The Independent Report into the Maternity and Neonatal services in East Kent was published on 19 October 2022 and raises fundamental concerns about the provision of maternity services. The report makes for difficult reading. The criticisms are wide ranging but there are 4 broad areas for action, which as the report makes clear, have national applicability. These are summarised below:
Key Area 1: Monitoring Safe Performance
The report found that, despite the volume of data that is collected nationally about maternity services, there is very limited value in much of the information obtained. The concern is that important information that could assist with the effective monitoring of outcomes is being lost among the noise of other data of “dubious significance”. Two requirements were identified to assist in the monitoring of safe performance. The first is the formulation of timely and meaningful measures. These need to be: straightforward; clearly related to outcomes; risk adjustable (taking into account the complexity of work in a maternity unit and its impact), and available (in the sense that insight can be obtained from the information already being collated and therefore without introducing an additional burden on Trusts). The second requirement, flowing directly from this, is that the measures must then be analysed and presented in an effective way to highlight the trends so that Trusts can identify warning signs and take any necessary action.
The report recognises that identifying measures that can meet these requirements in a maternity setting can be difficult, particularly compared to other specialities, but concluded that it will be possible to generate outcome measures of national applicability to maternity care that are available for the use of clinicians, units, Trusts, regulators and the public.
The immediate recommendation flowing from these findings was for the prompt establishment of a Task Force to drive the introduction of valid maternity and neonatal outcome measures for mandatory national use. The goal is to differentiate signals from noise and to enable significant trends and outliers to stand out.
Key Area 2: Standard of Clinical Behaviour – Technical care is not enough
The report highlighted the importance of compassion and kindness alongside technical skills as well as the damaging effect that negative behaviours can have on both patients and staff, particularly junior staff. It recognised that compassionate care is integral to clinical practice for all healthcare staff, and must be embedded as a part of continuous professional development across all levels. This must include the ability effectively to sanction poor behaviour so that it can be addressed immediately and effectively before it becomes intractable. In terms of frontline clinical care, the importance of listening to patients must be re-established as a key part of clinical practice, and this must also form part of ongoing professional development so that it becomes embedded.
The formal recommendations flowing from this finding were that those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning, and that relevant bodies be commissioned to report on how the ongoing oversight of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance.
Key Area 3: Flawed Team-working – pulling in different directions
The report makes a further and related point about the impact on maternity services when there are factions or divisions between clinicians or teams, compromising the service’s ability to work towards a common goal of patient safety. There is a need for integrated maternity and neonatal services based on an explicit understanding of, and respect for, the contribution of different care pathways and the skills of different members of the team. Objectives in national guidance must be the same for obstetricians and midwives, all focused on patient safety.
There should be increased awareness of the importance of the language used in maternity services, particularly in the description of a “normal birth”. This language can promote unrealistic expectations of delivery on both mothers and staff which can have wider unintended consequences.
The report recommends that bodies including the Royal Colleges should focus on improving teamwork – promoting an increase in the understanding of the roles and responsibilities of others,establishing common purpose and, especially, common training.
Similarly, under-training and poor morale were noted as key features arising from recruitment difficulties alongside a lack of collaborative working. Relevant bodies, including the Royal Colleges and hospitals, are tasked with reviewing patterns of working and training for junior doctors to improve support, teamwork and development.
Key Area 4: Organisational behaviour – looking good while doing badly
It is important for NHS organisations to demonstrate true accountability, to focus on learning from concerns that are expressed rather than focusing on managing an organisation’s reputation.
Incentives for and regulation of NHS organisations need to be changed to elevate openness, honesty, disclosure and learning in place of denial and concealment. This should include incentives for an organisation to ask for support. The risk of loss of public confidence is significant and healthcare organisations must establish a lasting duty of care to patients who experience harm. Indeed, the report advocates a government bill to place a duty on public bodies not to deny, deflect or conceal information. How this differs from, or would fit with, the existing duty of candour is unclear.
There should be a review of the current NHS England model that seems to emphasise changes in leadership roles in the face of problems within NHS organisations. Problems should not be seen as a sign of individual or collective failure, but as an opportunity to learn and improve.
The Independent Report into the Maternity and Neonatal services in East Kent presents specific areas for action – to support NHS organisations in identifying where improvements can be made, particularly where harm has been caused, and to commence a restorative process by working collaboratively with all healthcare staff and patients.
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