Organisation objective
- NHS Long Term Plan
- NHS Long Term Workforce Plan
- NHS Mandate from Government
Working with people and communities
What approaches have been used to ensure people and communities have informed this programme of work?
- recruited patient and public voice partners
- consultation/engagement
- partnership working with voluntary, community and social enterprise organisation.
The Maternity and Neonatal Programme work closely with service user voice representatives who are involved in projects across the programme. The representatives are also embedded in the governance of the programme, sitting on the executive committees, leadership group and programme board. In addition, the programme has a Stakeholder Council to influence and contribute to the work of the programme.
Action required
The Board is asked to note and discuss the information provided in the report.
Executive summary
1. This paper sets out progress on our Three-year delivery plan since it was published in March 2023. The plan sets out what the NHS will do to make maternity and neonatal care safer, more personalised, and more equitable.
2. We have made progress across the 4 themes of our plan: listening to women, workforce, culture and standards. This includes working with service users to improve care, rolling out specialist services for women that need them, leadership teams in all units taking part in our programme to improve culture and developing an approach to identify earlier those trusts needing support.
3. Whilst it is too early to see a demonstrable impact on all outcomes, we have some positive indications. Women’s reported experience of maternity care is showing some improvement in the most recent survey, and action on recruitment, support and retention has helped to grow the maternity and neonatal workforce – with a record number of midwives currently in England.
4. However, there is much more to do. This week we have seen the publication of the APPG into Birth Trauma and the Sands and Tommys joint policy unit report on Saving Babies’ lives. Both reports make sobering reading and a stark reminder of why improving maternity and neonatal care remain of the highest priority for the NHS. We have committed to working with government to develop a cross-government strategy to help ensure we are maximising the impact of the Three-year delivery plan.
The three-year delivery plan – one year on
5. Our outcome goals are to halve the rates of stillbirth, neonatal mortality, maternal mortality, and intrapartum brain injury by 2025. These are the national maternity safety ambitions.
6. Since our last report to the Board, new national data is available on maternal mortality. This showed an increase in the maternal death rate comparing the triennia 2020-2022 to 2017-2019. Thrombosis and thromboembolism were the leading cause of maternal death, with a similar increase to the overall adult population. Covid-19 was the second most common cause, followed by cardiac disease and mental health-related causes.
7. We are seeing changes in demographics across the population leading to increases in pre-existing conditions, changing maternal BMI and age, and increases in caesarean delivery, all of which are risk factors for thrombosis and thromboembolism. The full MBRRACE-UK surveillance report will be published in October with a focus on causal factors including thrombosis and thromboembolism. This will help to identify further interventions required, and the Royal College of Obstetricians and Gynaecologists is updating guidance to support best practice.
8. Maternal deaths are often caused by medical conditions that pre-date or develop during pregnancy. Pregnant women with significant medical problems now have access to more specialist treatment, since December 2022 the 14 maternal medicine networks, with 17 centres of excellence established across England, provide extra care to women with pre-existing medical conditions, or conditions that arise during pregnancy. The Spring budget announcement included an increase in training provision for obstetric physicians to support women using these centres. The implementation of maternal mental health services is set out below.
9. The latest national data on other safety ambitions remains as last reported to the Board. The stillbirth rate for 2022 was 3.9 per 1000 births, a 22.6% reduction compared to the 2010 baseline. Neonatal mortality rate rose from 1.3 per 1000 live births in 2020 to 1.4 in 2021 but remains 30.4% lower than in 2010. For intrapartum brain injury, 2019 data showed a 9% reduction from the 2014 peak.
10. Action taken across the 4 themes of the delivery plan will support further progress on the national maternity safety ambitions, and an update on implementation is set out below:
Listening to and working with women and families with compassion:
11. Listening and responding to all women and families is an essential part of ensuring safe and high-quality care. It improves the safety and experience of those using maternity and neonatal services and helps address health inequalities. To support trusts and systems to listen to, and work with women and families to plan and implement improvements, we have published guidance for maternity and neonatal voices partnerships. Additional funding announced in the spring budget (rising to £3 million per year) has been allocated to integrated care boards (ICBs) to further strengthen this work, particularly in relation to neonatal services.
12. The role of maternity and neonatal independent senior advocates is to listen to and support families when they have experienced an adverse outcome and have concerns about their care. We are undertaking a pilot of this role which has been more complex to operationalise than expected. Evaluation of the pilot is expected to conclude in March 2025.
13. The 2023 Care Quality Commission maternity survey published in February 2024 provided us with a useful measure of women’s experiences of maternity care. It showed significant improvements since 2022 in 7 out of 10 key measures of women’s experience. Whilst this is a positive improvement, only 1 of these has returned to its pre-pandemic 2019 level and there was little change in 2 measures, this does highlight the importance of continuing to implement the three-year delivery plan to improve women’s experiences of maternity care.
14. In the delivery plan, we committed to providing specialist care for women who need it, this includes implementing perinatal pelvic health and maternal mental health services in every ICB and funding to extend bereavement services to a 7-day service in every trust. Latest data shows that 20 ICBs have perinatal pelvic health services in operation and there are 39 maternal mental health services established. 81 out of the 117 trusts who have provided information to date are delivering a seven-day service. Regional quality and performance meetings will ensure plans for service implementation are in place.
15. We remain committed to tackling inequalities for women and babies from ethnic minorities and those living in the most deprived areas. We asked systems to develop and publish equity and equality plans setting out local action. 41 out of 42 systems have done so and we expect the remaining one to publish their plan next month. A targeted intervention to support the most vulnerable women and babies is enhanced midwifery continuity of carer where women receive care from a known team of midwives throughout their maternity pathway. We know that this model improves women’s experiences of care and preliminary data indicates it may serve to improve outcomes, particularly for vulnerable groups. 34 teams are currently operational and funding allocations for 2024/25 provide for up to 210 teams which relies on increases in the maternity workforce.
Growing, retaining, and supporting our workforce
16. Skilled teams with sufficient capacity deliver high quality, safer, more personalised, and more equitable maternity and neonatal care. The latest data shows that we are making progress in reducing the gaps in staffing. The total number of midwives in substantive employment is now 25,140 full-time equivalent (FTE) which is the highest number ever recorded. The consultant obstetrician workforce has increased to around 1,867FTE.
17. Investment at national and trust level has facilitated growth in the establishments of midwives, maternity support workers and obstetricians. Trusts have funded an additional 1,500 FTE midwifery posts in addition to the 1,200 FTE funded by NHS England in 2021.
18. Since 2021, NHS England has invested an additional £185 million of recurrent funding in maternity and neonatal care, mostly on workforce. Further investment announced in the spring budget will be allocated starting in 2025/26 for an additional 160 midwives, with a focus on inequalities.
19. There has also been growth in neonatal staffing. Since 2021/22, we have invested to increase the establishment for neonatal nurses by 548 FTE and additional funding of £6 million this year will enable the recruitment of around 40 FTE neonatal consultants.
20. The three-year delivery plan set out that where trusts do not yet meet the staffing establishment levels set by Birthrate Plus or equivalent tools, they should do so and achieve fill rates by 2027/28. We will continue to track progress towards this goal.
Developing and sustaining a culture of safety, learning, and support
21. We want everyone to experience the positive culture that exists in many maternity and neonatal services – a culture of professionalism, kindness, compassion and respect.
22. Leadership teams from all maternity and neonatal units in England have now started the Perinatal Culture and Leadership Programme. This programme brings together neonatal, obstetric, midwifery and operational leads to understand the culture of their service, supported by a diagnostic survey, and provides practical support to nurture a positive safety culture. Feedback from leaders so far shows the programme is well received and they report a better understanding of their culture as well as improvements to team working and having a shared vision. All leadership teams will complete the programme by March 2025.
Standards and structures to underpin safer, more personalised, more equitable care
23. To deliver the ambitions set out in the plan, maternity and neonatal teams need to be supported by clear standards and structures which includes all units being supported to consistently implement best practice. The recently concluded Care Quality Commission inspection programme for maternity services shows that there is variation with 7 maternity units now rated ‘outstanding’, 92 ‘good’, 92 ‘require improvement’ and 18 ‘inadequate’.
24. We are taking steps to improve early identification of trusts requiring additional support, such as through our Maternity Safety Support Programme. In line with the recommendation from ‘Reading the Signals’, we are developing a maternity outcomes signal system to highlight safety issues promptly. Data for the tool will be provided by the Submit a Perinatal Event Notification Service. Subject to testing and validation processes, this is due to go live in early 2025 with the tool launching shortly after.
25. The quality and capacity of the estate can inhibit positive outcomes and experience. To increase and align neonatal cot capacity, £45 million capital was allocated, over 3 years, across a number of providers to deliver an overall increase of more than 50 cots, 10 of these cots are now operational.
Tracking progress on the three-year delivery plan
26. We published our approach to tracking progress alongside the delivery plan as well as how we are improving our timely understanding of impact on outcomes and experience. In addition to the maternity outcomes signal system mentioned above, we are improving our insight into experience through a patient reported experience measure and an annual survey of neonatal parents’ experiences.
27. We aim to track progress without imposing an undue burden on frontline staff. We have worked with NHS Resolution to reduce the burden of demonstrating compliance for the Maternity Incentive Scheme. The most recent results saw the proportion of trusts compliant with all safety actions rising from 52% to 77%.
Looking ahead
28. The priorities and actions set out in the delivery plan continue to guide what the NHS is doing to improve maternity and neonatal care.
29. Priorities for 2024/25 include: delivering the Maternity Outcomes signal system, progressing the pilot of maternity and neonatal independent senior advocates; completing delivery of the perinatal culture and leadership programme and expanding support for systems and delivering quality improvement programmes including the Avoiding Brain Injury in Childbirth Project.
30. At the same time, we will continue to learn from new challenges and opportunities.
31. Donna Ockenden’s review into maternity services in Nottingham University Hospitals is scheduled to publish its final report in September 2025. Emerging issues are largely consistent with priorities set out in the delivery plan. Issues raised so far include: compassionate listening and communication; discrimination, racism and being treated differently; navigating care for children with additional needs and duty of candour. These are informing the trust’s maternity improvement plan and we have shared this learning through NHS England regional teams and with relevant stakeholders.
31. A growing issue facing maternity and neonatal services are factors influencing the complexity of care. Pre-existing conditions, changing maternal BMI and age, and improving care for very premature babies are leading to more complex care needs. We are working to understand the future implications of this for pathways of care, clinical policy, staffing, and estate requirements.
33. There is much more to do to ensure that women and babies consistently receive the best possible care. Building on the NHS Three-year delivery plan, we look forward to working with government to develop a cross-government strategy. We will seek input from service users, and from a broad range of experts to inform this. We will consider what more should be done, including action to address the wider determinants of health and inequalities, and provide mothers and families with a clear statement of what support they should expect.
Publication reference: Public Board paper (BM/24/20(Pu)