12 Mar CQC briefing on improving safety in NHS maternity services
The CQC calls for more training as part of recommendations to improve safety in maternity services.
By Sara Ledger, Head of Research and Development, Baby Lifeline Training
The Care Quality Commission (CQC) has published a report today setting out what it considers as important areas to improve maternity services nationally. One of the three main recommendations is “individual staff competencies, teamworking and multi-professional training”.
Improvements in Maternity Safety
The report Getting safer faster: key areas for improvement in maternity services builds upon the report from 2017 which found that half of maternity services were rated as either “inadequate” or “requires improvement” for the question “are maternity services safe?”. It has found that there are marked improvements, with only 2 trusts now being rated as “inadequate” rather than 13 previously. In addition, trusts that have been ranked as ‘good’ has increased by almost a third. Despite this, almost 4 out of 10 maternity units have been ranked as ‘requires improvement’ (75) or ‘inadequate’ (2) for maternity safety.
Sadly, the CQC has stated that maternity services stand out as “one of the core services [they] inspect that is not making improvements in safety fast enough”. Where they have inspected units rated as “inadequate” or “requires improvement” they have found that the same themes identified in the 2015 Kirkup Report “are still affecting the safety of maternity today”:
- Staff not having the right skills or knowledge
- Poor working relationships between obstetricians, midwives, and neonatologists
- Poor risk assessments
- Failures to ensure that there is an investigation
- Learning from when things go wrong
In order to achieve the national ambition of halving 2010’s rates of stillbirth, neonatal death, and brain injury by 2025, a greater rate of decline is needed than has been observed in recent years. The 2020 ambition of reducing these outcomes by 20% has been achieved in relation to stillbirth, according to 2018’s national figures; however, there is still more work to be done in neonatal mortality, and brain injuries. Similarly, maternal mortality has only decreased from 10.6 to 9.8 per 100,000 births according to the latest figures up to 2015. It will need to decrease to 8.5 by 2020 to achieve the ambition.
As such, the CQC has set out three key areas it believes will improve safety in maternity services in its briefing. The briefing is aimed at helping maternity services, their trust boards and stakeholders to focus on what is now needed to improve safety in maternity for mothers, babies, and the health professionals providing their care.
The areas are based on an analysis of a sample of current CQC inspection reports for services that have been rated as outstanding or inadequate; the findings from the 2019 CQC maternity survey; discussions with providers and members of the public at a CQC NHS co-production workshop held in February 2019.
- Governance, leadership and risk management
The CQC believes the new board-level ‘Maternity Safety Champion’ role in NHS organisations will play a key role in this area, ensuring that maternity services have staff who:
- Have the required knowledge and skills
- Work effectively as multi-professional teams
- Have the ability to recognise and act on any changes that move pregnancy from low-risk to high-risk
The briefing notes that “leaders at service-level also need to be accessible and to promote an inclusive culture in which staff feel able to raise concerns and make suggestions for improvement”.
Effective leadership is a key aspect of safety. The analysis found that the ratings for safe and well-led were the same in 61% of services, the closest alignment of any of the questions when related to safety. In addition, services with poor leadership and governance structures were not monitoring failures in teamworking, core staff training competencies, and not properly managing serious incident investigations. These gaps and pitfalls have the potential to threaten patient safety.
The quality of leadership and the culture of a service has an impact on staff recognising and reporting safety incidents in order to learn and prevent avoidable adverse events. In addition, the analysis found that NHS organisations that “encourage a culture of learning and openness alongside a willingness to listen to and prioritise the needs of women using their services are more likely to deliver care that is… safe, person-centred and empowering”.
- Individual staff competencies, teamworking and multi-professional training
The briefing lays importance to teams being trained regularly in key areas in order to allow them to work together well and respond quickly and effectively to emergencies in maternity. It notes that prioritising and investing in the capability and skills of the maternity workforce, and promoting effective multi-professional team working, are key in achieving the national ambition to improve care.
The analysis mirrors findings by Baby Lifeline’s Mind the Gap reports in 2016 and 2018: training in maternity, both in terms of topic areas covered and resources, varies widely.
The briefing lays out three elements that need addressing related to training:
- core competencies of individual members of staff
- effective teamworking between different staff groups
- scenario training that role plays planning for serious complications that require an effective multidisciplinary team response.
It also states that “every maternity service must ensure that the range of training matches the identified needs for their service”.
Nationally, the CQC report follows many other reports in stating the importance for effective training in fetal monitoring. The majority of cases investigating harm and death in maternity looked at by both the RCOG’s Each Baby Counts report and NHS Resolution’s Early Notification Scheme involve fetal monitoring as a contributory factor in those cases where the outcome may have been different with different care.
In addition, it noted concerns around the frequency and quality of multi-professional scenario training – stating that it needs urgent attention at a local and national level. The briefing highlights and praises organisations that have come up with “innovative examples of trusts addressing this through rotational joint appointments that are shared between large and small maternity units”.
We were so pleased to see the mention of the benefit of multi-professional maternity scenario training for ambulance professionals in the briefing; stating how ambulance services had highlighted how valuable it was for them to be involved in scenario training with other frontline maternity professionals. This is something we have regularly observed on our Childbirth Emergencies in the Community study days : where knowledge, confidence and empowerment scores had statistically significantly improved following multi-professional scenario training, which was sustained after 12-weeks (Jomeen et al, 2020) Read more here.
- Active engagement with women using maternity services
We’re so happy to see another report highlighting the importance of listening to service users in the bid to improve safety – noting it as “vital”.
In its latest survey the CQC showed that most women felt that they had received high-quality maternity care, however, there were areas that needed to be addressed including:
- Perinatal mental health
- Access to help and support outside acute settings
- Awareness of medical history during antenatal check-ups
- Postnatal care; particularly emotional support and communication after birth
The work around Maternity Voices Partnerships should help ensure that women are placed at the centre of care and improvements.
Maternity services are getting safer, and the majority of women and babies receive good care; however, CQC inspections have found that more work needs to be done to improve safety in maternity, especially if the national ambition is to be achieved.
It recommends three key areas to improve safety, which includes staff competencies, teamworking and training as a major component alongside listening to service users, and improvements to leadership, risk management and governance strategies.
The briefing ends with “safe maternity care is not an ambitious or unrealistic goal. It should be the minimum expectation for women and babies – who should also be receiving care that is person-centred, supportive and empowering. Improvements in safety still need to be made to ensure that this is the case for everyone, every time.”