An increase in funding of £200-£350 million per year is urgently needed to resolve the problems of understaffing endemic in NHS maternity units, say MPs in a report from the House of Commons Health Committee. Safety of patients is being compromised by a lack of staff with over a third of NHS maternity units needing to improve on safety.
Although NHS maternity services have made large strides in improving safety, a lack of staff coupled with a culture of blame is preventing the NHS from improving still further. The report calls for a radical new approach to investigating and resolving incidents of harm to patients to enable the NHS to move away from a culture of blame.
Reacting to the report, Gill Walton, Chief Executive of the Royal College of Midwives, said that maternity staff have been “working incredibly hard, under extraordinary pressure for many, many years to deliver the safest and best possible care. They have been doing this within a system that often fails them by not giving them the staff, resources, and modern facilities they need to do their jobs as safely as possible….These reports show that the Government must step up and they must give our maternity services the staff and the money it needs, and they must do it quickly.”
Professor Ted Baker, the Care Quality Commission’s chief inspector of hospitals, told the committee that its inspections had found that 38% of NHS maternity services “require improvement for safety” more than in any other medical speciality.
At the heart of everything is a lack of staff. The Committee heard that although staff numbers had increased in some areas, there continue to be gaps in all maternity professions – midwives, obstetricians, and anaesthetists.
The figures for staff also do not take into account the high levels of sickness and attrition present in a workforce that is overstretched and demoralised; even if a unit is fully staffed on paper, the reality is very different on the ground due to staff absences.
Health Education England has calculated that the NHS remains short of 1,932 midwives and a recent RCM survey indicated that 8 out of 10 midwives reported that they did not believe that there were enough staff on their shift to be able to provide a safe service. NHS Providers estimates that an extra 496 consultants are needed to work in Obstetrics and Gynaecology.
A recent example is Nottingham University Hospitals Trust’s maternity unit, which is currently trying to fill 70 vacancies for midwives on its wards. Maternity services here are rated inadequate by the watchdog the Care Quality Commission (CQC) and have been understaffed for several years. An investigation by the Independent newspaper found managers at the trust were labelled a “Teflon team” who ignored pleas from staff about midwife shortages. The trust has seen dozens of babies die or been left with brain damage, according to The Independent.
The MPs on the committee were told of managers refusing to fund more midwives. Heads of Midwifery at maternity units can calculate how many midwives are needed using a well-established tool known as Birthrate Plus, however as Gill Adgie, Regional Head, Royal College of Midwives (RCM), told the committee:
“What we know from our Directors of Midwifery is that if a head of midwifery needs 30 more midwives in a service based on Birthrate Plus®, when she goes to the trust board with a business case, it is quite often knocked back.”
A lack of staff means that training, which is crucial to maintaining patient safety and staff development, can not take place as often as it should. Often midwives can not be released to attend or to teach as there are no staff to cover for them. This is also the case with other specialties. As one trainee doctor told the committee:
“The problem with the staffing is that if it’s so minimal then actually you can’t release people. Study leave requests are often denied so how can we develop if we aren’t given the tools to develop.”
The MPs recommend that a proportion of maternity budgets should be ringfenced for training in every maternity unit and it must be sufficient to cover not only the provision of training, but the provision of staff to cover for those providing and attending training.
The NHS has seen major scandals in recent years that have left many babies with brain damage and many bereaved parents – Shropshire & Telford, Morecambe Bay, East Kent – and these have their origins in staffing and work culture issues. Investigations, such as those into Morecambe Bay maternity services and the Ockenden review into Shropshire & Telford maternity services, have found that the trusts involved have not learnt lessons, continued to not investigate properly and failed to identify underlying issues in maternity care with evidence of blame instead being shifted to mothers. Parents seeking compensation, an apology and to make sure the same mistakes are not made again, often face many years of litigation as Trusts and individuals need to be found to ‘take the blame’.
In 2019–20, NHS Resolution paid out £2.3 billion in compensation and associated costs for maternity claims, representing 40% of all claim payments. The NAO warned back in 2017 that this is likely to keep rising without fundamental change. A third of the bill is reported to go on lawyers’ fees and the report noted that “if we were better at learning from and eliminating mistakes, this money could be spent on the provision of safe maternity care.”
The MPs are calling for major reform of the compensation system for the NHS, with the UK adopting the system used in Sweden – a non-blame compensation scheme for injuries sustained as a result of medical treatment. Compensation is paid if care is not good enough, unlike the current system in the NHS where negligence has to be proved and cases can drag on for years. The Swedish system leads to a culture of openness and a willingness to learn from what went wrong that led to a baby, its mother or both suffering serious injury or dying. In Sweden the number of avoidable birth injuries in its hospitals was halved after introducing this system.
The Ockenden report in 2020 triggered some new funding, with a £46.7 million funding package to provide 1000 more midwifery posts plus an additional £10.6 million has also been given to increase the obstetric consultant workforce by 80 FTE in 2021–22.
However, NHS Providers told the MPs on the committee that this funding is not sufficient to fund the 496 consultants required to reach the recommended 20% increase in obstetric consultants, which is £81 million per annum. NHS Providers also noted that maternity care needs a team – anaesthetists, maternity support workers, neonatal nurses – and to fully fund the broad team £200 – £350 million per year will be needed.
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