A Spotlight on Maternity Safety - by James Titcombe

This week (9-15 October) marks the 20th Baby Loss Awareness Week and for everyone touched by pregnancy and baby loss, is an opportunity to come together to share experiences in a supportive and kind space. The week will cumulate with a global ‘wave of light’ where at 7pm (local time) on 15th October, families can join in lighting a candle in remembrance of babies that have died too soon.

This year, Baby Loss Awareness Week comes at an especially poignant time for many families, being just ahead of the publication of the East Kent Investigation report on 19th October, chaired by Dr Bill Kirkup.

Losing a baby in any circumstances is a life changing tragedy, but it’s hard to overstate the impact of losing a baby in circumstances where unsafe maternity care contributed to the outcome – yet this continues to be the reality for too many families.

Earlier this year also saw the publication of the final Ockenden report which exposed serious failures in maternity care at the Shrewsbury and Telford NHS Trust. And back in May, Donna Ockenden was appointed as the Chair of yet another major investigation into a maternity service, this time at Nottingham University Hospitals NHS Trust.

The continued spotlight on maternity safety will be difficult for everyone effected, including  maternity professionals who are currently working under a huge amount of pressure, but this focus also offers an opportunity for learning and change.

Listening to Families

Last month, Baby Lifeline (a charity I’m proud to work with) held the 3rd  National Maternity Safety Conference in Birmingham. This event heard directly from three incredible families whose lives have been shattered following the avoidable loss of babies spanning each of the inquiries mentioned above. Although the stories heard were different, stark and common themes were highlighted. When the very worst outcome imaginable happened, instead of being treated with kindness and compassion – families described a sense of being met with defensiveness, closing of ranks and a lack of openness and candour.  

Derek Richford, the grandfather of baby Harry Richford who tragically died due to serious failures in care at East Kent, described the problem succinctly:

“Denial is the thief of learning”

Derek’s quote captured a sentiment that ran throughout the day and resonated with many speakers and delegates.

Whilst there has undoubtedly been a considerable focus on maternity safety in recently years, the biggest mistake we could make now would be to believe the problems highlighted in major inquiry reports are ‘one offs’. Instead, we have to recognise that many of the themes and issues described are system wide, and that lasting change will only happen if there is a united and consistent approach, with policy leaders, national organisations, families, politicians and maternity professionals all working together.

Pressure on the front line

In July this year, the Care Quality Commission published a blog summarising a recent project that heard from a range of front line maternity professionals across England about the challenges they face and their views on what needs to change.

The CQC heard how staff are currently working in ‘exceptionally demanding circumstances’ and that ‘staffing pressures, a drive to meet targets, and insufficient funding’ are all impacting on the safety of maternity services right now.

Speaking as a maternity campaigner involved in the Morecambe Bay Investigation in 2015, the sense of history repeating is hugely disappointing. There has undoubtedly been significant progress in some key areas since then, but the unavoidable conclusion now, must be that progress hasn’t been enough – and that step change is needed.

The Health and Social Care Committee’s 2021 report ‘The Safety of Maternity Services in England’ highlighted a need for 496 more obstetricians and 1,932 midwives and called for an immediate increase in funding for maternity services of ‘between £200m - £350m’. So far, the government have committed to increases in funding that fall well short of this.

With the current system and workforce pressures in maternity services, my real fear is that however ‘right’ we get the individual components of the national maternity improvement strategy moving forward – implementation of ‘essential actions’, recommendations and achieving lasting and sustainable change, is going to be very difficult to achieve.

Along with many other families, at 7pm this Saturday, I’ll be lighting a candle to remember a much-loved baby who is no longer with us.  We can’t turn back the clock and change the past, but we should be doing everything possible to learn from it. That can only happen if everyone works together and if we properly support front line professionals by creating the conditions that enable safe care and improvement to happen.

n.b. you can access the recordings from the Baby Lifeline Conference mentioned above here

Targets and Safety - by Jeremy Hunt

Last week, amongst praising much of what she said, I found myself criticising the new Health Secretary for introducing a new two week waiting target designed to improve access to GPs. No one can argue with the aim behind it – everyone wants to make accessing GPs as easy and quick as possible. But there are two major issues with this approach. Firstly, simply creating a new target won’t make it a reality as I found many times. One example: I very much wanted to go back to everyone having their own GP so negotiated a change in the GP contract for everyone to have a 'named accountable' doctor. The result? People got a letter in the post telling them they had one - and absolutely nothing else changed.

In this case the reason the new target won't work is that the fundamental issue is GP capacity: we need more GPs to speed up access and having a 73rd target won't magic them up. It also misses the real point about why people feel disappointed with their GP experience: we are turning surgeries into call centres where you are as unlikely to see the same GP twice as the same Uber driver, something that is as demoralising for doctors as it is for patients. Restoring continuity of care saves lives as we know from last year's Norway study - but it also makes people less stressed when they want to see a GP. Many are happy to wait a couple of days longer if it means they can see a GP they know.

The second issue I have with the new target is a much broader cultural one, and something I devote a whole chapter to in my new book Zero. The NHS has more targets than any other healthcare system in the world. The result is a system that depersonalises patients, deprofessionalises frontline staff and fails on the most basic level to prioritise in the way targets are meant to do. 

 As I argue in Zero this is for a number of reasons:

• Having one or two targets can make sense as they give focus for an organisation. But with GPs already operating under 72 targets via QOF, and the wider NHS striving to meet 8 different cancer targets, 5 mental health waiting times targets and targets or ambitions for A&E, elective surgery, MRSA, C-Diff, vaccines, maternal/baby deaths, HIV and many, many other issues simply adding still more just means staff can’t deliver on them all. In other words, the effectiveness of targets are in inverse proportion to their quantity and we already have too many!

• As we saw in the Mid Staffs scandal, when hospitals focus too heavily on targets and not enough on patients, then safety suffers. Targets effectively turn patients into numbers rather than people and in the worst-case examples targets become more important than basic good, safe care.

• The culture created by a ‘hit these targets at all costs’ approach makes this issue even worse. Poor managers who become obsessed with hitting their numbers lose sight of the fact that not al aspects of care can be quantified. This leads to a disconnect between management priorities and clinical best practice. And safety again suffers.

So if these are some of the problems with targets what are the solutions? I think we should learn from the system of regulatory oversight we havein the education system. There we charge Ofsted with driving up standards but not with hitting certain numbers of A grades. Schools are given budgets, a national curriculum and then empowered to do the best they can without the micromanagement you see in health from DHSC, NHSE, CCGs or a plethora of other bodes. We should set the new ICSs free by scrapping national targets and devolving them down to the 42 new systems, giving them autonomy to innovate as to the best way to deliver them. The CQC should work like Ofsted, not as a regulator but as a way of letting patients and staff know how well their organisation is doing and how it can improve. The good news is that the new Health Act puts in place structures that would make this a relatively simple change - but will Therese Coffey and NHS England be bold enough to scrap national targets and prescriptive commissioning guidance?

With the country gradually moving back to normal following Her Majesty’s funeral people are beginning to think again about problems in the NHS. Rightly the new Health Secretary will be focusing on the elective backlog (6.8m and counting) and the current crisis in emergency care which is seeing stroke patients wait for one hour for an ambulance. Both are massive risks to patient safety - but both also risk overwhelming a new Secretary of State with firefighting rather than the long term strategic planning the NHS desperately needs. So here are six patient safety priorities that will help reduce elective and emergency pressures and save money that I’d like to see in the Health Secretary’s statement tomorrow. What’s not to like?

Firstly, we must see a credible and comprehensive NHS and social care workforce plan. The government rejected an amendment to the Health and Care Act put forward by me and nearly every other NHS body including all the Royal Colleges. But we have a new PM, a new Health Secretary and, crucially, a new Chancellor. Theresa May becoming Prime Minister gave me the opening to secure a 25% increase in doctor, nurse and midwife training places with six new medical schools - now Therese Coffey has the chance to do the same. The biggest single source of waste in the NHS is £6bn we spend on locums and on agency nurses - all because we have fewer doctors per head than France and Germany despite spending a similar proportion of our GDP on health. Training more doctors and nurses and boosting retention by sorting out the pensions issue (as Liz Truss promised in her leadership campaign) would make a big difference to the capacity of the NHS and be a massive boost to morale. It would also save lives because short-staffing increases risks to patients (as I explain in my new book Zero).

Secondly a reform to primary care would make a massive difference to the morale of GPs. Last year’s BJGP Norway study showed you are 30% less likely to go to hospital and 25% less likely to die if you see the same doctor over a long period of time. Family doctors are crying out for more continuity of care, and although it does need more doctors to deliver it, select committee evidence showed it can be done even under current constraints. So bring back individual GP lists, notoriously scrapped by the Blair government in 2004. And whilst we’re at it, scrap QOF and all the micromanaging that goes with it, replacing it with an additional income stream for primary care if they can reduce emergency admissions. Both that and individual lists would not just reduce pressure on hospitals, they would re-professionalise General Practice and stop people quitting the profession.

Thirdly the Health Secretary should provide a timetable by which the vital recommendations from the Ockenden Review will be implemented, in particular the 2000 more midwives and 500 more obstetricians. Thousands of babies lives are at stake and we MUST be able to promise new mums their care will be safe. The government has accepted the recommendations so putting a timetable on them shouldn’t be too hard. But hanging around any longer won’t pass muster: we have the Kirkup East Kent review coming out soon and families will be very angry if nothing has started to happen by then.

I believe the new health secretary is a reformer, so the next two proposals should warm the cockles of her heart. My fourth one is to be really bold and scrap national NHS targets to free up staff to focus on patients not paperwork. With more centrally imposed targets than any other healthcare system (see the targets chapter in Zero) the NHS pressurises staff to look over their shoulders to their line manager rather than look at the patient standing in front of them. We don’t have targets for GCSE or A-Level results, instead we rely on Ofsted ratings to know if a school is performing well or not. The CQC is capable of providing the same service for our health service and stop us turning patients into numbers as too often happens. We have the new ICBs - if we don’t want them to be rehashed SHAs or PCTs let’s free them up to get on with the job.

Fifthly - and another bold reform - the new Health Secretary she should join forces with the Treasury and radically reform our litigation and compensation systems so that we focus on learning what went wrong instead of seeking to blame those who made a mistake. The adversarial nature of the way we do things at the moment means staff are not given the opportunity to learn why something happened and therefore be in a position to ensure they and others don’t repeat their mistakes. Instead, they have to defend themselves from accusations of clinical negligence from patients and their families who are forced down that route simply to get the support their deserve. A no fault system would be fairer to staff and patients and ultimately bring down costs by reducing errors as we detail in a recent Select Committee report.

Finally and slightly more technically to some (but very important none the less) she should revamp the Learning from Deaths programme so that all Trusts are publishing data on the avoidable deaths that happen in their services as they are legally required to. Only by knowing exactly how many of these are taking place each year can we actually know if hospitals are getting safer or not - but around half of hospitals do not comply with their legal obligation to do so. Without data on preventable death how can we prevent it?