A fifth of maternity services in England are inadequate, review says

BMJ 2008; 336 doi: (Published 31 January 2008) Cite this as: BMJ 2008;336:238
  1. Susan Mayor
  1. 1London

    One in five maternity services in England—mainly in London—are failing to provide adequate quality of care and will have to produce action plans for improvement, warns a comprehensive review of maternity services published last week.

    Some obstetricians countered that lack of a central information system and clearly defined quality indicators had prevented maternity services from being able to report data on clinical care requested by the review, resulting in their being labelled as “under-performing, despite other indicators demonstrating high quality care.”

    The Healthcare Commission, the watchdog that monitors quality of care in the NHS, carried out the assessment after concerns that this area of care currently accounts for one in every 14 of cases referred on safety grounds to its investigation unit.

    The review set performance benchmarks for maternity for the first time. It assessed all 148 trusts that provide maternity services in England in three main areas: clinical focus, woman centred care, and efficiency and capability. It used 25 indicators that had been identified as important by guidelines, clinicians, and a survey of women. These included the type of scans offered to women, staffing levels, women’s assessment of the cleanliness of units, and the number of contacts with a midwife after women had gone home.

    The Healthcare Commission ranked 31 trusts, just over one in five, as being “least well performing.” These trusts scored at the lowest end of the performance distribution and lagged behind in a range of key areas. A similar proportion (32 trusts) were “fair performing.” They were considered to need major improvement in at least one key area. Nearly a third (47 trusts) were “better performing,” with scope for improving in some areas, while only 38 were classed as “best performing.”

    Trusts in London performed least well, with 19 out of 27 London trusts (70%) falling into the “least well performing” category. In contrast, trusts in the north of England performed relatively well, with 33 out of 44 trusts (75%) judged as “better performing” or “best performing.”

    Antenatal and postnatal care tended to be poorer in London, while the quality of care around the time of birth varied. A higher percentage of women in London than in other areas reported not getting the recommended number of antenatal checks.

    Nationally, the review showed weakness in the availability and quality of data. A total of 103 trusts were unable to provide full data, which reduced their score. In the assessment of clinical care 11% of trusts were unable to provide data on major haemorrhages after delivery, which is considered important in managing this major risk. Sixty two per cent of trusts were unable to provide complete data on the effectiveness of interventions to manage the number of caesarean sections.

    One of the major problems has been the failure of the National Programme for Information Technology to provide a system that maternity services can use, argued Derek Tuffnell, consultant in obstetrics and gynaecology at Bradford Hospitals NHS Trust. “The maternity module they offer has been a disaster,” he said.

    His unit was one of those labelled as “least well performing” in the review, even though the provision of care had already been judged to be good in other audits. It received low scores in some areas because the lack of an information system meant that the service did not have the required data. The Bradford service has purchased an information management system from outside the NHS, so it could now provide the information the commission required. Dr Tuffnell said, “It is harsh to criticise units for the lack of information when there has been a central failure to allow that information to be collected.”

    Another problem with the review was that some of the indicators used were not part of what is currently included in a standard dataset, Dr Tuffnell said.

    Staffing levels varied. On average, maternity units had 31 midwives for every 1000 deliveries; however, nine trusts had 26 or fewer. Six of these trusts scored poorly, suggesting that low staffing may be associated with poor performance. The royal colleges recommend 36 midwives per 1000 deliveries to enable one to one care in labour.

    Just over two thirds (68%) of trusts were meeting guidelines requiring consultant doctors to be in the labour ward for at least 40 hours each week, but 32% of trusts had not yet achieved this.

    Anna Walker, chief executive of the Healthcare Commission, said, “Those trusts that were least well performing should as a matter of urgency take steps to improve, and we shall be checking that they do so.”

    She added, “The review raises real concerns about performance in London. There are a number of factors that may have influenced these results, such as lower staffing levels and the mobility and mix of the population. But London trusts need to rise to these challenges.”

    The Royal College of Obstetricians and Gynaecologists welcomed the review as part of initiatives to improve the quality of maternity care, but it cautioned that certain factors, such as high risk populations, are beyond the control of individual providers. It noted the importance of maternity services having adequate capacity and staffing levels.

    Every trust that was least well performing now has to produce an action plan, which the commission will check, and implementation will then be monitored. Alan Johnson, the health secretary, announced extra funding for maternity services over the next three years to reach an additional £122m (€164m; $242m) a year. He said the funds would help maternity services improve the flexibility of their opening hours and increase the number of midwives and support staff.

    The commission will publish a detailed national report on the service review later this year, giving deeper analysis and recommendations.


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