The state of care in England’s maternity services

Unproved improvement interventions

Maternity services enter NHS England’s maternity safety support programme if the CQC rates them as “requires improvement” or “inadequate” in the “well led” or “safe” inspection domains. Typically, the support includes improvement advisers providing mentoring, advice, guidance, and promoting quality improvement methods. However, no evaluation of the programme’s effectiveness has been published. Some trusts have been in the programme for several years, and some trusts that exited the programme have re-entered.8 An earlier observational study using routine data reported little evidence of improvement in lower performing maternity units on inspection ratings.9

Of course, the maternity support programme is not the only improvement effort targeting maternity services. Recent years have seen no shortage of recommendations and initiatives seeking to stimulate, incentivise, advise, or support services to get better. The large volume of initiatives and recommendations, and the range of bodies issuing them, is itself a problem. “Priority thickets”10 may result, where units become overwhelmed, distracted, and confused, paralysing their ability to respond and often lacking the resource and expertise to convert recommendations into effective local solutions.

The volume problem is compounded by common weaknesses in existing improvement efforts.11 Many are not evidence based, do not include maternity service users or staff in their design, do not align with human factors and ergonomics strategies, lack support for implementation, and are uncosted. Perhaps most damningly, few are formally evaluated, so the evidence base for supporting improvement remains seriously underdeveloped.12

A further threat to the effective functioning of the cybernetic model of regulation is that a poor CQC rating—even when a fair judgment—can make things worse rather than better. Affected healthcare staff may experience emotional distress, including feeling ashamed, demoralised, and stigmatised,13 which may act as a barrier to improvement. And staff recruitment and retention, which are essential to improvement, may be more difficult when an organisation is reputationally damaged. In this sense, one element of the regulatory system (monitoring) is potentially destabilising another (improvement).

Despite the scale of current improvement efforts, it remains unclear whether they are tackling the right problems in the right way at the right level. Some issues in maternity services are deeply structural, including workforce shortages, poor quality estates and facilities, and inadequate technological infrastructure. These require specific action backed by policy support and investment. But a disturbingly recurrent factor blamed for problems in quality and safety of care is culture. Simply exhorting colleagues to behave better towards each other and those they care for has had limited effect. More evidence based strategies for improving culture, including professionalism, civility, respectful communication, and anti-racist behaviours are much needed.14

Improving maternity care is a priority for families who use maternity services and staff who work in them. An evaluation of the CQC’s maternity inspection programme is under way, but a hard look at how “improvement” is currently being done and where efforts can add most value is now overdue. It will require rationalising and streamlining of current approaches, meaningful co-design in partnership with families and staff, and building an evidence base through rigorous evaluation.