A model for the future of maternity services in the Bristol area
1 Introduction
The proposed reorganisation of health services in Bristol involves contracting the acute hospital services from three sites to two, with Frenchay becoming a community hospital. One of the stated aims of the reorganisation is to concentrate all children’s services on a single site within the United Bristol Healthcare Trust. Assuming that neonatal intensive care must be available to all acute obstetric units, this suggests that there should eventually be only one acute unit at St Michael’s Hospital. This paper offers a model for the future of maternity services based on a single obstetric unit and a number of community midwife-led birth centres
The model proposed has a considerable number of advantages including:
- Providing greater choice for women and families
- Offering a phased approach that will eventually enable all acute maternity services to be on a single site alongside paediatric and neonatal care
- Transferring the care of women with uncomplicated pregnancies out of the acute units and into the community
- Reducing travel for women, visitors and staff
- Enhancing the role of midwives and preserving key midwifery skills
- Saving costs in both capital and revenue terms
- Reducing the rate of interventions and surgical deliveries
- Helping to meet the standards of the Maternity Services NSF and the government commitment to one-to-one midwife care for all women
The diagram above shows how a single acute unit supported by birth centres in the community will, over time, replace the current two acute units at St Michael’s Hospital and Southmead. This paper presents the key points in favour of a decision to promote this model of maternity services.
2 Structure of overall service
Over the next five or six years, half of Bristol’s 10,000 births a year will be transferred to about ten locally based midwife-led birth centres, retaining St Michael’s Hospital as the centre of excellence for all maternity cases requiring obstetric care. The birth centres will be run by community midwives, who will continue to provide clinics at local health centres, to carry out their community work and to attend home births. As the new service model develops, midwives will be transferred out of the acute units into the community.
3 Booking process
Every woman will book with a community midwife at her local birth centre or health centre. The midwives will use agreed selection criteria to assess women and book them for a home or birth centre birth. Women not meeting the criteria for local birth will be booked to give birth at St Michael’s, but for almost all women most antenatal care will be provided in the community. The guiding principle will be for women to give birth locally as far as possible within the capacity of the birth centre (about 500 births a year including home births). The flowchart in Appendix A shows the process for booking women for maternity care.
Experience elsewhere shows that, when these principles are followed, at least 50 per cent of women in any given area choose to have their babies in a birth centre.
4 Management Structure
The Primary Care Trust will direct the management of maternity services through two management teams, both under the overall direction of a Director of Maternity Services. One midwife manager will run the birth centres and another will run St Michael’s as at present. The two management teams will liaise closely to achieve an integrated service within the Bristol area, agreeing procedures for care pathways, transfer to the acute unit, management of antenatal and postnatal care, risk management, clinical governance, training and staff development. The birth centres will have their own individual management board including users.
The diagram below illustrates the suggested management structure, which has the added advantage of offering more opportunities for midwifery managers and a new framework for career progression and professional development.
5 Revenue costs
The costs of antenatal and postnatal care are assumed to be the same whether provided at the birth centre or at St Michael’s. The costs of delivery will be less, averaging £600 at the birth centre, compared to between £800 and £2,200 at St Michael’s, the latter figure being for caesarean sections. (Per capita costs at St Michael’s may increase because all complicated cases will be booked for delivery in the acute unit.)
The table below assumes that, with half of Bristol’s babies delivered in community birth centres, rates of normal birth will increase (as is demonstrated by the available research evidence). It also assumes that the proportion of women delivering in the acute unit by caesarean section will be the same as at present (approximately 25 per cent) and that the average cost of non-surgical deliveries at St Michael’s is £1,000.
| Description | Average cost | Number of women | Total cost (£000s) |
|---|---|---|---|
| Post/antenatal care | £750 | 10,000 | 7,500 |
| Current delivery costs: | |||
| Normal birth | £800 | 2,500 | 2,000 |
| Some intervention | £1,000 | 5,000 | 5,000 |
| Caesarean section | £2,200 | 2,500 | 5,500 |
| Total current costs | 20,000 | ||
| With 50% births in community birth centres: | |||
| Normal birth | £600 | 5,000 | 3,000 |
| Some intervention | £1,000 | 3,700 | 3,700 |
| Caesarean section | £2,200 | 1,300 | 2,800 |
| Total future costs | 17,000 | ||
Revenue saving for maternity services in Bristol will be about £3 million a year or 15 per cent. This saving will allow the costs of setting up and refurbishing the birth centres (see section 6) to be recovered within a two-year period.
6 Capital costs
The capital costs of setting up this new service will be considerably less than those involved in extending St Michael’s Hospital to accommodate a doubling of throughput to 10,000 births a year, even if this were desirable.
It is envisaged that many of the birth centres will be based at or alongside existing community midwifery bases. Birth centres could also be located in other NHS properties being taken out of use, such as Cossham Hospital, selected to give the best spread of community provision throughout the area. There are strong arguments for birth centres to be based in the new community hospitals and health care centres, where an element of new build could be economically provided.
The table below suggests, purely for illustrative purposes, a number of possible sites for community birth centres in the Bristol area, serving several different locations.
| Possible sites for birth centres in the Bristol area | Community location |
|---|---|
| Bristol South Community Hospital | Hengrove |
| Central & East Community Health Care Centre | Easton/Lawrence Hill |
| Shirehampton Health Centre | Shirehampton |
| William Budd Health Centre | Knowle West |
| Southmead Hospital | Southmead |
| Frenchay Community Hospital | Frenchay |
| Cossham Hospital | Kingswood |
| Granby House | Bedminster |
| Mortimer House Clinic | Clifton |
| Blackberry Hill | Fishponds |
| Thornbury Community Hospital | Thornbury |
| Keynsham Community Hospital | Keynsham |
Birth centres set out to promote normal birth through continuity of care and low rates of intervention and the requirements for equipping a birth centre are modest. A birth centre with facilities for 500 births a year is quite small, some 300 square metres to provide five beds and antenatal and postnatal clinics. Exact requirements will depend on the facilities already existing at each site.
Allowing £500,000 for building or refurbishing each unit, the total cost of providing ten birth centres will be approximately £5 million. This compares with an estimated cost of up to £20 millionNote 1 to extend the existing acute unit at St Michael’s.
The overall saving of £15 million capital costs will save £1 million in annual charges.
This results in overall revenue savings of £4 million a year.
7 Staffing issues
Currently there is a crisis of recruitment and retention in the midwifery profession. Staff turnover at birth centres is low, because birth centres offer considerable job satisfaction to midwives, who see themselves as the guardians of normal birth. In addition, local birth centres will appeal to local midwives, particularly those who may want to come back into the profession with flexible part-time jobs. Birth centres can also provide an important training environment as part of the process of professional development for midwives, in particular offering a wider experience of normal birth than is currently available in the acute units. The workload for each midwife will be about 30 births per year, which is the average across the maternity services in the United Kingdom, achieved through staffing the birth centres with a combination of midwives and midwifery assistants.
To cover 500 births a year will require 16 to 20 whole time equivalent (WTE) community midwives, or a total of 200 in ten birth centres. This compares with 82 WTE midwives (in round numbers) now working in the community, 39 based at St Michael’s and 43 at Southmead. At present there are 90 WTE midwives working in the acute unit at St Michael’s and 109 WTE at Southmead, so the overall number of midwives would remain about the same, given that St Michael’s is funded for an establishment of 137 WTE midwives and currently employs only 129 WTE in total.
8 Programme and strategy
The current reorganisation of health services offers a unique opportunity to introduce birth centres in a progressive and evolving manner. Birth Centre Bristol envisages two birth centres a year being set up over the five-year period of the overall reorganisation. This will enable maternity services at Southmead to be wound down in an orderly fashion, keeping the number of births at St Michael’s stable, while at the same time extending the network of birth centres.
The initial opening of a single birth centre, perhaps at Granby House in Bedminster, will give the opportunity for an early evaluation to confirm that this model of care does indeed provide a cost-effective, popular and high quality service, enabling the Primary Care Trusts to pursue with confidence its full implementation.
The diagram in Appendix B illustrates how maternity services for women with uncomplicated pregnancies could be progressively transferred from the acute units to community birth centres, eventually permitting the obstetric unit at Southmead to become a midwife-led birth centre, with St Michael’s Hospital remaining as the central obstetric unit. The aim will be to maintain stable numbers at St Michael’s by transferring about 1,000 births a year into the community while gradually winding down the acute maternity services at Southmead.
9 Conclusion
A programme to transfer 50 per cent of births in the Bristol area to a maternity service model based around ten community birth centres and a single acute obstetric unit is timely, cost effective and offers a wide range of benefits.
The reorganisation of health services in Bristol offers a once in a generation opportunity to make this move. It will save both capital and revenue expenditure, will be welcomed by women and midwives alike, and will result in real public health benefits for mothers and their babies.
June 2005
Note 1
Two wards at £8 million each and an additional operating theatre at £3-4 million.
Appendix A
Flowchart illustrating the booking process
Appendix B
Diagram (for illustrative purposes only) showing the progressive transfer of non-acute maternity services from St Michael’s and Southmead Hospitals to community birth centres, with acute services gradually becoming centralised at St Michael’s Hospital
