1. Supporting maternity services and staff to deliver safe maternity care
2. Learning from patient safety incidents (including reform of the clinical negligence system)
3. Providing safe and personalised care for all mothers and babies

Supporting maternity services and staff to deliver safe maternity care

The report notes that suboptimal staffing levels has been a persistent problem that has already been identified as a cause of poor maternity care, and that, apart from a shortage of midwives and obstetricians, the process of determining the right staffing levels for maternity units is complicated.  The key developments/recommendations arising out of the report in relation to these issues are that:

• The Department of Health and Social Care has committed to funding the Royal College of Obstetricians and Gynaecologists to develop a tool that can be used to calculate obstetrician workforce requirements (similar to the Birthrate Plus tool that is already used to calculate midwifery staffing requirements).

• The committee calls for an immediate increase in the budget for maternity services by £200 - £350 million p.a., in order to bolster the obstetrician workforce by at least 496 more posts and the midwifery workforce by at least 1,932 more posts.

• The committee calls for a proportion of maternity budgets to be ring-fenced for training, not only to fund the training itself, but to ensure that maternity unit staff are able to attend (by funding “back-fill”). The report particularly emphasises the value of multi-professional training sessions and it recommends “a single set of stretching safety training targets”, which should be established by the Maternity Transformation Programme Board in conjunction with the Royal Colleges and the CQC.

Learning from patient safety incidents

This section of the report includes some important insights in relation to how the committee considers patient safety to be affected by the litigation process.  It also includes an assessment of the role of Healthcare Safety Investigation Branch (“HSIB”) in learning from incidents in maternity care, and an assessment of how data relating to such incidents is collated across the NHS.  Some of the key conclusions set out in the report in relation to these issues are as follows:

• The committee concludes that “in its current form the clinical negligence process is failing to meet its objectives for both families and the healthcare system”, because it does not provide families with the support that they need in a timely and compassionate way and its adversarial nature promotes a culture of blame instead of learning.

• It calls for the establishment of an alternative system, such as that which is in place in Sweden, whereby compensation is awarded if an incident was “avoidable” and there is no requirement to prove negligence.

• It calls for an end to “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 pay outs”. This essentially amount to a recommendation that section 2(4) of the Law Reform (Personal Injuries) Act 1948 should be repealed and that the occupations of the parents of injured babies should not be taken into account when calculating loss of earnings claims.

• The report is generally positive about the role of HSIB, but it recommends that more work should be done in relation to the timeliness of its investigations and in relation to the improvement of its relationships with Trusts and clinicians (not just at senior management level, but at junior level as well, in order to achieve better engagement with its investigations and its recommendations).

• The report notes that there are several organisations involved in the collection of data relating to maternity outcomes and the standard of maternity services, but that they are not doing so in a coordinated way. It calls for NHS England and Improvement to streamline the data collection process in order to ensure that the data is collected and disseminated in a timely manner.

Providing safe and personalised care for all mothers and babies

In this section of the report the committee explore inequalities in outcomes, as well as issues relating to continuity of carer, informed choice and personalised care, and the need to ensure that women are not pressurised to have unassisted vaginal births.  Some of the key points in this section of the report are as follows:

• Women and babies from minority ethnic and socioeconomically deprived backgrounds are at greater risk of stillbirth, neonatal death, brain injury and maternal death compared to their white and less deprived privileged peers. The committee recognises that is a wide range of reasons for this that go beyond the remit of the Department of Health and Social Care and calls upon the government as a whole to develop a strategy to end this inequality.  However, the committee considers that having continuity of carer (i.e. consistency in the midwife or clinical team caring for the mother and baby throughout the pregnancy, labour and the postnatal period) could help to achieve this goal.

• The committee heard evidence that women were made to feel like failures for having caesarean sections and the report issues a challenge to all of those working in leadership positions in the NHS to “stamp out the damaging ideological focus on ‘normality at all costs’ and to instead focus on the ideology of “the only birth is a safe birth”. It calls for an end to the use of the term “normal birth” to describe vaginal deliveries, and that every woman giving birth should have “a right to their choice of pain relief during birth, in line with clinical advice on what would be safe for them and their baby”.

• It calls for NHS England and Improvement to establish a working group made up women and their families 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 in relation to the safest option for delivery.

Conclusion

This report sets out a vision for a well-funded, safe and reflective healthcare system that would surely significantly reduce the number of injuries and deaths that sadly continue to occur, though the report does acknowledge that “England remains a largely safe place to give birth and efforts to increase the safety of maternity services have led to further improvements”.  It remains to be seen whether there is an appetite in government to spend the very substantial sums of money on expanding the maternity workforce that the report calls for, and the merits of the Swedish approach to compensation need further exploration, but there is plenty in the report that will be welcomed and embraced by anyone who wants to see a safer NHS for mothers and babies.