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Coming less than a week after the Ockenden Review, Valerie Amos’ independent investigation into maternity and neonatal services in England paints a damning picture of failure and racism.
In the second report into maternity services in less than a week, maternity services in England has been found lacking. The final report of Valerie Amos, Baroness Amos, of her independent investigation into maternity and neonatal services in England has found that they are “no longer fit to consistently deliver high-quality, compassionate care to every woman and family” and require “urgent reform to put safety at its centre, embed a focus on listening to women, and ensure anti-racist practice at every level”.
The national investigation was launched in July last year by then health and social care secretary Wes Streeting to drive urgent improvements to care and safety after a number of high-profile cases and rising medical negligence claims. An interim report, released in March, set the tone with stories of distress, pain and racism.
The findings of the report echo those of the independent review into maternity failings at Nottingham University Hospitals NHS Trust (NUH), led by senior midwife Donna Ockenden, and published last week.
“Women, babies and families deserve maternity and neonatal care that is safe, compassionate and equitable wherever they live. Too often, this Investigation heard that people were not listened to, that harm was repeated, and that families were left without clear answers or accountability when things went wrong,” said Amos.
“This report sets out practical action to change that. It recommends stronger national leadership, clearer accountability, better listening, safer service design, improved investigations, stronger teamworking and leadership, and investment in the buildings and digital systems where families receive care and deliver it,” she continued.
Eight recommendations
The investigation has done its research. Since September last year, the investigation has listened directly to more than 450 families from across the country and received more than 10,500 responses to a public call for evidence. Over 9,000 staff contributed through surveys, Trust visits and one-to-one interviews. In addition, 38 national leaders were interviewed and evidence panels were convened with national stakeholder organisations to understand system-wide challenges and solutions.
The investigation analysed more than 9,500 pieces of evidence, including data and documentation, and undertook a review of previous recommendations to understand why previously proposed changes have not been implemented or sustained. Visits to 12 NHS trusts, selected to reflect geography, socio-economic variation, trust type, case mix and feedback from families, provided direct insight into frontline care, leadership, culture and operational pressures.
After that, Amos outlines several themes repeatedly heard from women, families and staff. First, that women are not being listened to, heard or believed; racism and discrimination are embedded throughout the maternity and neonatal system; service design and planning is slow to respond to safety and demand and is not equipped to meet the changing needs of women, babies and families; and the system is fragmented and care is inconsistent.
She sets out eight recommendations to redesign the maternity and neonatal system. These include the creation of a statutory national maternity and neonatal commissioner; systematically listening to the voices of women and families; improving how the system responds when something goes wrong; creating a modern service framework which sets out national standards to achieve high quality maternity and neonatal care consistently; tackling racism, discrimination and inequality; improving system governance and accountability structures and regulatory oversight; improving culture and teamworking, and strengthening leadership at all levels of the system and across professions; and delivering estates and digital systems that are fit for modern maternity and neonatal care.
“These recommendations must be implemented in full. They are designed to deliver lasting system change, strengthen accountability, and create a system that learns when harm occurs,” said Amos.
Immediate response
The response to the report has been immediate.
“Today must be the turning point, at which reports and recommendations become action,” said Alison Wright, president of the Royal College of Obstetricians and Gynaecologists.
Her response was echoed by health and social care committee chair, Layla Moran.
“After so many reports on failing maternity services, this must be the last. We must now turn the recommendations into reality, not allow them to gather dust like so many reports before,” she said.
The report has not fallen on deaf ears at the government either. As the ink was drying on the report, the government announced the creation of the UK’s first maternity and neonatal commissioner – Amos’ first recommendation.
The government said that new commissioner will provide independent leadership to “hold the system to account, drive change and rebuild trust”, co-chairing the national maternity and neonatal taskforce with health minister.
Driven by the taskforce, a comprehensive national action plan will be published in December, and the government is also investing a further £41 million to tackle urgent safety risks in maternity and neonatal facilities.
Further changes announced include the national rollout of the perinatal equity and anti-discrimination programme and a total of 1,000 temporary roles will be created to help newly qualified midwives join the NHS, backed by more than £10 million in government funding.
“For too long women, babies and families have been failed by a system that didn’t listen. Their stories are heart-breaking and demand action,” said secretary of state for health and social care, James Murray. Appointing the UK’s first maternity and neonatal commissioner will drive lasting change and make sure women and families are never ignored again, he added.
