Written evidence submitted by RCOG and RCM (MSE0023)

 

Health and Social Care Committee Inquiry

The safety of maternity services in England

 

Evidence submitted on behalf of the RCOG and RCM

3 September 2020

 

Summary

  1. The Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM) have a vision for maternity that is bold, ambitious and within our grasp: to make the UK the safest and best place in the world to give birth. We are committed to working together to make this happen.

 

  1. We propose that the RCOG and RCM create and host a Women’s Health Improvement Centre that joins up and aligns the current fragmented and crowded maternity landscape to focus on the delivery of better, more personalised maternity care as well as value for money. Given our track record of working together to design, implement and evaluate programmes to improve safety in recent years, plus our national reach, we are ideally placed to take on this role.

 

  1. We propose that that Centre’s work falls into three broad areas – clinical, research and data and support. This three-pronged joined up approach has already demonstrated improvements in care and outcomes in maternity systems at home and abroad, and been shown to reduce both the frequency and costs of maternity litigation. We are confident that using the same joined up approach, we can achieve the same results in the UK.

 

  1. The RCOG and RCM have a strong track record of designing and implementing improvement programmes in maternity care including Each Baby Counts, Each Baby Counts + Learn and Support, the National Maternity and Perinatal Audit and the Tommy’s National Centre for Maternity Improvement. This experience makes us ideally placed to create and host the Centre.

 

  1. There are several areas that require immediate attention to make our maternity services the safest and best in the world. One of the common findings from previous investigations of failing maternity services has been evidence of poor, even dysfunctional working relationships between maternity professionals, weak leadership and bullying workplace cultures. There is strong evidence about the importance of team working and developing positive cultures in improving services, but we know that this is not being implemented consistently across the country.

 

  1. Like multi-professional working, strong and effective leadership is essential for the development of safe and improving maternity services and is a key determinant of the organisational culture in which front line teams operate. The voice of midwifery is integral to this. However, the voice of midwifery leaders can struggle to reach the highest levels of management within trusts and within health services more widely.

 

  1. It is impossible to ignore the long-standing problems with maternity workforce staffing in any discussion about improving maternity safety. The RCM has calculated that the NHS remains short of almost 1,500 midwives; the RCOG’s 2018 workforce report identified gaps in middle-grade rotas in nine out of 10 obstetric units and 100% of trainees reported rota gaps at their level in their current unit.[i] These staff shortages can affect job satisfaction, postgraduate training, quality of care and staff wellbeing. It is imperative that more work is done to both get staffing numbers right and make the best use of the staff already working in maternity.
  2. We envisage the Women’s Health Improvement Centre playing a central role in tackling these issues, working with key partners including NHS England/Improvement, the Department of Health and Social Care, NHS trusts, clinicians and women and their families.

 

  1. There is much more that can be done to reduce litigation costs. Research in this area has identified four principles for safer care that will help reduce litigation costs including dealing with structural problems, and a real commitment to learning. However, the benefits of these principles have been missed as a result of poor implementation. The proposed approach for the Women’s Health Improvement Centre would address this issue of poor implementation by providing unit- and system-level support to drive improvements in clinical practice and culture. One of the results would be a reduction in the number of adverse outcomes that result in clinical negligence cases and a corresponding drop in litigation expenditure.

 

  1. In addition, the litigation risk is important and strategic enough to require that trusts appoint a Director of Midwifery, with direct access to the board, to lead initiatives to reduce litigation.

 

  1. All recent national reports have identified that staff struggle with a lack of resources and capacity to provide best care. We aim to reduce the current unequal provision of care by using digital platforms and practice-based tools to personalise care for women, improve allocation of precious NHS resource as well as enabling staff to provide best care by making ‘the right way, the easy way’.

 

  1. There are several examples of good practice in personalisation of care. These include the HaMpton App, developed by the maternal fetal medicine team at St. George’s University Hospitals NHS Trust, in conjunction with the Health Foundation, to monitor hypertension in pregnancy, and the Tommy’s App, developed through the Tommy’s National Centre for Maternity Improvement, that will allow women to input their own data and be signposted to advice related to their care or lifestyle choices that can improve their chance of a healthy baby.

 

  1. Through our Women’s Health Improvement Centre we would continue to work with a variety of stakeholders to provide and disseminate accessible information, in a variety of formats, to pregnant women and to those who are planning a pregnancy.

 

  1. There are a number of areas of training and clinical practice that could be improved to deliver safer maternity services. Fetal monitoring is one such area, where ultimately services need to ensure that women are receiving the right monitoring for them and their baby, at the right time. A national programme, led by the Women’s Health Improvement Centre, would aim to provide a consistent approach to the provision of training in fetal monitoring, improve shared decision making between pregnant women and clinicians and ultimately reduce the incidence of avoidable harm and improve safety for women and their babies during the intrapartum period.

 

  1. There is also a need to improve the way data is collected and used at individual patient level. Although there is no shortage of data relevant to maternity safety, it is currently dispersed and fragmented across different bodies. This means that learning is frustrated and data collection expensive and burdensome. Further work and investment is required to increase data quality and completeness, both at the point where data are recorded, and in the flow from local to central datasets. This could sit with the Women’s Health Improvement Centre.

 

Health and Social Care Committee Inquiry

The safety of maternity services in England

 

Evidence submitted on behalf of the RCOG and RCM

3 September 2020

 

 

About us

 

  1. The Royal College of Obstetricians and Gynaecologists (RCOG) is a professional membership organisation made up of over 16,000 members worldwide. We work to improve health care for women, by setting standards for clinical practice, providing doctors with training and lifelong learning, and advocating for women’s health care.

 

  1. The Royal College of Midwives (RCM) is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team. We provide workplace advice and support, professional and clinical guidance and information, and learning opportunities with our broad range of events, conferences and online resources.

 

  1. This evidence explores some of the key issues relating to maternity care and safety that we felt it important to highlight. Where possible, we have set these out in response to the questions posed by the call for evidence. Where that has not been possible we have included separate sections, to ensure our submission is as comprehensive as possible.

 

  1. The RCOG and RCM are committed to working together, visibly role-modelling partnership working at an organisational level, to bring about positive improvements in maternity care, both for women and families and for the staff who work in maternity services. We have established joint programmes, including the National Maternal and Perinatal Audit and the Tommy’s National Centre for Maternity Improvement, that have played a central role in the achievements in maternity safety to date. However, we know there is more to do. This evidence highlights some of the potential solutions to the problems still facing maternity services in England. It also shows the leading role we believe we need to play, as two national organisations speaking with one voice. We have worked hard in recent years to embed a strong culture of partnership working across our organisations, which puts us in a strong position to lead from the top, with support from government, the NHS and wider stakeholders.

 

What good looks like

 

  1. We are fully supportive of the Committee’s focus on maternity safety. However, it is important to acknowledge that safety is one element of high-quality care. We support the World Health Organisations definition[ii] that healthcare must be:

 

 

  1. All of these individual elements come together to create excellent services, where staff are empowered to work to the best of their abilities in a system that values and supports them, in order to provide the best possible care for women and their families.

 

  1. Building on this, work undertaken at the University of Cambridge has identified the features of very safe maternity units.[iii] The research shows that there are six mechanisms that appear to be important for safety in the unit studied, including collective competence, insistence on technical proficiency, clearly articulated and constantly reinforced standards of practice, behaviour, and ethics, and a highly intentional approach to safety and improvement.

 

  1. We are committed to learning from research such as this, elements of which are covered in the following evidence. The solutions we present here are designed to enhance our existing understanding of what good looks like, enable us to work together to translate learning into practice, and allow us to share evidence-based learning and best practice across the system. Ultimately, we want to join-up current programmes and resources within the maternity system to help the Government deliver on its manifesto promise to make the UK the best place in the world to give birth.

 

  1. An important part of this drive to improve maternity services must be reducing inequalities. The coronavirus crisis has thrown into sharp relief the existence of significant disparities in provision, experience and outcomes of maternity care. It is absolutely essential that urgent action is taken to better understand and address these inequalities. Without this, ‘good’ will remain out of reach for too many women and their families.

 

  1. The gaps in both collecting and sharing data during pregnancy, which could help to tackle poorer outcomes for Black, Asian and Minority Ethnic (BAME) women, are discussed at question 5. Alongside addressing these data gaps, it is vital that the relationship between social deprivation and disadvantage and poor maternal and infant health is examined, so we can ensure the best possible outcomes for women and families from deprived and disadvantaged backgrounds.

 

  1. It is impossible to ignore racial inequality, which manifests itself in poorer maternal outcomes for BAME women, and has been a factor in COVID-19 infection and mortality rates. Both the RCOG and RCM are working with a wide range of stakeholders to tackle these issues for women and their families and for staff working in maternity services.

 

  1. In addition, we have written to the Joint Human Rights Committee, as part of its inquiry into COVID-19, urging that it recommend to Government a target of a 50% reduction in the disparity in maternal mortality rates for BAME women in the next five years. This target should act as a driver for a much broader analysis of, and improvement in, how maternity services care for pregnant BAME women.

 

Our role in improving maternity services

 

  1. Our vision is bold, ambitious and within our grasp: to make the UK the safest and best place in the world to give birth.

 

  1. This vision will require a national maternity improvement centre with traction at all levels of the system.
  2. A centre like this has the opportunity to bring together excellence in Implementation and Improvement Science hosted by the RCM and the RCOG representing the entire UK maternity workforce, the charity sector, a national women’s voices partnership, a multi-professional group of academics, subject experts and a national network of partner NHS Trusts to drive an innovative programme of improvement.

 

  1. We will enable services to provide more personalised care for women throughout their maternity journey, by harnessing data that is already collected by front-line maternity staff and the system.  We will enable use of these data for improvement and to streamline the current care system to effectively implement what we know today across all UK maternity settings. Finally, we will provide support for improvement in those settings that require or seek it.

 

  1. Our primary recommendation is that the RCOG and RCM create and host a Women’s Health Improvement Centre that joins up and aligns the current fragmented and crowded maternity landscape to focus on the delivery of better, more personalised maternity care as well as value for money. Given our track record of working together to design, implement and evaluate programmes to improve safety in recent years, plus our national reach, we are ideally placed to take on this role.

 

  1. We propose that that Centre’s work falls into three broad areas:

 

  1. This three-pronged joined up approach has demonstrated improvements in care and outcomes in maternity systems in the UK, US, Australia and Zimbabwe. In particular, this approach led by UK teams now based at the RCM and RCOG has been associated with a 50% reduction in both the frequency and costs of maternity litigation across the state of Victoria in Australia.

 

  1. We are confident that using the same joined up approach, we can achieve the same results in the UK, which has the potential to save the NHS £2bn per year in maternity negligence costs and claims in England alone.

 

  1. We are certain that we have the experience and expertise required to set up and host the Centre, which will run as an independent entity using the same model as the National Guideline Alliance (NGA). The RCOG has been successfully running the National Guideline Alliance (NGA) since 2016, following a tender award by the National Institute for Health and Care Excellence (NICE). The NGA is independent and delivers the NICE contract as a multi-specialty guideline development centre, with a diverse topic portfolio across women and children’s health, mental health, cancer and social care. The NGA offers a wide range of services and products and provides a value for money, flexible and adaptable service. This experience in delivering a multi-million pound contract on behalf of a large body such as NICE, showcases our ability to work in the way needed to set up and maintain the Women’s Health Improvement Centre.

 

Question 1. What has been the impact of work which has already taken place aimed at improving maternity safety? To what extent are the recommendations of past work on maternity safety by Trusts, Government and its arm’s-length bodies, and reviews of previous maternity safety incidents, being consistently and rigorously implemented across the country?

Our Impact

  1. The RCOG and RCM have a strong track record of designing and implementing improvement programmes in maternity care.

 

  1. Each Baby Counts[iv] was the RCOG’s vanguard national quality improvement project, set up in 2015 to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. This groundbreaking programme mobilised 100% of maternity units using a confidential enquiry style and paved the way for a number of other maternity safety initiatives including Healthcare Safety Investigation Branch (HSIB) maternity investigations and the NHS Resolution Early Notification Scheme.

 

  1. The NHS recognised the value of Each Baby Counts with its commitment to fund Each Baby Counts + Learn and Support, which is focused on supporting trusts to implement recommendations that will improve care, including improved working within multidisciplinary teams. We are working with a number of NHS trusts in England to develop, test and evaluate new approaches to promote a more positive and supportive workplace environment. The programme runs until December 2021, when the results will be published.  This will support the system in understanding the key learning and support components for staff and units to enable them to locally implement best practice. 

 

  1. The National Maternity and Perinatal Audit (NMPA), led by the RCOG in partnership with the RCM, the Royal College of Paediatrics and Child Health and the London School of Hygiene and Tropical Medicine, and commissioned by HQIP (Healthcare Quality Improvement Partnership), further demonstrates the positive impact we are already having on maternity safety. As the largest audit of NHS maternity services across England, Scotland and Wales, it plays a key role in driving improvement and showcases the integral role of high quality data in improving services.
  2. The audit acts as a source of high-quality information about the organisation and outcomes of maternity care, developed by obstetricians, midwives, neonatologists and methodologists. It provides accurate, up to date information about the national risks of major complications such as postpartum haemorrhage and third and fourth degree tear. It also provides information about rates in local sites which can be used for benchmarking and quality improvement.
  3. An interactive online facility allows maternity care providers and commissioners to access timely reports, and benchmark the care provided by their service against other, similar services, regional or national averages, or local or national standards.
  4. Taken as a whole, the information provided by the NMPA enables service providers, commissioners, policy makers and women and their families to reflect on variations in care and work together to drive improvement.

 

  1. As mentioned previously, in 2019, the RCM and the RCOG formed an alliance to launch the Tommy’s National Centre for Maternity Improvement. The three-year programme of work - which involves the creation of a digital tool to personalise and improve maternity care for women - is in support of achieving the Government’s objectives to reduce stillbirth and preterm birth. The Centre has committed to 600 fewer stillbirths per year and 12,000 fewer infants born pre-term. The programme is funded by the Tommy’s charity and is a collaboration between obstetricians, midwives, data analysists and behavioural scientists from leading UK universities and clinical centres, as well as women and their families. This alliance represents our ongoing commitment to improving care across the maternity system to make the UK the safest place in the world to give birth.

 

  1. We also have several other collaborative programmes of work that have had a positive impact across the UK, including:

 

 

  1. These joint initiatives sit alongside the work we do as individual organisations, which includes producing a wide range of guidelines, research projects and reports, policy recommendations and information and support for women and their families.

 

  1. We also worked together closely on our response to the COVID-19 pandemic, creating a raft of guidance for clinicians and advice for women and their families. Our ability to mobilise quickly in response to the pandemic, bringing together a variety of clinical and non-clinical professionals from across our two organisations and beyond, shows that we are ready and able to take the lead in maternity safety.

 

  1. Furthermore, an RCM evaluation of the implementation of the Kirkup recommendations identified progress in respect of:

 

 

 

 

 

Team working

 

  1. One of the common findings from previous investigations of failing maternity services has been evidence of poor, even dysfunctional working relationships between maternity professionals, weak leadership and bullying workplace cultures. As the recent Each Baby Counts report concluded: “Lasting cultural changes in learning, leadership and multi-professional working are the key to tackling the number of incidents in our maternity services”.[v]

 

  1. We know that taking a multi-disciplinary approach to certain factors can positively influence safety in maternity services and contribute to supportive workplace cultures, including:

 

 

  1. Further evidence is emerging from HSIB and from NHS Resolution’s Early Notification Scheme that problems of culture are implicated in many instances of poor outcomes.  For instance, cultural features of maternity units may inhibit staff from taking the appropriate action, communicating their concerns, or reacting appropriately to a request for intervention. Fear of asking for help or advice, working under pressure,[vi][vii] fear of speaking up to a more senior person,[viii] blaming individuals for systemic failures[ix] and bullying and undermining of doctors in training[x] may all be implicated in poor practice. Disagreements and divergences between midwives and obstetricians and conflicts over professional boundaries are present in some maternity units and may erupt into tensions about appropriate intervention.[xi] Deficits in culture are also associated with poor implementation of training and improvement initiatives.[xii]

 

  1. Despite this strong evidence about the importance of team working and developing positive cultures, we are concerned that this is not being implemented consistently across the country. For example, it is well known that appropriate resources and protected time for training are essential but there still appears to be considerable variation across England as to the provision and accessibility of training.

 

  1. The above illustrates the need for a Women’s Health Improvement Centre that will collaborate with clinicians and other stakeholders to achieve these recommendations across the UK.

 

Leadership

  1. Like multi-professional working, strong and effective leadership is essential for the development of safe and improving maternity services and is a key determinant of the organisational culture in which front line teams operate. Unfortunately, the voice of midwifery leaders can struggle to reach the highest levels of management within trusts and within health services more widely. There are many issues that still need to be addressed, including:

 

 

 

 

 

 

  1. It is also important to develop leadership skills among all clinicians, not just those in official leadership positions, so there is effective leadership from all those working on the frontline of healthcare. By recognising that different professional groups and individuals hold specific knowledge and expertise, it is possible to provide safe and more efficient care, by making sure that the right skills are brought to the fore with the right people at the right time.[xiii]

 

  1. The rapidly adopted changes to ways of working in response to COVID-19 have undoubtedly placed stress on frontline staff. However, in many areas strong leadership and positive relationships with service user and patient groups have allowed teams to respond quickly, and agile ways of working have emerged across health services, in order to introduce and measure change safely and at pace. Some RCOG members have reported greater cohesion and better team working as a result of the changes, with more opportunities to show leadership and management skills.

 

  1. Services have also reported improved relationships between management and clinical staff as a result of the need for more frequent and effective communication during the pandemic.  

 

  1. It is clear that clinicians feel there have been some positives to come out of the response to the pandemic. However, before decisions are taken about sustaining changes, robust evaluation must take place, to ensure that any changes that have occurred can be shown to be beneficial to patient care and outcomes.

 

  1. The work of the Women’s Health Improvement Centre would directly address these issues, using data and research to create practical support packages to help maternity services embed collaborative team working, a culture of learning and strong, effective leadership.

 

Workforce

  1. It is impossible to ignore the long-standing problems with maternity workforce staffing in any discussion about improving maternity safety. Both the Kirkup and Francis reports highlighted the need for robust procedures for establishing how many staff are needed to provide safe, effective and high quality care. As a result, NICE established the safe staffing guidance programme that led to the development of the safe midwifery staffing guideline in 2015.

 

  1. The RCM has calculated that the NHS remains short of almost 1,500 midwives; the RCOG’s 2018 workforce report identified gaps in middle-grade rotas in nine out of 10 obstetric units and 100% of trainees reported rota gaps at their level in their current unit.[xiv] The proportion with entirely unfilled gaps decreased from 43% to 35% between 2017 and 2019, while the proportion requiring locum cover to staff the rota remained the same at 83%. These staff shortages can affect job satisfaction, postgraduate training, quality of care and staff wellbeing.

 

  1. We are also aware of the pressures on other parts of the workforce. O&G services rely on the significant contribution of SAS (Specialty and Associate Specialist) and locally employed doctors). There is a significant turnover among this group with around 12% leaving the NHS workforce in England each year.[xv]

 

  1. It is imperative that more work is done to ensure the NHS has the right people, in the right place, at the right time.

 

  1. One strand of this is getting the numbers right. The Government must fulfil its commitment to create 3,650 midwifery training places between 2019/20 and 2022/23. It should also invest in work to identify the best medical staffing models for maternity, complementing the existing midwifery staffing guideline. The system needs to know what models give the best outcomes and the best experiences in order to be able to ascertain what level of staffing is required.

 

  1. Any medical staffing model must take into account dedicated time for training, sickness absence and maternity leave which is not currently built into medical rotas or workforce planning. This lack of headroom makes it extremely difficult for maternity units to even manage the training requirements of their doctors without a knock-on effect on patient care and on the staff left to cover gaps.
  2. The other strand of tackling staffing issues is making the best use of the staff already working in maternity, one key element being shared learning and training. In general, non-medical staff are not skilled-up to be able to provide cover for other colleagues when they need to attend training or carry out other non-clinical duties. Greater provision of shared learning and training between different groups of the maternity workforce, and commitment to on the job training, would enable these staff to enhance their skills. This would blur the boundaries between roles sufficiently enough to allow staff to provide safe cover for colleagues when needed, without undermining the value of each role within the maternity team. Being better placed to manage staff absences would naturally enable units to provide more efficient care.
  3. Furthermore, overstretched staff who are providing cover for absent colleagues and vacant posts with little time other than for direct clinical care do not have the capacity to provide the oversight and leadership required to focus on safety, governance and projects which drive improvement. Our Women’s Health Improvement Centre would develop metrics to ensure appropriate medical staffing levels which will give visibility to these shortages.

 

Human factors

 

  1. Throughout the course of the Each Baby Counts project we have raised the importance of human factors and non-technical skills as key features of safe maternity care. However, staff training alone is unlikely to be effective - human factors are recurrent themes that need to be urgently addressed at a systemic level.  The social skills of communication, team-working and leadership and the cognitive skills of situational awareness and decision-making need to be embedded into all clinical training.

 

Shrewsbury and Telford

  1. Both the RCM and RCOG have concerns about the way in which the current inquiry into maternity care at Shrewsbury and Telford Hospital NHS Trust is being conducted. We have particular misgivings about the lack of clarity on the methodology of the review, progress to date, timescales and how improvement within the trust can be supported. In terms of this last point, we are keen to work with the trust and with the wider system to sustain high quality, safe services during the review, which will help to improve confidence in the service among local families. It is vital that maternity staff currently working at the trust feel valued and supported. We will also work to find the most appropriate way we can support the findings of the report once they are published.

 

Recommendations

  1. All trusts should undertake an evaluation of the role of the board-level Maternity Safety Champion, to identify progress so far and improvements for the future.

 

  1. All trusts should appoint as many consultant midwives as there are maternity units. Trusts in remote and rural areas could appoint a consultant midwife across more than one trust, providing consistency and clarity of professional guidance for this very specific kind of midwifery service.

 

  1. Every trust should have a range of specialist midwife roles. The mix of specialisms will depend upon the needs of the service locally. Midwives should have access to and be able to draw upon these midwives’ skills and experience.

 

  1. The Government must fulfil its commitment to create 3,650 midwifery training places between 2019/20 and 2022/23.

 

  1. Subject to the establishment of the Women’s Health Improvement Centre, the Department of Health and Social Care should commission research to identify the best medical staffing models for maternity, complementing the existing midwifery staffing guideline.

 

  1. NHS England and Improvement (NHSE/I) should commission the Centre to create and deliver maternity-specific human factors training to support trusts to turn understanding of human factors into practice. This training should be mandatory for all maternity units.

Question 2. The contribution of clinical negligence and litigation processes to maternity safety, and what changes could be made to clinical negligence and litigation processes to improve the safety of maternity services?

 

  1. The NHS paid £2.4bn in clinical negligence claims in 2018-19, according to NHS Resolution. This sum equates to about 2% of the entire budget for the NHS in England. The Public Accounts Committee has identified that a small number of high value claims, mostly related to maternity care, is a major contributor to these costs.[xvi] Maternity accounted for 50% of the total value of claims received by NHS Resolution in 2018-19, though it represented only 10% of the total number of claims.[xvii]

 

  1. Spending on clinical negligence was forecast to consume 4% of trusts’ total income in 2020, meaning a corresponding loss in the amount available for patient care.[xviii] Furthermore, spending on clinical negligence is increasing much faster than funding for the NHS, tripling in the decade from 2009.[xix]

 

  1. The Early Notification Scheme, which requires reporting within 30 days all maternity incidents when babies have had severe brain injuries diagnosed, has introduced several benefits. It avoids lengthy litigation processes where early liability is admitted, and increased use of mediation and other forms of dispute resolution is helping to avert claims going to formal court proceedings. It also pools clinical information as to causes of poor outcomes, which should help to reduce injuries caused to babies.

 

  1. Yet there is still much more that can be done to reduce litigation costs. A recent BMJ article[xx] identified four foundational principles for safer care that will help reduce litigation costs: dealing with structural problems, a real commitment to learning, learning from high performance, and facilitating system-wide improvements. The authors argue that the four principles are evidence based but the benefits have been missed as a result of poor implementation.

 

  1. The proposed approach for the Women’s Health Improvement Centre would address this issue of poor implementation by providing unit- and system-level support to drive improvements in clinical practice and culture. One of the results would be a reduction in the number of adverse outcomes that result in clinical negligence cases and a corresponding drop in litigation expenditure.

 

  1. This type of approach has yielded results overseas. The implementation of PROMPT produced a very substantial return on investment in Victoria, Australia. The Victoria Managed Insurance Authority (VMIA) allocated each health service with A$65,500 funding to help implement a multi-professional training programme for managing obstetric emergencies. It spent a total of A$1,244,500 supporting implementation in 19 health services/hospitals. The programme was associated with an overall saving of A$29,582,261 in maternity litigation costs. The return on investment for the VMIA’s investment was therefore of the order of 24:1.

 

  1. In addition, the litigation risk is important and strategic enough to require that trusts appoint a Director of Midwifery, with direct access to the trust board, to advocate for safe, high quality maternity care and lead initiatives to reduce litigation. Furthermore, given the scale of negligence claims in maternity, all NHS organisations at all levels, from the national to the local, should have a lead midwife in a senior position within that organisation.

 

 

 

 

Recommendation

 

7.               All trusts should appoint a Director of Midwifery. Given the scale of negligence claims in maternity, all NHS organisations at all levels, from the national to the local, should have a lead midwife in a senior position within that organisation.

 

Question 3. Advice, guidance and practice on the choices available to pregnant women about natural births, home births and interventions such as C-sections, and the extent to which medical advice and decision-making is affected by a fear of the “blame culture”.

 

  1. All recent national reports have identified that staff struggle with a lack of resources and capacity to provide best care. We aim to reduce the current unequal provision of care by using digital platforms and practice-based tools to personalise care for women, improve allocation of precious NHS resource as well as enabling staff to provide best care by making ‘the right way, the easy way’.

 

  1. We strongly support greater personalisation of care, where women are supported to make informed choices. This includes availability of clear and accessible guidance and information about different birth options and the opportunity to discuss birth choices with a named midwife or obstetrician. Information must be available in a variety of formats and languages, to suit all women living in different situations, to make it as accessible as possible. Achieving this will mean that more women will be able to ask the relevant questions and receive the information they need to make informed choices about birth.

 

  1. One example of good practice is the innovative HaMpton App, developed by the maternal fetal medicine team at St. George’s University Hospitals NHS Trust, in conjunction with the Health Foundation, to monitor hypertension in pregnancy. This App, currently being rolled out across the NHS, allows patients to monitor their blood pressure, urine and symptoms at home. Standard care pathways for women who have high blood pressure in pregnancy involve frequent hospital visits. This has significant cost implications, both to the NHS and to patients, in terms of time and money. Furthermore, such frequent hospital visits can cause anxiety to pregnant women. The results of the implementation of the App have been extremely positive and included:

 

 

  1. We have also developed the Tommy’s app, through the Tommy’s National Centre for Maternity Improvement, that will be freely available to every woman and their healthcare providers, in the UK. Women will input their own data and be signposted to advice related to their care or lifestyle choices that can improve their chance of a healthy baby. Medical professionals will also contribute clinical data to a woman’s record, and these combined data will be used to personalise risk and choices with signposting to advice and more options. A prototype of the digital tool is to be developed by September 2020 and tested in following three months. Then a study of the evaluation of implementation is scheduled to run from January 2021 to June 2021 leading to the pilot run from July 2021.[xxii]

 

  1. Furthermore, through our Women’s Health Improvement Centre we would continue to work with a variety of stakeholders to provide and disseminate accessible information, in a variety of formats, to pregnant women and to those who are planning a pregnancy. This would include the options available to them when developing their birthing plan, the possible interventions that may be required and use of tools such as IDECIDE, which supports women to make informed choices in labour. This information is vital in supporting women to make informed choices throughout their pregnancy journey, enabling them to discuss their options with healthcare professionals and will also help with consent.

 

Optimising women’s health

  1. It is also necessary to consider the links between maternal outcomes and women’s health more broadly.  Improving the advice, guidance and care available to women before and during pregnancy would result in better outcomes for them and their babies.

 

  1. Two of the key issues in improving maternal outcomes were initially highlighted by the 2017 NMPA report[xxiii]. There was an increase in maternal obesity that was confirmed in the 2014-16 MBRRACE-UK report, published in 2018. This reported that 37% of the women who died were obese and a further 20% were overweight. There is clear evidence that weight loss between pregnancies reduces the risk of stillbirth, hypertensive complications and poor outcomes related to large babies. The other major risk factor highlighted by the NMPA report was the extremely wide variation in the proportion of women who stopped smoking during pregnancy. Smoking during pregnancy is responsible for an increased rate of stillbirths, miscarriages and birth defects. Smoking remains the biggest modifiable risk factor for poor birth outcomes and a major cause of inequality in child and maternal health.

 

  1. Prioritising pre-conception public health could improve the health of women planning pregnancy and therefore optimise their chances for a safe birth. Women should be offered advice on smoking cessation and body weight and lifestyle in primary care, such as during pre-conception counselling and appointments about contraception. A structured weight-loss programme and a referral to a dietician or an appropriately trained healthcare professional may be recommended where appropriate. Attention to pre-existing medical conditions is essential to complement this approach and will help to reduce the number of maternal deaths.

 

  1. All of this must be done in a joined-up way across health and other public services, with the required investment in the workforce to enable delivery of the full range of women’s health services. The Government’s recently published obesity strategy was a missed opportunity, with no mention of the need to support pregnant women, and those hoping to get pregnant, to maintain a healthy weight.

 

  1. The RCOG and RCM have publicly expressed concerns regarding the recent decision to redesign Public Health England. Nationwide initiatives to improve pre-conception health, decrease smoking during pregnancy, reduce obesity through the life course and reduce perinatal mental health issues, are incredibly important for the ongoing health and wellbeing of pregnant women, as well as being cost-saving for the NHS. Public Health England has made good progress in these areas and therefore it is imperative that the ‘prevention’ element of this body is not lost and we have clarity about who has overarching responsibility for these vital priority areas.[xxiv]

 

Recommendation

 

8.              Pre-conception health should be prioritised to improve the health of women planning

pregnancy. Women should be offered advice on body weight and lifestyle in primary care, plus a structured weight-loss programme and referral to a dietician or an appropriately trained healthcare professional where appropriate.

 

9.              The specific importance of supporting pregnant women to maintain a healthy weight should be included in the implementation of the obesity strategy.

Question 4. How effective is the training and support offered to maternity staff, and what improvements could be made to improve the safety of maternity services?

  1. ‘Safety Action 8’ of the Maternity Incentive Scheme has a requirement that at least 90% of each maternity unit staff group have attended an 'in-house' multi-professional maternity emergencies training session within the last training year and multi-professional training occurs at least twice a year with anaesthetic/maternity/neonatal teams in the clinical area, and that risks/issues identified are addressed.

 

  1. However, due to aforementioned staffing constraints, including rota gaps, alongside funding constraints, we know that not all training is equal, effective, or utilised by all staff. Furthermore, the scheme does not mandate that all trusts must meet all of the safety actions. Instead it rewards trusts that meet ten safety actions, therefore uptake nationally is patchy.

 

  1. There are a number of areas of training and clinical practice that could be improved to deliver safer maternity services. Fetal monitoring (FM) is one such area, as identified by Each Baby Counts where ultimately services need to ensure that women are receiving the right monitoring for them and their baby, at the right time. This involves multiple factors including risk assessment of the mother, the culture of the unit and the processes and procedures for escalation when problems are identified.

 

  1. Within this broad area, we have designed specific interventions targeted at addressing two of the top causes of maternity-related clinical negligence claims - addressing failures in risk assessment and fetal monitoring during labour, and managing impacted fetal head at caesarean section. We have worked with multiple agencies, arms-length and professional bodies and evaluation experts to create these programmes. We propose that these are taken on by the Women’s Health Improvement Centre, backed by government funding.

 

  1. A national programme, led by the Centre, would aim to provide a consistent approach to the provision of training in fetal monitoring, improve shared decision making between pregnant women and clinicians and ultimately reduce the incidence of avoidable harm and improve safety for women and their babies during the intrapartum period.

Risks associated with CTG

  1. Failures in interpretation and action in response to continuous cardiotocography (CTG) traces are a leading contributory factor in cases identified by Each Baby Counts and amongst those notified to NHS Resolution under the Early Notification Scheme. At present, training for healthcare staff is the most frequently proposed solution to inappropriate CTG practice. However, current training programmes and the classification of CTGs are not standardised, and do not consistently demonstrate positive impacts.

 

  1. Interpretation and response to intrapartum CTG traces involves a series of complex socio-technical processes with many potential points of failure. Many vulnerabilities arise at the level of culture, behaviour, and organisational systems. Reducing risks associated with CTG must therefore take a holistic approach that both targets the specific challenges of CTG and strengthens organisational functioning, culture and behaviour in order to support optimised implementation and response.

 

  1. Some potential initiatives to make improvements have already been surfaced by our research collaboration with the University of Cambridge, including high quality clinical simulation bundled with structured organisational learning interventions, to improve systems, culture and behaviour supportive of appropriate CTG interpretation and response.

Risks associated with impacted fetal head

  1. Impacted fetal head, where the baby’s head becomes wedged in the mother’s pelvis during caesarean section, may result in serious maternal and neonatal complications. It is rated as one of NHS Resolution’s highest priority emerging risks. In its recently published Early Notification Scheme Report, NHS Resolution identified that 9% of cases of fetal injury involved an impacted fetal head. A surge of coroners’ enquiries into fetal trauma associated with impacted fetal head at caesarean section is also occurring. These injuries may result in very high cost claims.

 

  1. How injuries occur and how they might best be prevented is currently poorly evidenced, but the emerging consensus is that the techniques used during the delivery require a gentle, skilful and efficient approach to ensure safe performance. Researchers have hypothesized that the risk of cranial injury may be reduced if delivery is undertaken by more senior obstetricians. Given that consultant supervision may not currently always be feasible, it is essential that all obstetricians are trained to perform these delivery techniques safely, particularly as there currently are no accurate methods of prediction.

 

  1. Clinical simulation techniques, including innovative Augmented Reality techniques, can be used to highlight actions that may result in fetal injury and train practitioners to perform actions safely, thereby avoiding these injuries. Similar methods have been successfully used to improve care, improve outcomes and reduce litigation after shoulder dystocia.

 

  1. There are also non-clinical areas of training that need to be tackled to make sure women and their families receive the best possible care, wherever and whenever they need it.

Support for medical locums

  1. Comprehensive guidance for healthcare providers, locum agencies and individual locum doctors has been produced by NHS England which is applicable to all specialties. For maternity, in longer term placements new RCOG/NHSE guidance outlines the processes which should be in place to ensure locums meet the required standards before undertaking clinical work especially out of hours with indirect supervision. This guidance has been recently launched.

 

  1.         However, in short term placements (less than two weeks) the assessment and sign off process which are outlined in the guidance cannot be undertaken by the individual unit. These positions are frequently offered at short notice out of necessity, when internal means of cover have failed or when doctors who have worked previously in the service are unavailable. These occasions often involve night time or weekend shifts where supervision is by indirect, non-resident substantive senior colleagues.

 

  1.         Recent high profile cases in maternity care have highlighted the need for robust vetting, assessment and support processes before locums without knowledge of the organisation or familiarity with other staff are allowed to work independently. This will help to ensure that there is no compromise in patient safety and quality of care.

Recommendation

10.              NHSE/I should implement without delay the locum passport for O&G, to support the use of short-term locums undertaking clinical practice with only indirect supervision. This pre-requisite for employment in short-term O&G placements could be written into agency frameworks. Individuals would need to provide evidence of certain experience and skill in order to be employed as a short term locum with indirect supervision on a middle grade rota.

 

Maternity Safety Training Fund

  1.         Following the publication of Better Births in 2016, and to support the Government’s target of halving stillbirths, neonatal and maternal deaths by 2025, Health Education England (HEE) introduced the Maternity Safety Training Fund (MSTF) to distribute over £8.1 million to NHS trusts with maternity services in England. The purpose of this initiative was to fund multidisciplinary training to improve maternity safety and care for mothers and babies.

 

  1.         An HEE-commissioned evaluation into the MSTF, published in 2019, concluded that trusts had successfully incorporated learning and training skills into their mandatory programmes and that the training had impacted on everyday practice.

 

  1.         In total, 30,945 training places were delivered across many professional groups, and on a broad range of courses. The funding initiative also allowed trusts to upskill their workforce and develop pathways for sustaining learning through extending their mandatory training programmes, creating champions and training staff in key positions to disseminate the knowledge through everyday practice. Although this is certainly an example of good practice, there has been no improvement in maternity outcomes recorded as of yet.

 

  1.         While sustainability of training beyond the funding period was an aim of the programme, the data collected during the evaluation suggests that without ongoing financial support, there is a risk that the benefits of the MSTF will diminish over time, especially for trusts that have not yet achieved a sustainable programme of learning. Therefore, it recommended that maternity services receive regular funding in order to maintain their learning and training gained through the MSTF.

 

  1.         It also recommended that future funding for maternity safety training should be more flexible and offer courses from a range of providers so that bespoke training programmes can be developed to meet the specific contexts and needs of each trust. This is particularly pertinent when addressing specific workplace culture issues which may have an effect on safety.[xxv]

Recommendation

11. HEE should follow the recommendations of the evaluation and reinstate regular funding for effective training programmes to improve care, outcomes and costs in maternity settings. The Women’s Health Improvement Centre has a central role to play in designing and delivering this type of training.

 

 

 

Question 5. The role and work of the Healthcare Safety Investigation Branch in improving the safety of maternity services, and the adequacy and appropriateness of the collection and analysis of data on maternity safety.

 

  1.         The role of local safety reviews in investigations of maternity services needs urgent clarification. This is particularly the case following the dissolution of Parliament, which effectively put paid to the Heath Service Safety Investigations Bill. The Bill included proposals for the establishment of a Health Service Safety Investigations Body (HSIB) to investigate incidents which have implications for the safety of patients in the NHS.

 

  1.         During the second reading of the Bill, the question arose of where the new arrangements would leave the status of local maternity investigations, currently undertaken by HSIB. A joint committee of MPs and Peers has scrutinised the Bill and recommended that programmes for local maternity investigations, undertaken by HSIB, should not be part of the new body’s remit. With no clarity as to whether and when the Bill will be reintroduced, future arrangements for the investigation of maternity incidents remain uncertain.

 

  1.         The RCOG and RCM also acknowledge that there are some issues with HSIB which need to be addressed, especially around the culture and quality of investigation. We are also concerned about delays to maternity investigations, which is partly due to a lack of staff and resources. Furthermore, the reports are difficult to aggregate into national learning. However, it is important to note that HSIB has had some good engagement with families and has a greater perception of independence than internal maternity investigations.

Recommendation

12. The Government must urgently clarify future arrangements for the investigation of maternity incidents.

 

  1.         There is a need to improve the way data is collected and used at individual patient level. Detailed data about physical and mental health and social circumstances is routinely collected from every pregnant woman in the UK. Currently, this data is not easily accessible to either the woman or her health care professionals, during or after her pregnancy. This is a missed opportunity to accurately identify those women who are at greater risk of pregnancy-related morbidity and to empower women to better manage their own health.

 

  1.         For example, the 2014-16 MBRRACE-UK report identified that the marked increase in mortality among black women could be accounted for by pre-existing medical problems, anaemia during pregnancy, diabetes, previous pregnancy problems, multiple pregnancy, poor antenatal care, substance misuse, maternal age and unemployment. Since all of these risk factors are identifiable during pregnancy, the NHS needs to develop robust methods to capture and share these data for each individual woman, in ways that ensure that everyone involved in her care can access and utilise them.

 

  1.         Though there is no shortage of data relevant to maternity safety, it is currently dispersed and fragmented across different bodies. This means that learning is frustrated and data collection expensive and burdensome. As such, there is a pressing need for better data to support improvement in care quality and to facilitate research that is relevant to the needs and priorities of patients and clinicians.

 

  1.         This is demonstrated in the quality of data available to the NMPA. Not every trust is able to provide all the necessary information for every measure, and a small number of NHS trusts in England are unable to provide any data. There are also some data items which are not available in every country in the format required for the NMPA measures. The majority of trusts and boards failed the NMPA data quality checks for at least one measure, and data quality remains a national issue. Further work and investment is required to increase data quality and completeness, both at the point where data are recorded, and in the flow from local to central datasets. This could sit with the Women’s Health Improvement Centre. 

 

  1.         We propose that the Centre be supported to work with NHS Digital to bring together existing data sets into a digital learning health system that can be used for monitoring, service improvement, evaluation, and research. Leveraging the capabilities of electronic health records and other digital resources, learning health systems seek to generate new knowledge as an “ongoing, natural by-product of the care experience[xxvi] and facilitate improvements in quality, safety, and value.[xxvii] This would enable big picture overviews of maternity safetymonitoring performance, celebrating excellence, identifying regional variations in core outcomes, and detecting deterioration in services so that early intervention can occur.

 

  1.         Importantly, the learning system we propose would address the challenge of better supporting struggling units by developing a set of leading and lagging indicators to build profiles at an organisational level. This would allow much earlier detection of red flags for deterioration and opportunities for intervention before serious harm occurs. The learning system also could be used to evaluate the impact (clinical, legal and economic) of national improvement programmes and interventions, and would facilitate the introduction and evaluation of new interventions in real-time in ways that are not currently possible.

 

Recommendation

13. Work towards interoperable digitised maternity care records, accessible by a range of healthcare professionals and women alike, should be continued at pace.


References

21

 


[i] National Maternity and Perinatal Audit, Organisational Report 2019 (2019)

[ii] https://www.who.int/maternal_child_adolescent/topics/quality-of-care/definition/en/

[iii] Liberati EG, Tarrant C, Willars J, et al. How to be a very safe maternity unit: An ethnographic study. Social Science & Medicine 2019;223:64-72. doi: https://doi.org/10.1016/j.socscimed.2019.01.035

[iv] Each Baby Counts. https://www.rcog.org.uk/eachbabycounts

[v] RCM press statement, RCM responds to Each Baby Counts report (2020)

[vi] Simpson KR, James DC, Knox GE. Nurse‐Physician Communication During Labor and Birth: Implications for Patient Safety. Journal of Obstetric, Gynecologic & Neonatal Nursing 2006;35(4):547-56. doi: 10.1111/j.1552-6909.2006.00075.x

[vii] McKevitt S, Gillen P, Sinclair M. Midwives’ and doctors’ attitudes towards the use of the cardiotocograph machine. Midwifery 2011;27(6):e279-e85. doi: 10.1016/j.midw.2010.11.003

[viii]Simpson KR, James DC, Knox GE. Nurse‐Physician Communication During Labor and Birth: Implications for Patient Safety. Journal of Obstetric, Gynecologic & Neonatal Nursing 2006;35(4):547-56. doi: 10.1111/j.1552-6909.2006.00075.x

[ix] Magro M. Five years of cerebral palsy claims - A thematic review of NHS Resolution data. London, UK: NHS Resolution, 2017:92

[x] General Medical Council. Building a supportive environment: a review to tackle undermining and bullying in medical education and training. Manchester, UK: General Medical Council, 2015:52.

[xi] Simpson KR, James DC, Knox GE. Nurse‐Physician Communication During Labor and Birth: Implications for Patient Safety. Journal of Obstetric, Gynecologic & Neonatal Nursing 2006;35(4):547-56. doi: 10.1111/j.1552-6909.2006.00075.x

[xii] Lenguerrand E, Winter C, Siassakos D, et al. Effect of hands-on interprofessional simulation training for local emergencies in Scotland: the THISTLE stepped-wedge design randomised controlled trial. 2020;29(2):122-34.

[xiii] https://www.gmc-uk.org/-/media/documents/somep-2019---full-report_pdf-81131156.pdf?la=en&hash=B80CB05CE8596E6D2386E89CBC3FDB60BFAAE3CF

[xiv] National Maternity and Perinatal Audit, Organisational Report 2019 (2019)

[xv] RCOG, O&G Workforce Report 2018 (2018)

[xvi] House of Commons Committee of Public Accounts. Managing the costs of clinical negligence in hospital trusts. Fifth report of session 2017-19 (HC 397). https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/397/397.pdf

[xvii] NHS Resolution. Annual report and accounts 2018/2019. 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/824345/NHS_

Resolution_Annual_Report_and_accounts_print.pdf

[xviii] House of Commons Committee of Public Accounts. Managing the costs of clinical negligence in hospital trusts. Fifth report of session 2017-19 (HC 397). https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/397/397.pdf

[xix] National Health Service Litigation Authority. Report and Accounts 2009 (HC 576). 2009.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/248285/0576.pdf

[xx] Clinical negligence costs: taking action to safeguard NHS sustainability BMJ 2020;368:m552 doi: 10.1136/bmj.m552 (Published 2 March 2020)

[xxi] NHSE, NHS Innovation Accelerator, Supporting Evidence for HaMpton (2018) and The Health Foundation, Final Report, Innovating for Improvement Home Monitoring of Hypertension in Pregnancy (HaMpton)

[xxii] RCOG, RCOG forms alliance with RCM to launch The Tommy’s National Centre for Maternity Improvement (2019)

[xxiii] NMPA, https://maternityaudit.org.uk/downloads/NMPA%20Clinical%20Report%20(Executive%20Summary)%202018.pdf

[xxiv] RCOG, RCOG comments on the restructuring of Public Health England and RCM, RCM comments on Matt Hancock speech and decision to axe PHE (2020)

[xxv]https://www.hee.nhs.uk/sites/default/files/documents/Maternity%20safety%20transformation%20fund%20evaluation%20Feb%202019.pdf

[xxvi] McGinnis JM, Powers B, Grossmann C. Digital infrastructure for the learning health system: the foundation for continuous improvement in health and health care: workshop series summary: National Academies Press 2011.

[xxvii] McGinnis JM, Stuckhardt L, Saunders R, et al. Best care at lower cost: the path to continuously learning health care in America: National Academies Press 2013.

9 September 2020