Secretary of State Jeremy Hunt's blog on Maternity Safety
I will never forget meeting Carl Hendrickson. He came to a meeting I had with families who suffered from poor care at Morecambe Bay and I couldn’t quite work out why he insisted on bringing his son. Then he told his story, notably meeting and marrying the love of his life, the joy of a first child and then – in a devastating sequence of events – losing both his wife and a second child because of poor maternity care. He bought his son to see me because he wanted him to see with his own eyes that he had taken his concerns right to the top.
There are a million different things you can focus on as Health Secretary. But you also know that if you don’t set just a few top priorities you won’t change anything at all. Meeting people like Carl – alongside other brave campaigners like James Titcombe, Scott and Sue Morrish and Paul and Melissa Mead – made my choice for me: patient safety. Why would we not want to do more to avoid the appalling human misery created by the 150 NHS hospital deaths every week that have a 50% or more chance of being avoidable?
That’s why two years ago, I set out a simple ambition for the NHS: to be one of the safest places in the world to give birth by halving rates of stillbirth, maternal and neonatal deaths and birth-related brain injuries in babies by 2030. And last year I launched the Maternity Safety Action Plan to give us a practical framework for achieving this ambition.
As the US surgeon Atul Gawande has written, success in modern medicine has a lot to do with our ability to manage complexity. The big paradox is that the march of medical science, and with it the need to co-ordinate technology, people and expertise, can actually increase the potential for error rather than decrease it.
Where there is poor teamwork, or blurred lines of accountability, or there is anything less than a 100%, systemic focus on safety across an organisation, the result is almost inevitably points of failure. In an air disaster, these would be called “signatures” of failure, and would result in a whole system response to learn lessons and eradicate these fault lines before further tragedy results. We need to introduce the same, systematic approach across the NHS.
So what does this mean in practice?
Whenever I visit an NHS maternity or neonatal service I’m often struck by the leadership, commitment and innovation demonstrated by midwives, obstetricians, neonatologists and others working together to ensure that mothers and babies stay safe throughout pregnancy, in labour and after birth. Some, such as Southmead under the leadership of Tim Draycott, are world-beaters but many others are also genuinely world class.
Yet we know from recent surveillance reports, and the RCOG’s Each Baby Counts report, that there is still significant room for improvement within maternity care. The latter found that a quarter of local reviews into stillbirths, neonatal deaths and severe brain injuries did not contain enough information to draw conclusions about the quality of care provided. Parents were invited to be involved in only 34% of reviews. Although it is improving, we still have one of the highest rates of stillbirth in Western Europe.
But we also know that, with determined focus, extraordinary progress can be made. In just two years Taunton and Somerset NHS Foundation Trust has reduced stillbirths by around 35%, increased the detection of small babies before birth and boosted flu vaccine uptake by pregnant women to levels well above the national averages. How has it done this? With a system-wide focus on building a culture where teams have the confidence to learn from what they do well as well as learning when things go wrong.
This year, through the £8.1million Maternity Safety Training Fund, every maternity service in the country is undertaking multi-disciplinary training on leadership, team working and communication, human factors, fetal growth monitoring, cardiotocography (CTG) interpretation or emergency drills – all of which are vital for targeting and learning from the failings that lie behind previous mistakes.
Meanwhile, the Maternal and Neonatal Health Safety Collaborative has started working with 44 Wave One trusts to develop their quality improvement expertise and enable them to work collaboratively to improve clinical practices and reduce unwarranted clinical variation. The Collaborative’s central support team is helping local teams to use data to design improvement projects aligned to the national maternity safety ambition.
I have said many times I want the NHS to be the world’s largest learning organisation. Well let’s start with maternity safety. We are proud to have a National Health Service – so let’s make sure when there is a mistake or point of learning in one part of the country we have the systems in place to transmit that to every corner of the NHS. And when we have achieved it for maternity, let’s make sure the same thing happens across every specialty.
When the NHS was founded in 1948, we said as a country that all citizens had equal value and we didn’t want anyone to worry about the size of their bank balance before accessing medical care. Focusing on patient safety is part of that ideal because it says every single patient matters. Or every single baby counts. So congratulations to the RCOG, Royal College of Midwives and the British Association of Perinatal Medicine on the work it is doing to support this ambition and let’s make this a turning point in our ambition to offer the safest maternity care available anywhere on the planet.