Fourth Report - The safety of maternity services in England

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.

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 be 496 more obstetricians and 1,932 more midwives. While we welcome the recent increase in funding for the maternity workforce, when the staffing requirements of the wider maternity team are taken into account– including anaesthetists to provide timely pain relief which is a key component of safe and personalised care - a further funding commitment from NHS England and Improvement and the Department will be required to deliver the safe staffing levels expectant mothers should receive.

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 levels.

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 consider the anaesthetic workforce.

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.

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.

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.

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 is also disappointing to hear the implementation of training still described as ‘variable’.

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

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.

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).

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 mental health of the clinicians themselves but it also reduces their ability to learn from their errors.

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.

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.

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.

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.

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 of litigation promotes a culture of blame instead of learning after a patient safety incident. Alternative approaches are already in place in other countries where the use of a threshold of ‘avoidability’ rather than ‘negligence’ to award compensation has helped to tackle the debilitating culture of blame, accelerate learning and provide timely support to patients and their families. We believe that adopting such an approach is an essential next step in shifting the culture in maternity services away from blame to one of learning.

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 earnings are taken into account. Therefore, we welcome the Government’s proposal to review clinical negligence in the NHS more broadly. We note that elements of the Rapid Resolution and Redress scheme have been implemented. However, we are disappointed that the scheme has not be been implemented in full. Until it is, there is a high risk that the fundamental changes needed to improve the safety of maternity services will fail to be achieved. (Paragraph 102) The safety of maternity services in England 55

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.

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 the vast majority of cases and establish a substantially less adversarial process.

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.

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 allow them to open up more about mistakes that are made. (Paragraph 106) Providing Safe and Personalised Care for All Mothers and Babies

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.

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 to Black mothers where the disparities are the greatest.

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.

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”

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.

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.

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.

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.

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 using the Robson criteria to measure Caesarean Section rates more intelligently. NHS England and Improvement must write to all maternity units to ensure that they are aware of this change. (Paragraph 168) 58 The safety of maternity services in England