A review of how well health professionals are being taught to provide compassionate care is among the actions pledged by the government in response to a damning maternity report.
The Department of Health and Social Care (DHSC) has this week published its full response to Dr Bill Kirkup’s review into maternity care failings at East Kent Hospitals NHS Foundation trust.
Dr Kirkup’s review, published last year, found that up to 45 baby deaths might have been avoided at the trust if they had received appropriate care.
It found “a pattern of recurring harm” that was visible from 2009 to 2020, and which could have been acknowledged and rectified at any time over that period.
The DHSC has now pledged that further action will be taken on a national level to improve safety for mothers and their babies within the NHS, to ensure that maternity and neonatal care is of the highest standard.
In its new report, it said it would work with other interested parties to evaluate current practice and identify gaps in a number of key areas including compassionate care training.
This work would look to “map how compassionate care is currently being taught at all levels and across professions, whether this be formally or as part of in practice training”.
The report added: “This will allow us to understand where there are gaps that may be preventing this being embedded and forming a sustained compassionate culture, but also where it is working well.”
Similar review work would also take place to look at current approaches to team working in maternity units, as well as the “oversight and direction of clinicians” in these services.
There would also be a focus on supervision, with NHS England set to soon publish a new “standardised framework for what good midwifery supervision looks like”.
Alongside the supervision framework, there would be an “audit tool that will help trusts to evidence their commitment to ongoing training and supervision”.
The report said the Nursing and Midwifery Council was about to launch a series of “mini campaigns” to raise awareness of its Future Midwife standards and how they should be applied.
It also made reference to some of the pledges in NHS England’s ‘three-year delivery plan for maternity and neonatal services’, which was published in March 2023.
The delivery plan made it clear that trusts should have an “executive and non-executive maternity and neonatal board safety champion to retain oversight and drive improvement”.
Alongside the plan, NHS England announced the appointment of Louise Weaver-Lowe as the country’s first-ever neonatal lead nurse.
Meanwhile, one of the key recommendations from Dr Kirkup’s report was for the establishment of a taskforce that could roll out “valid maternity and neonatal outcome measures”.
In its response to this particular recommendation, DHSC pointed to two new groups that had been set up by NHS England.
One of them is the ‘Reading the Signals Data Co-ordination Group’, which will evaluate whether data is currently being used effectively enough to identify trusts at risk of providing bad maternity care.
The other is the ‘Maternity and Neonatal Outcomes Group’, which is acting as the taskforce called for by Dr Kirkup.
“The work will lead to a draft clinical outcome measurement tool that can be used as an early prompt, early surveillance or early screening system in the autumn,” stated the report.
To monitor progress against these pledges and others, and to generally oversee maternity services across the country, the DHSC said it had set up a new oversight group.
The Maternity and Neonatal Care National Oversight Group will be chaired by minister for women’s health, Maria Caulfield, and would include “key people from the NHS and other organisations”.
Separately, Ms Caulfield will also chair a local forum for East Kent to monitor and share updates on the improvements being made to maternity services there.
She said: “I’m determined to see safety standards in maternity and neonatal care improve across the country.
“While this invaluable report focuses on the situation in East Kent, I want to see its recommendations implemented nationwide.
“This government will continue investing in the maternity workforce and working with the NHS to raise standards.”
In its report, DHSC acknowledged that staffing levels could contribute to issues in services and said it had expanded midwifery, obstetrics and gynaecology training places.
Dr Kirkup will provide an ongoing leadership role in supporting the delivery of some of the recommendations in his East Kent report, which was titled Reading the Signals.
He said: “I see the government’s response to Reading the Signals as an important step forward in addressing the issues that I identify.
“I welcome the opportunity to lead this significant work.
“I look forward to drawing together an action group to advise me in doing so.”
NHS England welcomed the government’s response report.
Dr Matthew Jolly, national clinical director for maternity and women’s health at NHS England, said: “We welcome the government’s response to Dr Bill Kirkup’s report – the failings in care for women, babies and their families using East Kent Hospital must not continue to be repeated.”
He went on to explain the measures being taken NHS England to monitor the situation at the East Kent trust.
“NHS England has installed an improvement director at the trust alongside a senior advisor, and both are providing expert practical advice to the organisation on the actions it needs to implement to improve its maternity and neonate care, while senior national NHS clinical leaders are regularly visiting both maternity units to monitor progress,” he said.
Responding to the statement from the government, the chief executive of the Royal College of Midwives, Gill Walton, said: “This response has been a long time coming.
“What is important now, though, is that all of us with a stake in maternity services – policy makers, clinical staff and the women and families in our care – work together to make sure quality and safety are paramount.
“Women and their families deserve and should expect to be cared for in services that are safe, adequately staffed and properly resourced.”
The director of policy and strategy at NHS Providers, Miriam Deakin, also welcomed the report.
She said: “Increased national efforts to prevent failings in maternity care services, which have a devastating impact on families, are a vital step forward.
“Trust leaders are committed to learning from the Kirkup report, improving the quality of care for all mothers and their babies and tackling disparities in outcomes based on race.”
Ms Deakin argued that it was vital that the government aligned the findings of Dr Kirkup’s review “with wider work on maternity safety”, including recommendations from other recent reports.
She added: “While this government announcement is welcome, sustainable improvement will depend on proper investment in workforce and capital.”