IN JUNE last year, Health Secretary Wes Streeting announced a rapid inquiry into NHS maternity services. In February, Baroness Amos published her Interim Report as Chair of the independent National Maternity and Neonatal Investigation.
After engagement with more than 400 families and thousands of evidence submissions, the report identifies six major factors contributing to problems in maternity and neonatal care:
· Poor responses and lack of accountability
· Culture and leadership
· Workforce pressures
· Racism and discrimination
· Capacity pressures
· Poor quality of estates
Evidence gathering is continuing and final recommendations are expected later this year.
Poor responses, lack of accountability, culture and leadership
The interim report, based largely on accounts given by families, reports feelings of ‘cover-up’ when harm occurred. Falsification of data and ‘cover-ups’ in relation to poor outcomes are, indeed, common practice but this behaviour is driven largely by the numerous financial incentive schemes that operate within maternity care. These schemes reward units whose data meets certain safety targets, and this secures future funding. Removing these perverse incentives, and the large number of staff who are employed to implement them, is key to moving in the right direction. Otherwise, we shall continue to fan the flames of obstetric litigation which is inevitably where patients go to get what they perceive as ‘real’ answers.
Workforce pressures
The report linked shortage of staff with reduced quality of care and delays in assessment and treatment. I take issue with the oft-quoted trope ‘shortage of staff’. Workforce data confirm we have more midwives and obstetricians than ever before and, with the birth rate falling, staff to patient ratios look favourable by international comparisons. What Baroness Amos is describing is shortage of front-line staff, a crucial distinction never made by investigators. Many clinically trained staff are working in back-office roles collecting data for maternity financial incentive schemes and therefore are ‘unavailable’ to participate in patient care.
Racism and discrimination
While Baroness Amos mentions medical complexity (advanced maternal age, pre-existing disease, high BMI, assisted conception, comorbidities), vital non-medical co-contributors (socio-economic factors, educational status, limited attendance and engagement with the service, poor compliance with medical advice, ideological fixation on natural birth, inability or unwillingness to comprehend risk) remain unacknowledged. These factors are more prevalent in certain demographics including refugees, asylum seekers, women who have been trafficked, the homeless and the traveller community too, so it is not just a black and ethnic minority issue. The latest MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) maternal death data show that more than 90 per cent of ethnic minority women had at least one other contributory factor. Throughout history, maternity outcomes have been inextricably linked to socio-economic and lifestyle factors, something that NHS maternity services cannot address or be held wholly responsible for in the relatively short time in which a mother falls under their care. With some 34 per cent of nursing and midwifery staff coming from black and ethnic minority backgrounds, it will be a challenge to explain the findings on racial grounds alone and many staff are deeply hurt by accusations of racism.
Refreshingly, the report also mentions the anger directed at front-line staff which occurs on a daily basis. Lack of compassion and discrimination is a two-way process and failing to value staff who work in a stressful environment feeds into low staff morale, stress, burnout, absenteeism, disengagement, defensive care and ultimately staff attrition. We need to dial down the angry rhetoric, stop stoking public objection and work purposefully towards rebuilding a service that addresses the needs of all pregnant women irrespective of background.
Capacity and estates
After 30 years of mergers, closures and centralising or abolishing specialist care, why are capacity issues surprising? As for crumbling buildings, the commitment governments of all persuasions have demonstrated in relation to large scale infrastructure projects says it all.
Improving maternity care for all involved – my views
We need front-line clinicians involved in designing and implementing solutions. Not former clinicians long lost to management, but practising professionals who understand existing realities.
We must reform the incentive structure completely. At present, the carrot-and-stick approach means managers chase funding while staff dodge blame. Neither focuses on patient outcomes. We need to reward clinical excellence, staff retention, and team stability rather than tick-box compliance.
We should recognise that different areas need different solutions. A unit serving a stable, affluent English-speaking population has different needs from one serving an impoverished transient, multilingual community with complex health needs. Stop pretending universal protocols solve local problems.
We need to optimise data collection and use it better. NHS maternity units already track comprehensive metrics through various software systems. Instead of fixating on a few specific targets that can be gamed, we should use this wealth of data to understand performance holistically.
We must address why clinical work is undervalued. When moving into management or investigation work pays significantly more than delivering babies, we’re telling our best clinicians that their expertise is worth less than bureaucracy. We need to value and reward the work of providing care.
We should create psychological safety for staff. The constant fear of blame, investigation, and media scrutiny paralyses clinical decision-making. Staff need to know they can raise concerns without destroying their careers, make clinical judgements without defensive documentation, and learn from mistakes without punishment.
The question we must answer
At its heart, this is about deciding what the NHS maternity service is for. Is it a bureaucratic institution focused on compliance, targets and ratings? Or is it a service dedicated to providing safe, compassionate care to mothers and babies?
We’re trying to be both, and failing at both.
This isn’t about eliminating management or abandoning all oversight – of course we need some administrative structure and accountability. Neither is it about excluding patients from the debate. But we’ve lost the balance. The pendulum has swung so far towards acceding to patients’ demands and implementing bureaucratic processes that clinical care has become secondary. We need to consciously shift that balance back towards the people who deliver babies and care for mothers.
Managers aren’t deliberately obstructing care. Staff aren’t being rude, uncaring or lazy. Patients aren’t being unreasonable. Investigators need to grasp the sensitivities on all sides to come up with balanced and workable solutions. Without this fundamental change in approach, my fear is that this current inquiry will likely produce similar recommendations to its predecessors: more transparency, more patient involvement, more oversight, more protocols, more training, more targets. The cycle will continue. I hope I’m proved wrong.
