• Trust leaders criticise lack of clarity on maternity safety measures
  • Women’s trust CEO calls for “focused rethink”
  • Ockenden assessments gave “false assurance” to trusts, say chiefs

The management of fragile maternity services is being hamstrung by a lack of clear standards and direction from government and regulators, trust chairs and chief executives have told HSJ.

Kathy Thomson, the retiring chief executive of Liverpool Women’s Foundation Trust, told HSJ that a major overhaul of regulation and oversight of maternity care was needed.

She warned that trust leaders were confused about what was expected of their stewardship of maternity services. Much of the increased scrutiny of the sector was coming from people with little knowledge and experience of maternity care, and maternity was beset by too many initiatives which “somebody thinks are a nice thing to do”.

Ms Thomson’s comments were echoed by a wide range of other NHS leaders (see ’damaging confidence’ below). 

Maternity services have come under intense scrutiny since the Ockenden investigation into the care failures in Shropshire, as well as a string of scandals exposed at East KentNottingham and Morecambe Bay. The Care Quality Commission has run an intense programme of maternity reinspections over the past year, downgrading many units and often highlighting short staffing and other problems. The latest, this week, saw University Hospitals of Derby and Burton maternity services moved from “good” to “inadequate”

Ms Thomson told HSJ: “How clear are we nationally about the real ask of maternity services? Are we going to say it’s the ten NHS Resolution (NHSR) safety standards, which are really tough to achieve and which we agonise over? Or is it the CQC standards, because they will often take a different view around very similar issues?

“We’ve had that this year after we’ve been assessed as compliant by NHSR, but then had to re-provide evidence after we’ve been criticised by the CQC for something… and then NHSR have written back to say we’re still fully compliant.

“So, should you put your time and energy into the NHSR standards, or do you spend the time on the more subjective drivers? Because we can’t keep doing all of it and having different parts of the NHS saying this is what you need to do or expecting something different.”

LWFT saw its safety rating for maternity downgraded from “good” to “inadequate” in June after the CQC raised concerns including around staffing levels, monitoring and training.

But Ms Thomson said this included various issues that were relatively binary in terms of measurement, and which the trust had been confirmed as compliant by NHSR.

She added: “We need to ask, what are the really important bits? And how do we have a much more intelligence-led approach to maternity services, rather than what somebody thinks is a nice thing to do?

“We’ve had some of that with ‘continuity of carer’ in recent years. We did a pilot here on continuity of carer and our evidence back was that to really do this well, you need more midwives than this country has currently got.

“But you know, you were pushed to do it, so we adopted a form of it in certain areas, really targeted on deprived areas for non-English speaking women…

“It was tough on some of our staffing levels, but actually we had some really good results through in terms of improved breastfeeding and engagement. But then CQC came in and said ‘why are you doing continuity of care when you haven’t got fully staffed wards’?”

She also said the levels of complexity and acuity now faced by maternity departments do not appear to be understood at a national level, and the payment tariff for maternity care still falls far short of the real costs of care. Although the tariff issue is hidden in larger trusts, it means maternity departments “always feel like the poor relation” in comparison to other services, she said.

Damaging confidence

Ms Thomson’s comments were echoed by Gillian Norton, chair of St George’s, Epsom and St Helier University Hospitals and Health Group. She told its board that “the challenge of defining a safe service” in maternity was worsened because there is “no nationally agreed set of metrics by which to measure the performance of services”.

A non-executive director of the South London Trust also told the board meeting last month there was a “disconnect between the assurance the board had previously taken about the position of the service following the Ockenden visit and the issues identified by the Care Quality Commission.”

The trust received a section 29 notice from the CQC following an inspection in March. 

After the Ockenden report in 2022, all maternity providers assessed themselves against a set of metrics she had recommended; a process overseen by NHS England. Several hospital leaders said this work had given false assurance of services which were subsequently severely criticised by the CQC.

Several NHS leaders who spoke to HSJ echoed the concerns expressed by Ms Thomson and Ms Norton.

NHS Providers called for ministers to act on confusing rules and regulations. Director of policy and strategy Miriam Deakin said: “Trusts need government support to invest in their workforce and the design of services plus recognition that the regulatory environment has become very complex and difficult to navigate.

“Trusts need support in making maternity services positive and attractive places to work, with oversight focused on the needs and outcomes of mothers and babies.”

An executive trust director told HSJ that governance had become confused by different regulatory expectations.

He said: “The stuff that goes to board is getting weird, including full ‘serious incident reports’ which just encourages non-executive director rubbernecking as opposed to real understanding of risk via the lens of a board assurance framework.

“What should a board do if a bunch of midwives write a letter saying they think staffing is unsafe? The NED champions for maternity are walking around saying ‘we need extra investment’ like a trade union rep, not somebody holding an executive team to account. It’s all gone mad.”

A hospital chief executive told HSJ: “The Ockenden reviews gave us false assurance in regards to what the CQC regard as safe. CQC looks at potential risk and local staff views not data and outcomes. Our board looks at outcomes, clinical negligence and other data to ensure the unit is safe. They were not interested in that at the [CQC] visit. So it is no wonder no one knows what they are supposed to do or measure.”

Another hospital leader said: “The CQC seem to rely a lot on anecdotal information. They also have a focus now on staff wellbeing which does lead to the answer to everything being more staff (even where data wouldn’t support it).

“Some of this resonates with the Kirkup report which says we are asking the wrong questions, and I think Ockendon has made a lot of the info going to board incomprehensible to the average non-executive director.”

A third hospital chief executive said: “Ockenden and the CQC [interventions] has had the cumulative effect of damaging confidence in maternity services and it feels like we’re now in a spiral due to loss of workforce off the back of it. [It’s] a clear example of where well-intended regulation has made things worse.”

Maternity asks

There are various measures and standards which trust boards are required to report against. These include compliance against 10 safety standards set by NHS Resolution, a scheme which incentivises trusts’ good performance against measures including compliance with the national Saving Babies Lives care bundle, perinatal death reviews, and demonstration of effective workforce planning.

Trusts are also required to self-assess against national criteria set by the two Ockenden reviews into poor care at Shrewsbury and Telford Hospitals Trust, while they are also asked to adhere to CQC maternity standards to prevent ratings for the well-led and/or safe domains being categorised as “requires improvement” or “inadequate”.

Organisations with such ratings are formally entered into NHS England’s national maternity safety support programme, which encourages trusts to benchmark themselves and self-assess against standards set by the MSSP.

The CQC said in a statement: “Inspections of maternity services nationally have found many units that are providing good care, and we know that’s what staff want to be able to deliver every time. But there remains a variation in the quality and safety of maternity care across the country and a need for greater support to help services put the systems in place to make safety a top priority.”

NHS England said in a statement: “The three-year delivery plan for maternity and neonatal services [launched in March this year] brings together national recommendations and clearly sets out how local teams and staff can take action, providing four key areas of focus – as part of this, we have established a new national maternity and neonatal outcomes group, to establish how data can be used more effectively to track outcomes and identify significant trends, so the appropriate support can be provided.

“The maternity safety support programme is the highest level of response that the NHS has to support trusts where there are concerns about maternity care and provides dedicated maternity advisers to support an organisation’s improvement.”

The DHSC was approached for comment.

Trust leaders raise alarm over ‘mad’ approach to scrutiny of maternity services