Recommendations & Conclusions
31 items
1
Conclusion
Fourth Report - The safety of maternity…
The Expert Panel overall rated progress towards safe staffing as ‘Requires Improvement’. Appropriate staffing levels are a prerequisite for safe care, and a robust and credible tool to establish safe staffing levels for obstetricians is needed. We were pleased that following our evidence session, the Department has committed to fund …
Government response. 24. The Government is considering this recommendation. 25. The inquiry’s report welcomed the recent investment of £95.6m by NHSEI to target the three overarching themes identified in the first Ockenden Report: workforce numbers, training and development programmes to support culture …
Department of Health and Social Care
2
Conclusion
Fourth Report - The safety of maternity…
With 8 out of 10 midwives reporting that they did not have enough staff on their shift to provide a safe service, it is clear that urgent action is needed to address staffing shortfalls in maternity services. Evidence submitted to our inquiry estimates that as a minimum, there need to …
Government response. 24. The Government is considering this recommendation. 25. The inquiry’s report welcomed the recent investment of £95.6m by NHSEI to target the three overarching themes identified in the first Ockenden Report: workforce numbers, training and development programmes to support culture …
Department of Health and Social Care
3
Recommendation
Fourth Report - The safety of maternity…
We recommend that the budget for maternity services be increased by £200–350m per annum with immediate effect. This funding increase should be kept under close review as more precise modelling is carried out on the obstetric workforce and as Trusts continue to undertake regular safe staffing reviews of midwifery workforce …
Government response. 24. The Government is considering this recommendation. 25. The inquiry’s report welcomed the recent investment of £95.6m by NHSEI to target the three overarching themes identified in the first Ockenden Report: workforce numbers, training and development programmes to support culture …
Department of Health and Social Care
4
Recommendation
Fourth Report - The safety of maternity…
We further recommend that the Department work with the Royal College of Obstetricians & Gynaecologists and Health Education England to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come. This work should also …
Government response. 29. We accept this recommendation. 30. The Department and Health Education England (HEE) already work closely with system partners to determine the number of training places for a particular specialty, including obstetrics and gynaecology and anaesthetics. 31. An example of …
Department of Health and Social Care
5
Conclusion
Fourth Report - The safety of maternity…
The 2016 Maternity Safety Training Fund was widely welcomed by healthcare professionals and it is clear to us that the Fund delivered positive outcomes. However, for those positive outcomes to endure, more funding is required to embed on-going and sustainable access to training for maternity staff.
Government response. 36. We accept this recommendation in part. 37. In collaboration with national maternity partner organisations, the MTP has led on the development of a Core Competency Framework to address known variation in training and competency assessment and ensure that training …
Department of Health and Social Care
6
Conclusion
Fourth Report - The safety of maternity…
Training is essential for staff to deliver safe care. Evidence submitted to our inquiry highlighted that insufficient staffing is not only impacting the number of healthcare professionals available to deliver care for mothers and their babies but also the ability of staff to participate in vital training.
Department of Health and Social Care
7
Recommendation
Fourth Report - The safety of maternity…
We recommend that a proportion of maternity budgets should be ringfenced for training in every maternity unit and that NHS Trusts should report this in public through annual Financial and Quality Accounts. It should be for the Maternity The safety of maternity services in England 53 Transformation Programme board to …
Government response. 36. We accept this recommendation in part. 37. In collaboration with national maternity partner organisations, the MTP has led on the development of a Core Competency Framework to address known variation in training and competency assessment and ensure that training …
Department of Health and Social Care
8
Conclusion
Fourth Report - The safety of maternity…
While it is encouraging that 93% of trusts are meeting the training objective set out in the Maternity Incentive Scheme, it is disappointing that only 8% of units across the UK are meeting the very highest standards of training, as set out in the Saving Babies Lives Care Bundle. It …
Department of Health and Social Care
9
Recommendation
Fourth Report - The safety of maternity…
We recommend that a single set of stretching safety training targets should be established by the Maternity Transformation Programme board, working in conjunction with the Royal Colleges and the Care Quality Commission. Those targets should be enforced by NHSE&I’s Maternity Transformation Programme, the Royal College of Midwives, the Royal College …
Government response. 41. We accept this recommendation. 42. In collaboration with national maternity partner organisations including the Royal Colleges, HSIB, NHS Resolution and the CQC, the MTP’s Recommendation’s Group has undertaken a review of training recommendations from maternity reports. These insights have …
Department of Health and Social Care
10
Conclusion
Fourth Report - The safety of maternity…
Involving families in a compassionate manner is a crucial part of the investigation process. Too often, maternity investigations have failed to do this in a meaningful way. Families must be confident that their voices are heard and that lessons have been learnt to prevent the tragedy they have endured being …
Government response. 51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions which allow for NHS England …
Department of Health and Social Care
11
Conclusion
Fourth Report - The safety of maternity…
We believe that HSIB’s ability to take a broad and independent view of the services and factors contributing to maternity incidents is a valuable step in the right direction to learning from maternity incidents. It is essential that an independent, standardised method of investigating the most serious incidents is maintained. …
Government response. 51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions which allow for NHS England …
Department of Health and Social Care
12
Conclusion
Fourth Report - The safety of maternity…
Clinicians of all disciplines should also receive training before they are qualified in how they should respond to the sorts of error that these investigations may uncover. This would include help for clinicians on accepting a degree of fallibility. Being unable to respond appropriately to mistakes is harmful to the …
Department of Health and Social Care
13
Recommendation
Fourth Report - The safety of maternity…
We recommend that HSIB investigations continue, but that HSIB reviews how it engages with trusts to ensure that the investigation process works in a timely and 54 The safety of maternity services in England collaborative manner which optimally supports local learning and development. That review should include processes to ensure …
Government response. 51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions which allow for NHS England …
Department of Health and Social Care
14
Recommendation
Fourth Report - The safety of maternity…
In addition, we recommend that HSIB shares the learning from its maternity reports in a more systematic and accessible manner. A top level summary of individual cases together with the key learnings derived from them should be shared rapidly across the NHS.
Government response. 64. We accept this recommendation in part. 65. HSIB recognises the importance of sharing learning from their investigations. HSIB has generated substantial data about safety risks in maternity services after having completed over 1700 investigations by July 2021. However, there …
Department of Health and Social Care
15
Conclusion
Fourth Report - The safety of maternity…
We recognise the effort of individual organisations to collect data and insights on maternity care. The potential value of this information to drive improvements in maternity care is clear. However, at present these insights are not being fully utilised.
Government response. 70. We accept this recommendation in part. 71. We agree that data collection should be streamlined, and that insights collected should be collated in a coordinated way and shared across organisations in a timely manner. The MTP will be commissioning …
Department of Health and Social Care
16
Conclusion
Fourth Report - The safety of maternity…
NHSE&I must streamline the data collection process to reduce the burden for trusts. The Department must ensure that insights collected by all bodies are collated in a coordinated manner and shared across organisations in a timely manner. As part of this process, the Department must assess current data gaps and …
Government response. 70. We accept this recommendation in part. 71. We agree that data collection should be streamlined, and that insights collected should be collated in a coordinated way and shared across organisations in a timely manner. The MTP will be commissioning …
Department of Health and Social Care
17
Conclusion
Fourth Report - The safety of maternity…
It is clear to us that in its current form the clinical negligence process is failing to meet its objectives for both families and the healthcare system. Too often families are not provided with the appropriate, timely and compassionate support they deserve. For those delivering maternity care, the adversarial nature …
Government response. 81. We reject this recommendation. The Government does not intend to put in place a Rapid Redress and Resolution Scheme, as explained in the Department’s evidence to the Committee in February 2021. 82. The Department consulted on the Rapid Resolution …
Department of Health and Social Care
18
Conclusion
Fourth Report - The safety of maternity…
Providing appropriate financial redress to families after an incident is important. However, the rising costs of maternity claims without sufficient learning and outdated mechanisms for calculating compensation is unsustainable. It is particularly unfair that wealthier families receive more compensation for a severely disabled child than poorer families because likely lost …
Government response. 85. In order to continue to improve patient safety and address the rising costs of clinical negligence, the Government announced in Spending Review 2020 that it will publish a consultation on these issues. Decisions on next steps will be taken …
Department of Health and Social Care
19
Recommendation
Fourth Report - The safety of maternity…
While the review of the negligence system is underway, we recommend the Department must implement the Rapid Redress and Resolution Scheme in full. We also recommend the Department provides the Committee with the scope and timetable for its review of clinical negligence by September 2021.
Government response. 86. The Government plans to consult on next steps to address the rising costs of clinical negligence. Decisions on next steps will be taken following the consultation.
Department of Health and Social Care
20
Recommendation
Fourth Report - The safety of maternity…
We recommend that following that review, the Department brings forward proposals for litigation reforms that award compensation for maternity cases based on whether an incident was avoidable rather than a requirement to prove clinical negligence. That approach would allow families to access compensation without the need for the courts in …
Government response. 85. In order to continue to improve patient safety and address the rising costs of clinical negligence, the Government announced in Spending Review 2020 that it will publish a consultation on these issues. Decisions on next steps will be taken …
Department of Health and Social Care
21
Recommendation
Fourth Report - The safety of maternity…
In addition, we recommend that the Department and NHS Resolution remove the need to compensate on the basis of private healthcare provision where appropriate NHS care is available; and that compensation is standardised against the national average wage to prevent unjust variability in compensation payouts.
Government response. 86. The Government plans to consult on next steps to address the rising costs of clinical negligence. Decisions on next steps will be taken following the consultation.
Department of Health and Social Care
22
Recommendation
Fourth Report - The safety of maternity…
Finally, given their recognition of the role the professional regulators have in ending the blame culture, we recommend that the General Medical Council and the Nursing and Midwifery Council review what changes are required to their remits or working practices to reduce the fear clinicians have of their regulators and …
Government response. 87. We welcome the Committee’s recommendation that the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC) have a role to play in helping to end the blame culture that currently exists in the health sector. DHSC is …
Department of Health and Social Care
23
Conclusion
Fourth Report - The safety of maternity…
England remains a largely safe place to give birth and efforts to increase the safety of maternity services have led to further improvements. However, the Expert Panel overall rated the Government’s progress on maternity safety outcomes as ‘Requires Improvement’. The Expert Panel highlighted that the Government’s commitment to halve the …
Department of Health and Social Care
24
Conclusion
Fourth Report - The safety of maternity…
Having the right skill set, as noted above, is crucial for the successful implementation of continuity of carer. We therefore recommend that those involved in delivering this model have received appropriate training and that all professionals are competent and trained in all areas that they work in, particularly in relation …
Government response. 102. We accept this recommendation. 103. NHSEI agrees that all professionals involved in maternity care should be competent and confident in all areas of their work, including when working in Continuity of Carer teams or with them. 104. As part …
Department of Health and Social Care
25
Recommendation
Fourth Report - The safety of maternity…
Given the underlying causes of these outcomes for women from Black, Asian and minority ethnic groups relate to a range of issues beyond the remit of the Department, 56 The safety of maternity services in England we recommend that the Government as a whole introduce a target to end the …
Government response. 106. The Government accepts this recommendation in part. 107. The NHS Mandate7 sets out an aim of year on year reductions in the difference in the stillbirth and neonatal mortality rate per 1,000 births between that for black, Asian and …
Department of Health and Social Care
26
Conclusion
Fourth Report - The safety of maternity…
We were pleased to hear that the UK National Screening Committee believed that the current evidence for a 3rd trimester breech presentation scan “looks promising” and may be a “suitable candidate for a screening programme once further research had been published in the coming years”
Department of Health and Social Care
27
Recommendation
Fourth Report - The safety of maternity…
The central aim of maternity services must be to achieve, in the words of Michelle Hemmington, “a safe, healthy, positive experience of birth and to come home with a baby”. And yet, during the course of this inquiry, we heard of women who were made to feel like a failure …
Department of Health and Social Care
28
Conclusion
Fourth Report - The safety of maternity…
The Expert Panel overall rated the Government’s progress towards providing personalised care as ‘Inadequate’. We believe that personalisation must go hand in hand with safety and women must be fully and impartially informed about the safety risks associated with all birthing options. Women should also be provided with clear information …
Department of Health and Social Care
29
Conclusion
Fourth Report - The safety of maternity…
Timely and appropriate pain relief is also an essential part of safe and personalised care, and we believe that every woman giving birth in England should have a right to their choice of pain relief during birth, in line with clinical advice on what would be safest for them and …
Department of Health and Social Care
30
Recommendation
Fourth Report - The safety of maternity…
We recommend that NHS England and Improvement establish a working group comprising of women and their families, organisations providing support for women throughout their pregnancy and clinicians to develop a set of actions for maternity services to consider in order to ensure no woman feels pressured to have a vaginal …
Government response. 125. We accept this recommendation in part. 126. NHSEI acknowledge concerns about a focus on “normality at any costs”. Our vision is that our staff of all professions and disciplines will work together with women and families to deliver co-produced …
Department of Health and Social Care
31
Recommendation
Fourth Report - The safety of maternity…
It is deeply concerning that maternity units appear to have been penalised for high Caesarean Section rates. We recommend an immediate end to the use of total Caesarean Section percentages as a metric for maternity services, and that this is The safety of maternity services in England 57 replaced by …
Government response. 130. We accept this recommendation. 131. NHSEI agrees that caesarean section rates should not be used to performance manage Trusts and supports the use of the Robson criteria to measure caesarean section rates more intelligently. 132. Robson group data is …
Department of Health and Social Care