Tuesday, 1 November 2011

Anyone done the maffs?

We have been informed that a Caesarian section will now be a right rather than a medical necessity. A few thoughts occurred to the team. Let us suppose that you work at a hospital that does 12 deliveries a day and that all the women opt for a Caesarian section rather than a natural childbirth.

Let us assume that each Caesarian takes half an hour of operating time then any hospital operating new NHS C-choice™ would have to find a mere 6 hours minimum of theatre time a day above what is provided now. Operating time is not the only thing that would have to be found there would need to be found additional anaesthetic and associated personnel time, surgeon and assistant time, midwife time, paediatrician time as well as porters et al and of course those most essential for true patient care the NHS commissars to prepare the bills that allow the NHS to work independently of all of the aforementioned non essential personnel.

The hospital would also have to find 12 beds a day as well as recovery staff time and ward nursing staff time and that is assuming that these are all done as general anaesthetics rather than epidurals which take longer to work and all were done as day cases.

Indeed our recollection of elective Caesarian sections done under regional anaesthesia which you can bet will be the norm for those too posh to push so they could see their darling little Tarquin or Chantelle-Detritus-Leah (it's exotic!) born and post the event on YouTube was that 2 maybe 3 could be done in a half day session.

So 6 hours of operating time is being optimistic it is more likely to be 2 or possibly 3 theatres operating for a full day plus the increased number of staff. In order to work this would need to be available for 365 days a year as well as facilities for any emergency C-sections.

Obviously as this would be C-choice there would be peaks and troughs for Tarquin’s and Chantelle-Detritus-Leah’s planned arrival into the world. For example I couldn’t deliver at Christmas as I would miss my turkey and heaven forbid any obstetrician says to a woman the only slot we have for an elective C-section is on the night of an X-factor final, FA cup final, or a Big Brother eviction. How would Wayne Trotter the father cope? You can bet that he and Sharon will know their rights then.

The article quotes a figure saying that a one percentage point reduction in C-section rate saves £ 5.6 million. Does that mean that if 100% of births were done by C-section up from the current 25% the NHS would have to find £ 420 million a year for a procedure that some would argue is not being done for a medical reason?

And in order to double check the maffs if one takes the figure of 708, 708 births in 2008 take 75% of these and multiple by the quoted £ 800 extra per birth you get a figure of £ 425 million. Not a small chunk out of £20 billion NHS efficiency savings over five years in the midst of a recession.

Then there is the morbidity and mortality to add in. Yes deaths from anaesthetic complications have decreased in pregnant women over the years but if more women have abdominopelvic surgery then DVTs will increase. We believe that 60 in 100,000 women who are pregnant will have DVTs which is an old figure presumably based on a 25% C-section rate. If that rate increases will DVTs and PEs and their 1% mortality go up as well as general morbidity for example wound infections to match the increase in numbers done? More operations means more chance of misadventure so what would happen to NHS indemnity bills and defense society charges?

Now we are simple GPs here at ND Central and while doing home visits one of the team heard an interesting point being made on a popular TV show as they listened to the normal chest of the infirmed but “too idle to come to surgery”, the ancestor of the "too posh to push" generation. This urgently infirmed geriatric had wanted to be sure they were well enough to go to their granddaughter’s Halloween Party and outdoor barbeque – presumably as the evil looking witch with nicotine stained nails, eau d’cigarette body odour and scary brown hag dentures –  followed by trick or treating with Jemima-Louise.

The point was made on the programme that NICE stood for National Institute of Clinical “Excellence” (not) – got us listening – and that Marshall DC’s poll rating with female voters is low. Could this be the answer to another medical blogger’s posed question?

We await the final publication of any NICE guidance and their reasons for suggesting their policy. We hope that following on from this that all cosmetic procedures will now be available on the NHS for surely if everyone is now too posh to push then no-one is too poor to be ugly?

Praise be to the Party and its NICE organs who evaluate “evidence” rather than science and come to some fairly doubtful “best” political practice ideas.


Doctor Zorro said...

One or two comments. Firstly there is no way that 100% of parturients would take up the option, and I think the actual number is going to be quite small. Secondly if 100% had an elective section you would not have to provide facilities for emergency C sections, as they would all have been done already, and we know from CEPOD that any op done electively in the daytime is safer than done as an emergency at 0200. Thirdly you do not have to have had a C section to suffer a DVT in pregnancy which is itself high risk. Finally the risks of C section, surgical and anaesthetic, are now so low to both mother and baby that it is arguably no more risky than vaginal delivery, and lesser long term complications are far less likely after section.
So I disagree with you on this one. Bring it on

the a&e charge nurse said...

The key principle still holds, Dr Zorro, although there may be some dispute about precise numbers.

In A&E, for example we are bombarded, and I mean literally BOMBARDED with all manner of initiatives, pathways, and protocols - we have even reached the stage where we have now developed a protocol to determine if a protocol is necessary!

Now on the face of it there is a certain amount of common sense when each of these are taken in isolation, but nobody gives even the remotest consideration to the cumulative impact of trying to meet all of them?

Deep in our hearts we know that such standards can never be met (in every case) - at least until the day when situational factors which so affect individual experiences are more easily controlled.
Only then will clinical staff be able to give their full attention to one, or maybe two bundles of care, rather than the ever growing forrest of things that must be done when condition A or circumstances B arise.

In my book, nobody seriously believes that protocols will bring about clinical excellence but are rather a device to beat staff up with when things go wrong (because of a failure to meet a proscribed gold standard).

From what I hear maternity services are already stretched, so even a modest increase in pressure when set against a burgeoning resource/demand mismatch is likely to result in more bad experiences for patients and staff alike?

Isn't it time to call a halt to the practice of protocol mania until the time and cost implications are spelt out in order to achieve ALL of them?

Doctor Zorro said...

Nobody is talking about a protocol here, simply giving women the option of a caesarian delivery.
I agree with you entirely on the runaway proliferation of protocols, mostly based on very little evidence.
However in Obstetrics the minutely detailed audit of maternal mortality that has been ongoing for over 40 years has led to well supported protocols for surgeon and anaesthetist. I strongly believe that these protocols are responsible for the steady improvement in caesarian safety that has been apparent over the years.

the a&e charge nurse said...

"Nobody is talking about a protocol here" - if c-sections are elevated to the status of 'right' (irrespective of clinical need) than as sure as day follows nights a pathway or protocol will emerge to cover the ass of staff who may come to fear patients complaining that their 'rights' have been abused in some way.

For example, let's imagine 8 hours of pushing becomes too much to bear, and an exhausted mother changes her mind and say's I'm claiming my 'right' to surgery - presumably there will need to be some sort of standard as to how soon theatre should be available and what grade of staff should be around to carry out the procedure in these circumstances?

You are quite right about the painstaking and detailed work done to reduce birth related surgical complications, but now they will have to consider risk amongst women who have a right to surgery irrespective of clinical need (leaving aside psychological issues, or personal preferences for the moment).

You say the extent of this additional work should be relatively modest (and I'm sure you are correct) but in the current climate perhaps greater emphasis should be put on reducing the number of car park or ambulance related births instead?
Put another way, if maternity staff are busy ensuring the 'right' to unnecessary surgery then presumably fewer of them will be available to deal with heavily pregnant women who are being turned away due to lack of resources?

To my mind this a classic case of robbing Peter to pay Paul - a mind set that permeates a great deal of clinical activity when certain kinds of action are only considered in isolation, or free of situational context?

Doctor Zorro said...

Well that is the job of NICE. to view a particular treatment in isolation and to make recommendations purely on a risk/benefit basis the only financial consideration being that a QuOLY should not cost more than £20K. The broader picture is beyond their remit and they are expected to make their recommendations regardless. In any event it could be argued that in the long term the saving on treatment of perineal damage could offset the cost of C section. Even in the short term the cost of a prolonged labour, and repair of a third degree tear exceeds that of a section.

Anonymous said...

So someone who is going blind with macular degeneration can only have treatment in one eye and only once they are completely blind in one eye because of shortage of funds and yet women will be able to have caesarians that are not clinically necessary?

Someone I know was smashed up in an accident and waited weeks in severe pain for surgery to reconstruct a joint with metal. But then, he's old. Who cares if an old person has several weeks of severe pain if that leaves more money for someone to avoid a couple of days of pain.

I wonder if it's anything to do with who votes? Blind people and people who can barely walk don't get as far as the polling station.

Jenny Woolf said...

Problem with the NHS seems to be that so much is done in isolation