Few things are worse than the death of a baby. An innocent life is snuffed out almost before it has begun, its parents’ hopes and expectations dashed in a moment. More than 1,300 babies were killed or maimed at birth last year, each one a tragedy for their families. Britain has the second worst record in Western Europe on infant mortality. Jeremy Hunt, the health secretary, was among those amazed and appalled.
“Shocking that 1,300 babies killed or harmed in childbirth last year. We must go further and faster to make the NHS the safest system globally,” he tweeted. It is not only the human cost that is shocking – so is the economic cost. Errors at childbirth are by far the biggest single cost of litigation in the NHS and the bill has reached almost £1bn.
Yesterday, Lord Carter reported that big savings could be made if only the NHS would count its pennies more carefully. In his review of the NHS’s approach to purchasing, he observed that replacing the £1.50 soluble version of a tablet with a 2p non-soluble version had saved one hospital £40,000. Closer monitoring of staff leave had saved another £10,000.
These are not insignificant sums. But compare them with the £6m compensation awarded to the family of Joseph O’Reggio, now aged 14, who was brain damaged at birth in New Cross Hospital, Wolverhampton, after staff failed to act when his heart rate dropped over several hours during his mother’s labour. Avoiding a single error of that kind at the critical moment of birth would not only save a life or prevent a tragedy, it would also bring huge economic benefits to the NHS.
Can it be done? We have become accustomed to believing that progress in healthcare is inevitably costly. New techniques, new gizmos, new drugs all come with hefty price tags attached. Think of cancer and the eye-watering cost of the new drugs which target specific genetic types of the disease and buy a few extra months of life for six-figure sums.
But there are other much simpler things we can do to improve our healthcare – and we may need to look in unlikely places to find them. Uttar Pradesh in India, for example, where the childbirth safety is being transformed with a single A4 sheet of paper.
India is the world’s largest democracy, and among democracies it has the world’s largest number of maternal and newborn deaths. Every year, one million babies die before the end of their first day and 300,000 women die giving birth.
Most of these deaths are preventable and the trial now being run across 120 public hospitals across Uttar Pradesh shows how. On the A4 sheet distributed to maternity staff are listed 29 vital tasks that must be carried out for every birth. These include handwashing, taking the woman’s blood pressure and having to hand all the critical life-saving equipment necessary to deal with whatever occurs in the first few minutes of life, including key drugs, a sterile blade, a suction bulb (to extract mucus from the airway) and a bag mask for resuscitation.
This is the Safe Childbirth Checklist, developed by the World Health Organisation, and it is already being hailed as a game changer in the search for new ways of improving the quality of care. The hospitals in Uttar Pradesh have seen the percentage of babies dried immediately after birth to keep them warm rise from 54 to 81 per cent and the percentage whose breathing is checked within an hour of delivery rise from 49 per cent to 73 per cent. The impact on the newborn and maternal death rate will be available later this year.
The idea of using checklists was originally developed by the aviation industry to help pilots ensure they made the necessary cockpit checks, reduce complexity and foster teamwork. In medicine, checklists were first devised to help prevent infections and then to make surgery safer. The surgical checklist includes basic questions such as “Is this the right patient?” and “Is this the right limb?” – so basic that many surgeons scoffed at the idea that it could make a difference. Yet when trialled in hospitals around the world, it was found to have a dramatic effect – it cut complications by a third and deaths by almost a half.
The most surprising finding was that it was just as effective in the UK as it was in hospitals in Africa and India. Subsequent studies have confirmed its impact showing an 18 per cent lower death rate in hospitals run by the Veterans Administration in the US and a 47 per cent reduction in hospitals in the Netherlands. The surgical checklist is now mandatory in all UK hospitals and in many other countries.
Could the Safer Childbirth Checklist have a similar impact? What caused Joseph O’Reggio to be starved of oxygen at birth, resulting in severe, permanent brain damage, was that medical staff failed to observe and act upon his falling heart rate. Indeed, this single basic error accounted for a quarter of all the maternity negligence claims last year, amounting to £268m.
Maternity departments are busy places, the work is unpredictable and emergencies happen with frightening speed. In such circumstances, an aide-memoire for stressed staff whose attention is being pulled in all directions could make a vital difference.
Money, equipment and staff would also help, but this is not about money – it is about basic safeguards and better organisation to ensure they are observed. The technique of “frugal innovation” – doing more with less – first developed in India and then taken up by Western industries, has much to teach us.
There may be many more lessons we can learn from Uttar Pradesh for our healthcare.