Delivering The Truth by Lorin Lakasing; Right Book Press, £12
A RELATIVE is a lawyer in a large law firm. Her specialist interest is in clinical negligence, but in defence. She handles a whole variety of cases from different specialities. The saddest, most difficult and most expensive are those relating to obstetric claims and birth-injured babies. During her work she goes into considerable details of the case, reviewing case notes and liaising with front-line staff and expert witnesses, both obstetric and midwifery. Due to her insights, such are her concerns about the state of maternity services in the UK that, several years ago when her sister was due to have her second baby, she seriously considered becoming her birthing partner since she was aware of all the warning signs for a poor birth outcome.
Which leads me to the recently published book by Dr Lorin Lakasing, Delivering the Truth – Why NHS maternity is broken, and how we can fix it together.
I wrote an article for TCW in 2022 reviewing the report into East Kent maternity services by Dr Bill Kirkup, and I stated that in any hospital Trust the maternity service was ‘the canary in the coal mine’, an expression which, incidentally, the author also uses in her introduction: that maternity is a microcosm of the whole hospital. If significant issues are not being identified there, this likely reflects the culture of the Trust as a whole. Pregnancy is not an illness, but a natural process. While excess deaths among the frail elderly may pass largely unnoticed in an acute medical ward, if this is happening in maternity, alarm bells should be ringing at the top levels of the hospital.
The author, Dr Lorin Lakasing, is an obstetrician with 30 years’ experience. She has an academic background, being awarded a Doctorate of Medicine in 2000. She has a wide-ranging CV, and first-hand knowledge of the problems associated with the maternity service. She also has extensive experience as an expert witness in maternity litigation. The aims of her book and her passion for the subject are clear from the title, and from the very start she is brutally honest about the state of maternity services in England.
Her writing is lucid and easy to read and she avoids too much medical terminology, although she includes a useful glossary of medical terms. The book is also well referenced.
The text is sprinkled with anecdotes. One that comes to mind is the postnatal ward staffed only by two agency midwives who had never worked there before, neither of whom knew the code to the emergency drug cupboard. Ouch!
In the first chapter she lists the many reports and reviews into maternity services over the last 30 years or so. To quote Mark Antony as he exposes the body of Julius Caesar, ‘If you have tears, prepare to shed them now.’ She lists a litany of failures, missed opportunities, disasters, lessons not learned, inadequate staffing levels, poor staff morale, bullying culture, blame culture, lack of leadership and many other issues. The real tragedy is that despite many recommendations from a variety of bodies, nothing has changed. Indeed, they may have got worse. The aim of her book is not so much what went wrong, but why it went wrong, and continues to do so.
She continues with a deep dive into the background of maternity services going back to the mid-1800s when data began to be collected on baby and maternal mortality. In those years the figures were dire, but improvements in housing, nutrition and hygiene played a substantial role in better outcomes, although figures still place the UK well below other developed countries.
Her section on the historical development of midwifery and obstetrics was interesting with the establishment of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists in 1947. She breaks down the current maternity staff to those with direct patient contact (front-line service providers) including midwives, obstetricians and a range of other staff groups; and secondly managers who are indirect service providers.
The most concerning chapter relates to the recruitment, training and retention of midwives. Thirty to 40 years ago they were highly trained and experienced, not taking sole supervision of a pregnant women until seven and a half years of training under supervision had been completed. But to address the severe shortfall of midwives, in 1986 the training was changed to a degree course taking only three years. The consequence of this is ‘a generation of midwives whose clinical comfort zone is limited and whose mindset is so ideologically committed to normal pregnancy and birth that they are less able to recognise and deal with clinical deviations from the norm, until the clinical picture becomes overtly pathological’. If this conclusion is correct, and it may be open to challenge, it is devastating. However, to balance this she details the huge pressures that midwives are required to work under, especially including the need to plug gaps in rotas with agency staff who have no operational knowledge of the department. She emphasises that there is no greater priority than addressing staffing levels.
A further section deals with the training of junior doctors in obstetrics and gynaecology, but this applies to all junior doctors (now inexplicably called resident doctors – they are not resident as my generation were for the early parts of our career). I skim-read this part since it was the background to my 42 years at the coal-face, but if a reader wishes to understand the frustrations facing resident doctors today, it is worth a read. I agree with the author that they are in a far worse position than my generation despite the pressures we had to face.
She moves on to the crucial role of managers in the service, and outlines some of the huge complex changes in the commissioning of all health care – a brave attempt (I once tried and gave up due to the complexity), and the various regulatory bodies. Taking pot-shots at NHS managers is a popular blood sport these days, and cries of ‘sack all the managers and bring back matron and the almoner’ are still heard. If only it were that simple.
She makes some excellent points, particularly the obsessive political pursuit of ‘targets’ which I always hated for exactly the reasons she states. There is no evidence that these improve clinical outcomes, but generate legions of administrators with clip boards, and data which at best is ‘creative’. But I think she is rather hard on managers. I worked with many as a clinical director and Trust cancer lead (without sacrificing clinical work), and in general they were hardworking and did their best to grasp the clinical issues and to resolve problems, despite being very constrained by budgetary targets. The dreaded yearly ‘cost improvement programme’ (how to do the same work on less money) was always a trial. In my experience they were not malign. Perhaps the author has had a different experience.
However, one important target she focuses on is the fixation on national caesarean section rates which came to dominate practice for two decades. This target was well supported by regulatory bodies and the midwives themselves, and decisions by clinicians to perform sections were challenged by managers. Sadly, it resulted in some of the worst practices on labour wards and a range of severe disabilities in babies. The ideological culture which grew around ‘natural birth’ as opposed to timely intervention proved a disaster. This section of the book makes disturbing reading.
She discusses clinical governance in some detail, and why it largely fails to bring improvements to the service. I identified with this section since I have been involved in external governance reviews (non-obstetric) in Trusts where things had gone badly wrong. Predictably the problems are largely the same: poorly motivated, often insufficient staff, warning signs ignored, a bullying culture, poor inter-staff relations, out-of-touch management etc. Much of this is endemic in the NHS.
She devotes significant sections to obstetric litigation and it is clear that she does not like lawyers (which doctor does?) and barristers in particular. ‘Most lawyers I encounter are pedantic, fretful and anxious characters,’ she says. She wishes to ‘challenge the broken medico-legal system’ and expresses concerns that around 50 per cent of cases are settled with no regard to the effect on the reputations or feelings of the front-line staff, although pointing out that most cases are settled without a trial
Be that as it may, it seems to me that she has missed a very significant issue. Defence costs are not paid directly by the Trust, but by NHS Resolution (NHSR), a central body. NHSR has contracted with several large legal firms to carry out this work. However, despite inflation, NHSR has not increased remuneration to the firms since 2010. Hurrah, you may say. Why should we pay taxpayers’ money to fat-cat lawyers? However, this means that what NHSR are paying the lawyers no longer covers their costs and may actually result in financial loss to the firm.
Law firms are businesses, not charities, and the inevitable result of this will be that the large, experienced firms which are generally good at their job will eventually pull out, leaving the defence work to the smaller, cheaper, less experienced firms where the work will, almost certainly, be passed on to the minimally experienced and cheaper para-legals. They will be even less interested in protecting the reputations of the maternity staff and will go for quick, cheap settlements. So everyone loses.
All the initial background in the book was leading up to chapter nine, ‘Pressing the Reset Button’, where I hoped she would provide clear workable solutions to the vast array of problems, ‘how we can fix it together’. Unfortunately, I found this chapter the most difficult to read. It is crammed full of suggestions and ideas for change, jumping all over the place. I have read it several times, and I do not necessarily disagree with any of it, but in my view, it lacks necessary focus, and there are so many messages that it is difficult to identify the key priorities. I wonder if the introductory chapters could have been reduced, and more space given to the solutions rather than cramming them into a final chapter. This is perhaps an editorial issue.
Nevertheless, some clear threads emerge from the book as a whole. First, it is essential that a serious effort is made to train, recruit and retain midwives. This needs a far more supportive regime, and perhaps increased remuneration and improved career progression. There needs to be far more psychological support and understanding for front-line staff when things have gone wrong – it is frequently the system that has failed the patient, not the midwife. During the external reviews which I was part of, we spent time with front-line staff, and it became clear that this was the first time that anyone had listened to their stories. Many were still traumatised by the events. Safety and risk management strategies should be re-evaluated. And perhaps crucially, there needs to be investment in real leadership rather than just management.
This book is polemical (nothing wrong with that), and very thorough; rather than the legions of more formal external reviews, her book is deeply personal, and she is clearly deeply passionate about improving maternity services, as we all should be. However, my final concern is that I am unclear as to whom it is directed. Will those who have the authority to make change read it, and take on board its message?
In his review into East Kent maternity services (October 2022), Dr Bill Kirkup states: ‘As indicated in Chapter 1, this chapter puts forward an approach that is different from the norm: in particular, we have not sought to identify multiple detailed recommendations. NHS Trusts already have many recommendations and action plans resulting from previous initiatives and investigations, and we have no desire to add to their burden with further detailed recommendations that would inevitably repeat those made previously, or conflict with them, or both. We take those previous recommendations and the resulting policy initiatives as a given.’
Or to put it more pithily, what is the point of saying the same thing again and again when it is still ignored?
I hope that Dr Lakasing’s book is not ignored: it is well worth a read.
