Maternity services in smaller hospitals: a call to action

Smaller hospitals are under pressure across the United Kingdom (UK). Their viability is constantly questioned, even though more than 50% of patients are cared for in smaller hospitals, and the UK’s smaller units are comparatively large by international standards. These pressures are magnified for maternity services, which, despite the lack of evidence for a direct relationship between volume of births and outcomes, are viewed as being less safe in smaller hospitals.

This working paper was written following a workshop with representatives of the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives (RCM), and the Nuffield Trust. The workshop was convened to examine the challenges facing smaller maternity services in rural areas. It does not claim to offer a comprehensive picture of all the factors affecting the delivery of safe and effective maternity services but serves as a call to action on some key areas of improvement that are within the control of local employers and national organisations.

Those involved in our workshop identified a number of actions. Many could be implemented by individual organisations or are collaborative in nature. Some require specific actions on the part of regulatory bodies, as they either involve a coordinated approach at the national level or are statutory in nature. A recurrent theme was the notion that the regulators should act first, thereby sanctioning innovation. However, most of what is outlined here represents good practice that is already in place in pockets across the country. So without waiting for a regulatory ‘green light’, there is much that can and should be done to support already fragile services.

Summary of recommendations 

• Promote the benefits of rural practice
• Improve the working environment for all staff
• Invest in training programmes and develop mechanisms that allow nurses and midwives to practise at the ‘top of their licence’
• Develop high-quality local training programmes geared to the needs of rural areas 
• Place senior trainees in rural locations to support the viability of rural services and to prepare medical staff better for consultant roles
• Review ambulance provision for maternity care
• Develop skills-based and team-based approaches to the delivery of maternity care in smaller units
• Base professional standards for rural services on outcomes rather than staffing numbers (inputs) 
• Develop and implement more effective, networked, models of care
• Change payment systems to reflect the higher costs of smaller-scale maternity services.