While keeping women and babies safe has always been at the heart of everything midwives do, the approach to safety across maternity services is changing, from policy level right down to the language used to talk about risk. Here, Juliette Astrup takes a look at the defining features of the new safety landscape.
A healthy baby and a healthy mum: this is what most people would understand as a ‘safe’ birth. Fortunately in the UK that is what happens in the vast majority of cases.
While the desired outcome is obvious, the question of what makes a maternity service safe is far more complex and nuanced, encompassing everything from staffing levels and training to the wellbeing of staff and the relationships within a team.
Since the publication of the public inquiry report into Mid Staffordshire NHS Foundation Trust in February 2013, attitudes and approaches to safety have been transformed across the NHS, from policy level right down to the shop floor.
Openness, candour, listening to women, embedding learning from errors and instilling the right culture from top to bottom – this is the new language of safety. It’s ‘about a culture of learning, not blame’ as health secretary Jeremy Hunt puts it (Department of Health, 2015).
While the overwhelming majority of births are safe, some are less safe than they could and should be. The recent update on The Lancet stillbirth series ranks the UK 21st out of 49 high-income countries for stillbirth rates (Flenady et al, 2016).
And while the stillbirth rate in the UK fell by almost 8% between 2013 and 2015, down to 3.87 per 1000 total births, significant variation remains across the country that cannot be explained solely by factors such as poverty, mother’s age, multiple birth and ethnicity (MBRRACE-UK, 2017).
As well as the emotional cost to families, the NHS incurs huge costs when avoidable harm happens. Last year, its clinical negligence payments in England, including costs and settlements, totalled £1.7bn – up 15% on the previous year. This was driven by claims relating to childbirth: while obstetric claims accounted for 10% of clinical claims in 2016-17, they amounted to 50% of the total value of new claims reported (NHS Resolution, 2017a).
These pressures, compounded by the high-profile failings in care at Morecambe Bay, have intensified the focus on safety in maternity services, heralding a raft of new policies, the direction of funding to safety programmes, and new initiatives at both national and local level.
Among them is the National Maternity and Perinatal Audit. For the first time, this has evaluated the quality of care received by women and newborns within hospital services across England, Wales and Scotland, bringing a new level of consistency and clarity to the data. An organisational survey to understand the structure and delivery of maternity services is already complete, and the first annual clinical audit report has recently been published (read more on page 48).
Also under development is a standardised Perinatal Mortality Review Tool that will support and improve the quality of local reviews of stillbirths and neonatal deaths. Its roll-out across NHS maternity and neonatal units in England, Scotland and Wales is expected by the end of the year.
The Spotlight on maternity guidance: five ways to improve safety
1. Build strong leadership in maternity services: from board level downwards
2. Build capability and skills for all maternity staff: improve communication through safety briefings and review shift handovers; implement and complete multidisciplinary training
3. Share progress and lessons learnt across the system: be open about safety implementation plans and their progress
4. Improve data capture: have appropriate collection and reporting of high-quality data and follow national guidelines for patient-safety reporting
5. Focus on early detection of the risks associated with perinatal mental illness: ensure staff can identify the risks and symptoms and are aware of local pathways of care.(NHS England, 2016b)
Changing the culture
Better data can only go so far, points out James Walker, professor of obstetrics and gynaecology at Leeds University, and national professional advisor for maternity care to the Care Quality Commission (CQC).
‘In maternity, where the vast majority of women have a good outcome, the variation in percentage points is actually quite small,’ he says. ‘Even in units where safety is not that great, the outcome measures might be within normal ranges and people get false reassurance of how good they are.’
He says that, from the CQC’s point of view, there is now a far greater focus on the culture within a service and how well led it is.
‘Are they looking for support from each other? Is there a feeling that people know they can call on each other?’ he says. ‘Similarly, how visible are the more senior people? Is the coordinator supporting other midwives? How supportive are the doctors? When a difficult situation arises, do the midwives feel free to call on the coordinator or call directly on the doctor without being criticised or made a fool of?’
In agreement is Professor Jane Reid, clinical director at Wessex Patient Safety Collaborative, co-chair of the Learning to be Safer Expert Group, Health Education England, and non-executive director at Salisbury NHS Foundation Trust.
She believes that efforts to improve safety across the NHS are focused on consistency around communication and escalation points, and a recognition of the importance of relationships and integration between groups of professionals.
‘There is a focus on teamworking and team building, respecting competencies and equality. Look at [the] Kirkup [review], at all the recent enquiries. The bottom line is behaviour. That is a massive thread in terms of the national programme and what we’re doing regionally. It’s about teamworking, positive open behaviour and positive reporting.’
She adds: ‘It’s also about really understanding the difference between work as imagined and work as done. Safety and harm come from the same place. Why is it we were able to keep the wheels on the obstetric unit on Monday, but they fell off yesterday?
‘We need to celebrate and capture what was done really well, as well as focus on what went wrong. That is a huge area of change. So much of what we do now is in retrospect, looking in the rear-view mirror. When actually if we focus on the positive – how did we get that right? – then we can replicate that and inculcate it so that it keeps happening.’
She also points to a growing recognition within the NHS of ‘human factors’ – human fallibility and frailties – and the need to mitigate and manage them through processes and training.
Improving safety in the four nations
England
The national ambition is to halve the rates of stillbirths, neonatal and maternal deaths and intrapartum brain injuries by 2030, with a 20% reduction by 2020. Announced in November 2015, this aim was followed by the Spotlight on maternity guidance, and in October last year by the Safer maternity care action plan (Department of Health, 2016), setting out the next steps to achieve it. Support includes £8m of Health Education England funding for trusts to improve safety training, a £250,000 maternity safety innovation fund to support local maternity services to create and pilot new ideas, and a new national maternal and neonatal health quality improvement programme.
Wales
Efforts here to reduce the rate of perinatal death include the work of NHS Wales’ 1000 Lives Improvement National Stillbirth Working Group, Maternity Network Wales and the Safer Pregnancy Wales campaign.
Northern Ireland
The Maternal and Infant Steering Group prioritises improving care related to all baby deaths from miscarriage to babies who die at up to one year old.
Scotland
The key effort is coming from the Scottish Patient Safety Programme, which sought, among other things, to address smoking in pregnant women and highlight the importance of mothers being aware of their babies’ movements, the Maternity and Children Quality Improvement Collaborative, and the expert Scottish Stillbirth Group. All are making headway on the overall aim to reduce the incidence of avoidable harm and acute maternal morbidity in women and babies by 30% by March 2019.
Shifting priorities
Managing the impact of human factors was also one of three key recommendations that came out of the RCOG’s Each baby counts report (RCOG, 2017). It involved an assessment of the reviews into the care of 1136 babies born in the UK during 2015: 126 were stillborn, 156 died within the first seven days after birth, and 854 were left with severe brain injuries. It concluded that 76% of those cases might have had a different outcome with different care.
Human factors are ‘an organising principle’ in other safety-critical industries, says Professor Reid. ‘And that should be the focus in healthcare.’
This resolve to understand the impact of culture, systems and relationships on a team, particularly when it is under pressure, is reflected in the shift in emphasis when things go wrong: there has been a palpable move from assigning blame to learning lessons.
This change runs to the heart of the new understanding of safety, and resonates at every level. For example, in England the reformed NHS Litigation Authority became NHS Resolution in April, and now takes a different approach to delivering compensation with a ‘shift upstream to support candour and learning to address the rising costs of harm in the NHS’ (NHS Resolution, 2017b).
It has introduced an early notification scheme for maternity services, and expects to be informed within 30 days of potential cases of brain damage at birth ‘so that help and learning can be provided more quickly’.
What’s more, a new national network offers peer-to-peer support for affected healthcare staff, including advice on delivering candour in practice, and mediation when the relationship between the organisation and the family is at risk of breaking down.
In the same vein is the rapid resolution and redress scheme for severe birth injuries proposed in Better births, which envisages prompt investigation and a package of support for eligible families to open up opportunities for learning much earlier (NHS England, 2016a).
Furthermore, the Healthcare Safety Investigation Branch (HSIB), which began operating in England in April, has the aim of making safety recommendations ‘for learning and improvement, not to attribute blame or liability’ (HSIB, 2017).
Donna Owen, lead midwife in North Powys/clinical risk, Powys Teaching Health Board, has witnessed these changes happening on the ground over the past eight years in her role.
‘I think there is much more appetite to review things and learn lessons from them,’ she says. ‘We are moving from a blame culture to looking at the processes around an incident – almost a cause analysis – looking at every single bit of the process and how
to improve on that.
‘I work closely with the quality safety team within my area and midwives are actively encouraged to fill in incident reports. We had a big drive to get people to report some years ago and that reporting rate has continued. They all come to me for review, and I use them in the learning and the skills and drills training.
‘It’s about discussion, continuity, openness, transparency and looking at the bigger picture for women, giving them individualised care.’
SAFETY IN NUMBERS
21/49 Where the UK ranks for stillbirth rates among high-income countries (The Lancet, 2016)
£1.7 bn The NHS’s clinical negligence payments in England last year, including costs and settlements (NHS Resolution, 2017a)
50% The amount by which stillbirths, neonatal and maternal deaths, and intrapartum brain injuries in England should be cut by 2030 in order to meet the national maternity ambition (Department of Health, 2016)
18% The reduction in the rate of stillbirths in Scotland between 2013 and 2016 (Healthcare Improvement Scotland, 2016)
Setting up a safe service
Individualised care and listening to what women want – core messages in both the Scottish and English maternity reviews (Scottish Government, 2017; NHS England, 2016a) – are fundamental to a safe service, believes Sascha Wells, director of midwifery, obstetrics and gynaecology at University Hospitals of Morecambe Bay NHS Foundation Trust. She joined the trust in 2011 and has seen the service undergo a transformation that has been shaped by input from women at every stage.
‘We have made huge improvements, huge changes across the services and what we have done in order to do that is engage the community and listen to women and families,’ she says.
‘The feedback from women has been incredibly positive. We don’t get it right 100% of the time, but when we don’t get it right, we absolutely seek to understand what we could have done differently and to learn from it, share it – and share it with women and families. That is very much part of that learning. It’s about supporting a positive safety culture where people feel they can be honest with each other and honest with women and their families.
‘What assures me we are safe from a clinical perspective is that the harm we are causing women and babies is minimal. We have high reporting levels and low levels of avoidable harm.
‘What women are telling us in their feedback is that they feel safe, they feel supported in their birth wishes, and that they feel they’re being heard. That is the best evidence of a changing culture.’
She adds: ‘If you want to ensure services are safe you need to work with women and provide personalised and individual care that meets her needs. And in doing that, we will keep her safe.’
Sascha also reflects on the changing language of safety – the move away from ‘high risk’ and ‘low risk’ to talking about ‘complexity’, and the connotations of the terms ‘natural’ and ‘normal’ birth.
‘We stepped away from the natural birth movement some time ago,’ she adds. ‘Now we talk about providing a safe, active birth regardless of the complexity, be that physical, mental, emotional or social.
‘Through all of our engagement work, what women have clearly said to us throughout is that if you use the word “normal” and that’s not what I achieve, then that makes me abnormal.
‘Women don’t want to be categorised. Better births talks about how we provide personalised care. No human fits neatly into a category, and neither does a woman in pregnancy or childbirth.’
From the very language used by midwives, safety is being considered from a new perspective, with many forces driving through the change,
including government policy and national programmes, as well as best practice and innovation on the ground (see panel, Improving safety in the four nations, on page 42).
Reducing harm THAT leads to avoidable admissions
NHS Improvement in England analysed litigation claims data and neonatal admissions data to identify four key clinical areas of potentially avoidable harm to babies. It estimates that more than 20% of admissions of full-term babies related to these areas could be avoided. The four key areas are:
- Respiratory conditions
- Hypoglycaemia
- Jaundice
- Asphyxia (perinatal hypoxia-ischaemia). (NHS Improvement, 2017)
Safety agenda advances
The evidence suggests that these combined efforts are making a difference.
Avoidable harm in hospitals in England is down 8% over the last three years (Department of Health, 2017). Across the UK, the rate of extended perinatal mortality has fallen from 6.04 to 5.61 deaths per 1000 total births between 2013 and 2015 for babies born at or over 24 weeks. This has been fuelled by a reduction in the rate of stillbirths, down from 4.20 to 3.87 per 1000 births, especially stillbirths of at least 32 weeks gestational age (MBRRACE-UK, 2017).
The devolved governments are making real progress. The registrar general’s annual report for Northern Ireland (2016) highlighted that 2015 saw the lowest rate of stillbirths ever recorded in the province; in Wales, stillbirth rates fell to 4.12 per 1000 births in 2015 (All Wales Perinatal Survey, 2015); and in Scotland there was an 18% reduction in the rate of stillbirths between 2012 and 2015, surpassing the nation’s 15% reduction target (Healthcare Improvement Scotland, 2016).
Mandy Forrester, RCM head of quality and standards, says the RCM is committed to pushing the safety agenda even further forward.
‘Safety has got to be the thread that runs through everything. In the past, we might have waited for things to happen and reacted to them, but moving forward, we want to be much more responsive and reflective to things as they come up.
‘The RCM is trying to take a broad all-encompassing view, to join the threads across the work being done to improve safety, as well as supporting consistency in care across services up and down the UK.
‘For example, we are producing a comprehensive new set of guidance, updating evidence-based care in labour, and extending that to postnatal care as well.
‘And work is being done to standardise safety huddles and handovers to a consistent standard – important activities that can make a big difference to safety.
‘The RCM is also developing a career framework with a really clear description of what a role involves and what you need to fulfil it.’
And the RCM continues its work improving the wellbeing of midwives, student midwives and MSWs through its Caring for You campaign.
‘Yes, we need to make sure that practitioners are safe,’ says Mandy. ‘But are they working within a safe service and a safe system? Is their personal wellbeing supported? Have they worked a 12-hour shift without taking a break?
‘Everything we are doing is to support the ambitions to reduce neonatal and maternal deaths. It’s not an impossible ask, even within a stretched NHS. It’s about how the services are organised, and how local maternity systems are able to share the workload. I think there will be a lot more collaboration going on.
‘We will continue to attempt to influence policy around safety and work tirelessly to progress the safety agenda in everything we do.’
Staying safe: A mother’s story
Lynne Campbell was 30 weeks pregnant when she became aware that she hadn’t felt her unborn baby move for more than 24 hours. She recalled an earlier conversation with her midwife who had stressed the importance of being aware of the baby’s movements – a practice promoted by Scotland’s Maternity and Children Quality Improvement Collaborative – and that she should contact the hospital if anything changed.
‘I remembered my midwife had told me not to hesitate to get in touch if anything changed and she had also given me some leaflets to take away. After reading the leaflets, we decided to call the midwife, even though it was the middle of the night. She advised us to come to the hospital immediately to get checked. Following some tests, I was urgently transferred by ambulance to the maternity unit in Dundee.
‘Within 15 minutes, Innes was delivered by caesarean section. He was 10 weeks early, weighing only 3lbs 15oz, and was kept in hospital for a few weeks. Innes is now a happy, healthy little boy. I’m so thankful I had that conversation with the midwife, and that I read the leaflets she gave me.’ (Healthcare Improvement Scotland, 2016)
