Maternity under the spotlight

By Sean O'Sullivan, Head of Health and Social Policy on 08 July 2021 Maternity Services Government Safety Midwifery Continuity of Carer - MCOC

The past week has seen the publication of not one, but two, landmark reports into the state of maternity services in England. On Monday, the House of Commons Health and Social Care Committee published a report on the safety of maternity services in England. This follows an inquiry that the Committee launched last year, and to which the Royal College of Midwives (RCM) and Royal College of Obstetrics and Gynaecologists (RCOG) submitted joint evidence.

While acknowledging that the NHS offers some of the safest maternity care in the world, the report describes a system where there is worrying variation in the quality of maternity care as well as evidence of a poor safety culture in some units. Particular concerns include:

• Significant staffing shortages, estimated to be in the region of 2,000 midwives, and survey evidence from eight out of ten midwives that they did not have enough staff on their shift.
• Limited opportunities for staff to participate in vital safety training, due to staff shortages.
• Maternity investigations failing to involve families, engage with junior staff or optimise learning opportunities.
• The persistence of a 'blame culture' that is preventing clinicians from responding appropriately to or learning from mistakes.

The Committee's recommendations to address these, and other issues, include:

• Increasing the maternity budget by £200m-£350m per annum with immediate effect.
• Ringfencing a proportion of the maternity budget for training, including for back-filling posts.
• Reviewing how HSIB maternity investigations engage with clinicians at all levels.
• Awarding compensation based on whether an incident was avoidable, rather than a requirement to prove clinical negligence.
• Introducing a target to end the disparity in maternal and neonatal outcomes between mothers from different ethnicities or socio-economic backgrounds.

Hot on the heels of the safety report, the Committee has also published an evaluation by an Expert Panel of key maternity policy commitments relating to safety, continuity of carer, personalisation and safe staffing. The Panel rated the Government’s overall commitment to maternity services as ‘requires improvement’, identifying systemic problems with the way that maternity commitments are defined, resourced, monitored and evaluated.

In terms of progress made, none of the policy areas emerge well from this evaluation, with the Panel particularly critical about the failure to meaningfully progress the commitments on personalisation of care. The chapter on maternity safety is balanced and fair, with acknowledged progress on reducing rates of stillbirth and neonatal death offset by concern about the absence of improvements elsewhere, especially on maternal death rates. The Panel makes some astute criticisms of the gap between the strong evidence in support of continuity of carer and the failure to properly consider or prepare for the scale of change required, leading to insufficient funding and training and increased stress and pressure on an already overstretched workforce.

Perhaps the most important judgement was reserved for safe staffing, because, as the Panel observed, “none of the other commitments can be achieved without ensuring that maternity services have the right number of staff, in the right place, at the right time and with the right skills.” The Panel was scathing in its criticism of a lack of clarity in defining safe staffing, an absence of timescales and measurable targets and a failure to match recruitment initiatives with a similar focus on staff retention.

An extra chapter has been added on equality of outcomes, because a strong theme that the Panel identified for all the policy commitments was the presence of persistent inequalities in outcomes and experiences for minority ethnic and socio-economically deprived women and babies.

The RCM has welcomed the findings and recommendations in these two comprehensive and balanced reports. There is little in either report that we would take issue with; indeed, we were pleased to note that both reports address many long-standing concerns that we have about how maternity policy is implemented. We were also pleased that both reports refer extensively to the evidence that both the RCM and RCOG submitted to the Committee and Expert Panel. Neither report pulls any punches and both are likely to make for uncomfortable reading for the Government. The Government is required to respond to these reports within the next two months. Over to you Mr Javid!