This article was originally published on 14 December 2022. We have decided to republish it after the news broke by The Observer that almost half of the maternity services provided by the NHS in England have been rated as substandard.
This week, anonymous midwives told the BBC that pressures on maternity services in the Gloucestershire Hospitals NHS Foundation Trust where they work are putting lives at risk. According to the report, a combination of workloads, staff sickness and workforce shortages mean that “mistakes will be made”, the midwives said. Meanwhile, yesterday (13 December) midwives in Wales voted to go on strike over pay.
And this is only the latest on the poor state of this country’s maternity services. In October, the Care Quality Commission (CQC) published a “State of Care” report showing that 6 per cent of maternity services were failing, and 32 per cent needed improvement. These rates are higher than in previous reports, despite recommendations for change since 2015. The CQC report found that other health services are also struggling. Indeed, over half of A&E services were reported as being inadequate or requiring improvement.
There is a tendency to assume that current healthcare problems are due to Covid-19 and its aftermath. While this may be a factor, the pandemic has also magnified already existing fault lines in both health and social provision. Maternity care is a specific example of a general trend.
The CQC report acknowledges the contribution of severe understaffing to poor-quality care. Much is being done to try to resolve the situation, including recruiting overseas staff. However, this won’t work long-term if the reasons for poor retention are not recognised and addressed. The recent review of East Kent maternity services argues that underlying organisational cultural norms may be even more influential for poor-quality care than low staffing levels (which may itself be a consequence of adverse organisational culture).
The report specifically highlights the defensiveness of NHS trusts when faced with critique, noting that, for some years now, trusts have been subject to a bewildering and increasing array of external governance requirements from a range of different bodies, that do not always appear joined up. Some are even contradictory, allowing for the potential increase in creative reporting to ensure that all the essential boxes are ticked, therefore protecting the trust from external criticism.
This situation has arisen partly because of targets introduced as part of the public sector internal market, and partly in response to specific adverse events, or review report recommendations. Under these conditions, organisations tend to default to command and control via inflexible rules and procedures, in order to minimise non-standard actions. This reduces trust in staff to act competently, flexibly and with autonomy. In addition, to maintain this system, time is diverted towards recording and reporting compliance, further impacting on the capacity and morale of front-line care staff.
Most professionals come into maternity care to provide safe, compassionate services. However, the context described above can create organisational (and peer) pressure to behave in ways that violate these fundamental beliefs and values, resulting in moral distress for some. Lack of time to form mutually respectful relationships with service users or with colleagues means that personalisation of care is difficult or impossible, and authentic team-working based on shared values is deprioritised.
Eventually, this leads to burnout. If burned-out staff don’t leave, the further consequence is compassion fatigue, a lack of concern for the safety and wellbeing of service users and peers, and dehumanised, aggressive and abusive behaviour between staff and towards service users. This further risks physical, psychological, emotional and cultural harm to mothers, birthing people, babies and families.
Despite awareness of the impact of cultural norms, most public sector responses to failure prioritise technical, quick-fix solutions, without consideration of the unintended consequences or the opportunity costs. In maternity care – and despite the strong recommendations from safety reviews of the need to listen to women – this has led to a reduction in some kinds of care that many women consistently say they prefer, which is in fact often safer for them and their newborn babies, and better for staff. This includes properly run continuity of care that also enables staff life-work balance; access to safe, properly staffed birth centres and home birth for those who want it; one-to-one care in labour for all; and attention to tailored solutions to ensure equity for everyone.
The downward spiral in which some maternity care organisations are currently trapped will not be resolved within cultures of fear and blame. In this environment, no one dares to speak out, bullying and incivility go unchecked, and lessons cannot be learned.
While learning from what goes wrong is necessary, it is not sufficient. The tendency is to enforce corrections across whole systems, without taking into account how this may adversely affect things that usually go right. This can result in over-generalisation and interventions that work for some, without evidence that they work for everyone, or that everyone is happy to receive them. In fact, most maternity services are doing well despite all the pressures they are under. Human-factors thinking – which considers the way environmental, organisational and job factors influence our behaviour at work and affect health and safety – holds that learning from failure is only one part of what is needed. Learning from what goes right in the same socioeconomic context is also critical, making sure that any changes made do not adversely affect what is currently working.
And yet, continuing to do the same things we have done previously to make a difference has not worked. Indeed, as the 2022 CQC “State of Care” report, and the most recent CQC maternity survey reveal, overall, things are getting worse. All women, birthing people, babies and families should expect to leave maternity care healthy, happy and able to take on parenting with optimism and capability. Staff should expect to be able to do the work they have trained for, with autonomy, competence, kindness, compassion, shared aims and mutual respect, while maintaining their work-life balance. But that is not the case.
It is time to set up a public conversation to agree a realistic social contract for maternity care. We need a root-and-branch review of the whole service, to build out organisational defensiveness, fear and blame, and to identify and remove routine practices and procedures that don’t work. We must also find and reinforce what does work and, in line with the East Kent report, create a single governance system to ensure that the new social contract can be delivered effectively. These steps are urgent – both for those who use maternity care and for those who provide it.