - Conduct an analysis of activity of the City stand-alone unit on the basis of a number of likely scenarios which may occur as a result of the wider healthcare economy options appraisal work - Demonstrate any risks associated with each of these scenarios - Consider the impact of City trends in births, home births and patient choice on the viability of a stand-alone unit - Consider the affordability of each scenario, both to the PCT as commissioner and to any provider as part of the national tariff system and clinical practice - Take account of the relevant National Institute of Clinical Excellence (NICE) guideline on Intrapartum Care 3 THE PORTSMOUTH CITY STAND-ALONE MODEL AND LOCATION In order to test the feasibility of the stand-alone unit model proposed by the initial business case this report assumes it would be a stand-alone midwifeled maternity unit on Portsea Island comprised of 2 birthing beds with 4 ante/post natal beds (en suite). The unit would be located at the St Mary s Hospital site. The model of staffing remains as laid out in the initial business plan, namely 6.5 wte Midwives (including a senior midwife in charge) plus 5.5 wte Midwife Care Assistants. 6

13 4 NATIONAL INSTITUTE OF CLINICAL EXCELLENCE GUIDELINE The NICE guideline Intrapartum Care: care of healthy women and their babies during childbirth was published in draft form in June 2006; a consultation exercise was completed by September The draft guideline examined research relating to whole care pathway of intrapartum care (labour at term weeks). This included a comparison of places of birth, including at home, within birth centres and in hospital. In order to compare each place of birth, NICE reviewed: - The likelihood of complications during the birth - Maternal satisfaction with the place and process of birth - The perinatal mortality incidence in each setting (stillbirth or death of the baby within the first week of life) - The proportion of women who needed to be transferred from their chosen place of birth to a hospital unit due to complications during pregnancy or labour ( transfer rates ) - Cost and cost-effectiveness A key problem with comparing levels of safety or risk relating to place of birth is that women giving birth in hospital settings are often those who have been identified, through good clinical care, as having a higher risk pregnancy. Thus samples of births from hospital-settings would be expected to have a higher number of high-risk births than samples from other settings. Most studies attempt to control for this bias, however it can still influence findings. 4.1 Home Births versus Hospital Births NICE examined a number of studies looking at women s and babies outcomes for home births. Evidence was of limited quality, but NICE concluded that planned home births can result in less complications and higher maternal satisfaction when compared to a planned birth in hospital. In this instance in hospital referred to both midwifery-led (birth centres) and consultant-led maternity units based in a hospital setting. NICE concluded that evidence relating to perinatal mortality and home births is ambiguous. However, NICE suggests that there is some evidence that a home-birth may be higher risk than a hospital-birth for perinatal mortality. The proportion of women who planned a home birth but transferred to hospital ranged from 10-45% in pregnancy and labour and from 4% to 20% in labour. 4.2 Stand Alone Birth Centres versus Consultant-led Units (Hospital) NICE concluded there is poor quality evidence on maternal and infant outcomes for stand-alone birth centres. However, where studies had been conducted, these indicated that women attending stand-alone birth centres were less likely to need interventions (eg analgesia use) or experience complications when compared with women attending a consultant-led unit. However, the previously highlighted issue relating to high-risk births more usually attending hospital units should be borne in mind. 7

14 Women attending stand-alone birthing units were more satisfied with their care and the location. Perinatal mortality may be higher in stand-alone units than in consultant-led units. Transfer rates (from stand-alone unit to consultant-led unit) were 30% for pregnancy and labour and 12% for labour. 4.3 Co-located Birth Centre versus a Consultant-led Unit NICE concluded that the evidence-base to support co-located units was of better quality than the evidence-base for stand-alone or home births. Women giving birth in a co-located unit need less intervention (eg analgesia) and have less complications than those giving birth in a consultant-led unit. Although NICE warned that information on perinatal mortality needed further investigation, it suggested that there was a possible increase in perinatal mortality in co-located units compared with consultant-led units. Transfer rates from co-located to consultant-led units were 45-52% during pregnancy and labour and 25-30% in labour. There was no evidence presented relating to maternal satisfaction with a colocated birth unit. 4.4 Cost and Cost-Effectiveness There were no UK-based reviews of cost or cost-effectiveness of reasonable quality. NICE considered evidence from studies conducted in the USA which suggested that, for low risk women, both home births and birth centre births are less expensive and safer than hospital births. Further, home births were lower cost than birth centres which, in turn, were lower cost than consultantled units. These findings are perhaps unsurprising. However, NICE raised significant problems with using findings from the USA. In some instances, the costs of transferring a woman from home or birth centre to hospital were not considered. More significantly, the US studies considered either costs to insurance agencies or charges to the patient, which do not necessarily equate to the cost of providing the service. Additionally, clinical practice in the USA and UK differ, which would impact on cost. NICE thus attempted economic modelling based on NHS costs and UK places of birth and compared both cost and cost-effectiveness of each option. The indicator of cost-effectiveness used was perinatal mortality (ie the more perinatal deaths prevented, the more effective that place of birth was deemed to be). This model indicated that: - home birth is the cheapest yet least effective birth setting (ie it has the highest rate of perinatal mortality) 8

15 - stand-alone birth units are lower cost and more effective (ie lower perinatal mortality) than co-located units - consultant-led units may be higher cost than any of the other options, but, in terms of avoiding perinatal mortality, are the most cost-effective (ie they prevent more perinatal deaths per costs than the other options) NICE however does not draw any firm conclusions on cost-effectiveness due to the weakness of UK-based evidence. 4.5 NICE Guideline Summary The NICE guideline states that birth outside a consultant-led unit is consistently associated with normal births, less complications and an increase in maternal satisfaction. It notes, however, that the evidence for stand-alone and home births is of poor quality. NICE raises some concerns about possible trends in perinatal mortality, with births outside consultant-led units possibly demonstrating a higher mortality rate, despite the bias towards higher risk births usually being delivered in a consultant-led unit. However, it does not consider the evidence on this issue to be strong enough to support any decision to either increase or decrease birthing provision outside of consultant-led units. 4.6 NICE Recommendations The NICE guideline recommends that women should be offered the choice of planning birth at home, in a midwifery-led unit or in a consultant-led unit. The guideline does not favour any single birth place option over another, but states that, when making their choice, women should be given the relative merits and risks of each option as outlined in previous sections. All options should have explicit clinical governance structures and procedures in place, including clear pathways and referral systems (the guideline details specific clinical governance issues that must be addressed across all options). 9

16 5 THE LOCAL PICTURE 5.1 Current Services For women registered with Portsmouth City PCT and planning a venue for a birth, the following choices are available within the City: - Main Maternity Unit at St Mary s Hospital a consultant and midwife unit - Mary Rose Unit, St Mary s a midwife-led unit co-located with the Main Unit - At home with midwife support Women from Portsmouth City also use other services within the area, including stand-alone (midwife led) units in Gosport (Blake Unit) and at Petersfield Hospital. A proportion of women also give birth in maternity units outside the Portsmouth and SE Hants area, including St Richards Hospital (Chichester) and Princess Anne Hospital (Southampton). 5.2 Births in 2005/06 There were a total of 2,236 births to women registered with Portsmouth City PCT in 2005/06. Table 1 below sets out these births by the service in which the birth completed; it also gives figures for the Portsmouth and SE Hampshire area for comparison. Table 1: Births by location, 2005/06 ALL BIRTHS 2005/06 City PSEH SE Hants 2004/ / / /06 Main Unit (St Marys) Co- located (Mary Rose) Home St Richards Hospital (Chichester) Princess Anne Hospital (Southampton) Other areas Petersfield Hospital Born before arrival Blake (Gosport) Royal Hants Hospital (Winchester) Royal Surrey Hospital (Guildford) Blackbrook (Fareham) Not recorded TOTAL BIRTHS Source: Portsmouth Hospitals NHS Trust The majority of births to City mothers take place within the Main Unit at St Mary s, with the co-located Mary Rose unit being second most likely venue. Home births appear to be the third venue of choice for the City. A small proportion of City births occur at St Richards Hospital in Chichester. 10

17 6 ACTIVITY ANALYSIS AT THE PROPOSED STAND-ALONE UNIT: METHOD Predicting future activity for births based on as-yet undeveloped maternity services is extremely difficult. This has been highlighted in the initial business case. Thus all activity assumptions must be treated with some caution. For the purposes of this feasibility study, two possible scenarios were used to inform activity analysis. Both scenarios are based upon previous options appraisal work on a Portsmouth and SE Hants basis. The two scenarios are given in Table 2 below. Table 2: Two Scenarios for Activity Analysis Scenario One: Scenario Two: A stand-alone unit at St Mary s A stand-alone unit at St Mary s + + A stand-alone unit in the SE Hants area A stand-alone unit in the SE Hants area + + A co-located unit at QAH The main unit at QAH + The main unit at QAH (there would be NO co-located unit at QAH) Within each Scenario, 4 different approaches were used to predict likely activity at the City stand-alone unit. For each of the 4 approaches, a different set of assumptions were made. In summary, the approaches were; (A) (B) (C) (D) Identify configurations of maternity services from elsewhere in the UK which are a close match to the proposed Scenario and examine the proportion of activity seen at stand-alone units in these other areas. Conduct a local and national survey of pregnant women, asking them where they would choose to have their baby if all choices were available and apply these proportions to predicted activity. Assume that the same proportion of City births are seen at the new City stand-alone unit as are seen at the Blake stand-alone unit (Gosport). Assume that all low-risk births to City residents are seen in either a colocated or stand-alone unit or delivered at home Methods C and D were also included in the initial business case and are included here in order to test these assumptions. Once activity had been calculated for the City stand-alone unit consideration was given to other influencing factors, in particular: - Trends in home births - Impact of proposals regarding nearby maternity services - Trends in births to the local population 11

18 7 ACTIVITY PROJECTIONS 7.1 Activity based on a Comparison with similar configurations in the United Kingdom (A) By looking at births within maternity units established elsewhere in the UK, a generally reliable picture can be generated of how local birth activity would be distributed if either Scenario One or Two were the future for local services. In order to enable a comparison, a UK search for services set up within similar configurations to each Scenario above was conducted via a combination of internet, and phone conversations. In order to be included within the comparison, configurations must include all types of Unit in the Scenario, must have recent birth activity data and have clear patient flows between each unit. For example, the main unit must clearly be the unit which takes transfers from the other units within the configuration. Additionally, all units should be within miles of each other (or less). Within each configuration, the number of births completing within each unit was obtained. This was important in order to negate the need to adjust for possible transfers of women from either stand-alone or co-located units to the main unit during their pregnancy or their labour. Thus the numbers given for each unit related to births completed in that unit, regardless of whether the mother and baby were transferred in from elsewhere. The search yielded 8 similar configurations to Scenario One and 7 configurations closely matching Scenario Two. Table 3 shows the results of the UK search for matching configurations. Strengths of the approach: This approach uses the experience of services elsewhere to predict what may occur locally if either Scenario was implemented. Weaknesses of the approach: Information on the usage (capacity) of each stand-alone unit was not available; thus there is no method of judging whether the activity given for each unit was representative of its full capacity. Population profiles within each configuration will be different and thus it cannot be assumed that the patterns of births, choice in mothers and (eg) age profiles are similar to Portsmouth City. 12

19 Table 3: UK Configurations Matching Scenarios One and Two Scenario One Scenario Two Area Grouping No of Standalones Number of delivery beds in Standalones Share of all births (%) Area Grouping No of Standalones Number of delivery beds in Standalones Share of all births (%) Gloucestershire* % Bath* 3 2, 2 and % Southampton* 3 2, 2 and % Portsmouth* 3 2, 2 and % Oxford* 3 2, 2 and % Shrewsbury 2 2 and % Yorkshire % Aberdeen* 3 2, 2 and % Cornwall 2 1 and % Dorset % Chelmsford 2 2 and % Bronglais (Wales) 2 1 and % Scarborough 3 2, 2 and % Wansbeck 2 1 and % Dundee 2 3 and % Median: % Median: % * Proposed/actual stand-alone closures Implications for Scenario One Across the 8 configurations, it was established that each stand-alone unit was likely to take 2.74% of all births completing within any of the units. This was the median point, the full range being from 0.62% to 8.94%. This was then applied to the birth activity for Portsmouth City (2005). Thus it was assumed that in the local scenario, the City stand-alone unit would take 2.74% of births to all units within the proposed configuration. As the figure 2.74% is a median, the local rate of 1.63% was also applied to the same birth activity, in order to give a local focus. Using this methodology, it is predicted that a City stand-alone unit would see 133 births per year. Using the local figure of 1.63%, it is predicted that a City stand-alone unit might see 79 births per year Implications for Scenario Two For the 7 configurations that matched Scenario Two, each stand-alone unit was likely to take 4.21% of all births completing within any of the units. This was the median, the full range being from 1.1% to 15.09%. In this case there was no local data as the Portsmouth & SE Hampshire area did not fit the selection criteria, having a co-located unit. Applying 4.21% to the birth activity for Portsmouth City (2005), it can be predicted that the City stand-alone unit might take 204 births per year. 13

20 7.2 Activity based on a Survey of Women s Preferred Choice of Delivery (B) From July to September 2006, Portsmouth City PCT conducted a survey of pregnant women, asking them to indicate their preferred place of delivery. The survey explained each option available to them, these being a standalone unit, a co-located unit, a main unit or at home. The difference between each option was explained. The survey used two collection methods. Staff from City PCT conducted faceto-face semi-structured interviews with pregnant women attending ante-natal clinics in Portsmouth City. In addition to this, the PCT posted an on-line questionnaire and contextual information on a number of forums and web-based communities for pregnant women. All respondents were also asked to give any comment or feedback about choice of delivery venue. This aspect of the survey was open to anyone in the UK. On completion and collation of the survey, the proportions of women choosing each birthing venue were applied to the local birthing activity Adjusting for Transfer Rates Data from the survey was based on where women would choose to have their baby. It is widely accepted that a proportion of women need to be transferred from their preferred birthing location to the main unit during pregnancy or labour when there are concerns about her or her baby s health. Thus the activity based on this survey was adjusted to take account of these transfer rates. Rates used to adjust were either from local information or from the recent NICE guideline findings for England. Table 4 shows the transfer rates used. Table 4: Transfer Rates Used to Adjust Survey-based Activity Projections NICE Guidance Min (%) Max (%) Mid-range Home to Main Pregnancy/Labour 10% 45% 27.5% Labour 4% 20% 20.0% Stand-alone to Main Pregnancy/Labour 30% 30.0% Labour 12% 12.0% Co-located to Main Pregnancy/Labour 45% 52% 48.5% Labour 25% 30% 27.5% Local Data Co-located to Main Pregnancy/Labour 29% 44% 36.5% Figures in bold were used to adjust activity projections Source of local rate: Options Appraisal Report and First Business Case, February

21 Strengths of this Methodology Activity is based on women s expressed choices, including women from Portsmouth City. Weaknesses Survey returns, though of good number, were not sufficient to constitute a statistically viable sample Survey Results The survey received 480 responses. Of these 388 were from the on-line survey and 92 from the face-to-face interviews. Overall, the preferred venue for birth was a co-located unit with 171 (36%) of respondents choosing this option. 153 (32%) indicated they would prefer to deliver within a main unit, and 117 (24%) would prefer to deliver at home. 39 (8%) of mothers opted for a stand-alone unit. Figure 1 summarises the results for all respondents. Figure 1: Summary of all survey responses Main Unit 32% At Home 24% Stand-alone 8% Co-located 36% Women who were having their first baby ( Primips ) were less likely to choose a home birth than women who had previously given birth ( Multips ). In addition, women who had already had a previous child were more likely to choose the main unit. There was no significant difference between Primips and Multips with regards choosing a co-located or stand-alone. Figure 2 summarises the split in responses by first or multiple pregnancies for each venue. 15

22 Fig 2: Differences between Multips and Primips 100% 90% 80% 70% 60% 50% Multips Primips 40% 30% 20% 10% 0% Home Stand-alone Co-located Main Implications for Scenario One Applying the survey proportions to local birth activity, and adjusting for transfers, a City stand-alone unit in Scenario One would see 121 births. Table 5 demonstrates the predicted activity at each venue based on this survey; it shows numbers with and without adjustments for intrapartum transfers. Table 5: Activity at Scenario One Maternity Services based on Choice Survey Venue Births (Adjusted for Transfers) At Home 376 Stand-alone unit 121 Co-located unit 481 Main unit 1148 Note: Assumes births completing outside the PSEH area remain constant Implications for Scenario Two In order to apply the survey results to Scenario Two, a further assumption was needed. The survey included a co-located unit as a possible option, however Scenario Two does not include a co-located unit. Thus those women choosing a co-located unit in the survey were re-allocated to either the main unit or a stand-alone unit. The assumption was that in the absence of a colocated unit, some women would choose the main unit, but that a proportion would choose a stand-alone unit. The proportion allocated to the stand-alone unit was 4.21% and this represents the proportion of births a stand-alone unit might take from all births as explained section 7.1. The survey results would thus suggest that, for Scenario Two, a City standalone unit would see 143 births (adjusted for transfers). Table 6 demonstrates the predicted activity at each venue based on this survey. 16

23 Table 6: Activity at Scenario Two Maternity Services based on Choice Survey Venue Births (Adjusted for Transfers) At Home 376 Stand-alone unit 143 Main unit 1607 Note: Assumes births completing outside the PSEH area remain constant 7.4 Activity Based on Current Birth Activity at Blake Unit, Gosport (C) The Blake unit in Gosport is a stand-alone maternity unit. The initial business case modelled possible activity at a City-based stand-alone unit by using activity at the Blake unit as a comparator. This study adopted the same approach and used updated data where available. In 2005/6 there were a total of 2,003 births to mothers in Fareham & Gosport of which 239 completed in the Blake stand-alone unit. These 239 births represent 11.93% of all Fareham & Gosport births. Thus it was assumed that 11.93% of all City births might complete at the City stand-alone unit. Strengths of this approach This methodology uses local data. Blake Unit is a stand-alone unit and thus more directly comparable with the proposed City Unit Weaknesses: It is difficult to predict whether the current activity at Blake is influenced by restricted transport links to the current St Mary s main unit. It is also difficult to predict whether the close proximity of a new co-located unit at QAH would affect women s choices, leading to fewer women choosing either Blake or the City unit in the future Results for Scenario One Using this approach, the total number of births that might be expected at a City stand-alone unit would be Results for Scenario Two For Scenario Two, the total number of births that might be expected at a City stand-alone unit would be the same as Scenario One, Activity based on Transferring Low-risk Births from a Main to a Co-located or Stand Alone Unit (D) The Birthrate Plus report examined the records of all births completing at the Main Unit, St Mary s Hospital. The report suggested that a proportion of these births were deemed low-risk. Of critical importance is the understanding that these births were deemed low-risk after the pregnancy and labour had completed and not during the pregnancy/labour. During pregnancy it is likely that a number of these births presented clinical concerns and thus a delivery 17

24 was booked to the Main Unit as the safest option for mother and baby; the births then completed with no complications. The Birthrate Plus report indicated that 29.6% of births born in the Main Unit were deemed low risk post-natally. Applying this to 2005 City births completing at the Main Unit (1,656), this would suggest that 491 births could be deemed low-risk births post-natally. However, given the issue highlighted above, it cannot be assumed that all 491 births would easily transfer out of the main unit to either a co-located or stand-alone unit. Some of these births would still be booked to the Main Unit due to clinical concerns during the course of the pregnancy. This could be due to the mother s choice or midwife/gp/consultant advice. For the purposes of activity projections, it was assumed that, of the 491 births defined as low-risk, 30% (147) of these would still be booked for delivery at the Main Unit. This proportion is based on the known transfer rates from all units to the Main Unit and probably underestimates the actual. In 2005, 10.2% of City births completing outside the Main Unit were home births. It is also reasonable to assume that of the 491 potential low-risk births, 10.2% (or 50 births) might occur in the home setting. With these adjustments, it was thus assumed that a total of 309 births could potentially be moved from the Main Unit to either a stand-alone or co-located unit. Of these 309 births, it is difficult to predict (for Scenario One) how many might complete within the co-located unit, yet it is reasonable to assume a proportion of women will indeed choose the co-located unit. Thus, for Scenario One, three methods were used: - Assume 2.74% of these births would go to the stand-alone (in line with stand-alone proportions identified in section 7.1) - Assume that 8% would choose the stand-alone unit (and complete their birth there) in line with the findings of the survey - Assume a 50/50 split Once the number of low risk births transferring to the stand-alone unit had been determined, these were then added to the activity already planned for the unit using activity determined in approach A (UK configurations). Strengths of the approach: This method makes use of local data. It also assumes a change in clinical practice rather than basing service on the status quo. Weaknesses: In the absence of research looking at the proportion of births deemed low risk throughout the ante-natal phases of the pregnancy it is difficult to predict how many of the 491 City births would be booked for a stand-alone or colocated unit and would complete in that venue. 18

25 This approach does not look at staffing, resource or clinical implications of transferring all low-risk births away from a main unit. This approach does not allow mothers to actively choose the Main Unit as preferred location for delivery Implications for Scenario One Using this approach, it can be predicted that totals of 141 births (if 2.74% go to the City stand-alone) or; 158 births (if 8% go to the stand-alone) or; 287 births (if a 50/50 split between stand-alone and co-located is assumed); might be expected at a City stand-alone unit Implications for Scenario Two This approach indicates that a total of 498 births might be expected at a City stand-alone unit. This assumes that all low risk births are transferred to the City stand-alone (adjusted for home births and transfers back) in the absence of a co-located unit. 7.6 Summary of Activity Projections Table 7 summarises the activity projections for each Scenario and approaches described more fully in preceding sections. Table 7: Activity Projections for City Stand-alone Unit No. of Births in Stand-alone Unit National Survey Blake Low risk to units comparison A B C D Scenario One Scenario Two National rate Local rate National rate Survey 50/ Other Factors Influencing Stand-alone Unit Activity Trends in Home Births Between 2001 and 2005 there was a 12.88% increase in home births to mothers within Portsmouth City. Although levels vary from year to year, this would suggest a 3.22% annual growth in home births for Portsmouth City PCT. This assumption was applied to the activity predictions for both Scenario One and Two in order to assess the impact of increasing home births on the City stand-alone Unit within the first year of its operation. If this rate of growth were to continue, this would see a decrease in births to maternity units over time. 19

26 Table 8 shows the possible impact of home births on the various activity predictions for the City stand-alone unit in both Scenarios Table 8: Impact of Home Births, One Year of Activity No. of Births in Stand-alone Unit National Survey Blake Low risk to units comparison A B C D National rate Local Transfers National rate Survey 50/50 Scenario One Adjusted Home Births Scenario Two Adjusted Home Births Note that the survey results have not been adjusted for home births, assuming that these already reflect trends Configuration of Maternity Services outside of Portsmouth & SE Hampshire In 2005, there were 836 births to Portsmouth and South East Hants women in units outside of the Portsmouth and SE Hants area. Of these, 46 were women registered to Portsmouth City PCT. Given the geography of the area and the current location of the Main Unit at St Marys Hospital in the City, it is unsurprising that more women from Fareham, Gosport and East Hampshire than women from Portsmouth are giving birth in out of area units. A significant number of women use maternity services within St Richards Hospital, Chichester. A recently announced consultation process regarding the future role of the St Richards Hospital in Chichester is currently underway. St Richards includes a main consultant/midwife unit. In 2005, 24 women from Portsmouth and 400 women from the SE Hants areas gave birth at this unit (total = 424). Although no decision has been made regarding the maternity services at St Richards Hospital, this study considered the implications for the proposed stand-alone unit in Portsmouth City if the St Richards main unit were not available as a choice of birth for local women. For the purposes of this feasibility study, it was assumed that this would have nil impact on births at the proposed City stand-alone unit due to the low number of Portsmouth City women attending services at St Richards. Those that do attend St Richards are likely to continue to choose a main or colocated unit. It must be noted that this is a speculative approach purely to ensure this feasibility study considers possible future trends. No decision regarding St Richards Hospital has been made at this time. 20

27 7.7.3 Overall trends in birth rates The Options Appraisal report (February 2006) identified trends in birth rates to the Portsmouth and South East Hampshire populations. Overall population size and trends were also considered. A reduction of 2.6% in births to Portsmouth and South East Hants women is predicted from a 2001 base-line up to For Portsmouth City this reduction is likely to be 1.6%. For the purpose of this study, it was assumed that this reduction in births over the next 20 years was not significant enough to warrant adjusting the activity predictions. 8 FINANCES 8.1 Capital costs: building the unit The initial business case gave a comprehensive assessment of the preferred option for the location of the stand-alone unit for the City. It indicated that, with the main maternity unit transferring to the QA Hospital site in 2009, the most feasible and cost-effective location for a City stand-alone unit would be on the St Mary s Hospital site. The initial business case proposed that the stand-alone unit be comprised of 2 birthing rooms and 4 ante/post natal rooms, all ensuite. Space requirements for this configuration are given in Table 9. Table 9: Space Requirements for a City Stand-alone unit Facility Square metres Lobby 10 1 x Single ante/post natal bedroom, en suite 20 1 x single ante/post natal bedroom, en suite (assisted) 25 2 x 2 bedded ante/post natal rooms, en suite 45 2 x dedicated labour rooms, en suite, with pools 45 Dining room 15 Kitchen 15 Staff room 15 Office 15 1 x w.c 2 1 x assisted w.c 3 2 x storage rooms 20 Dirty linen room with hand basin 5 Community midwife base 40 Community midwife manager office 10 General purpose/health education room 35 Examination room 15 Circulation space 40 Total: 375 m 2 The estimated cost of building a new stand-alone unit on the St Mary s hospital site is between 1.6million and 2million. This is in line with the initial business case conclusion. These costs would need to be identified from PCT capital allocations. 21