1. Introduction

The Perinatal Quality Surveillance Model (PQSM) was published in December 2020 and trusts and systems were expected to implement the actions with immediate effect. Following revision to bring it up-to-date, the model is now being re-published as the Perinatal Quality Oversight Model (PQOM). 

Because of the interdependence between neonatal services and maternity services, we use the term ‘perinatal’ to refer to maternity and neonatal throughout this document.

2. What is the model for?

The Perinatal Quality Oversight Model (PQOM) has been developed in response to the need to proactively identify trusts that require support before serious issues arise.

It provides consistent and methodical oversight of NHS perinatal services and ensures we collect the information and insight we need to drive service improvement.

While provider trusts and their boards ultimately remain responsible for the quality of the services they provide and for their improvement, the PQOM supports trusts and integrated care boards (ICBs) to discharge their duties and provides a mechanism for escalation of any emerging risks, trends or issues that cannot be resolved at local level or would benefit from wider sharing. 

3. Who is responsible for what?

The model provides a structure with clear lines of responsibility and accountability for addressing and escalating quality and safety risks at trust, ICB, region and national level. 

• Trusts are the main operational unit of maternity and neonatal services in the NHS and the employer of most staff. Trust boards have accountability for perinatal oversight, with a statutory duty to ensure the safety of care, including ensuring staff have the resources they need and to consider health inequalities. The board is supported in discharging this responsibility by the perinatal leadership team and the Board Safety Champion.
• Integrated care boards (ICBs) commission most maternity services and have now had responsibility for neonatal care delegated to them. ICBs commission maternity and neonatal voices partnerships (MNVPs) which are designed to facilitate participation by women and families in local decision making. ICBs (and NHS England) have legal duties (under the Health and Care Act 2022) to take account of health inequalities issues in the exercise of their functions.
• Neonatal operational delivery networks (also known as ‘neonatal critical care clinical networks’ or NCC clinical networks) were established to ensure high-quality neonatal care, improving outcomes for all babies and families, providing safe expert care as close to their home as possible, and keeping mother and baby together while they need care. Neonatal operational delivery networks (ODNs) help to manage patient flow across the network, balancing capacity and demand, ensuring services meet the needs of patients.

It is everyone’s duty to provide or support high-quality care. That includes a responsibility at each level of the NHS to understand the quality of care and identify, address, and escalate risks. Quality care must be equitable, focused on reducing inequalities and addressing wider determinants of health.  

The NHS is in a period of transition to enable delivery of the new government mandate and the 10 Year Health Plan. The role of ICBs is being reshaped to lay the foundations for delivery of the plan, with a focus on strategic commissioning to improve population health, reduce inequalities and improve access to consistently high-quality care. As system governance evolves, it is important to recognise that the model of perinatal governance may also change.

4. The approach

Good practice principles for quality management are set out in National Quality Board’s (NQB’s) National guidance on system quality groups and includes creating an open culture and learning system that enables improvement based on a shared understanding of needs and issues.  The NQB’s guidance on quality risk response and escalation  sets out how quality risks and concerns should be mitigated and managed through the established governance, in alignment with the NHS Oversight Framework and other frameworks.  This includes the use of rapid quality reviews and quality improvement groups where concerns are being identified and need to be managed.

Quality is defined in this document in accordance with the National Quality Board’s Shared commitment to quality, as care that is safe, effective, equitable, provides a personalised experience, is well led and sustainable.

We have sought to improve our approach to quality oversight at trust, ICB, regional, and national level in alignment with the NHS Oversight Framework. Quality oversight brings together all relevant partners at every level to facilitate robust understanding and action, informed by shared and accurate information.

Safety oversight should take place as near to the patient-level as possible. An ICB and its related provider trusts, led by their boards, should take responsibility for monitoring and improving quality. Within the ICB, this will be embedded in the commissioning cycle. Only if an issue cannot be resolved at this level should it be formally escalated to the next level, unless there are significant failings representing a threat to service users or staff – or opportunities for learning. Resolution means that active action or improvement plans to meet the required standards are in place and being delivered consistently, effectively and on time.

The role of regional and national oversight is usually to support the trust and ICB to make the required improvements, rather than to lead those improvements. This will vary, depending on identified need.   

Shared working principles across all levels

• agree shared ways of working, based on trust, collaboration, sustainable improvement and equality
• develop shared views of the quality, operational, workforce and financial position in all circumstances
• share intelligence in an open, timely way
• Proactively monitor and follow up on early warning signs, including feedback from staff and people using services
• agree responsibilities, accountabilities and governance routes
• monitor and mitigate future risks

5. Roles in perinatal oversight across the NHS 

5.1 Trust

5.1.1 Role of the provider trust

The provider trust’s role includes:

• statutory responsibility for high-quality services that are safe, effective, efficient and take account of health inequalities
• effective system working and delivery of their contribution to ICS strategies and plans.

We expect trusts to carry out dynamic monitoring of the quality of maternity and neonatal services, supported by clinically relevant data, which should be informed by the key data items and wider insights identified in Annex 1.

This includes the need to identify opportunities for learning from patient safety incidents, regardless of severity of impact.  Further information on defining and recording patient safety events including how to record levels of harm can be found in the Policy guidance on recording patient safety events and levels of harm. 

Perinatal board safety champions have been in place since 2017. Their remit is to develop strong partnerships, promote the professional cultures needed to deliver better care, and play a central role in ensuring that mothers and babies receive the safest care possible by adopting best practice.

Each trust should have the following in place to ensure that board oversight for perinatal quality and safety is robust:

1. a board safety champion non-executive director (NED) is visibly working alongside the board safety champion for perinatal (midwifery, obstetric and neonatal) to provide objective, external challenge and enquiry
2. an identified frontline midwifery, obstetric and neonatal safety champion who meets on a regular basis with the board safety champion(s)
3. the trust board (or an appropriate sub-committee with delegated responsibility) discusses perinatal safety intelligence at least quarterly, demonstrates professional curiosity and is responsible for shared learning across the organisation. Discussions must include:
   • ongoing monitoring of services and trends over a longer time frame
   • concerns raised by staff and service users
   • progress and actions relating to a local improvement plan utilising the Patient Safety Incident Response Framework (PSIRF)

For neonatal incidents, the trust should work with the relevant neonatal operational delivery network (ODN) to identify and manage risks alongside the ICB. 

4. a board report should be presented by a member of the perinatal leadership team, who will provide supporting context. While the specific content may vary and will be agreed locally, it is recommended that the report includes the measures outlined in Annex 1. Where possible, data should be broken down by subgroups – at a minimum by ethnic group and  deprivation based on the mother’s postcode – to help identify potential health inequalities for investigation and action

5.1.2 Share safety and quality intelligence with ICB

Providers are expected to share safety and quality intelligence with their ICB through the commissioning cycle and must escalate any risks where mitigating actions are not bringing about the required change within agreed timeframes.  Providers are also expected to identify opportunities for shared learning. 

Where common issues or contributory factors to poor outcomes are identified, these can be addressed as part of the trust’s patient safety incident response plan.

5.1.3 Share safety and quality intelligence with the neonatal operational delivery network (ODN)

As per the neonatal critical care service specification and trust contracts, provider trusts must have a process for sharing patient safety concerns with their neonatal ODN.  This should include proactive engagement on quality and workforce issues.

Trusts must engage with ODN governance processes and attend relevant governance meetings to raise concerns appropriately to the ICB or to the NHS England regional specialised commissioning function.

5.1.4 Service user voice

The maternity and neonatal voices partnership (MNVP) lead is a key partner for the trust frontline safety champions. They should be a member of relevant trust maternity and neonatal safety meetings – such as safety champion meetings, governance meetings, perinatal quality meetings, and audit meetings. They will provide scrutiny from a service user perspective and help improve transparency and service quality oversight. They should be able to contribute insight from surveys, walkabouts and other engagement activity carried out by the MNVP. MNVP leads should receive follow-up information on any risks they raise, including the actions taken to address safety issues. 

5.2 System

5.2.1 Integrated care boards

As we transition to new ways of working, ICBs will focus on strategic commissioning to improve population health, reduce inequalities and ensure access to high quality care. 

ICBs have the following responsibilities:

• achieving the 4 principal integrated care system (ICS) purposes: improving population health and healthcare; tackling inequalities in outcomes, experience and access; enhancing productivity and value for money; and supporting social and economic development
• arranging local services through effective strategic commissioning
• holding their partners in the ICS to account using the system levers that bind them together (such as their joint system plans, partnership agreements, joint committees and collaboratives)

ICBs should continue to manage clinical quality risks in line with the National Quality Board guidance on risk response and escalation

ICBs should retain expertise in strategic commissioning of maternity and neonatal care. This will include monitoring outcomes, identifying unwarranted variation and setting priorities for quality assurance. Quality management will primarily be through contractual routes. Commissioning includes a systematic approach to user involvement and co-design. 

NHS England has commissioned a review of direct commissioning functions to determine where accountability and responsibility should sit in future and how these can most effectively be supported. In the interim, ICBs have delegated responsibility for commissioning neonatal care services. 

With respect to neonatal services, ICBs should collaborate with their neonatal operational delivery network (ODN) in the development, maintenance and review of provider patient safety incident response policies and plans. Where an ICB has concerns with neonatal services, they should, in the first instance, agree an action plan together with the relevant neonatal ODN.  

Additionally, ICBs should ensure that:

• where there is an incident arising from the mental health of a woman who is pregnant or up to one year post-partum, any implications for maternity services or for joint working between maternity and mental health services are acted on
• where there is a risk relating to pregnant women outside of maternity services (for example, emergency departments, ambulance services, primary care), there is joint working with maternity safety champions

5.2.2 Service user voice

There should be strategic service user voice leadership embedded within the ICB maternity and neonatal strategic commissioning function. In line with the Maternity and neonatal voices partnership (MNVP) guidance, this should enable a clear and accessible pathway for intelligence and insights from provider-level MNVPs. It should feed into quality meetings and allow meaningful service user involvement. 

5.2.3 Neonatal operational delivery network (ODN)

The neonatal ODN’s role is to:

• be responsible jointly to ICBs and regional specialised commissioning for the management of local pathways and the monitoring of locally agreed targets
• be accountable to the NHS England regional team through the appropriate regional board
• agree a single network plan and deliverables – aligned with the ODN specification – in collaboration with regional specialised commissioning and all ICBs within the network’s footprint. This should be signed off by the region

The ODN is integral to neonatal oversight and will lead quality improvement. The ICB should work with the ODN across the perinatal pathway. 

Each neonatal ODN should:

• share data with the ICBs within its geography
• share intelligence on neonatal critical care services with the relevant ICB(s)
• escalate any risks or opportunities for shared learning to the ICBs within its geography and the regional team

5.3 Region

5.3.1 The NHS England regional team

The regional team’s role is to:

• provide oversight of ICBs’ delivery of plans and performance and, through this, gain assurance about place-based systems and individual organisations
• translate national strategy and policy to fit local circumstances, ensuring local health inequalities and priorities are addressed
• share good practice, learning and improvement to support peer learning, including thematic learning
• support systems to manage quality in perinatal services, including statutory interventions, if required
• discuss and escalate risks and concerns with the Specialised Commissioning Quality and Governance Group, National Perinatal Surveillance Group and/or regional quality group as appropriate
• work jointly with other regulators to share intelligence and support improvement (for example, the Care Quality Commission (CQC))
• identify cross-cutting themes that may require a regional or national response (for example, additional policy guidance)

Each region will have a perinatal quality forum to review insight drawn from a wide range of quantitative and qualitative sources. These may include, but are not limited to, the key data items and wider insight identified in Annex 1.  Specialised commissioning for neonatal critical care services should have full membership of this forum and perinatal mental health should have associate membership. Other statutory agencies able to provide insight into maternity services such as the CQC and Maternity and Neonatal Safety Investigations Programme (MNSI) should also be represented. 

This regional perinatal quality forum will determine whether to escalate matters to the National Perinatal Surveillance Group (NPSG). The objective of escalation should be to support effective risk management or to enable the sharing of good practice and learning across maternity, neonatal services, and wider health services. 

When issues are escalated, it should be clearly stated whether this is for management, decision or information.  Requests requiring management or decision making should not be sent to more than one meeting.    

If risks cannot be resolved following discussion at national level – or if the expected progress is not being made – they will be referred to the regional support group to agree what support can be provided to ICBs to enable delivery.  

5.3.2 Service user voice

A service user voice representative should be a member of regional maternity and neonatal safety meetings and be able to contribute insight from system maternity and neonatal voices partnership (MNVP) leads or regional engagement activity – as well as providing a service user perspective on the safety issues discussed.

5.4 National

5.4.1 NHS England’s national team

The national team’s role is:

• to set national strategy, priorities and incentives to improve standards of care
• with regions, to facilitate supportive interventions to improve performance and outcomes
• to lead on support for organisations where performance falls below an acceptable standard or where there are governance concerns about an ICB or a provider that have led to entry into the recovery support programme

The NHS England Maternity and Neonatal Programme operates the National Perinatal Surveillance Group (NPSG). This is the national quality oversight meeting for maternity and neonatal services and is the national escalation point of the PQOM.

The purpose of the NPSG is to support the timely identification and escalation of concerns from regional teams and draw on insights from service users, regulators and other national bodies to inform decisions and action.

The NPSG identifies best practice and opportunities for shared learning and provides oversight of trusts on the Maternity Services Support Programme (MSSP) alongside the Recovery Support Programme.   

The NPSG reports into the Quality Surveillance Group, a committee of the Maternity and Neonatal Programme board, and has representation from 2 nationally appointed service user voice representatives to provide the voice of service users and families.  They provide additional insight based on issues and themes raised with them by regional service user voice representatives.   

NPSG also has representation from specialised commissioning to ensure that any national risks relating to neonatal critical care services can be considered by the group. This also enables effective cross-referencing with the Specialised Commissioning Quality and Governance Group.  A clear decision should be made about whether ownership of a risk raised—and the subsequent actions—rests with the NPSG or the Specialised Commissioning Quality and Governance Group.

6. Identifying risks, taking proportionate action and triggering escalation

Wherever possible, oversight, action and response should take place at trust level with the support of the governance team, safety champions and trust board – and other trusts in the system or neonatal ODN.  

If issues are identified, there should be a collective decision – drawing on the views of representatives on the Trust board or sub-committee – about responsibility and actions.

Systems are encouraged to use an ‘appreciative inquiry’ approach to learning and oversight. Appreciative inquiry is a strengths-based approach to creating change. Rather than identifying a problem and looking at how to solve it, appreciative inquiry involves exploring what is already working and how to build on that.

Providers and ICBs are encouraged to use the following tools (also referenced in  Annex 1) to support the identification of risks:

• the Maternity and Neonatal Three Year Delivery Plan Oversight Tool (available via NHS Futures): for trust-level outcome and progress measures against the priorities set out in the delivery plan
• the Maternity Services Dashboard: for trust-level clinical quality improvement metrics that benchmark performance against peers
• local, system or regional quality improvement dashboards (where available). We recommend that these use run charts or statistical process control (SPC) to identify changes in trends and to benchmark against best practice. NHS IMPACT provides a recommended approach and key resources to support continuous improvement
• neonatal dashboards: National Neonatal Audit Programme (NNAP) and the Specialised Services Quality Dashboard
• the MBRRACE-UK Real Time Data Monitoring Tool (available via local MBRRACE-UK accounts) for regular monitoring of critical safety issues for maternity and neonatal services; a potential excess in stillbirth and neonatal deaths over a period of time
• from November 2025: the Maternity Outcomes Signal System (MOSS), which also relies on near-real time data. This will allow regular monitoring of critical safety issues within intrapartum care

6.1 Action and support

Action and support for both trusts and ICBs, where there is an identified concern in relation to maternity or neonatal services, is aligned to the NHS Performance Assessment Framework, and, where needed, the Recovery Support Programme.

Enhanced:

If the provider is in segment 1 or 2, then it would not normally receive support from the Maternity Services Support Programme (MSSP). Instead, the appropriate support offer would be determined at a rapid quality review meeting or equivalent that includes the provider, the Care Quality Commission (CQC), the ICB, neonatal ODN where appropriate and the region. This review meeting would also consider wider intelligence from regulatory bodies and stakeholders.

Enhanced/intensive:

If the provider is in segment 3, the support offer will be customised on the basis of recommendations from a rapid quality review meeting including the provider, the ICB or neonatal ODN, the region and the MSSP. There are 3 possible decisions:

1. If all are in agreement that intensive support is required rapidly, the trust may be entered onto the MSSP as part of a regionally agreed recovery plan.
2. The MSSP may be asked to undertake a targeted diagnostic visit to gain a better understanding of the challenges being faced. This would take place over several days and be conducted by a team that would ideally include maternity improvement advisers, as well as representatives of the ICS and/or the region. The visit would offer a valuable learning opportunity for all involved and help foster greater alignment among stakeholders regarding the most appropriate next steps. Outcomes might include the trust entering the MSSP or, alternatively, remaining under regional and/or ICB supervision.
3. The review meeting may conclude that MSSP input is not necessary. The region and ICB would provide support and oversight of the improvement journey.

Intensive:

If the provider is in segment 4 and going onto the Recovery Support Programme (segment 5) then entry to the MSSP would be considered. The MSSP will work in very close collaboration with the Recovery Support Programme and  regional and ICB teams to ensure the sustainability of the improvement journey and agreeing clear exit criteria. Maternity improvement advisors operating within the MSSP will liaise with the relevant neonatal ODN in order to address any safety and quality concerns relating to these services or to the interface between neonatal and critical care services. 

ICBs will receive oversight in line with the NHS Performance and Assessment Framework. Where there are identified concerns, an improvement plan will be agreed between the system and the region following a discussion with regional quality and performance teams. ICBs experiencing the most serious or complex problems will enter the recovery support programme. 

For ICBs and trusts allocated to segment 4, the national Recovery Support Programme can provide focused and integrated support. It works in a coordinated way with the ICB, regional and national NHS England teams. Where necessary, regional teams will lead and co-ordinate support requirements identified for the ICB.

National Perinatal Surveillance Group (NPSG)

• referral of a risk to the regional director(s) for a discussion with one or more regions, for management between region and system
• development of national policy or guidelines
• referral to the Specialised Commissioning Quality and Governance Group
• referral to the Maternity and Neonatal Quality, Performance and Surveillance Committee
• referral to the Executive Quality Group (a sub-committee of the NHSE England Board) where there is a risk or learning broader than maternity and neonatal services.  

7. Who to involve at each stage

As a minimum, core membership at each level of the PQOM should include representation from the following:

• neonatal, midwifery, obstetric and perinatal manager representatives
• the quality lead(s) for maternity and neonatal care
• a service user representative

At regional and national level, representation should also include – but does not have to be limited to:

• the Care Quality Commission (CQC)
• the Maternity and Newborn Safety Investigation Programme
• the Nursing and Midwifery Council (NMC)
• the General Medical Council (GMC)
• NHS Resolution
• specialised commissioning representatives for neonatal, or the neonatal ODN
• perinatal mental health

Annex 1: Key data and insights to consider under the perinatal quality oversight model

Trusts and integrated care systems should give due regard to the outcome and progress measures published in the Maternity and Neonatal Three Year Delivery Plan, which are collated in technical guidance and available to view at trust level through the Maternity and Neonatal Three Year Delivery Plan Oversight Tool on NHS Futures. We recommend these should form the basis of a locally agreed report to be presented by a member of the perinatal leadership team at trust boards. Data should, where possible,  include subgroup analyses – at a minimum by ethnic group and by deprivation level based on the mother’s postcode – to help identify potential health inequalities for investigation and action. 

Trusts and integrated care systems should consider additional key insights and data to include in locally agreed reports.

We recommend the following items associated with key themes from the delivery plan.

Listening to women and families

Workforce

Culture of learning, safety and support

Structures and standards underpinning safer, more personalised, equitable care

As a minimum, trust boards should consider the following data measures at least quarterly.

1. Findings of review of all perinatal deaths using the real time data monitoring tool with actions
2. Findings of review of all cases eligible for referral to Maternity and Neonatal Safety Investigations (MNSI) programme with actions
   • Report on:
   • themes and actions from patient safety incidents
   • training compliance for all staff groups in maternity and neonatal critical care related to the core competency framework and wider job essential training (%)
   • minimum safe staffing in maternity and neonatal services to include obstetric cover on the delivery suite, gaps in rotas and midwife minimum safe staffing. Planned cover versus actual
3. Service user voice feedback – themes
4. Staff feedback from frontline champion and walkabouts – themes
5. Maternity and Neonatal Safety Investigations (MNSI) programme, NHS Resolution, Care Quality Commission (CQC) or other organisation with a concern with or request for action made directly to the trust
6. Coroner Reg. 28 made directly to trust, where applicable
7. Progress in achievement of Maternity Incentive Scheme – 10 safety actions
8. Proportion of midwives responding ‘agree’ or ‘strongly agree’ to whether they would recommend their trust as a place to work or receive treatment (reported annually)
9. Proportion of specialty trainees in obstetrics and gynaecology rating the quality of clinical supervision out of hours as ‘excellent’ or ‘good’ (reported annually)

Publications reference: PRN01692