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Putting safety at the heart of care
Tomorrow (27 March) marks the two year anniversary of Better Births. Celia Ingham Clark, Medical Director for Clinical Effectiveness at NHS England and interim National Director of Patient Safety at NHS Improvement, says this is the perfect opportunity to reflect on what has been achieved to date and how we can continue to work together to ensure that safety is always at the heart of the care given to women and their families.
Patient safety is something that I am passionate about. At NHS Improvement we continually strive to increase our understanding of what can go wrong in healthcare. We also seek to support and enhance the capability and capacity of the NHS to improve and tackle the challenges and barriers that can impact patient safety improvement.
So it is crucial that safety is the golden thread running through the Maternity Transformation Programme, as we work together to deliver the Better Births vision for maternity services to become safer, more personalised, kinder, professional and more family friendly. Every area of work in the Maternity Transformation Programme has a significant contribution to make to safer outcomes in maternity services, whether that is preventing smoking and obesity, enabling system communication by improving data quality, and personalisation, ensuring the women feel empowered, decisions facilitated and their voice heard throughout the maternity journey, all of this activity supported through Local Maternity Systems.
The National Maternity Safety Ambition, launched in November 2015 and updated in November 2017, is to reduce the 2010 rates of stillbirths, neonatal and maternal deaths and brain injuries in babies that occur during or soon after birth by 20 per cent by 2020 and 50 per cent by 2025; and to reduce the national rate of pre-term births from eight per cent to six per cent by 2025. This ambition for maternity and neonatal services is an inspirational, but achievable goal, and has created a once in a generation opportunity for real change. We now have to translate this goal into improvement at a clinical level.
The Maternity Transformation Programme coordinates a range of initiatives and activities which collectively seek to achieve the vision set out in Better Births and the Secretary of State’s maternity safety strategy – by bringing together a wide range of organisations to lead and deliver across 9 work streams. The information and intelligence that comes from MBBRACE and EBC is essential for ensuring that we focus our efforts in the right places.
Workstream 2 of the Maternity Transformation Programme, promoting good practice for safer care, is where we can add value and drive clinical improvements through programmes such as the Maternal and Neonatal Health Safety Collaborative, the Saving Babies Lives care bundle, Maternity Safety Training Fund and ATAIN, providing the tools and techniques to effect change. Collectively, these initiatives equip the system to understand and address the issues that can impact patient safety, such as the need to develop and nurture an effective safety culture and the benefits of mobilising collaboration and system level improvement.
A number of safety initiatives, coordinated within workstream 2 are already making a significant contribution to the realisation of these aims. For the first time in England, we have a nationally coordinated improvement programme, the Maternal and Neonatal Health Safety Collaborative, involving every maternity and neonatal service in the country. The programme has been set up to support frontline teams to lead a range of improvements, drawing on leadership roles within maternity while also developing capability using evidence based improvement science to enable teams to continue their safety journey beyond the life time of the Maternity Transformation Programme.
The Maternal and Neonatal Health Safety Collaborative has just ended its first year with a national learning event to share the learning and reflections from trusts who participated in wave 1. There has been a huge leap in the skills and confidence of frontline staff, with around 200 staff now trained in quality improvement, creating a movement of improvers. Wave 1 trusts have developed 176 improvement projects focusing on areas such as smoke-free pregnancies, stabilisation of the very preterm infant and recognition and management of deterioration in mother or baby.
Everything we do in the Maternity Transformation Programme contributes to improving safety. And it’s what women want too. As Better Births was developed, women consistently told us was that they want personalised care, continuity of carer, safer care, kinder care, a service that was family friendly. They want to have a say, to make decisions about their maternity care, their birth and their aftercare.
We have set ourselves very high standards for safety in maternity and neonatal care. We have achieved some fantastic results but there is still much more we can do. Please come and join us tomorrow (27 March) in Manchester and see where the next 12 months will take us.
Safety should be at the heart of any system, moreover those which impact either directly or indirectly on the people using a service or those offering a service. It’s more than shameful then that NHS England and others in the NHS family don’t provide protection to individuals be they patients of members of its own workforce, whilst it does provide protections to senior managers engaged in wrongdoing, thus making every attempt to limit its liability. The excessively high level of Employment Tribunals which are now published will bear this out, although a researcher will be hard pressed to see how much money is being misappropriated by NHS managers in an attempt to stop cases being heard, the same is true of cases before the Parliamentary Health Service Ombusman
in the airline industry pilots are encouraged to report ‘incidents’ so that lessons may be learned by the whole industry to the benefit of all.
Too many in OUR=NHS seek to hide their errors – or in some cases are forced by bean counters to be
“Economical with the truth”. to the Nth degree.