Organisation objective

• NHS Long Term Plan
• NHS Mandate from Government

Executive summary

This paper sets out progress on maternity and neonatal care since the publication of our three year delivery plan in March 2023.

Action required

The Board are asked to note the progress, current and future challenges to improving care.

Introduction

1. The NHS is continuing to prioritise making maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families. Led by Ruth May, Chief Nursing Officer for England, Kate Brintworth, Chief Midwifery Officer for England, Louise Weaver Lowe, Lead Neonatal Nurse, Ngozi Edi-Osagie, National Specialty Advisor for Neonatal, and Dr Matthew Jolly, National Clinical Director for the Maternity and Women’s Health, we are delivering on commitments made in the NHS Long Term Plan and since to improve experience and outcomes, including specific actions to reduce known inequalities.

2. To strengthen our approach we are expanding the leadership by appointing a neonatal National Clinical Director and we have announced the appointment of ICB Chief Executive Officer, Sam Allen, as Chair of the Maternity and Neonatal Programme Board. The Chair will work alongside the NHS England maternity and neonatal programme to represent the programme at the most senior levels of the NHS, wider health sector and with key stakeholders. They will also provide additional advice, scrutiny and challenge to drive the delivery of the maternity and neonatal programme. We are also developing the data and tools available to enable Trusts to identify issues earlier and take action, and we have increased staffing numbers across the maternity and neonatal workforce.

3. In March 2023, the NHS England Board agreed the Three-Year Delivery Plan for Maternity and Neonatal Services. The plan brings together existing national commitments alongside action in response to independent reports on services in East Kent and Shrewsbury and Telford. This paper sets out progress against the four themes of the plan:

• Listening to and working with women and families with compassion
• Growing, retaining, and supporting our workforce
• Developing a culture of safety, learning and support
• Standards and structures that underpin safer, more personalised, and more equitable care.

Outcomes

4. The NHS is making progress on the National Maternity Safety Ambitions to halve the rates of stillbirths, neonatal death, maternal death and brain injury in babies between 2010 and 2025, and to reduce the national rate of pre-term births. We exceeded the interim target of a 20% reduction in stillbirth and neonatal mortality by 2020. The latest available data shows:

• The stillbirth rate fell to 3.9 per 1000 births in 2022, 22.6% lower than in 2010.
• The neonatal mortality rate rose from 1.3 per 1000 live births in 2020 to 1.4 in 2021 but remains 30.4% lower than in 2010.
• MBRRACE-UK data showed that there was a rise in the UK maternal death rate between 2018-20 and 2019-21, from 10.90 to 11.56 per 100,000 maternities. Covid-19 was the leading cause of maternal death in 2019-21. Excluding Covid-19 deaths, the rate has fallen 6.3% since 2009-11.

5. Because maternity and neonatal data is lagged, the data above still reflect the direct and indirect impact of the Covid-19 pandemic. We set out work below to identify more timely data.

6. While longer term trends in perinatal mortality for all ethnic groups and deprivation levels show improvement, long-standing inequalities in outcomes persist. The perinatal mortality rate for black and Asian babies was 9.3 per 1000 births in 2021, compared to 5.7 per 1000 births for white babies. Black and Asian babies were at 1.6 times higher risk of perinatal mortality than white babies in 2021, a small improvement from 1.8 in 2017. For babies from the most deprived quintile, the perinatal mortality rate was 8.7 per 1000 births in 2021 compared to 5.0 for babies from the least deprived quintile.

Listening to women and families

7. Our ambition is that women always experience care that is kind and compassionate, that they are listened to, and have equitable access to specialist care. We are transforming services to provide the care that women need including consistent access to pelvic health services, maternal medicine networks and perinatal mental health services. National data from May 2023 show that an additional 16,000 women per year accessed specialist community perinatal mental health services and maternal mental health services (for women experiencing loss or trauma arising from pregnancy or birth, or fear of birth) compared to two years previously.

8. We have established Maternity and Neonatal Voices Partnerships (MNVPs) in every system to work with families to improve care. Lessons from independent reports highlight the need to go further. Through the three-year delivery plan we have set clear expectations for trusts and ICBs about the involvement of MNVPs and that they should be well supported with a fully funded workplan.

9. Since the publication of the delivery plan in March, the National Institute of Health Research has tendered for a programme of work to develop a patient reported experience measure in order to help trusts and ICBs monitor and improve personalised care. We have also piloted choice and personalisation training, and are working with ten areas of high need to deliver culturally sensitive genetic services, which give families from underserved groups the opportunity to make informed reproductive decisions, whilst respecting their culture, values and beliefs. This year, we are investing a further £5.9m in bereavement care – sufficient to enable all trusts to provide seven-day provision by no later than the end of this financial year.

10. We are committed to tackling health inequalities; every Local Maternity and Neonatal System is implementing an equity and equality action plan with evidence-based interventions which reflect the needs of the local population. We are implementing enhanced midwifery continuity of carer (MCoC) to ensure safe, consistent, and personalised care in the areas of highest need. In 2022/23, we provided funding for the rollout of 53 teams, with an additional 21 teams being funded and supported to commence their rollout in 2023/24. This is in line with our overall approach on continuity of carer, that trusts are not expected to deliver against a target level of MCoC, and this will remain in place until maternity services in England can demonstrate sufficient staffing levels to do so. In the meantime, providers must ensure that safe staffing is in place before the rollout of further MCoC teams.

Workforce

11. Our ambition of safer, more personalised, and more equitable care can only be delivered by skilled teams with sufficient capacity. The 2023/24 NHS Priorities and Operational Planning Guidance set a key objective to increase fill rates against funded establishment for maternity staff, and trusts are responding. However, NHS maternity and neonatal services in many trusts do not yet have the number of staff they need.

12. Since 2021, NHS England has invested an additional £165m/year to improve maternity and neonatal care. This will rise to an additional £186m/year from 2024/25 with part year effect in 2023/24. This national investment provides for an increase in midwifery establishment by 1,200 FTE and obstetric consultant establishment by 100 FTE; additional neonatology consultant capacity will be achieved through the funding made available in August 2023 . Our latest data show that NHS trusts have invested over and above this, with midwifery establishment already rising by 2,100FTE and obstetric consultant establishments by more than 400 FTE. NHS data shows an increase of over 600 FTE midwives between June 2022 and June 2023 and, as of July 2023,  c175 FTE more obstetric consultants substantively employed in post compared to a year ago. This workforce increase has supported the reduction of Midwifery vacancies from a peak of over 3,400 in August 2022, to around 2,900 in July 2023. In addition to the substantive workforce increase there has also been a correlated increase in the number of temporary staff deployed with around 2,300 FTE of Midwifery bank and agency staff utilised each month in 2023 compared to around 1,600 FTE in 2021. Maternity support worker posts have increased to a new high of more than 7,000 FTE following an increase of more than 300 FTE posts, and nurse establishment working in neonatal care (including registered and unregistered workforce providing cot-side care) have risen by 550FTE to 8,400FTE.

13. We are improving workforce supply. We increased the number of starters on midwifery courses by 4,096 over the four years up to 2023, exceeding the target to increase by 3,650 over that period by more than 400. Going forward, the NHS Long Term Workforce Plan sets out a further expansion of midwifery training places to support a growth of 1.8-1.9% in midwives each year.

14. We continue to focus on supporting the maternity and neonatal workforce and retention of midwives is improving. The number of midwives leaving the profession reduced to 5.6% in June 2023, compared to a peak of 7.3% in August 2022. Sickness rates have stabilised at 5.5%, down from a peak of 9.4% in January 2022. Retention midwives have continued to be funded for every unit during 23/24.

15. In August, we announced a further £4m for Professional Midwifery Advocates and Professional Nurse Advocates to support staff wellbeing and provide restorative clinical supervision in maternity and neonatal services. We continue to grow the number of education and workforce leads to support the retention and recruitment of staff caring for babies in neonatal units. In 2023-24, we are investing an additional £5.75m in neonatal nurse quality roles, to support the retention of staff and learning from incidents with at least 98 FTE posts allocated so that every trust now has funding for this role.

16. On training, in May we published an updated version of the Core Competency Framework. This sets clear expectations for trusts to address known variation in training and competency assessment across maternity teams.

17. Trust Boards and ICBs are expected, in line with the three year delivery plan for maternity and neonatal services to undertake regular workforce planning and ensure the right numbers of the right staff are available to provide the best care for women and babies. Decisions on priorities for any further investment in maternity and neonatal workforce growth above current levels will be for government as part of future spending reviews.

Culture

18. We want everyone to experience a positive working culture – where all staff are supported to work with professionalism, kindness, compassion and respect.

19. A key part of our strategy is the Perinatal Culture and Leadership Programme to support perinatal leadership teams to develop the conditions for a positive culture of safety and continuous improvement. It aims to improve the quality of care by enabling leaders to drive change with a better understanding of the relationship between leadership, safety improvement and safety culture. So far, 98 perinatal leadership teams (out of 152 maternity and neonatal sites) have started our culture and leadership programme. All trusts will have been enrolled onto the programme to all trusts by November 2023, with every site having completed the programme by September 2024. While initial feedback is positive, we recognise that cultural change is a long-term process.

20. We have provided guidance and resources to support Non-Executive and Executive Maternity and Neonatal Board Safety Champions via our FutureNHS Platform. Engagement with this is incentivised via NHS Resolution’s Year 5 Maternity Incentive Scheme. We are providing further targeted support to Board Safety Champions in fourteen organisations, aligned with the Maternity Safety Support Programme. This is focussed on analysis to underpin timely, evidence-based decision making and high-quality conversations for safety improvement.

21. We continue to strengthen our national leadership for maternity and neonatal care with two new roles; we will shortly be interviewing for a neonatal National Clinical Director and have appointed a Neonatal Nurse lead.

Standards and structures

22. To deliver our ambitions to improve care, maternity and neonatal teams need to be supported by robust standards and structures – including best practice, timely access to data, and appropriate digital and estates infrastructure.

23. In May, we published an updated version of the Saving Babies’ Lives Care Bundle. This sets out best-practice clinical guidance to reduce perinatal mortality and pre-term births, and is accompanied by tools to support implementation and track progress. We expect trusts to implement the care bundle by March 2024. We have developed a Care Bundle implementation tool on FutureNHS, which helps providers baseline compliance and measure improvement against the interventions set out in each element. It will also be used to generate snapshots of progress with implementation nationally.

24. On data, there is existing good practice in several regional teams using heatmaps to identify any areas of concerns and bringing together all regional partners to share intelligence to improve safety. Dr Edile Murdoch, Chair of the Maternity and Neonatal Outcomes Group, is leading a programme of work, supported by Bill Kirkup, to further improve the use of data in maternity services. The group is developing an early warning surveillance tool using more timely outcome data to identify potential issues earlier for Trust Boards to act on as well as identify the services needing support. Recommendations from this group will be reported later in the autumn, with the tool operational before the end of 2024. On neonatal data, we are working with national partners such as the Neonatal Audit Programme and the National Maternity and Perinatal Audit to reduce the burden for providers and improve data quality.

25. On digital infrastructure, the maternity digital capabilities framework, which was made available on the NHSFutures platform in August, enables secondary care providers to procure electronic patient record systems that are suitable for maternity services.

26. In relation to estates, a £45m investment announced last year has already started to increase and realign neonatal cot capacity in London, the North East and Yorkshire and the South East regions. By March 2025, there will be an increase in cots in each of these regions. The North West, Midlands and South West regions have not yet been able to progress and finalise their review of cot configuration to meet the national standards. In order to make further progress, it will be important to prioritise further capital investment in neonatal cot capacity in the next spending review period. We will conduct a wider review of the maternity and neonatal estate by March 2024.

27. Trust Boards are responsible for the quality and safety of their maternity neonatal services but, over the last four years, NHS England has strengthened regional oversight, establishing chief midwives, deputy chief midwives and lead obstetricians in every region, and a robust approach to perinatal quality surveillance. On neonatal care, the Maternity and Neonatal Programme established strong collaboration with Operational Delivery Networks. Through the Neonatal Implementation Board, which oversees the implementation of the Neonatal Critical Care Review, we are supporting Integrated Care Boards to develop a critical new role in commissioning and overseeing the quality of maternity and neonatal care – our work on timely outcomes indicators will be a key part of this.

Trusts needing support

28. The Maternity Safety Support Programme provides hands-on intensive support to trusts that are rated ‘requires improvement’ or ‘inadequate’ in the well-led or safe domains by the CQC. Trusts are provided with support from a dedicated advisor. There are 32 services on the Programme. As a result of improvement over the last two years, six have exited the Programme and a further six are expected to exit by the end of 2023.

29. Since March, the CQC has published inspection reports for 53 provider units as part of the targeted inspections of maternity services announced by the government in July 2022. 19 units have seen their overall rating go down, and 5 went up. Across the 53 units, three are now rated as outstanding overall, with a further two achieving the highest rating for the ‘well-led’ domain. 31 units were rated as ‘requires improvement’ or ‘inadequate’ in the well led or safe domains. Key emerging themes identified by the CQC are leadership and staffing, culture, personalised care and triage. The majority of these are addressed through workstreams of the programme described above. The increased demand for triage is requiring a multi-organisational approach including good practice guidance being produced by RCOG.

30. We are currently reviewing the Maternity Safety Support Programme and its alignment with the Recovery Support Programme to identify ways to strengthen and improve the support available to Trusts.

31. The independent review of maternity services at Nottingham University Hospitals NHS trust changed to an ‘opt-out’ approach, meaning that families will have to opt-out of the investigation if they do not want to participate, rather than opt-in if they do; this seeks to ensure that all learning will be captured. In early September, we communicated to families that, following Sir David Sloman’s retirement, Dame Ruth May is the new Senior Responsible Owner for the review. Learning and review meetings facilitated by NHS England provide a forum for Donna Ockenden, the review chair, to regularly feedback emerging findings, enabling the trust to drive improvement ahead of the final review findings.

Next steps

32. Making sustainable improvements across maternity and neonatal services remains a major priority for NHS. We are strengthening the services delivered further through targeted investment, leadership and support for quality and safety improvement. However, maternity and neonatal services face significant challenges. While we have made good progress, and there are encouraging signs, sustainable improvement will take time and require ongoing focus and investment.

Public Board paper (BM/23/32(Pu)