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Maternal Safety Strategy

Volume 787: debated on Tuesday 28 November 2017


My Lords, with the permission of the House, I shall repeat a Statement made by my right honourable friend the Secretary of State for Health in the other place on the maternity strategy. The Statement is as follows:

“Giving birth in England is the most common reason for admission to hospital. Thanks to the dedication and skill of NHS maternity teams, the vast majority of the roughly 700,000 babies born each year are delivered safely with high levels of satisfaction by parents. However, there is still too much avoidable harm and death. Every child lost is a heart-rending tragedy for families that will stay with them for the rest of their lives. It is also deeply traumatic for NHS staff involved. Stillbirth rates are falling, but still lag behind many developed countries in Europe, and when it comes to injury, brain damage sustained at birth can often last a lifetime, with about two multi-million pound claims settled against the NHS every single week.

The Royal College of Obstetricians and Gynaecologists said this year that 76% of the 1,000 cases of birth-related deaths or severe brain injuries that occurred in 2015 might have had a different outcome with different care. So in 2015 I announced a plan to halve the rate of maternal deaths, neonatal deaths, brain injuries and stillbirths. Last October, I set out a detailed strategy to support this ambition. Since then local maternity systems have formed across England to work with users of NHS services to make maternity services safer and more personal. More than 80% of trusts now have a named board-level maternity champion, and 136 NHS trusts have now received a share of an £8.1 million training fund. We are six months into a year-long training programme and, as of June, more than 12,000 additional staff have been trained. The maternal and neonatal health safety collaborative was launched on 28 February; 44 wave 1 trusts have attended intensive training on quality improvement science and are working on implementing local quality improvement projects with regular visits from a dedicated quality improvement manager; and 25 trusts were successful with their bids for a share of the £250,000 maternity safety innovation fund and have been progressing with their projects to drive improvements in safety.

However, the Government’s ambition is for the health service to be the safest, highest-quality care available anywhere in the world, so there is much more work that needs to be done. Today I am therefore announcing a series of additional measures. First, we are still not good enough at sharing best practice. When you fly to New York, your friends do not tell you to make sure you get a good pilot. But if you get cancer, that is exactly what they ask about your doctor. We need to standardise best practice so that every NHS patient can be confident they are getting the highest standards of care. So when it comes to maternity safety, we are going to try a completely different approach.

From next year, every case of a stillbirth, neonatal death, suspected brain injury or maternal death that is notified to the Royal College of Obstetricians and Gynaecologists Each Baby Counts programme—about 1,000 incidents annually—will be investigated not by the trust at which the incident happened, but independently, with a thorough, learning-focused investigation conducted by the Healthcare Safety Investigation Branch, or HSIB. The new body started this year, drawing on the approach to investigations in the airline industry, and has successfully reduced fatalities with thorough, independent investigations whose lessons are rapidly disseminated around the whole system. The new independent maternity safety investigations will involve families from the outset, and will have an explicit remit not just to get to the bottom of what happened in an individual instance but to spread knowledge around the system so that mistakes are not repeated. The first investigations will happen in April next year, and will be rolled out nationally throughout the year, meaning we will have complied with recommendation 23 of the Kirkup report into Morecambe Bay.

Secondly, following concerns that some neonatal deaths are being wrongly classified as stillbirths, which means a coroner’s inquest cannot take place, I will be working with the Ministry of Justice to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law, giving due consideration to the impact on the devolved Administration in Wales. I would like to thank the honourable Member for East Worthing and Shoreham for his campaigning on this issue.

Next, we will do more to improve the training of maternity staff in best practice. Today we are launching the Atain e-learning programme for healthcare professionals involved in the care of newborns to improve care for babies, mothers and families. The Atain programme works to reduce avoidable causes of harm that can lead to infants born at term being admitted to a neonatal unit. We will also increase training for consultants on the care of pregnant women with significant health conditions such as cardiovascular disease.

We also know that smoking during pregnancy is closely correlated with neonatal harm. Our tobacco control plan commits the Government to reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less by 2022, so today we will provide new funding to train health practitioners, such as maternity support workers, to deliver evidence-based smoking cessation according to appropriate national standards.

The 1,000 new investigations into Each Baby Counts cases will help us transform what can be a blame culture into what needs to be a learning culture. But one of the current barriers to learning is litigation. So earlier this year I consulted on the rapid resolution and redress scheme, which would offer families with brain-damaged children better access to support and compensation as an alternative to the court system. My intention is that in incidents of possibly avoidable serious brain injury at birth, successfully establishing the new independent HSIB investigations will be an important step on the road to introducing a full rapid resolution and redress scheme in order to reduce delays in delivering support and compensation for families. Today, I am publishing a summary of responses to our consultation, which reflect strong support for the key aims of the scheme: to improve safety, patient experience and cost effectiveness. Going forward, I will look to launch the scheme, ideally from 2019.

Finally, a word about the costs involved. NHS Resolution spent almost £500 million settling obstetric claims in 2016-17. For every pound the NHS spends on delivering a baby, another 60p is spent by another part of the NHS on settling claims related to previous births. Trusts that improve their maternity safety are also saving the NHS money, allowing more funding to be made available for front-line care. In order to create a strong financial incentive to improve maternity safety, we will increase by 10% the CNST maternity premium paid by every trust, but refund that increase, possibly with an even greater discount, if they can demonstrate compliance with 10 criteria identified as best practice on maternity safety.

Taken together, these measures give me confidence that we can bring forward the date by which we achieve a halving of neonatal deaths, maternal deaths, injuries and stillbirths from 2030 to 2025, which I am today setting as the new target date for our ‘halve-it’ ambition. Our commitment to reduce the rate by 20% by 2020 remains and, following powerful representations made by voluntary sector organisations, I will also include a reduction in the national rate of preterm births from 8% to 6% within this ambition. In particular, we need to build on the good evidence that women who have continuity of carer throughout their pregnancy are less likely to experience a preterm delivery, with safer outcomes for themselves and their babies.

Mr Speaker, I would not be standing here today making this Statement were it not for the campaigning of numerous parents who have been through the agony of losing a treasured child. Instead of moving on and trying to draw a line under their tragedy, they have chosen to relive it over and over again. I have often mentioned members of the public such as James Titcombe and Carl Hendrickson, to whom again I pay tribute. I also want to mention Members of this House who have bravely spoken out about their own experiences, including the honourable Members for Colchester, for Eddisbury, for Lewisham, Deptford, for Washington and Sunderland West, for Banbury and for North Ayrshire and Arran. The passionate hope of bereaved families outside this House as they stand shoulder to shoulder with those Members inside this House is that by drawing attention to what may have gone wrong in their own case, mistakes are not repeated and others are spared the terrible heartache that they and their families endured. We owe it to each and every one of them to make this new strategy work, and I commend this Statement to the House”.

My Lords, I thank the Minister for repeating this important and very serious Statement today. To lose a baby is a heartbreaking matter for parents and families, and something from which sometimes they never recover. Clearly, it should not be so hard for parents to find out what may have gone wrong and why they do not have the healthy baby that they were so eagerly anticipating. So it is quite right to have a much simpler and more transparent process to find out whether anything went wrong, what it was and whether it might have been avoided, and to apologise in a timely fashion if things went wrong.

I welcome the announcement that all notifiable cases of stillbirth and neonatal death in England will now receive an independent investigation by the Healthcare Safety Investigation Branch. The HSIB is a new organisation; are we going to see primary legislation in this Session establishing it? This development is definitely an important step that could bring certainty and closure to hundreds of families every year. We on these Benches also welcome the moves by the Secretary of State to allow coroners to investigate stillbirths. There is much else to welcome in this, including the tobacco control plan, which is a passion of my own.

Our National Health Service offers some of the best neonatal care in the world, and the progress set out today is a tribute to the extraordinary work of midwives and maternity staff across the country. However, it is shocking and heartbreaking that in nearly 80% of the cases referred to by the Minister, improvements in care might have made a difference to the outcome for the baby when things have gone wrong. There is no doubt that staffing shortages mean that midwives are under enormous pressure, which can lead to situations that have a devastating impact on families. While of course we welcome the Secretary of State’s ambition to bring forward to 2025 the target date for halving the rate of stillbirths, neonatal deaths, maternal deaths and brain injuries that occur during or soon after birth, that can be delivered only if the NHS units providing those services are properly resourced and properly staffed.

I looked in vain for something in the Statement to tackle the low levels of maternity staff, an issue that is clearly linked to safety. Noble Lords will know that the heavy workload in maternity units was among the main issues identified by today’s report, with service capacity in maternity units affecting over one-fifth of the deaths reviewed. Earlier this year, research revealed that half of maternity units had closed their doors to mothers at some point in 2016, with staffing and capacity issues the most common reasons. The Royal College of Midwives tells us that we are around 3,500 midwives short of the number needed, and this summer, for the first time, there were more nurses and midwives leaving the register than joining it. This issue will be exacerbated by the fall-off of new recruits from Europe post Brexit.

A survey published by the National Childbirth Trust this year showed that 50% of women having babies experienced what NICE describes as a red-flag event. These are indicators of dangerously low staffing levels, such as a woman not receiving one-to-one care during established labour. What action will the Government take alongside some of these excellent proposals properly to address the staffing shortages as part of the strategy to improve safety? I hope that the Minister can reassure us today that the Government will provide the resources that NHS midwives and their colleagues need to deliver on these ambitions.

Finally, if and when parents resort to legal remedies, as they sometimes feel they have no choice but to do, do the Government intend to deal with the performance of the NHS Litigation Authority in terms of both timeliness—acknowledging fault in a timely manner—and learning lessons which are properly disseminated? As the Minister quite rightly said, we must have a learning culture, but one area which fails is the conduct of the NHS Litigation Authority.

I thank the Minister for the Statement, and we would be very interested in working with him to put legislation on the book that makes these proposals happen.

My Lords, I pay credit to our midwives, who do a wonderful job all across the country, and to those who campaigned to get the report and have spoken about it—I woke up this morning to a very moving Radio 4 piece on the “Today” programme.

I also welcome the Statement from the Secretary of State. Bereaved parents certainly want an answer, and this is an ideal way of helping them to reach some sort of closure. One of the critical points that the Each Baby Counts report makes about maternity care is the importance of continuity of care both for the expectant mother and for the team in the delivery suite. Staffing is an issue, with the workforce being short by 3,500 and a third of our midwives approaching retirement. Some midwives are adopting different patterns of work or choosing to leave the profession, but temporary midwives, be they bank or agency, are not the solution. They undermine the continuity that is so critical. A perfect storm is approaching about recruitment and retention.

Will the Government reconsider some form of financial support for midwives in training? Are any other incentives being considered? Will they guarantee an NHS midwife who is an EU national a job should we leave the EU? What measures are being considered to bolster the morale of NHS midwives, because at the moment, it is really quite low?

My Lords, I thank both noble Baronesses for their overall support for the important announcements made today, and join them in paying tribute to both the staff, who provide amazing care every day, which of course is the norm for most parents, and those campaigners who have campaigned so bravely to raise the profile of these issues with great success.

I shall deal with the issues raised in order. First, on legislation, it is important to point out that the Healthcare Safety Investigation Branch is up and running. Obviously, the intention is that the Bill will put it on a statutory basis, which will give it a degree of security and continuity. Draft legislation will be considered by a committee before turning it into a fully fledged Bill. Although I am not entirely sure of the timetable, I reassure the noble Baroness that we intend to have proper primary legislation following consideration of the draft Bill.

It is important to recognise that the number of staff has increased in the past few years, whether maternity nurses working in maternity services and neonatal nursing, midwives or doctors working in obstetrics and gynaecology. It is also important to recognise, first, that the number of births has risen, so there is a greater workload; and secondly, that on average births are becoming more complicated, as mothers become older, on average, and have more concomitant health problems—smoking and obesity are two of the greatest. I recognise the challenge.

I should point out that more than 6,800 midwives are in training, so there is an intention to continue growing the workforce. However, I recognise that more needs to be done to support them so that they can deliver the care. That is why the training packages announced today are so important.

In terms of learning lessons, the whole point of the rapid-resolution redress process by involving the HSIB is to provide resolution to parents so that they are satisfied while avoiding the sometimes adversarial situation that can emerge, when all that happens is that the problem is delayed for 10 years and creates great heartache for the families involved. We are trying to come up with a process that deals with it more quickly, without disadvantaging the families concerned, and means that it is easier to spread the lessons. That is why the independent HSIB investigations are so important.

Finally, I emphasise the point about the importance of continuity of care, which is referred to on page 16 of the maternity strategy. Here is a stark fact: women who receive continuity of midwife-led care are 16% less likely to lose their babies. That is about one in six, an extraordinary statistic. I understand that it does not necessarily require more staff to deliver that but it does require staff to be organised differently. That is one of the challenges that we have ahead.

My Lords, credit where credit is due: I commend the Government for this initiative. It was first suggested some years ago but that does not matter; it is here now. My question relates to the root cause analysis, which is rightly the way to analyse stillbirths that occur. It should take account of all the circumstances, including staffing levels, as mentioned. It is not just about the care itself. Can the Minister clarify how the system of doing root cause analysis of every stillbirth will work if, at the same time, a coroner is doing an investigation?

I thank the noble Lord for his support for today’s announcements. Obviously, independent investigations are just that. They will be operated by HSIB, which will be able to delve into the causes of the tragedy, however it might have happened, and provide an opinion on that. On the interaction with the coroner’s report, obviously we have focused mainly today on these new independent investigations and we are looking at extending coronial law to take in stillbirths that were previously not included. That is one of the issues that needs to be worked out in the coming months through interaction with the Ministry of Justice.

My Lords, I start by declaring my interests. I am a fellow of the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Nursing, and president of the National Childbirth Trust. Those positions are unremunerated but I am remunerated by NHS England for implementing the report of the review of maternity services.

There is absolutely no doubt that the Secretary of State has concentrated the minds of all of those working in and for the NHS on safety. It is the golden thread that has run throughout his time in office, especially now when he is concentrating on maternity services. We have never seen safer services, but we are being urged to go further with some new initiatives that have been declared today.

I welcome the Statement, particularly the part on investigations. Those of us tasked with implementing the report Better Births—the review of maternity services for England—have been concerned by the way many investigations have been conducted, causing further misery and trauma to the families concerned. We have full confidence that the Healthcare Safety Investigation Branch will ensure independence, and above all, will involve the families. After all, the families were there; they knew what took place. They have a legitimate role in investigations, but often their views and experiences are ignored. Even worse, the learning that has been gathered has not been passed down to the teams within the trust, nor indeed has it spread to other organisations in the wider world. It is absolutely essential that that happens so that we see fewer stillbirths, early neonatal deaths and brain-injured children.

It was those anxieties that made us in the maternity review consider a new scheme, for which we coined the title “rapid resolution and redress”. I pay tribute to Professor Sir Cyril Chantler, who was my vice-chairman. He has worked tirelessly with colleagues across the world and in this country to frame the scheme, so we are delighted that Ministers see the merit of this proposal. However, I should like to question my noble friend about the timing. I understand that more policy work is to be done, but is it possible to bring forward the second part of the implementation of rapid resolution and redress so that the families in question do not have to wait until 2019?

I am interested in the coroner’s investigations. I understand the desire to ensure that no stone is left unturned, but I want to express my concerns at this moment because it is another inquisitorial initiative, when RRR is designed to avoid using the courts in order to spare parents from trials and tribulations. Therefore, I ask my noble friend to consider whether there could be a pause so as to wait for the evaluation of RRR; otherwise, we will have a range of initiatives which not only might cause confusion but will be in conflict with one another. I thank my noble friends for introducing continuity of care—something that is very close to my heart.

I am delighted to be able to respond to my noble friend, who, probably more than anyone else, has really led the charge in this area. I pay tribute to her for her work on better births, as I do to Sir Cyril Chantler, her deputy. She is right that patient safety is the golden thread that runs through all the work that the Secretary of State has led, and she is right to highlight that we have safer services. The changes that we are making, together with bringing forward the “halve it” ambition, will save 4,000 babies’ lives, which is a great prize.

With regard to my noble friend’s questions, the endorsement of the HSIB is very welcome. Some months ago I organised a briefing for noble Lords with Keith Conradi, who runs it, and I shall be very happy to organise another one. It is a very interesting organisation with an interesting methodology that has proved incredibly effective in the airline industry, where Mr Conradi comes from.

On RRR, I appreciate my noble friend’s concerns about the timing and I will certainly look into whether it is possible to bring forward its implementation. As she knows, there are some issues around governance and how it will operate that mean that we need to tread carefully, but I shall certainly take that into consideration because we want to get the scheme up and running as soon as possible.

My Lords, I too declare an interest. Like the noble Baroness opposite, I am an honorary fellow of the Royal College of Obstetricians and Gynaecologists. Of course I welcome this investigation that the Government have announced, but I am a little worried that at the end of the investigation we shall hear the usual phrase “lessons will be learned”. From past experience, lessons are never learned, especially in the health service, because the main cause of the difficulty and of these babies dying is a shortage of midwives and a lack of staff. When will the Government seriously address funding in all sectors of the health service but, on this occasion, especially midwifery?

The whole point of these reforms is that lessons should be learned, and they can be. The Francis inquiry, and other investigations that have taken place into poor practice, have led to dramatic improvements. The fact that there are over 10,000 more nurses on wards was a direct response to the Mid Staffordshire crisis and the finding that there were not enough staff on wards to look after patients and make sure that they were not vulnerable. It is possible to be optimistic about this. We are already seeing improvements through the learning from deaths programme and from the reduction in the number of stillbirths. The noble Baroness is shaking her head but that is rather a gloomy view, which does not reflect the support for these proposals in this House.

In answer to the point about staffing, there are more midwives in the service and more coming through training. We need to make sure that that continues so that the level of support that is needed is there.

My Lords, like others, I welcome the Statement and the determination to deal with this issue. The Minister will recall that a few weeks ago I asked him about coroners’ inquests on stillbirths and I will address myself to that. Does he agree that, for many parents, the depth of their bereavement at a stillbirth means that they feel the weight and authority of a coronial investigation is absolutely warranted? I therefore welcome the discussions that are to take place. Can the Minister tell me a little about the timing of that and about the legislative vehicle? I understand that primary legislation will be necessary and a Private Member’s Bill that refers to this is currently in the Commons.

I am glad to be able to return to the topic, which the noble Baroness has raised before. There was a powerful story on “Today” this morning, about parents who wanted precisely that for the level of authority it would bring. The hospital was not necessarily treating them as well as it could. These independent investigations will provide a degree of authority and independence that is perhaps sometimes lacking. We want to see how this pans out, but the Secretary of State is committed to looking at coroners investigating stillbirths. This is obviously a complex issue, so I hope the noble Baroness will forgive me if I am not in a position to provide more detail at this point. However, there is a desire and willingness to look into this in the months ahead. When we have some more details, I will certainly write to her.