Great court ruling about the cost of C Sections

[RedToothBrush]

www.bbc.co.uk/news/health-36048994

A senior coroner has warned of a risk of future deaths if the NHS favours vaginal delivery over caesarean sections on the basis of cost.

Great news. It should be about what is appropriate not the cost. I am sick of hearing the argument about cost when NICE say this argument should not be used.

At last something which categorically states the argument is nothing short dangerous.

[magratsflyawayhair]

I just watched a news article on this. A lady from one of the birth charities made the point, which is important, that they weren't talking about doctors and nurses in specific cases denying c-section, but that the hospital policy they are forced to operate under needs to reflect this. There was no accusation that it played apart at the point of necessary intervention, but at a broader, more far reaching, level.

[magratsflyawayhair]

Oh and i absolutely support choice.

[RedToothBrush]

To me, it is all about undermining the issue of targets for CS levels - and that affecting policy which doctors and nurses have to implement.

The more that is done to remove the idea that CS are 'bad' as that is the underlying attitude and rather we start asking whether its merely appropriate the better.

[HarlotBronte]

Absolutely. The idea of targets for section rates is so utterly revolting and unscientific that it needs to be attacked at all costs. There's a reason the WHO dropped their ludicrous 15% recommendation.

[TurquoiseDress]

I saw this briefly on the BBC this morning before going to work.

Hoping that some good will come out of this tragic case.

Only just read the details now- she did get a CS in the end (emergency & under GA) but not until they'd had a go at instrumental delivery (ventouse & forceps).

Poor, poor woman & baby

[TurquoiseDress]

I really hate this whole CS is bad vs vaginal birth good argument.

Bringing cost into the equation, with targets etc...receipe for disaster in certain clinical cases.

[minifingerz]

Creating conditions within maternity care which make an uncomplicated vaginal birth unattainable for many women, and then restricting access to Caesarean section.. :-( So wrong.

[HarlotBronte]

Restricting access to ELCS is wrong per se, even if conditions in maternity care were perfect which they clearly are not.

[Booboostwo]

I find the cost argument to be very misleadingly narrow. The true costs of delivery options should include all costs such as after care, further treatment for complications, life-long treatment and support in cases where things go terribly wrong, etc. I don't know the numbers but it is reasonable to assume that given the costs of treating and caring for babies left brain damaged from VB deliveries gone wrong, CS is the cheaper option overall.

[minifingerz]

Harlot - it's especially wrong and dangerous in a system with unprecedented rates of difficult vaginal birth.

[HarlotBronte]

Indeed, but we need to be very clear that it would be 100% wrong even in a perfect system.

[minifingerz]

Unfortunately the NHS hasn't set a precedent in any other area for providing the care most acceptable to the patient in preference to providing care leafing to the best clinical outcomes at a population, rather than at an individual level.

[RedToothBrush]

The thing is that patients have a LEGAL right to the most appropriate care in the NHS. This covers all areas. This rapidly seems to be forgotten when you talk about maternity. Its all about ideology and cost rather what is best for that individual.

It is deemed unacceptable to want / need a CS by society even in cases where it is entirely appropriate.

And its this pressure from outside - ideologically and politically - which is really interfering with that. It has to be stressed that NICE who won't recommend treatments for the NHS if they are too expensive state that CS are cost effective and cost should not be used as a reason not to perform them.

So if cost is even the vaguest concern in decision making there is a real problem here. It shows that potentially budgets allocated to maternity ARE simply insufficient. And this is widely acceptable to society to not provide women with their basic rights to health care. What's more is if the Trust deny cost was an issue but the judge is ruling it was, there is a suggest here that not providing women with basic care on the grounds of cost is institutionalised.

(Not that we didn't already know that).

[minifingerz]

Redtoothbrush* - what definition of 'most appropriate' are you using and where is it written?

A clinician may argue that in a particular case c/s is 1. cheaper and 2. associated with better clinical outcomes and that it's therefore the most appropriate form of care regardless of a mother's preferences.

[RedToothBrush]

Mini, in answer to your question

THE NHS CHARTER

Your rights and responsibilities
Within the charter, your rights and responsibilities fall under six headings:
Access - You have the right to access NHS services that are appropriate to your needs.
Communication and participation - You have the right to get information about your health and the services available to you. You also have the rights to be involved in decisions about your care.
Confidentiality - You have the right for your personal health information to be kept confidential, to know how it is used and how to access to it.
Respect - You have the right to be treated as an individual and with dignity and respect, no matter what.
Safety - You have the right to the best care and treatment possible by qualified staff in a safe and clean setting.
Feedback and complaints - You have the right to have a say about your health care and to have any concerns or complaints dealt with in the most appropriate way.

Therefore 'appropriate' means the best care available which is safe. This requires respecting patients as intelligent individuals and involves patient involvement in the decision making process based on their individual needs / preferences. Access to this level of care should be equally available across the country and not dictated by local budget restrictions or problems.

I actually think that the NHS Charter is pretty good in enshrining the balance of patient / doctor / government power in a way which SHOULD mean everyone gets the 'best possible' care which is unique to each and every individual.

[RedToothBrush]

sorry to clarify as that isn't 100%. This reads slightly better:

Therefore 'appropriate' means the best care available which is safe but this also requires respecting patients as intelligent individuals and involves patient involvement in the decision making process based on their individual needs / preferences and access to this level of care should be equally available across the country and not dictated by local budget restrictions or problems.

[HarlotBronte]

That sounds dangerously like you don't think women should be able to choose ELCS minifingerz. I do hope that isn't the case. And yy to everything redtoothbrush is saying. This is such a vital fight.

[minifingerz]

I think we all ought to be able to choose how we wish to be cared for in relation to every aspect of our care in the NHS.

I wanted caseloading care with my pregnancies, but it wasn't available to me because I didn't fit the criteria in my trust which qualifies you for caseloading care.

I also wanted my ds to be assessed for ASD as soon as possible - we knew he had autism from the age of two, but he wasn't diagnosed until he was 7 because it took that long to be referred and assessed.

Now he is diagnosed he needs help managing his emotions and we need help with strategies for parenting him. My ds2 needs a CAMHS referral for anxiety - he meets the threshold for assessment but because he isn't suicidal or self harming he will have to wait a long, long time for assessment and treatment.

My neice is about to start her one cycle of IVF that our trust will pay for. She has been trying for a baby for four years, and has been told that she should get three cycles but that the trust is only offering one for financial reasons.

NHS tight-fistedness results in very profound challenges for all of us in many areas of our lives.

In my case with my birth choices I ended up remortgaging the house and using the money to pay a private midwife. I know many people couldn't do that and wouldn't want to. It's just that I see the issue of c/s in relation to all other birth choices - the choice to have case-loading care/a homebirth/water birth/continuity of care/elcs. They are all important to women. It's just hard to know how they should prioritise spending if they are given a fixed budget.

[minifingerz]

"That sounds dangerously like you don't think women should be able to choose ELCS minifingerz."

No - I think we should be able to choose any sort of care we want to have a bearable experience of birth, and that the NHS should fund it.

[HarlotBronte]

Good to know you support ELCS on request. It is, of course, very far from clear that it's a more expensive option anyway, particularly for women who are inclined to prefer it. We all know, presumably, that ELCS would become even cheaper on average if more were being done: it would be easier to plan staffing levels and fewer women would give birth out of hours, both of which would be less costly.

[minifingerz]

Harlot - it really depends whether you choose to factor in the increased costs of caring for c/s mothers and babies in subsequent pregnancies. Financially c-sections involve diminishing returns over a woman's lifetime.

There's also the worrying issue of simply not having enough obstetricians in the UK.

[minifingerz]

I agree that just comparing first births there is bugger all meaningful financial difference given the vanishingly small number of first time mothers who have uncomplicated vaginal births.

Financial comparisons look different when you take parity into account. By way of example - emergency c/s and instrumental birth is rare in healthy mothers having a second baby. A planned c/s for a low risk mum having her second baby is generally going to work out vastly more costly than for a similar low risk mother who is in a birth centre where the likelihood of an emergency c/s is lower than 1%.

Also if you factor in long term health issues for babies on both sides (more severe birth injuries for babies born vaginally, possibly more immune system disorders for babies born by c/s).

It's a complicated issue.

Particularly once we start to take into account the looming horror of antibiotic resistance (all c/s mothers have antib's, only a minority of women having a vaginal birth do. At a population level that could be fairly significant...)

[HarlotBronte]

Well, a significant minority of women giving birth won't be having any future births, and it may well be the case that those women would be disproportionately likely to choose a section given that one of the main arguments against it is risk in future pregnancies. Whereas a woman on her second, low risk enough to have a meaningful choice of birth setting and knowing she wants several more has a strong incentive not to want an ELCS. So that would need to be taken into account.

As for the obstetricians point, this also relates to the planning issue, and I think it's reasonable to assume that women who know their chances of a straightforward VB are statistically lower for whatever reason are more likely than average to want an ELCS if given free access to one. In terms of costs of VB, it's certainly true that birth centre and homebirths for low risk second timers work out cheaper on average in terms of costs related simply to the birth itself, but there doesn't seem to be anything following up the effects. I don't know of anything considering eg long term continence, for example. Without this information, making a meaningful cost argument becomes very problematic. We also additionally have to presume that women choosing to give birth in OOH settings are doing so in the knowledge that they prefer a birth without pharmalogical pain relief, particularly as they often have to fight and/or travel a long way for it. This is clearly not a view shared amongst the entire birthing population. One simply can't assume that women not falling into this category would be as cheap, if indeed OOH birth is cheaper in the long run: the appropriate comparison may well be between ELCS and CLU VB.

[minifingerz]

Yes most women give birth in CLU's in the UK regardless of clinical need.

[RedToothBrush]

NHS tight-fistedness results in very profound challenges for all of us in many areas of our lives.
It's just hard to know how they should prioritise spending if they are given a fixed budget.

Therein lies the issue. Fixed budgets allocated purely by department with no consideration to the long term effects and costs which consistently are far higher than if the problem had been dealt with earlier on. Its poor cost economics.

I also agree re: 2nd births and costs. An alarming percentage of requests for ELCS for second and subsequent children stem from the result of poor care, management and lack of respect and dignity for the previous pregnancy. Which is absolutely not acceptable.

Money invested earlier in the chain is crucial ad its a false economy to make cuts in certain areas.