Recommendations & Conclusions
16 items
1
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 the Royal College of Obstetricians and Gynaecologists to develop a tool that trusts can use to calculate obstetrician workforce requirements that will be in place by autumn 2021. This work should also enable trusts to calculate anaesthetist workforce requirements within maternity services. We will contact the Department and RCOG for the outcome of this work in October 2021.
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Government response AI summary
The government states it is considering the recommendation but confirms its existing commitment to funding the RCOG to develop a workforce planning tool to calculate obstetrician requirements. The response details the tool's purpose but does not explicitly address the recommendation for it to include anaesthetist …
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Department of Health and Social Care
5
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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.
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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.
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Government response AI summary
The government accepts in part, stating that funding was announced in March 2021 for multi-disciplinary team training. NHSEI will undertake further work to align this funding with a Core Competency Framework and monitor its impact on training, also noting existing incentive schemes.
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Department of Health and Social Care
6
Conclusion
Fourth Report - The safety of maternity…
Accepted in Part
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.
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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.
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Government response AI summary
The government accepts the recommendation in part, citing the development of a Core Competency Framework and allocated funding for multi-disciplinary training and staff backfill. Further work is planned to align this funding with the framework and monitor its impact.
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Department of Health and Social Care
7
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 establish what proportion that should be; but it must be sufficient to cover not only the provision of training, but the provision of back- fill to ensure that staff are able to both provide and attend training.
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Government response AI summary
The government accepts the recommendation in part, confirming funding for maternity training and staff backfill, and the development of a Core Competency Framework. NHSEI will undertake further work to align funding and monitor training, leveraging existing incentive schemes, but does not explicitly commit to ringfencing …
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Department of Health and Social Care
9
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 of Obstetricians and Gynaecologists and the Care Quality Commission through a regular collaborative inspection programme. (Paragraph 56) Learning from Patient Safety Incidents
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Government response AI summary
The government accepts the recommendation, describing the development of a Core Competency Framework for essential training targets, with stretch targets to be considered later. While the MTP cannot enforce targets as it is not a regulator, it will collaborate with Royal Colleges and the CQC …
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Department of Health and Social Care
10
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 repeated. We welcome the independent nature of HSIB investigations and believe that HSIB has taken considerable steps to improve family engagement in investigations. However, it is important that they continue to pursue improvements in this area to ensure all investigations are informed by the experience of families.
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Government response AI summary
The government accepts the recommendation in part, detailing HSIB's ongoing efforts to improve family engagement and the timeliness of reports through enhanced collaboration, awareness building, and feedback mechanisms. It also notes future provisions in the Health and Care Bill regarding who will carry out maternity …
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Department of Health and Social Care
11
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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. …
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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. However, there is still work to be done to improve the timeliness of investigations and the relationship between HSIB and trusts to ensure there is local ownership of recommendations made and investigations maximise learning at the local level. That relationship should not be confined to senior management; all members of the team, and in particular junior members of the clinical team, should be able to engage with an investigation in a manner which increases learning and the implementation of recommendations. Trusts should also improve local and regional sharing of key learnings particularly through Local Maternity Systems (LMS).
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Government response AI summary
The Government accepts the recommendation in part, outlining HSIB's ongoing work to improve the timeliness of investigations, strengthen collaboration with trusts, and enhance engagement with multidisciplinary teams, including through surveys and staff engagement videos.
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Department of Health and Social Care
13
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 that healthcare professionals at all levels and across multidisciplinary team are able to engage with HSIB investigations. We further recommend that HSIB actively consults trainee doctors and midwives in that review.
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Government response AI summary
The Government accepts the recommendation in part, stating HSIB will continue investigations and noting that HSIB has already made changes in the last year to improve timeliness, collaboration, and engagement with trusts and staff, including conducting surveys and creating engagement videos.
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Department of Health and Social Care
14
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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.
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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.
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Government response AI summary
The Government accepts the recommendation in part, stating HSIB is working with academic partners to develop meaningful data for public sharing, and a new single notification portal (LFPSE) will be commissioned to streamline data collection and sharing across organisations.
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Department of Health and Social Care
16
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 develop a plan to address these. Particular focus should be given to using data to understand the causes of and reduce the variation between maternity units. National measures are driving improvements overall but there are some units being left behind. We need to know why.
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Government response AI summary
The government accepts the recommendation in part, committing to commission a single notification portal in 2021/22 to streamline data collection and enable sharing. It also highlights existing efforts through the CNST MIS and a Maternity Services Dashboard to improve data and identify gaps.
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Department of Health and Social Care
23
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 rate of stillbirths, neonatal deaths, brain injuries and maternal deaths is not currently achieving equitable outcomes, with women and babies from minority ethnic and socio-economically deprived backgrounds at greater risk when compared to their white or less deprived peers. We acknowledge the positive steps the Department and NHS England and Improvement have taken, including the commitment to continuity of carer for 75% of women from Black, Asian and minority ethnic groups. We support the principles of the continuity of carer model but conclude that further work is required to ensure it can be implemented in a sustainable manner. The Expert Panel overall rated progress towards delivering continuity of carer as ‘Requires Improvement’. Continuity of carer alone is also unlikely to resolve the deep seated and long-standing inequalities persisting in maternal and neonatal outcomes.
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Government response AI summary
The government accepts the recommendation in part, noting that health disparities have complex causes beyond the Department's sole remit. It outlines existing initiatives like the NHS Mandate's aim for reduction in disparities, support for PIGF based tests, the Maternity Transformation Programme, and the commitment to …
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Department of Health and Social Care
25
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 disparity in maternal and neonatal outcomes with a clear timeframe for achieving that target. The Department must lead the development of a strategy to achieve this target and should include consultation with mothers from a variety of different backgrounds.
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Government response AI summary
The government accepts this recommendation in part, pointing to the NHS Mandate's aim for year-on-year reductions in health disparities for Black, Asian and Minority Ethnic women. They highlight various ongoing initiatives and Equity Action Plans due by February 2022, but do not commit to a …
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Department of Health and Social Care
27
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 for having a Caesarean Section. We have heard clear agreement among those working in maternity services, that “the only birth is a safe birth”, and we challenge all those working in leadership positions in maternity services in NHS England and Improvement, the Royal Colleges, and individual services, to take action to enshrine that ideology at the heart of England’s maternity services. Furthermore, those organisations need to work hard to stamp out the damaging ideological focus on “normality at any costs”, which caused such huge loss and suffering at Morecambe Bay and Shrewsbury and Telford - and may exist in other trusts today. We heard that senior leaders in maternity services no longer use the term ‘normal birth’ and we urge an end to the use of this unhelpful and potentially damaging term.
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Government response AI summary
The government accepts this recommendation in part, outlining ongoing programmes for personalised and safe care, multi-disciplinary training, and shared decision tools. NHSEI has an improvement oversight group for personalised care and aims for every woman to have a Personalised Care and Support Plan by March …
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Department of Health and Social Care
28
Conclusion
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 about the likelihood of interventions.
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Government response AI summary
The government accepts this conclusion in part, outlining ongoing programmes for personalised and safe care, multi-disciplinary training, and shared decision tools. NHSEI has an improvement oversight group for personalised care and aims for every woman to have a Personalised Care and Support Plan by March …
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Department of Health and Social Care
29
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 their baby.
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Government response AI summary
The government accepts the recommendation in part, focusing on personalised care, multi-disciplinary training, and shared decision-making tools, with an ambition for every woman to have a Personalised Care and Support Plan by March 2022. It also notes a project to develop consensus on birth terminology.
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Department of Health and Social Care
30
Recommendation
Fourth Report - The safety of maternity…
Accepted in Part
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 …
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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 delivery and is always informed clearly what the safest option is for her birth. The working group’s remit should also include researching and addressing the wider societal factors, including media and social media, that put pressure on women to want to have an unassisted birth.
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Government response AI summary
The government accepts this recommendation in part, stating NHSEI has an improvement oversight group focused on personalised care and support planning, aiming for every woman to have a Personalised Care and Support Plan by March 2022. This addresses the intent for informed choice but does …
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Department of Health and Social Care