Policy paper

The government's response to the Health and Social Care Committee report: safety of maternity services in England

Updated 19 October 2021

Applies to England

Presented to Parliament by the Secretary of State for Health and Social Care by Command of Her Majesty

September 2021

1. Introduction

This is the government’s formal response to the recommendations made by the Health and Social Care Committee in its report, ‘The Safety of Maternity Services in England’.

The government welcomes this report. Maternity safety is a priority for this government, and the government remains committed to making the NHS one of the best places in the world to have a baby.

The committee’s inquiry examined evidence relating to the safety of maternity services. It builds upon current investigations following incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. The inquiry also considered whether the clinical negligence and litigation processes need to be changed to improve the safety of maternity services and explored the impact of blame culture on learning from incidents.

The committee’s report set out its conclusions and recommendations in three parts:

• chapter 1 addressed staffing numbers, funding, leadership and training.
• chapter 2 focused on learning from patient safety incidents. It considered the role of the Healthcare Safety Investigation Branch (HSIB) and examined the current clinical negligence system.
• chapter 3 explored women’s experiences of care. This included tackling disparities in outcomes; specific interventions to improve outcomes, including Continuity of Carer and screening; and supporting informed choices and personalised care.

The report makes 15 recommendations. The structure of this Command Paper directly corresponds to these recommendations.

1.1 The Committee’s Expert Panel Evaluation of Maternity Government Commitments

In 2020, the committee commissioned an independent panel of experts to assess the government’s progress in meeting its own targets in key areas of healthcare policy.

The expert panel evaluated the following four government commitments on maternity services:

• Maternity Safety: By 2025, halve the rate of stillbirths; neonatal deaths; maternal deaths; brain injuries that occur during or soon after birth. Achieve a 20% reduction in these rates by 2020. To reduce the pre-term birth rate from 8% to 6% by 2025.
• Continuity of Carer: The majority of women will benefit from the ‘Continuity of Carer’ model by 2021, starting with 20% of women by March 2019. By 2024, 75% of women from black, Asian and Minority Ethnic communities and a similar percentage of women from the most deprived groups will receive Continuity of Care from their midwife throughout pregnancy, labour and the postnatal period.
• Personalised Care: All women to have a Personalised Care and Support Plan by 2021.
• Safe Staffing: Ensuring NHS providers are staffed with the appropriate number and mix of clinical professionals is vital to the delivery of quality care and in keeping patients safe from avoidable harm.

The Panel rated the government’s overall progress to achieve key commitments in maternity services as ‘requires improvement’.

The Department of Health and Social Care (DHSC) has formally responded to the Expert Panel’s evaluation separately.

2. Summary of Government Response to the Recommendations

England is a safe place to give birth as evidenced by improving safety outcomes and women’s reported experiences of care. The Committee noted that the vast majority of NHS births in England are safe and at its best NHS care offers some of the safest maternal and neonatal outcomes in the world.

Good progress has been made in meeting the National Maternity Safety Ambition. The Office for National Statistics (ONS) reports that since 2010, there has been a 25% reduction in the stillbirth rate, and a 29% reduction in the neonatal mortality rate for babies born over the 24-week gestational age of viability.

Through the NHS England and NHS Improvement (NHSEI) led Maternity Transformation Programme (MTP), there has been improved partnership working between the Department of Health and Social Care (DHSC), its Arms-Length Bodies (ALBs), NHS maternity and neonatal providers, Royal Colleges and academics. There is also a significantly better understanding of the causal factors relating to mortality and morbidity in pregnant women and neonates which the system continuously seeks to address.

Overall, while the outcome data shows that maternity and neonatal services are making real progress, there is no room for complacency, and DHSC knows that unacceptable variations in the quality of care and outcomes remain. DHSC has worked with its system partners to put in place specific, focused support for challenged areas, and is working to further improve oversight and escalation processes to identify concerns about the quality of care.

DHSC acknowledges that key areas that require continuous development include organisational leadership and addressing poor culture.

Poor workplace culture is completely unacceptable in all areas of the NHS, and the government remains committed to tacking this issue. The government launched the Maternity Leadership Training Fund in early 2021 and has established strong leadership across the system through the appointment of named regional and local Maternity Safety Champions led by two national Maternity Safety Champions.

The Committee’s report highlighted that appropriate staffing levels are a prerequisite for safe care, and a robust and credible tool to establish safe staffing levels for obstetricians is needed.

As the committee notes, NHSEI are investing £95.6m to target the three overarching themes identified in the first Ockenden Report: workforce numbers, training and development programmes to support culture and leadership, and strengthening board assurance and surveillance to identify issues earlier.

DHSC has funded the Royal College of Obstetricians and Gynaecologists (RCOG) to develop a tool, which will calculate the number of obstetricians at all grades required locally and nationally to provide a safe, personalised maternity service within the context of the wider workforce.

DHSC remains committed to improving maternity safety and will take the recommendations made by the Committee and its Panel in relation to funding for staffing into consideration. As part of this, we will need to consider an assessment of midwifery and obstetric workforce levels. This assessment would also need to take into consideration time for healthcare professionals to partake in annual multi-disciplinary training and provide personalised care.

The Committee’s report also highlighted the importance of training for delivering safe care. NHSEI’s Core Competency Framework has been developed to address known variation in training and competency assessment and ensure that training to address significant areas of harm are included as minimum core requirements for every maternity and neonatal service.

Through the Avoiding Brain Injury programme, the MTP will work closely with the Royal Colleges and Care Quality Commission (CQC) to standardise the approach to fetal monitoring and to develop support tools as part of training.

The government acknowledges that there are disparities in maternal and neonatal outcomes and is committed to addressing these disparities. The Committee rightly states, the underlying causes of health disparities relate to a range of issues beyond the remit of DHSC. The root causes of disparities in health are a complex interaction between personal, social, economic and environmental factors. NHSEI have taken the approach of first setting metrics which have sufficient sensitivity (statistical power) to track changes in clinical outcomes for the groups most at risk, and second – through the equity and equality guidance - to identify priorities, design evidence-based interventions to address those priorities and promote an approach of continuous quality improvement.

DHSC thanks the Committee for its work and has considered the recommendations made in its report. A detailed response to each of the recommendations made by the Committee is set out in this response.

3. Supporting Maternity Services and Staff to Deliver Safe Maternity Care

3.1 Recommendation 1 – Funding for Staffing

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.

Response

The government is considering this recommendation.

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 and leadership, and strengthening board assurance and surveillance to identify issues earlier. A significant proportion of this sum will support the recruitment of 1,200 additional midwives and 100 consultant obstetricians.

As the committee notes, DHSC has commissioned the RCOG, to develop a new workforce planning tool to improve how maternity units calculate their medical staffing requirements.

The tool will calculate the number of obstetricians at all grades required locally and nationally to provide a safe, personalised maternity service within the context of the wider workforce.

DHSC remains committed to improving maternity safety and will take the recommendations made by the Committee and its Panel in relation to funding for staffing into consideration. As part of this, we will need to consider an assessment of midwifery and obstetric workforce levels. This assessment would also need to take into consideration time for healthcare professionals to partake in annual multi-disciplinary training and provide personalised care.

3.2 Recommendation 2 – Obstetric Staffing

We further recommend that DHSC 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.

Response

We accept this recommendation.

DHSC 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.

An example of this collaboration is HEE’s joint workforce group with the RCOG. The aim of this group is to explore and implement the deliverables for the development of the Obstetrics and Gynaecology (O&G) workforce outlined in HEE’s Maternity Transformation Workforce Strategy. The work is being progressed through five Task and Finish Groups, which are led by the RCOG. These groups are focusing on a range of initiatives including multi-disciplinary working and profiling and modelling of the O&G workforce.

We are working with partners to ensure that the number of training posts in O&G and anaesthetics, along with all other medical specialties, is in line with national and regional workforce requirements. We will continue to monitor the effectiveness of current arrangements, including considering the need for an expansion of training places.

In addition, as the Committee notes, DHSC recently funded the RCOG to develop a tool, which will calculate the number of obstetricians at all grades required locally and nationally to provide a safe, personalised maternity service within the context of the wider workforce.

Over the next year, the RCOG will collaborate with and gather data from across the health sector to determine how the tool can help NHS Trusts to understand their own medical staffing needs, and provide standardised, safe and personalised care tailored to their communities.

The tool will be freely available to NHS Trusts across the country next year, and will provide maternity staff with a new methodology that calculates the numbers, skill sets and grades of medical staff required within individual maternity units based on local needs. It will help Trusts tackle disparities by taking into account local factors such as birth rates, age of population, the socio-economic status of the area, and geographical factors.

3.3 Recommendation 3 – Ringfenced budgets for training in maternity units

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 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.

Response

We accept this recommendation in part.

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 to address significant areas of harm is included as minimum core requirements for every maternity and neonatal service.

Funding announced at the NHSEI Board in March 2021 will be put towards maternity multi-disciplinary team training and staff backfill as part of NHSEI’s response to the first Ockenden Report.

NHSEI will need to undertake further work to explore aligning this funding with the Core Competency Framework, and work with local systems, regions and the Royal Colleges to determine how best to monitor and assure that the additional funding is feeding through into training.

Safety Action 8 of the Clinical Negligence Scheme for Trusts Maternity Incentive Scheme (CNST MIS) ensures there is an existing lever in place, aligned to the Core Competency Framework, to ensure training requirements are in place and incentivised. As the scheme is revised annually, training requirements are reviewed regularly, informed through learning from reports, audits and enquiries. In addition, as new learning emerges, NHSEI is working with HEE to make it a requirement for more specialist training to be developed.   ### Recommendation 4 – Safety Training Targets

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 NHSEI’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.

Response

We accept this recommendation.

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 been used to inform a Core Competency Framework to address known variation in training and competency assessment and ensure that training to address significant areas of harm are included as minimum core requirements for every maternity and neonatal service.

This work has been included as a requirement for meeting Immediate and Essential Actions from the first Ockenden report. The Core Competency Framework provides an evidence-based set of essential training targets upon which stretch targets can be built, incentivised through Safety Action 8 of the CNST MIS. Stretch targets will be considered as part of the next iteration of the framework.

In addition, a national Registry of Recommendations is being produced which will help determine newly identify training needs going forwards.

Through the Avoiding Brain Injury programme, the MTP will work closely with the Royal Colleges and CQC to standardise the approach to fetal monitoring and to develop support tools as part of training. NHSEI’s MTP are not regulators and so are unable to enforce these targets. However, the MTP will open discussions with the relevant Royal Colleges and the CQC to share information around specific training targets in order to collaborate and support CQC’s inspection programmes.

4. Learning from Patient Safety Incidents

The government is clear that patient safety and reducing levels of avoidable harm must remain a top priority for the NHS in England.

A cross-system National Patient Safety Programme Board was established this year to provide new coordination and monitoring of improvements in patient safety and response to harm across the NHS. The Board’s work is currently underpinned by the development of a national action plan to deliver targeted, measurable improvement and will be reviewed annually.

The government is committed to the development of a safety and learning culture and transparency across the NHS so that treatment and care is always provided to the safest possible standard. Examples of initiatives include:

• The establishing of the HSIB - including a specific programme to conduct maternity investigations. HSIB examine the most serious patient safety incidents with the sole purpose of promoting system-wide learning and improvement by finding answers, giving safety recommendations and embedding new practices across the NHS. The government intends to legislate for HSIB to become a fully independent investigations body.
• A statutory duty of candour - regulated by the CQC - which means that Trusts must be honest with themselves and tell patients if their safety has been compromised and apologise, vital to learning from mistakes.
• Protections for whistle blowers when they raise concerns and Freedom to Speak Up Guardians across all Trusts supported by a National Guardian.
• Implementing medical examiners across the NHS, a critical reform to ensure that patterns in non-coronial deaths are acted upon by Trusts and much needed support is provided to bereaved families, thereby increasing transparency.
• The CQC undertakes strengthened assessment of Trusts’ learning from deaths and their engagement with bereaved families and carers as part of the regulator’s inspections of Trusts.
• Quality accounts published each year by every NHS provider provide transparency to regulators and the public about the quality of services by reporting on patient safety, the effectiveness of care and patient feedback.
• The first ever NHS Patient Safety Strategy published in 2019 builds upon these reforms and will deliver substantial programmes that are planned and underway to create a safety and learning culture in the NHS.

The government has this year also established in law a Patient Safety Commissioner who, when appointed, will become a champion for patients in relation to medicines and medical devices with the power to make reports and recommendations to providers and foster policies that are more conducive to an inclusive Just Culture.

4.1 Recommendation 5 – HSIB Investigations – Engagement with Trusts

We recommend that the Health and Safety Investigation Branch (HSIB) investigations continue, but that HSIB reviews how it engages with trusts to ensure that the investigation process works in a timely and 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.

Response

We accept this recommendation in part.

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 or any other public body to carry out maternity investigations in the future.

The government will decide which option is the most appropriate in due course and seek the views of the NHS, families and other interested parties.

HSIB recognises that timely production of its investigation reports is essential to support trusts and their staff with learning, to ensure that families are given the clarity they need about what happened during their care, and what actions can be taken by the Trust to reduce the risk of recurrence. In the last 12 months, HSIB has made changes to improve the timeliness of its reports, strengthened its collaboration with Trusts and multidisciplinary engagement with perinatal teams to ensure that learning is spread as widely as possible from its investigations.

Substantial adjustments to a range of processes along the investigation pathway has also enabled HSIB to clear the backlog of investigations that extended beyond six months, and to ensure that the average turnaround time for sharing the draft investigation report is four months and the final investigation report with Trusts is now completed within six months in over 90 percent of cases.

There is an established process in place to have open discussions around any concerns that are identified during the investigation. This enables immediate safety actions to be taken by the Trust. Where cases are exceeding the six-month timescale, this will generally be due to additional time needed by the family or the Trust to review the report.

HSIB investigations can sometimes be delayed by factors beyond HSIB’s control, such as access to medical records or access to specialist medical advice. In addition, parallel investigations being conducted by professional regulatory bodies, coroners or the police, can require HSIB to pause an investigation until those processes have been completed. However, HSIB recognises that the proportion of investigations which are affected by these processes is very small and the average duration of an investigation continues to improve.

HSIB has a formalised and standardised process for factual accuracy checking with families and Trusts on draft maternity investigation reports. This process requires Trusts to formally advise whether they have accepted HSIB’s recommendations. HSIB asks Trusts to ensure that any staff involved in the HSIB investigation are given the opportunity to contribute to the factual accuracy review. HSIB also ensures that the Trust board’s Maternity Safety Champion is informed about recommendations that the Trust has not accepted.

All families and Trusts are offered the opportunity to hold a tripartite meeting with HSIB at the conclusion of an investigation. Doing this enables HSIB to discuss the findings and allows the Trust an opportunity to share their planned actions with the family. This also helps to provides a clear point of conclusion for the HSIB investigation and facilitates a more constructive relationship between the trust and the family going forward.

HSIB is continuously improving the accessibility of local learning from their investigations to support improvement. They hold Quarterly Review Meetings (QRMs) with all Trusts which are open to multidisciplinary attendance and are also attended by senior trust leaders. The QRMs provide an opportunity to share national, regional and local Trust data on numbers of investigations, criteria breakdown and frequently recurring themes at each level. HSIB is developing mechanisms for more effective engagement with doctors in training and midwives, and they encourage Trusts to facilitate trainees’ and midwives’ attendance and participation at the Trusts’ QRMs. HSIB also attends, when invited, Trust perinatal and governance meetings and meetings with wider clinical teams to share their investigation findings. They continue to work closely with the Royal Colleges and HEE to build awareness of HSIB through healthcare training. They have also created a staff engagement video which explains the importance of staff involvement in HSIB investigations, which has been shared with all Trusts and is also publicly available.

HSIB’s collaborative approach also involves using Trust feedback to shape the programme. HSIB has recently commenced a survey of all Trusts participating in the maternity programme, building on learning and improvements that they obtained from conducting the survey in early 2020, the results of which were shared with Trusts. This has helped to build the confidence of Trusts and staff that HSIB is collaborative and willing to learn from their experience to continuously improve the programme.

HSIB is also developing a learning and development pathway for patient safety investigation, which was piloted in Newcastle recently with a view to rolling out more widely for NHS organisations during 2021-22. As part of this HSIB is exploring the feasibility of an HSIB investigator and a local Trust investigator working together throughout an investigation to help Trusts learn directly from HSIB’s approach, whilst ensuring that HSIB’s role as an independent investigation body is maintained. HSIB is also developing a standard definitions document, a clinical reference document and an investigation template with plans to make this available on their website for use by local investigation teams.

4.2 Recommendation 6 – HSIB Investigations – Sharing Learning

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.

Response

We accept this recommendation in part.

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 are large volumes of safety information already generated by Trusts through reporting for maternity services, and it is important that the national bodies work together to ensure all safety data on NHS maternity services is shared across the maternity system in a way that most effectively supports safety improvement.

Therefore, HSIB is working closely with academic partners to develop meaningful intelligence and useful data on safety risks in maternity services that can be shared publicly and across the system. HSIB has piloted the use of a quality matrix in their engagement with Trusts to aid their understanding of safety risks in their maternity services. They have produced a newsletter for all Trusts to spread the learning about actions that have been taken across the country in response to HSIB maternity investigations – this was welcomed by Trusts and they intend the newsletter to become a regular output.

HSIB now attend regional perinatal quality meetings which provides opportunity to share learning with NHS England Regional Chief Midwives, Clinical Commissioning Groups and local Integrated Care System representatives, Local Maternity System (LMS) partners, Maternity Voices Partnership representatives and CQC local representatives.

HSIB National Learning Reports have shared themed learning and made national recommendations drawn from recurrent safety risks identified in maternity investigations, and with academic partners they are developing a taxonomy of safety risks that will help inform future maternity themed reports.

Interactive learning opportunities with HSIB’s investigators have been welcomed by stakeholders – HSIB have held a maternity focused webinar for the ambulance sector and plan to hold more interactive learning opportunities on maternity topics going forward.

4.3 Recommendation 7 – Streamlining the data collection process

NHSEI must streamline the data collection process to reduce the burden for trusts. DHSC 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, DHSC 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.

Response

We accept this recommendation in part.

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 the build of a single notification portal in 2021/22, as part of the Learn from Patient Safety Events (LFPSE) service which is replacing the National Reporting and Learning System (NRLS). This single notification portal will reduce the burden reporting requirements for maternity services and enable sharing of data on incidents with multiple organisations.

Currently Trusts are required to notify various organisations of incidents within their services, and often a large amount of duplicate information is being reported to more than one organisation. The development and implementation of a single notification portal across Trusts in England will enable Trusts to submit a core dataset to multiple organisations at the same time. This will result in a clear and strong benefit to the frontline in having one place to report detailed information, avoiding duplication of work and consequently NHS resource. There will also be certainty for the organisations being reported to: NHS Resolution (Early Notification Scheme), HSIB, the National Perinatal Epidemiology Unit at the University of Oxford (MBRRACE-UK) and the University of Bristol (National Child Mortality Database), that they have all been made aware of the same incidents.

We believe that the current data gaps in maternity services are known and there is already a robust response in train to deal with these. The Maternity Services Dataset (MSDS) is a national, patient-level, secondary uses data set which captures key information at each stage of the maternity care pathway. Under the MTP, the MSDS was significantly updated in April 2019 in order to make sure that the right data is collected from maternity services. However, compliance with the updated dataset is heavily reliant on the maturity of Trusts’ Maternity Information Systems, which is variable across the country.

Consequently, data quality is currently variable, with many Trusts’ submissions containing incomplete data. This impacts the programme’s ability to report information in key areas such as provision of Continuity of Carer, which uses complex metrics that are reliant on the submission of multiple data items.

We anticipate the £52 million joint support package between NHSX and NHSEI announced earlier this year to accelerate the roll out of digitally mature Maternity Information Systems and women’s Digital Maternity Records in line with the Long Term Plan, should help improve data collected by the MSDS, although a mechanism for ensuring that the capture of clinical information in line with any updates to best practice will need to be considered. The funding package will ensure the delivery of three outcomes:

To empower women through a digital Personalised Care and Support Plan, incorporating access to curated healthcare information and their clinical data, in order to make informed decisions.