Health and Social Care Select Committee: The safety of maternity services in England (6 July 2021)

Summary

This is the report of an inquiry conducted by the Health and Social Care Select Committee in 2020/21 which examined the ongoing safety concerns with maternity services and the action needed to improve safety for mothers and babies. It suggests that improvements to maternity services have been too slow to date and recommends several changes, including increasing in the budget for maternity services and reforming existing to litigation processes.

Content

The Health and Social Care Select Committee’s report sets out conclusions and recommendations in three parts:

1. Supporting maternity services and staff to deliver safe maternity care – considering the essential building blocks of safe care - first and foremost staffing numbers and funding, underpinned by leadership and training.
2. Learning from patient safety incidents – considers the role of the Healthcare Safety Investigation Branch (HSIB); examines the current clinical negligence system and how to reform it to allow a more positive learning culture to take root.
3. Providing safe and personalised care for all mothers and babies – explores women’s experience of care and considers the changes required to ensure safe care is a reality for every mother and her baby. This includes tackling unacceptable inequalities in outcomes; specific interventions to improve outcomes, including continuity of carer and screening; and finally, and most importantly, supporting informed choices and personalised care, to ensure that no woman faces pressure to have an unassisted vaginal birth.

Key recommendations

Supporting maternity services and staff to deliver safe maternity care

• 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.
• 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.
• 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.

Learning from patient safety incidents

• 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 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.
• 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.
• 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.

 Providing safe and personalised care for all mothers and babies

• 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, 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 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 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.