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Shifting the balance of care—or imaginative healthcare accounting?*

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  2. Shifting the balance of care—or imaginative healthcare accounting?
  3. Conflict of interest

The UK has tended recently to centralise treatment of complex medical disorders in tertiary care centres. In parallel there have been moves to increase healthcare delivery by consultants and extend the role of nurses and midwives to include duties previously undertaken by doctors in training. The idea is both to improve patient care and make the best use of limited resources but such shifts may pose difficulties for obstetric practice. How do we safely define low and high risk pregnancy when we know that a patient's condition can change rapidly? Where are the limits of responsibility for a midwifery profession that is determined to reverse the unrelenting increase in rates of obstetric intervention and an obstetric profession that is focussed on minimising maternal and perinatal morbidity and mortality?

Oettle et al. (p. xx) have proposed an approach to the management of severe early onset pre-eclampsia that is a direct challenge to the direction we are taking in the UK. With increasing pressures on their tertiary care centre, they have allowed complex patients to be cared for in the secondary care setting. A single obstetrician with expertise in high risk care provides the medical lead and the unit works to a protocol determining timing of delivery and criteria for transfer to the tertiary care centre. Perinatal mortality was higher in the secondary care centre despite a lower risk patient profile, but the authors interpret this as an acceptable outcome. This is worrying. Either more training is needed, or it may reflect the complexity in evaluating changing patterns of care. A full evaluation would include not only the impact on the health of those who are transferred early and late, but also the effect on low risk patients in the secondary and tertiary units whose care will be altered by staff trying to care for additional high risk patients. There will also be an impact on the members of obstetric teams and neonatal intensive care facilities. Such complex evaluations of the remote effects of policy changes are difficult. Evaluating maternal mortality and morbidity is also difficult. The authors followed the approach of the confidential enquiries into maternal deaths (CEMD) in the UK and recorded individual adverse outcomes with care.

We must also wonder at a service that relies on only one specialist with the necessary expertise to care for such complex cases. The European working time directive would not allow this in the UK. We are faced with the additional challenge of a future workforce with shortened training and limited exposure to complex obstetric care. The UK will then have to face up to the issue of who will care for pre-eclamptic women in secondary care centres on a daily basis? Will they all have to be transferred to tertiary care centres? If not who will recognise that the mother or fetus is decompensating and requires stabilisation and delivery?

These are important questions and Oettle et al. have proposed an apparently cost neutral solution. The beauty of their approach is that they have recognised the importance of contemporaneous evaluation of maternal and fetal wellbeing and they have sufficient patient numbers to allow valid comparisons of important outcomes.

We are embarking upon dramatic changes to how we provide care to pregnant women within the UK. Besides changes in secondary and tertiary care, there is the issue of home birth opportunities and midwife led care. We must recognise that shifting care and shifting costs also involves shifting risks. We must rise to the challenge of evaluating healthcare changes as they are implemented if we are to look back with confidence at the changes we have initiated and not with regret at missed opportunities.

Conflict of interest

  1. Top of page
  2. Shifting the balance of care—or imaginative healthcare accounting?
  3. Conflict of interest

DJ Murphy is a medical advisor for the charity Action on Pre-eclampsia (APEC).