Maternity review sets bold plan for safer, more personal services

Maternity services in England must become safer, more personalised, kinder, professional and more family-friendly.

That’s the vision of the National Maternity Review, which today (Tuesday) publishes its recommendations for how services should change over the next five years.

The NHS England commissioned review – led by independent experts and chaired by Baroness Julia Cumberlege – sets out wide-ranging proposals designed to make care safer and give women greater control and more choices.

The report finds that despite the increases in the number of births and the increasing complexity of cases, the quality and outcomes of maternity services have improved significantly over the last decade.  The stillbirth and neonatal mortality rate in England fell by over 20% in the ten years from 2003 to 2013 (HSCIC Indicator Portal NHS Outcomes Framework Indicator 1c). Maternal mortality in the UK has reduced from 14 deaths per 100,000 maternities in 2003/05 to 9 deaths per 100,000 maternities in 2011/13 9 (MBRRACE-UK Confidential Enquiry into Maternal Death 2015. Figures exclude coincidental maternal deaths). The conception rate for women aged under 18 in England, a key indicator of the life chances of our future generations, reduced by almost half, between 1998 and 2013 (ONS, Conception Statistics, England and Wales, 2013).

However, the review also found meaningful differences across the country, and further opportunities to improve the safety of care and reduce still births.

Prevention and public health have an important role to play, as smoking is still the single biggest identifiable risk factor for poor birth outcomes. Obesity among women of reproductive age is increasingly linked to risk of complications during pregnancy and health problems of the child.

The framework highlights seven key priorities to drive improvement and ensure women and babies receive excellent care wherever they live. To make care more personal and family friendly, the report says that the following is needed:

Personalised care, centred on the woman, her baby and her family, based around their needs and their decisions, where they have genuine choice, informed by unbiased information.

  • Every woman should develop a personalised care plan, with their midwife and other health professionals, which sets out her decision about her care reflecting her wider health needs
  • It also recommends trialling an NHS Personal Maternity Care Budget which would give women more control over their care, whether it is through an existing NHS trust or a fully accredited midwifery practice in the community

Continuity of carer, to ensure safer care based on a relationship of mutual trust and respect in line with the woman’s decisions.

  • Every woman should have a midwife, who is part of a small team of four to six midwives, based in the community who knows the women and family, and can provide continuity throughout the pregnancy, birth and postnatally
  • Community hubs should enable women and families to access care close to home, in the community from their midwife and from a range of other services, particularly for antenatal and postnatal care.

Better postnatal and perinatal mental health care, to address the historic underfunding and provision in these two vital areas, which can have a significant impact on the life chances and wellbeing of the woman, baby and family.

  • Postnatal care must be resourced appropriately.  Women should have access to their midwife (and where appropriate obstetrician) as they require after having had their baby.  Those requiring longer care should have appropriate provision and follow up in designated clinics
  • The report endorses the recommendation of the Mental Health Taskforce published last week for a step change in the provision of perinatal mental health care across England

A payment system that fairly and more precisely compensates providers for delivering different types of care to all women, while supporting commissioners to commission for personalisation, safety and choice.

To make care safe, with better outcomes, the report says the following is needed:

Safer care, with professionals working together across boundaries to ensure rapid referral, and access to the right care in the right place; leadership for a safety culture within and across organisations; and investigation, honesty and learning when things go wrong.

  • There should be rapid referral protocols in place between professionals and across organisations to ensure that the woman and her baby can access more specialist care when they need it.
  • Teams should routinely collect data on the quality and outcomes of their services, measure their own performance and compare against others’ so that they can improve.
  • There should be a national standardised investigation process for when things do go wrong, ensuring honesty and learning so that improvements can be made as a consequence

Multi-professional working, breaking down barriers between midwives, obstetricians and other professionals to deliver safe and personalised care for women and their babies.

  • Those who work together should train together. Multi-professional learning should be a core part of all pre- and post-registration training for midwives and obstetricians, so that they understand and respect each other’s skills and perspectives.

Working across boundaries to provide and commission maternity services to support personalisation, safety and choice, with access to specialist care whenever needed.

  • Providers and commissioners should come together in local maternity systems covering populations of 500,000 to 1.5 million, with all providers working to common agreed standards and protocols.

The report also recommends that NHS England seeks volunteer localities to act as early adopters to test the model of care set out in the report determine which flexibilities are required, and identify the most viable solutions for the long term.

Baroness Julia Cumberlege, Chair of the Maternity Review said: “To be among the best in the world, we need to put women, babies and their families at the centre of their care. It is so important that they are supported through what can be a wonderful and life-changing experience. Women have told us they want to be given genuine choices and have the same person looking after them throughout their care. We must ensure that all care is as safe as the best and we need to break down boundaries and work together to reduce the variation in the quality of services and provide a good experience for all women.”

Simon Stevens, the Chief Executive of NHS England, said: “The independent review finds that quality and safety of NHS maternity services has improved substantially over the past decade, and most new mums tell us they are looked after well. But it rightly argues that the NHS could and should raise its game on personalised support for parents and their babies, better team working, better use of technology, and more joined up maternity and mental health services.”

Around 700,000 babies are born every year and for the majority, birth will be straightforward, with most families reporting they had a good experience.

However, as birth rates continue to increase, with more women giving birth later and increasing numbers requiring more complex care, the system is under increasing pressure. It is also clear that the quality of care varies across the country.

The review was tasked with setting out recommendations for how maternity services should be developed to meet the changing needs of women and babies. It was conducted by an independent panel consisting of NHS staff, professional bodies and user groups.

Categories: HomeMaternity reviewNews



  1. Ann Bentley says:

    The problem with lowering the still birth rate is that there are far more inductions being carried out. If a woman says that she is experiencing a reduction of fetal movement then she should be taken seriously with measures taken to ensure fetal well being. The problem is that a ctg can only show us how the fetus is at that moment in time, not what they will be like in an hour from now. If a woman reports 2 episodes of reduced FM then she is put forward for induction. IOL is the first step in the cascade of intervention that leads to women experiencing birth trauma. The problem is that some women are using the reduced FM scam to gain access to IOL when they get “fed up of being pregnant”. It is more effective than the waters going scam as this can be discounted by a simple test. We need to teach women to not fear labour as they do at present. Every woman should go to parentcraft classes where relaxation and other techniques should provide calm, in control labouring women instead of fear filled lambs to the slaughter.

  2. Michael Cole, Grandfather of Theo Hibbert (stillborn) says:

    This is the first part of my comments due to a 1,500 word limit on comments. Sections C and D are in a separate comment.

    A lot of what this report recommends is common sense but why is it mainly focused on local organisational changes? Apart from the care bundle mentioned on page 50, ways to rapidly identify complications in para 4.34 and some postnatal and mental health pointers in chapter 4, I was expecting to see a lot more about what the clinical elements of the future care model should be – what is maternity best and safe practise clinically?

    We often read that adverse outcomes could have been avoided with improved clinical care. What is that improved care? When things have gone wrong clinically what has been learnt and shared (or needs sharing) amongst the professions? Do the NICE clinical guidelines referred to need improving? For example, the current approach to assessing the risk for the woman and baby has been acknowledged as flawed. So what should it be? Do the guidelines support multi-professional team working? What needs to go into the new training programmes? And why no mention of the Group B Strep testing issue that currently has high public focus?

    The recent MBRRACE-UK report suggests that six in ten stillbirths are potentially avoidable and that babies are dying because of basic gaps in care. That report identifies failures in practise amongst the contributory factors, but no reasons why. So the faults are not just organisational. The delivery of safe maternity care is totally dependent on clinical staff who have the skills, knowledge, experience and support to know what they are doing. And there being enough of them.

    And why is there no mention of the regulators in your care model? They are a key part of the safety element. The legislation that governs the NMC’s operation (the Nursing and Midwifery Order 2001) says quite plainly that ‘the main objective of the Council in exercising its functions shall be to safeguard the health and well-being of persons using or needing the services of registrants’. Was the review leant on to keep the regulatory system and its failings (see below) out of the spotlight? Aside from updating the education standards, where/how do they sit in your proposed model?

    I am dismayed. My experience and evidence to the review focused on the serious problems with NHS investigations into serious clinical incidents, as in the case of my grandson, Theo Hibbert, who died of a cardiac arrest due to unnoticed foetal distress in the second stage of labour in a hospital Midwife-led Unit. The agency midwife leading the care did none of the correct things to help him. She had worked as a midwife for 14 years and because of serious concerns about her practise the hospital referred her to the regulators for investigation of her practise, which discovered that she did not know how to monitor a baby’s heartbeat correctly, did not understand what the abnormal heart recordings meant, did not recognise and escalate the seriousness of the foetal compromise and was unfamiliar with performing an episiotomy to expedite delivery (a pre-requisite for registration).

    We have fought for 4 years for answers to why she lacked these skills, knowledge and experience. So no lessons from these practise failures have been learned to prevent other avoidable tragedies.

    In Chapter 3 of this report (‘What we heard from women and their families’) and in Chapter 4 (‘When things go wrong’), the focus is exclusively on the failures in the local investigations into serious incidents. In Theo’s case, having established the full local facts and learning with the hospital (and personally validated their improvements), our experience is that the major problems lay with the Local Supervising Authority (LSA) and the Nursing & Midwifery Council (NMC) when midwives are referred to them for investigation of their fitness to practise.

    I submitted a paper to the review entitled ‘Blowing The Whistle On Midwifery Fitness To Practise Investigations’. Some of the key points were:

    a. The regulatory investigations only go as far as identifying what skills, knowledge and experience a midwife lacks when referred to them as unfit to practise.

    b. They don’t investigate WHY and so be able to learn lessons and manage the risk of repetition to future women and babies. There’s no root cause investigation of the systemic failures that led to the midwife’s practise failures. The LSA told me that such organisational failures could not be identified. When my MP and I met with the NMC’s CEO she simply told us that the NMC could not investigate systemic failures. That was it. The fact is that investigation of systemic failures is avoided. The NMC employed a lawyer to say that the hospital should do it – i.e. find the systemic failures in an agency midwife’s education, training, NMC registration, actual work experience, continuous development, LSA supervision, agency vetting and career appraisal. That’s nonsense.

    c. They only investigated the midwife’s practise in the second stage of labour where her failings occurred and her retraining covered only that. They did not check her fitness in other practise areas or settings, which ironically is where she’s ended up working because she no longer has the confidence to work in a labour setting.

    d. I was told that the LSA had two priorities – to ‘recover’ the midwife (i.e. get her back to work) and to support Theo’s parents, which only went as far as offering to explain the process to them. There was nothing about a priority to protect future women and babies, which is why the regulators exist in the first place.

    e. the midwife was retrained while the NMC investigation took place. The NMC legal people said there was a case to answer but the rules say if a midwife is no longer unfit to practise the case has to be closed without her having to answer the charges. So the failings were swept under the carpet.

    f. the NMC and LSA also show absolutely no interest in knowing the reasons why they have such a person on the register and will not even escalate the lack of root cause analysis to their superiors.

    From previous Parliamentary inquiries, from discussions with the Professional Standards Authority and the King’s Fund, from members of the review team that I met and from other families I met during the review, I know I’m not alone in identifying these failures.

    Aside from avoiding learning lessons (echoes of Morecambe Bay?) this is also not fair on midwives referred to the NMC. How can an NMC legal panel decide on the correct sanctions to apply to a midwife without knowing how much the system was to blame as well as how much the midwife was to blame for the practise failures?

    Why is there nothing in the report about this? And I see nothing about the experiences you heard about from other parents and families. Why not even a summary or some examples?

    Why is a ‘£3,000 birth budget’ the priority rather than staff having the skills, knowledge, experience and support to do the job and there being enough of them. That’s the baseline.

  3. Michael Cole, Grandfather of Theo Hibbert (stillborn) says:

    This is the second part of my comments due to a 1,500 word limit on comments. Sections A and B are in a separate comment, that should be read first.

    When it comes to your recommendations for future investigations, the report talks about a ‘national standardised investigation process (for local use) for when things go wrong’. Again, why just local? That sounds like it will not be able to investigate root causes laying outside the local scope. So the regulators will continue to avoid any investigation of the failures in systems and processes that they own or rely on to ensure fitness to practise. And will private providers working for the NHS be in the scope of these new investigations?

    This seems to contradict the original recommendation by the Public Administration Select Committee (PASC) inquiry for a new clinical accident investigative body for serious cases, which is now being set up as the Healthcare Safety Investigation Branch (HSIB). Bernard Jenkin MP, the chairman of the PASC, wrote to me to clarify that:

    a. ‘The (proposed) investigative body would look at all factors contributing to an incident, including why someone might have lacked the necessary skills. This would include what we refer to as the “whole system” approach – i.e. whether regulators or the policies of professional bodies contributed to that lack of key skills.

    b. It would be able to investigate agencies. In fact, you will see that we recommend it has capacity to investigate the whole of the health sector, not just the NHS.

    c. We did not consider whether it should be able to look at past cases. But in principle, where there is learning to be gained by looking at past cases, I hope they would do so, as part of dealing with the current workload.

    d. The new body would be only one component of the overall improvement, but it does seem to be the component which is wholly lacking at present – objective capacity to establish what has gone wrong quickly, without the need to find blame, so that lessons can be learned and disseminated across the whole health system. Had this occurred in Theo’s case, I hope it would have saved you so much distress.’

    Note, if past cases are not reopened and completed to learn lessons then that will mean that more babies and women will have to suffer and probably die before something is done to learn those lessons and fix the systemic failures. Please don’t let that happen.

    Are you convinced that the new HSIB will deliver this because you say that these investigations should be carried out under the auspices of regional maternity clinical networks? Who exactly do you envisage carrying out these investigations? They need to be truly independent unlike the problem identified with LSA investigations where midwives investigate other midwives.

    I have seen from meeting notes of the expert group setting up the HSIB that the Secretary of State has stated that, once established, the new safety investigation will be asked to consider a particular focus on maternity cases for its first year. Were you aware of that? I assume from all the evidence provided to you that you have the starter list of cases to reopen and complete.

    Who in NHS England will manage and steer the whole plan to deliver all the actions in Annex A? How will they report progress to the public?

  4. sharon oates says:

    where will the money come from that is needed and how will we employ more midwives and to a lesser extent doctors?

  5. John Ferguson says:

    An excellent report and long overdue. My observations on the comments and my experiences working in and with NHS commissioned midwifery services for the last few years.

    1. Obstetricians generally never support normality as the medicalised model is their business (and their livelihood). A few gladly are changing their minds but many feel threatened by this and can be selective on the evidence.

    2. The debate continues about c/sections and managing high risk. This report doesn’t dismiss this, in fact it supports the need for this to continue and improve. However the reality is most women have an uncomplicated birth without any problems so this is to be supported. Those who do have complications will be looked after. Pregnancy is more than just a physical process.

    3. What women don’t get is continuity, a relationship with their midwife (as they see so many) plus unbiased and evidenced based advice. By not getting this they are not in full control to make their decisions and their choices. The bar for women is very, very low. If a good outcome from a pregnancy is a living baby then whilst this is absolutely right surely we can aim for other outcomes as well. There has to be so much more.

    4. Choice. Many maternity providers say there is choice. The reality is there is choice but its all the same model. There is very little choice of other models of care e.g. MLUs, home birth etc. At the moment there is only one product on the shelf and all the shelves stock the same item.

    5. Choice (2). There is a consensus that women can chose any provider/service they want. The reality is they can’t. Women can only choose the providers their commissioners commission and in some areas the number of providers is low and unfortunately the quality is not good. So no options or real choice. This review if commissioners follow it will open the door completely. Currently providers are paid a tariff to look after women. If this tariff (or budget) is given to the woman then she can spend it where SHE wants. Therefore women will develop the market as they have the funds and we can move away from a landscape of monopoly and frankly substandard services.

    6. A number of heads of midwifery and midwives continue to say ‘we already do the things this review and previous ones have recommended ‘. Do what exactly? Practice hasn’t changed apart from a few trailblazers. The past reports advocating change have never been implemented so in reality nothing has changed. There is no transparency of outcomes or quality, it is all hidden. Too many midwifery services are unfortunately service led rather than women led and thats why the outcomes show this.

    Finally this review is not about obstetricians, midwives, GPs, hospitals, commissioners etc its about WOMEN AND THEIR FAMILIES. The greatest contributors to this report are the people it was meant for, the women. If those providing services don’t like what they read then they are not providing what the audience have asked for.

    Providers should completely review what they are doing and redesign their services and be driven by the women (or they may soon fail to exist). If professionals don’t feel they can do this in their organisations then break away and set up yourselves. It can be done and it is being done. This review now allows this happen more easily so please make it real. Women in the review so want you to do this so don’t let them down.

  6. HP Dietz says:

    I’m afraid I agree with Pauline Hull. There is nothing bold or new here. Quite on the contrary. The literature of the last ten years is largely ignored, as are the underlying reasons for some of the poor outcomes reported by the NHS.

    When Ms Cumberledge published her first maternity review in the 90s it contained very similar statements. The remedies suggested then are precisely what led to the disasters chronicled in the ‘Morecambe Bay Report’.

    And now Ms Cumberledge suggests more of the same. The NHS commissioned a whitewash, and they got something even worse: recommendations that are rather likely to make things worse.

    But then that’s what tends to happen whenever ideology collides with reality.

    Professor in Obstetrics and Gynaecology

  7. Pauline Hull says:

    Not a single mention of how a timely, planned cesarean birth can save lives (especially full-term babies at risk of stillbirth), protect against pelvic floor damage, and result in high maternal satisfaction for women who choose it.

    ‘Safety’ on pg.23 reads: “There was evidence from the data of opportunities for improvement in the safety of maternity services. For example: stillbirth … instrumental deliveries resulting in third and fourth degree perineal tears…[and] almost half of CQC inspections of maternity services result in safety assessments that are either ‘inadequate’ (7%) or ‘requires improvement’ (41%)”

    And despite the fact that a cursory glance at NHSLA obstetrics cases demonstrates significant (and costly) mortality and morbidity of mothers and babies when cesareans are carried out too late or not at all, England’s new National Maternity Review contains just three mentions of cesareans:

    Pg.3 refers to an anecdote about watching a twin caesarean delivery.
    Pg.27 refers to RCOG Clinical Indicators project data on emergency caesarean sections rates.
    Pg.77 cites ‘rates of caesarean section’ as a marker of quality in South West Trusts.

    Unsurprisingly, and disappointingly, the ‘Maternity review bold plan for safer, more personal services’ is not a bold one at all – just the same old, same old – IDEOLOGY continuing to trump balanced INFORMATION in NHS maternity care.

  8. Thérèse says:

    I agree with a previous comment that women can already self refer to have their care wherever they choose. Also, that the benefits of individualised care and continuity of carer are well documented. The barriers are not enough Midwives, culture of fear and blame, medicalisation of birth and crucially these issues result in women’s voices not being heard. Personal payments will NOT fix these things. This report is a huge missed opportunity, I feel sad and disappointed.
    It would have been far more powerful if maternity services were compelled to address staffing shortages, reduce unnecessary intervention and LISTEN to women and their families. 😥

  9. Ruth wiggins says:

    This all sounds wonderful – but says nothing that all those working in maternity services don’t already know and hasn’t been said before in previous maternity reviews. What this report doesn’t explain is how this is going to be achieved when finances are continuously being cut (in all areas of the nhs) and whether the review will be upheld and taken seriously by the powers that be. Maternity services are completely different than other services within the nhs, yet frequently are are expected to ‘fit’ with medical or surgical directorates within trusts. I would love to be inspired by this review and will certainly (as an nhs midwife) get behind any positive changes for women that can be gained from it – as I am sure my colleagues with. Sadly though, we have heard it all before and all action the government impose across the nhs has resulted in less rather than more choice for women and a shortage of midwives. I have the greatest respect for baroness cumberlege and agree wholeheartedly with the findings of the review, but unfortunately no faith whatsover in Jeremy hunt and David Cameron who ultimately hold the purse strings and to be honest, aren’t really all that interested. If you feel strongly about this, start by pressing your local MP’s by email / letter or in person to support the findings of the review and insist that their leaders take it seriously.

  10. Annette says:

    As a senior midwife working in a large tertiary unit and with many referrals from nearby units because of our specialist services, I will think it will be very difficult for us to loose a portion of our staff to the community to provide the type of care discussed. We are under staffed as it is and with the women we see becoming sicker with long standing health conditions let alone the number of women with obesity, should these women really have a choice where they deliver their babies. Some women have unrealistic ideas about labour and birth already, we will be putting midwives in a very difficult position (loss of their registration) if women are refusing to come in for care and some thing goes wrong.

  11. NHSWorker says:

    Interesting mixture of the mutually exclusive “competition” and “collaboration” as is usual in the confused NHS. Lots about “choice” but how does that help the woman whose local maternity unit has closed (and there are lots of those, even with substantial catchments) and her nearest one is now more than 30 minutes away, even in a fast car (in Holland 20 minutes is deemed acceptable based on relevant evidence).
    Another report containing old material and some new jargon, which we can’t disagree with – but which is intended to kick the real issues into the long grass (adequate services and staffing at all levels, proper choice based on unbiased information not prejudice, reasonable sized (not tiny but not too big) consultant-led maternity units that are accessible by all women – the average size of these units in Holland is 1700 births a year and nobody is more than 20 minutes away; as mentioned above, and the investment needed). Disappointing for ordinary women; a kick below the belt for Midwives. Not a morale booster for anyone. Missed opportunity.

  12. Kamie says:

    Greater control ourselfs. . They sometimes think they are gods. I begged for a stitch and closer cervical monitoring and always no. To get told have a positive attitude and more women have lost more babies than myself . . . A fight for a second opinion with a professor stated I did need a stitch after a loss at 20week’s and 22 weeks . People need to listen to us. Even ringing maternity ward for help I got fobbed off twice!!

  13. Anonymous says:

    Obstetricians, Midwives and other maternity healthcare providers need to start following and communicating with women and families the evidence. i.e Birthplace study and other research. A just in case philosophy or defensive practice is not acceptable as it can potentially make a straight forward birth a complicated one and therefore less safe. Evidence indicates place of birth and the environment (that includes her carers) can directly affect birth outcome.

  14. Lynsey says:

    I think that any report that prompts a discussion into this area can only be seen as a good thing. For too long people have given feedback and asked for improvements from a service that is clearly disjointed and flawed. Having had 3 very different experiences when pregnant with my children, I find it difficult to believe that such a poor level of service is allowed to go on, in particular with the support for families after the birth.

  15. Gina says:

    It still doesn’t address the need for a doctor to be available to a midwife led unit. Yes i understand that it’s a midwife unit, however after personally experiencing a 40 minute ambulance journey in latter stages of labour due to no doctors I think it’s definitely needed. This could free up the ambulances for others in dire need of them. 40 minutes to the hospital + paperwork/delivery of me to the unit time + travelling back to base time is almost 2hrs where that ambulance could have been used for an emergency out in the community. The ambulance service is stretched enough. All for cost cutting. I read something else elsewhere where women are going to be allocated 3k for their birth. Can this 3k not be used for doctors?? I trusted the midwife (Tracy at hcmu) totally to do the right thing she did the right thing in getting myself to a doctor. However she could have gotten me a doctor a heck of a lot sooner if there was one available close by.

  16. donna says:

    This is great news I don’t want another family to go through what I had. My care from the midwifes was amazing but from the locom Dr it was a disaster he nearly cost me my life after I had my stillborn. I still cant move on from that fact that he didn’t even care and never said sorry

  17. Diederik Sakkers says:

    “There should be rapid referral protocols”… but that also means that specialised care must be available within half an hour of travel (max.). I would therefore always have my birthing in a hospital #justtobesafe . But then again, I am not a woman.

  18. Ken says:

    The aspirations of this review aren’t different from “Changing Childbirth” and in some ways are less ambitious. The 1990s program achieved all of your “new” ideas and is still working now. It even survived the disastrous Cumberledge reorganisation of our integrated team, as we kept our three midwives and HV.
    The only new thing is the revision of the payments, yet we are delivering all of this without. A personal budget is not required unless you intend to fragment delivery, but then you would lose continuity as you cannot have every conceivable player integrating with every other player.
    This is a complete waste of effort, you have merely reproduced earlier work, probably because you didn’t read it.

    • jacqui lovell says:

      I completely agree this is privatisation of another arm of the NHS surreptitiously disguised as personal choice all part of the neoliberal agenda!!

  19. Julie willis says:

    I have noticed that midwives seem
    More stretched now than ever. I write as a mother of two (aged 4 & 1) and as a mature medical student who has completed obs & gynae placements.

    My midwife friends tell me there aren’t enough midwives and they’re worried that cuts to nursing bursaries will cause fewer to train.

    Do you plan to increase the number of midwives? If so, what do your plans entail?

    Of course it is nice for a woman to be in labour with a midwife that she knows but due to baby’s arrival being unpredictable this isn’t very practical. Adequate midwifery provision post natally is very important and adequate staffing is the most important factor in that respect.