More On The Future Of The NHS

We ambulance people are finding ourselves called to the Barkantine centre quite a bit these days. Amongst other things it is a birthing centre.

It's really rather nice actually – it's clean and airy, the rooms are large and have all the amenities like an en-suite bathroom, birthing pool, televisions and big bouncy inflatable balls (I have no idea, the midwife who taught us how to catch a baby never told us what that could be used for).

The staff are lovely, when I have seen them dealing with medical situations their clinical skills have been good, they also seem very happy at their job, something that is a rarity in some of the hospitals I visit, and yet I find it incredibly important. Their bedside manner has also seemed excellent, again something that I've found lacking with some staff in some hospitals.

So, why do I find myself going to such a paragon of 'how things should be done'.

Well, we are used as a a transport service when things start to go a bit wrong.

To be fair, from the policies that they have they do tend to err on the side of caution. For example if the labour is progressing too slowly we will get called to transport the mother to the Royal London Hospital Maternity department (and that department is quite a change from the Barkantine I can tell you), the Barkantine midwife will travel with them.

A little while ago I took a mother and baby to the hospital because the baby was a little strange and needed some medical attention that the Barkantine couldn't provide. Hopefully nothing too serious, but my knowledge of neonatal medicine is rather thin.

So, while it is indeed a superb place to give birth, I have just one small problem with the Barkantine – it's not in a hospital.

While they only accept patients with no expected complications, such things can always occur which is when we are needed, and while I don't begrudge them using us as a transport service, because we do this for other hospitals, it does seem to be a bit wasteful of resources.

I'd also hate to see something bad happen to a mother or child because of a delay brought about by the wait for an ambulance and the following transport through the streets of London.

The Barkantine is excellent, it's just in the wrong place – it should be in a hospital, with access to theatres and a SCBU, Consultants and 'Crash teams'. These options should not be twenty minutes away by blue light transport and dependant on there being an ambulance nearby that isn't dealing with yet another drunk.

So, when the new Royal London Hospital is built, can we transplant the Barkantine to the roof there please?

I'm working Friday, Saturday, Sunday nights – so don't expect an answer soon to any comments or emails.

16 thoughts on “More On The Future Of The NHS”

  1. I understand where you are coming from, but maternity is a completely different kettle of fish. This is not medicine, being pregnant (or in labour) is not an illness, its a natural thing. The women booked with these birth centers dont have medical problems; if the had they wouldnt be there. Of course emergencies in maternity do happen but they are rare and in between and in most of the cases provoked by our own interventions (epidurals, artificial rupture of membranes etc etc).It's a well known truth amongst us maternity staff that just by being in a consultant led unit you tend to get more interventions than you need. That is why we try to send women who dont need to be there home or to one of this centers, because if they sit around for too long the obtetritians tend to get itchy and want to do something instead of letting the normal process unfold. We do not tell them to come back by an ambulance, though 😉

  2. Being attached to a hospital is the sensible way to do it. We went to a birthing centre here in Sydney for number 2, and the staff were marvelous and the place was well setup. However, it is also part of a major hospital, so when he went into foetal distress, it was simply a matter of wheeling mum 50 yards down the corridor to an OR in a “proper” hospital.We couldn't use a birthing centre for number 3, and had to do the “normal hospital” routine. Ugh. I would not recommend that to anybody.

  3. It seems a waste of time to write in here and say – I totally agree. But I have anyhow. Maternity units in large hospitals are nothing but meat markets anyhow – but placing them away from the hospital is bizarre.My ex had our first (my second) in a little GP led hospital in Wales. I cannot fault it. She had elective caesarian and was well looked after. Her second – the GP convinced her going to the local DGH was best – in case of complications and shit like that (even tho the local hospital was quite capable) and so she went to the DGH as a worried mum who didn't want to be responsible for her baby unnecessarily dying from her bad decisions (yeah the GP did a real number on her – I was so impressed – he even 'promised' to sort her to be transferred soon as possible post op).

    After 3 days of mostly ignorance, stupidity or abuse by staff I'd seen enough and “arranged”* her transfer to the local hospital.

    [*told the ward sister if she didn't “arrange her fucking transfer in the next two hours” I would be taking her by car and putting in a series of complaints including … yada yada yada….. “..and what is your name please?”]

    It's not pleasant getting to that point but I have this strange belief that the service is there for the patient – not the other way round.

    I didn't put that complaint in – tho there were some valid issues – as I thought it might be unfair. And even tho it was over 10 years ago now, I still don't mention which hospital it was as it might be unfair on the staff of the Maternity Unit, Nevill Hall Hospital, Abergavenny, Wales.

  4. No, it shoudln't be in a hospital. There are many reasons why home birth can be safer than hospital birth for women with low risk pregnancies (this is not 'what I think' this is based on clinical evidence) and there are just as many reasons why some women would rather not give birth at home but still deserve a 'low risk' environment. We also know from the evidence that transfer to consultant led care happens a huge amount more when the low risk unit is on a consultant led site than if it is off site, which is why we at our unit are looking at moving ours off site as it reduces UNNECESSARY transfers. Given that midwives' threshold for transfer is fairly low as a rule, we don't transfer in for just any old thing, only for necessities. If you had more low risk birth centres away from hospitals this would actually IMPROVE outcomes and from that point of view woudl be hugely financially beneficial, but would require huge amounts of initial outlay and work.

  5. I get that you would want to reduce unnecessary transfers, but Tom is also right in that the necessary transfers shouldn't take more than a couple of minutes at most.

  6. Clarabelle, I'm not going to argue numbers with you, partly because I'm in the middle of nightshifts, partly because I have no access to ATHENs (or whatever its called… CINAHL?, I forget), and partly because you might well be right.Here is my argument, it's not a 'building location' problem, there is no mystical field of energy around hospitals that causes maternal problems. Instead it's a staff training issue, if they are properly educated as to the necessity, or not, of transfers then you wouldn't need an unnecessary (and possibly dangerous) artificial border of needing an ambulance transfer to weave through traffic.

    So, in my opinion, the best response would be to correctly train staff and have the policies in place to reduce admission to hospital, but still to have the facilities nearby should the need arrive.

  7. Tom- I recently discussed this at length with an NHS-in-hospital Midwife, and think I understand what Clarabelle means.Some mums (and professionals) feel that giving birth is fundamentally a natural & normal process that can take place in numerous small units easily accessible to mums-to-be. Too close proximity to all the paraphenalia of modern medicine may infer that there are worries about possible complications.

    Unfortunately, where hi-tech interventions are required, they are likely to require large investment in equipment and specialist staff. That implies a few 'centres of excellence' each taking what are likely to be time-critical cases from several 'birthing units'.

    They can't all be close at hand!

  8. I do get what you mean. But (from experience) it is not so much that the professionals transfer willy nilly just because they can, though this does happen. It is things like: if you are just a short walk from an epidural, psychologically you are less geared up to coping without one as you always have that get out clause. If you have to physically go somewhere for one then you only do it if you REALLY have to. Similarly I've done home/birth centre births where women have pushed a baby out absolutely against all odds because they'd have ended up with a ventouse in hospital (simply because they'd decided they'd had enough of this pushing for ages lark). Even women have admitted this to me, that if there had been the option to bail out then and there, they would have taken it. Psychologically, being right in the middle of a consultant led unit (or next to it) means you feel in a slight way that you ARE there.What I would suggest would be that for non-urgent transfers, including some in to hospital from the community (which I'm always terribly apologetic for even though I know I don't have to be) there is a 'lower tier' ambulance service that GPs etc could then use, that we could be triaged to through 999. That would mean that only the real emergencies would be transferred in by emergency ambulance and 'primip at 4cm wanting epidural' would not be taking away from someone needing cardiac care etc.

  9. Well here in Texas…more specifically Houston we have a very similar problem with such hospitals. Though they are not all stand alone Maternity Units we have what we in EMS have named “boutique” hospitals. These places are very beautiful, with large expansive hallways, in suite bathrooms, room service, etc. The problem is with these places is that they “church” themselves up. They tell the general public of how great they are with all of their “services”. They dont lie to the public, they just dont tell them the whole story. Example of them being a Level IV Tramua Center. Here in the states all that means is that they report their stats to the health dept. Anything over minor cuts, burns, broken bones, they start to scream for a transfer…but they dont tell the public this. These places are for minor emergencies only yet they wont tell the public this so many a transfer ambulance is called out to these places to take thier pt.s to a real hospital.We also have stand alone ERs….pretty much the same story, its an ER with no hospital attached to it…although nice, people drive their family members in not knowing the ER cant handle it.

    Why oh why can they just be realistic with the public and try and educate them???? and dont get me started on how yall educate the public…least yall try, we just…excuse the phrase..bend over and take it.

  10. Having a blood clot or a heart attack or an epileptic fit is also “a natural thing”. It happens naturally. Lots and lots of illnesses are “natural things”. Natural isn't always Nice.Without intervention, sometimes people survive these events. Sometimes they don't. Sometimes they survive but are left in a greatly weakened or disabled state.

    Childbirth is also a natural event which happens naturally. And sometimes people survive and sometimes they don't and sometimes they survive but are left in a greatly weakened or disabled state.

    We intervene medically to improve people's chances of surviving strokes and heart attacks and epileptic fits, rather than “letting the normal process unfold.”

    So why not intervene medically to improve someone's chance of surviving childbirth?

  11. Having an epilectic fit or a heart attack is not a natural thing, it means than something in your body isnt working as it should. On the other hand, being pregnant is something your body is designed to do. On top of this, pregnant women are mostly in their twenties or thirties with minimal, if any, medical problem. For these women is SAFER no to intervene and just let the natural mechanism of labour work. For example, if we try to induce your labour1) you have less than 2/3 chances of not needing further intervencions (NICE guidelines in Induction of Labour)

    2) it is more painful so you are more likely to end up with an epidural (with all its associated side effects including higher chances of forceps/ventous delivery )NICE Intrapartum Care guidelines 2007 and NICE Induction of Labour guidelines 2008

    3)you will have to be attached to a monitor all the time

    4) Induction of labour dobles the chances of having a c/section (which is after all, a mayor abdominal operation) Seyb, ST et all (1999) Risk of caesarean delivery with elective induction of labour at term in nulliparous women. Obstetrics and Gynaecology 94(4) p600-607

    5) etc etc

    Of course interventions are necessary for women with severe medical conditions. But these are the minority of the cases. For the rest of them sometimes less is more.

  12. I will argue to the bloody death that illnesses, especially those associated with old age, ARE natural, they occur naturally, they are a part of life. However, I take your point about how illnesses are “something in your body isn't working as it should” whereas pregnancy and childbirth, generally speaking, is things working exactly as they are supposed to.That said, I would like to extend the comparison with heart attacks:

    People whose pregnancies/births are going perfectly well do not need to be in a hospital or undergoing medical procedures.

    People whose hearts are beating just fine do not need to be in a hospital or undergoing medical procedures.

    I think we agree on this.

    However, I reckon if Tom encountered someone who was not immediately dying but whose heart was doing painful or unusual things it wasn't meant to do, he would want to get them into hospital, for the dual purpose of (1) getting them monitored so that the problem can be identified and (2) getting them close to a unit that CAN deal with it if they do suddenly start dying. Similarly, as soon as something starts to go a little bit wrong with a pregnancy/birth, I would want to be monitored and placed in or at least near a hospital, just in case. Certainly, in either case, cardiac or birth complications, I wouldn't want to have to be actually at death's door before embarking on an uncomfortable twenty-minute ride to the nearest available assistance.

    That said, you wouldn't leap straight in for a bypass 'to be on the safe side' and it would be downright dangerous to start waving a defib around when it wasn't necessary – so I do agree that inducing labour and mucking about beyond simple monitoring when things aren't at a life-threatening stage probably does more harm than good.

  13. Might be expensive, but they could go the route of paying to have a trained transport staff on duty.The Childrens Hospital in the service area of the company I worked for a few years ago did this. They contracted us for one specially outfitted ambulance for neonate transports and an EMT that stayed parked at the hospital. The hospital provided an on call team that included a nurse and respiratory tech that would hop on whenever necessary.I'm sure a similar setup could be done for transporting out of a birthing center. That would solve the problem of maybe an ambulance not being nearby. But yeah, more cost effective to just call for an ambulance if necessary…who cares about the occasional morbidity or mortality right?

  14. It woudl be great if these services were in place tbh. Then it could be not only used to transfer from birth centre or home to hospital intrapartum where caregivers are in attendance (homebirth etc) but also could be used for instance in our area where women do not have transport to the hospital: we tell our women ALWAYS to get a taxi or a lift unless instructed otherwise by the hospital (emergency or bleeding) but if it is Friday night and it's 12 midnight, chucking it down and it's a three hour wait for a cab then it's not unreasonable to call an ambulance to get to hospital to have your baby, because if you need to get there and there is no other way, needs must. I used to do home assessments in labour and hated calling 999 for this purpose but sometimes you just had to, no choice.This sort of service would also be great for things like transfers between units for pregnant women, eg if you were an antenatal patient needing transfer to a unit with a NICU cot. These sorts of transfers tie up normal ambulances too and sometimes they go hundreds of miles.

  15. My thoughts on this:>95% of deliveries in low risk women proceed without a hitch, but quick transit to a hospital (as you say, not 20 minutes in a blue light service) can be urgently needed if something does go wrong.

    However, moving something like the Barkentine (?sp) into a hospital might simply mean that those women who went there rather than choosing to deliver in hospital stop going there, and go for a home birth/alternative location instead.

    My suggestion: Move to a building <5 minutes drive from a hospital. This, in addition to keeping the Barkentine separate from the hospital, should still be far enough to stop unnecessary referrals, and close enough to stop maternal/neonatal deaths and other serious complications resulting from delay.

    Possible enhancement to cut down on ambulance call-outs: Have a vehicle on hand specifically for the purpose of transporting someone to the hospital if they really need it, complete with emergency driver (maybe training up enough willing people from the desk staff/midwives/cleaning staff in that role if keeping someone on hand just for that purpose can't be justified).

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