The independent investigation into East Kent Maternity Services led by Dr Bill Kirkup has highlighted serious failings and missed opportunities to improve, with these failings having a devastating impact on families whose babies were seriously harmed or died.
The investigation concluded that most of these deaths were avoidable with better care. The report sets out a series of actions: better identification of poorly performing units, giving care with compassion and kindness, teamworking with a common purpose, and responding to challenge with honesty.
While a commitment to act on these recommendations is necessary, it is not on its own sufficient. The Sands & Tommy’s Joint Policy Unit is urging the NHS to take a much more comprehensive, joined up approach to improving the safety of maternity services.
We cannot look at these reports and conclude that continuing with our current approach is adequate. The NHS must commit to properly evaluating the systems and processes it has in place for improving the safety of services, and the government must provide the resources required to support improvements.
In his 2015 report into failings at Morecombe Bay maternity services, Dr Kirkup highlighted that those working in the NHS owe the public a duty to be open and honest when things go wrong. This openness is a vital part of learning and improving services. It’s completely unacceptable that this is still not happening, and that bereaved families continue to have to fight for so long to highlight failings in maternity and neonatal services before action is taken.
These are not isolated issues
East Kent was the second major investigation into serious failings in maternity services in England published this year alone, following shortly after the Ockenden review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. A review of maternity services at Nottingham University Hospitals NHS Trust is also ongoing.
The latest Care Quality Commission report underlines that the issues raised in these investigations are sadly not isolated. The same themes continue to emerge which means we must act differently if we are going to change things for the better.
While we know there are lots of Trusts and healthcare professionals which offer good care, unfortunately, CQC ratings as of 31 July 2022 show that the overall quality of UK maternity services is getting worse. 6% of NHS services (9 out of 139) are now rated as inadequate and 32% (45 services) require improvement, meaning 2 out of 5 maternity units - giving care to tens of thousands of families a year - are not good enough.
The CQC report highlights the same issues emerging again and again: quality of staff training, poor working relationships between obstetric and midwifery teams, and a lack of robust risk assessment.
As reports published this year by Birthrights, Five x More and Muslim Women’s Network UK also show, for women from minority ethnic groups, the situation is often even worse. Our system has deeply embedded inequalities in care access and outcomes. Black and Asian women and women of mixed ethnicity remain far more likely to die, experience miscarriage, stillbirth, or birthing injury and to report worse experiences of pregnancy and childbirth than White women.
We need to properly re-evaluate our approach to improving services nationally if we are going to improve outcomes, tackle unacceptable inequalities and make the UK the safest place in the world to have a baby. The status quo is not good enough.
It’s important to emphasise that good care is available, but it depends on who you are and where you live - something which goes against the principles on which our NHS was built.
There has been a long-term failure to invest in the maternity workforce
It is clear that those in power need to provide adequate resources to support improvements in maternity care. Reports consistently highlight how an adequately sized, trained, and supported workforce is fundamental to improving maternity and neonatal care but unfortunately workforce numbers are going in the wrong direction.
We’re currently experiencing a severe shortage of midwives, both nationally and globally. The number of full-time equivalent midwives employed by NHS England fell by 633 between April 2021 and April 2022, the largest annual decrease since records began in 2009. The total number of midwives dropped further again in May 2022.
A recent report of the Baby Loss and Maternity All Party Parliamentary Groups paints a picture of maternity services that are understaffed and overstretched.
In 2021 the Health and Social Care committee recommended the budget for maternity services be increased by £200–350m per annum. While some recent welcome commitments have been made, we are still far short of the amount needed to fund a safe maternity workforce.
Sands and Tommy’s will be holding the NHS and Government to account on its commitments to learn from these reports.
Through our Joint Policy Unit, Tommy’s and Sands work together with the aim of saving babies’ lives and reducing inequalities in pregnancy and baby loss by ensuring maternity policy is informed by robust evidence and decision makers have access to up-to-date information.