18.In this chapter we consider the essential building blocks of safe care, staffing levels and funding, which are underpinned by leadership and training. In particular, we consider what is needed to deliver safe staffing levels in maternity units across the country; how this should be calculated, and the funding required to make safe staffing a reality. We will also consider how to ensure multi-professional maternity teams are led in a manner which promotes patient safety and receive the training required to deliver safe care.
19.In our first evidence session, we heard from Michelle Hemmington, whose son, Baby Louie, tragically died following mistakes in her care during labour. We are indebted to Michelle for the courage she showed in sharing her story with us. Michelle told us that the first thing said to her when she arrived at the hospital in labour was that she had “picked a bad day to have a baby as the unit was really busy”.22 Although factors other than staffing contributed to Michelle and Louie’s tragedy, Michelle highlighted staffing as a key issue. She said that there needed to be “more staff involved” and that there needed to be “more staff on labour wards and in maternity”.23
20.Suboptimal staffing levels were identified in the Morecambe Bay report, and Professor Ted Baker, Chief Inspector of Hospitals at the Care Quality Commission (CQC), told us that after Morecambe Bay the CQC was “very assertive in insisting that units have the right level of staffing”.24 He went on to tell us that a number of factors affected the level of staffing including “a big attrition rate” in trainee obstetrics and midwifery; incidences of bullying; and problems with the workplace culture:
There is an issue of staff numbers, but there is also an issue of how we look after the staff we have. […] The number of midwives has been a constant issue over the last few years. Our perspective at the CQC is that we expect providers to have adequate staff to provide safe care. Where they do not, we will insist that they find those staff, but we recognise that many units have difficulty recruiting.25
21.Staffing is also one of the four Government commitments our Expert Panel chose to assess (Box 2). The Expert Panel overall rated progress towards achieving safe staffing as ‘Requires Improvement’, stating:
There is a consistent message in the range of sources we evaluated that staffing across the whole area of maternity services requires improvement. While there have been recent improvements in the number of midwifery staff, persistent gaps in all maternity professions remain. Current recruitment initiatives do not consider the serious problem of attrition in a demoralised and overstretched workforce and do not adequately value professional experience and wellbeing. Staffing deficits undermine the ability of Trusts to achieve improvements in all areas. [Expert Panel]26
Box 2: Expert Panel CQC-style Ratings–Safe Staffing
Safe Staffing: Ensuring NHS providers are staffed with the appropriate number and mix of clinical professionals is vital to the delivery of quality care and in keeping patients safe from avoidable harm.
Overall: Requires Improvement
Further analysis can be found in the Expert Panel’s independent report: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England.27
22.Safe staffing means putting in place the right staffing levels for each maternity unit to ensure safe care is always possible, even at busy times. However, staff shortages have been a persistent problem. Health Education England calculated that the NHS remains short of 1,932 midwives28 and a recent RCM survey indicated that, 8 out of 10 midwives (83% of those surveyed) reported that they did not believe that there were enough staff on their shift to be able to provide a safe service.29 While the Government has told us that there are now 4.8% more obstetricians and gynaecologists on maternity units than there were in 2019, evidence from the Royal College of Obstetricians and Gynaecologists (RCOG) suggests that numbers still need to increase by 20%.30 NHS Providers estimates this would require an extra 496 consultants working in Obstetrics and Gynaecology.31
23.Determining the right staffing levels for maternity units is complicated. A maternity unit’s team involves healthcare professionals from a wide range of different disciplines, including midwives, obstetricians, operating department practitioners, maternity support workers, anaesthetists, and paediatricians. Many of those who work in maternity services do not always work exclusively in intrapartum care, with midwives and obstetricians also delivering antenatal and postnatal care, and obstetricians also working in gynaecology.
24.Since 2001, Birthrate Plus® has been used as a planning tool to determine safe levels of midwifery staffing. Birthrate Plus® is enshrined in NICE guidance and is used by many maternity units to plan their staffing requirements. However, there is no equivalent for obstetricians. The RCOG told us that urgent action was needed to rectify this, as not only were staff shortages widespread, there was also was no agreed way of establishing safe and appropriate staffing numbers. Dr Edward Morris, President of the RCOG, set out the extent of the problems as he told us “every single unit in the country has gaps in the rota of junior doctors and senior trainees who are delivering the service, which shows that we have a significant problem in staffing those rotas”.32
25.In the light of this issue, the RCOG set out a proposal for a rapid research and workforce planning exercise to establish safe staffing levels. Its proposals included: interviews with O&G clinical directors, clinicians, women and their families, in depth study of innovative multidisciplinary models for working, evaluation of the efficiency of current junior doctor rotas and consultant job plans and updating the RCOG’s previously published standards for maternity care and workforce.33
26.Timely pain relief is crucial to the delivery of safe and personalised care in labour, something we discuss more fully later in this report. Almost 21% of women receiving pain relief during labour require input from an anaesthetist.34 However, the Royal College of Anaesthetists has recorded a workforce gap of 11.8% for consultant anaesthetists, equivalent to 1,054 FTE, with an unfunded gap of 374.35
27.The Expert Panel overall rated progress towards safe staffing as ‘Requires Improvement’. Appropriate staffing levels are a prerequisite for safe care, and a robust and credible tool to establish safe staffing levels for obstetricians is needed. We were pleased that following our evidence session, the Department has committed to fund the Royal College of Obstetricians and Gynaecologists to develop a tool that trusts can use to calculate obstetrician workforce requirements that will be in place by autumn 2021.36 This work should also enable trusts to calculate anaesthetist workforce requirements within maternity services. We will contact the Department and RCOG for the outcome of this work in October 2021.
28.However, the development of a tool to calculate workforce requirements is only a first step towards ensuring safe staffing. Although Birthrate Plus® has existed as a tool to determine midwifery staffing levels for many years, those running maternity services report that even when is used to assess staffing needs, trust boards often refuse to fund the necessary expansion in midwifery posts. Gill Adgie, Regional Head, Royal College of Midwives (RCM), explained the problem in the following terms:
It is the gap […] between what Birthrate Plus® says and the funded establishments. What we know from our Directors of Midwifery is that if a head of midwifery needs 30 more midwives in a service based on Birthrate Plus®, when she goes to the trust board with a business case, it is quite often knocked back.37
29.In March 2018, the Department committed to increasing the number of available midwifery training places in England by more than 3,650 over a four-year period. The increase was introduced in the 2019 academic year, with an additional 650 training places, rising to 1,000 in subsequent years. However, Gill Adgie told us that while the expansion in training places was welcome, it did not provide a guarantee of a direct expansion in staffing levels in the units that needed them:
To put it plainly, if the head of midwifery has a whole-time establishment of 100 midwives, but has 10 vacancies, and the Birthrate Plus assessment says they need 30 more midwives to provide a safe service, actually that service needs 40 midwives. There probably are not the newly qualified midwives at the moment to fill those vacancies across the country.38
30.Following our evidence session, the Department provided us with gap analysis of the midwifery workforce. Health Education England (HEE) estimated that maternity services are currently short of 1,932 midwives. This included 844 vacant but funded posts and additional 1,088 posts that were not funded but would be required for trusts to reach the safe staffing levels recommended by Birthrate Plus®.39
31.Staffing levels were also identified as “a huge barrier” and a “major issue” by the frontline clinicians that attended our roundtable sessions.40 They pointed out that even when a unit appeared on paper to be fully staffed, when sickness and attrition rates were taken into account the reality was very different:
I would say the optimal numbers to fill shifts would be more than they currently are, but that’s what they’re funded for. They staff what they’re funded for. So, if there’s a challenging maternal situation which requires a second set of eyes on a CTG, or potentially there could have done with being two midwives in that room instead of one. I know loads of midwives who just don’t even get their breaks because they’re stuck in a room because things just get challenging. Funding is definitely an issue. [Midwife]41
Staffing […] is the main cog […] in all of this when things start to unravel at the seams. So you can put all these clever interventions in place about taking team working to the next level, about culture, about lots of things but actually if there’s just not enough bodies in the system to be able to aspire to those kind of goals, then you’re doing lots of clever things for no reasons really. And spending a lot of time, a lot of money […] So actually, the number one thing is staff. [O&G Trainee Doctor]42
32.Our attendees at the roundtable session also told us that rota gaps can lead both to burnout in staff who must try to cover those gaps, and to safety issues relating to working with locums:
But the fact that staffing numbers are poor across the board which leads to gaps, which leads to people covering those gaps, either internal or external candidates, which then leads to people working over their hours to try and help, to try and help fill those gaps which then leads to people getting worn out, which then leads to illness. [Paediatric Trainee Doctor]43
If there are rota gaps you then end up with people taking locum[s], so you tend to come to a night shift as a junior person and have never met the person you’re working with, who in order to practise safely you need to have a really good level of communication with so you can call them to say I’ve just seen 5 people in triage, these are my plans, are these correct. [O&G Trainee Doctor]44
33.The frontline clinicians who spoke to us also pointed out that staffing shortages can have a safety impact during the antenatal period as well as during labour and delivery:
A lot of problems often start in the antenatal period. [In] our antenatal clinics we sometimes have 60 plus patients per antenatal clinic and you only have five or six minutes per patient to actually see them and that’s often when a lot of problems can start. And often a lot of misunderstanding can happen as well during the antenatal period. [O&G Trainee Doctor]45
34.Witnesses to this inquiry made clear to us that funding is a critical factor in the delivery of safe staffing levels. In her oral evidence, Gill Walton, Chief Executive, Royal College of Midwives, told us that despite maternity services having been underfunded for a long time they were still “subject to cuts every year” which resulted in “the essential components of safe maternity care” being affected “year after year”.46
35.In response to the interim findings of the Ockenden report, NHSE&I announced a welcome £46.7 million funding package to provide 1000 more midwifery posts, bridging the gap between the current funded establishment and recommended establishment.47 An additional £10.6 million was also provided to increase the obstetric consultant workforce by 80 FTE in 2021–22. However, this would not be sufficient to fund the 496 consultants required to reach the recommended 20% increase in obstetric consultants.48 NHS Providers estimated that the funding increase required for that 20% increase in obstetricians is £81 million per annum.49 Furthermore, NHS Providers highlighted the fact that midwives and obstetricians are only part of the team of healthcare professionals delivering maternity services and estimated that an additional £121 million would be needed to tackle gaps in the anaesthetic, maternity support worker, and neonatal nurse workforce. NHS Providers concluded that to fully fund the wider maternity team would require an annual extra recurrent funding of at £200 - £350 million.50
36.With 8 out of 10 midwives reporting that they did not have enough staff on their shift to provide a safe service, it is clear that urgent action is needed to address staffing shortfalls in maternity services. Evidence submitted to our inquiry estimates that as a minimum, there need to be 496 more obstetricians and 1,932 more midwives. While we welcome the recent increase in funding for the maternity workforce, when the staffing requirements of the wider maternity team are taken into account–including anaesthetists to provide timely pain relief which is a key component of safe and personalised care - a further funding commitment from NHS England and Improvement and the Department will be required to deliver the safe staffing levels expectant mothers should receive.
37.We recommend that the budget for maternity services be increased by £200–350m per annum with immediate effect. This funding increase should be kept under close review as more precise modelling is carried out on the obstetric workforce and as Trusts continue to undertake regular safe staffing reviews of midwifery workforce levels.
38.We further recommend that the Department work with the Royal College of Obstetricians & Gynaecologists and Health Education England to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come. This work should also consider the anaesthetic workforce.
39.The concept and importance of multi-professional team working is not unique to maternity care. However, it is important to consider the unique environment in which those teams work. There is a breadth of healthcare professionals and services—perhaps wider than most specialties—who look after a mother throughout her pregnancy and ensure the safe delivery of her baby into the world. That care spans the antenatal period through to postpartum and is delivered in hospitals and in the community. Reflecting on the multi-professional nature of maternity care, Charlie Massey, Chief Executive and Registrar, General Medical Council (GMC), told us:
Ultimately, to provide the best care to women, we need teams that work effectively together, where leadership is shared, where there is a clear purpose and where responsibilities are understood. That is the area where reviews and inquiries have repeatedly pointed to there being a gap.51
40.An anaesthetic trainee that attended our roundtable told us that “the culture within the delivery suite is say very different to what you’d see in an orthopaedic centre or in paediatrics”.52 They said that “midwives tend to stick together, theatre staff tend to stick together, and the obstetrics team tend to stick together” and commented that communication was not always effective:
I think that people need to understand what the roles and responsibilities of each other are, what we can and can’t do, and improve the respect for each other’s professions. [Anaesthetic Trainee Doctor]53
41.In its written evidence, the Department stated that through the Maternity Safety Training Fund (MSTF), over £8.1 million had been distributed to 136 NHS Trusts across England to deliver maternity safety continuing professional development (CPD) training in 2016. That funding supported the delivery of over 30,000 training places across multi-professional teams. In addition to that funding, the Department also said that a new core curriculum for professionals working in maternity and neonatal services was being developed by the Maternity Transformation Programme (MTP) in partnership with professional organisations, clinicians, and service users. That curriculum was aimed at addressing variations in safety training and competency assurance across England and to enable the workforce to bring a consistent set of updated safety skills as they move between services and Trusts.54 More recently, a further £9.4 million has been announced to improve training in minimising incidents of brain injury during labour.55
42.NHS Resolution has also established a financial reward for trusts that meet certain standards. Its Maternity Incentive Scheme (MIS) enables trusts that have achieved all 10 safety actions to recover an element of their contribution to the Clinical Negligence Scheme for Trusts (CNST).56 One of those actions, Safety Action 8, requires trust to provide evidence that 90% of staff have attended in-house multi-professional maternity emergencies training. In 2019–20, 93% of trust achieved Safety Action 8.57
43.However, despite the high proportion of trusts achieving Safety Action 8, both the RCM and RCOG highlighted inconsistent levels of uptake of the training specified by the Maternity Incentive Scheme:
Due to aforementioned staffing constraints, including rota gaps, alongside funding constraints, we know that not all training is equal, effective, or utilised by all staff. Furthermore, the scheme does not mandate that all trusts must meet all of the safety actions. Instead it rewards trusts that meet ten safety actions, therefore uptake nationally is patchy.58
44.Baby Lifeline is a charity that promotes the safe care of pregnant women and newborn babies and provides training to maternity staff. It found in 2017/18 that fewer than 8% of trusts were providing all the training set out in the Saving Babies Lives Care Bundle.59 It is likely that things improved in 2018 although the global pandemic has almost certainly had a detrimental impact more recently. And while 79% of trusts mandate training in co-morbidities, training in cardiovascular co-morbidities, the leading cause of death during pregnancy and up to six weeks after birth, was provided by fewer than a third of trusts.60 Baby Lifeline told us that a key barrier to increasing the uptake of that training was staffing and resources.61
45.The RCM and RCOG are among many to argue that recurrent funding for training needs to be reinstated. In their joint submission, the Royal Colleges highlighted the risk that without ongoing financial support the benefits of the MSTF would “diminish over time in particular for those trusts that had not yet achieved a sustainable programme of learning”.62 Commenting on HEE’s evaluation of the MSTF, the Royal Colleges said that:
HEE should follow the recommendations of the evaluation and reinstate regular funding for effective training programmes to improve care, outcomes and costs in maternity settings.63
46.Concerns about training were also raised by frontline maternity services professionals at our roundtable. The most fundamental of those concerns was in relation to persistent difficulties in accessing training:
There are huge issues in practice about access to training, especially for midwives and nurses where there’s mandatory training put on, but because they’re busy or short of staff they don’t necessarily have the opportunities to actually attend. [Midwife]64
Staffing is very much an issue, if you don’t have adequate staff people don’t get released to go on training. [Paediatric Trainee Doctor]65
It’s just down to staffing. The problem with the staffing is that if it’s so minimal then actually you can’t release people. Study leave requests are often denied so how can we develop if we aren’t given the tools to develop. [O&G Trainee Doctor]66
47.Providing back-fill staffing to enable maternity professionals to take time away from their main responsibilities to attend training was seen as crucial, but often that backfill was not provided. The clinicians at our roundtable also described how, very often, training was cancelled at short notice because the people delivering it were themselves frontline professionals and had been called away to clinical duties. The trainers time was not safeguarded and as a result, on some occasions, training had to be delivered by more junior “stand in” staff, at a lower standard.67
48.In response to the interim findings of the Ockenden report, NHSE&I announced an additional £26.5m is being made available to support Trusts with the backfill costs of training as a multi-disciplinary team. NHSE&I have written to Trusts with the expectation that the investment through this additional funding route is ringfenced.68
49.The frontline professionals we heard from also highlighted difficulties for student midwives and newly qualified midwives to gain appropriate experience and supervision, as mentors are too stretched with their own clinical duties to provide this.69
50.Roundtable attendees also highlighted the importance of multi-professional training:
I would go back to the point that interdisciplinary training is really important. One of the challenges we’ve had in the past is that different groups of people are trained in different ways. We have a current situation where a lot of the training now is online so there is no opportunity for interaction and quite often that’s where the nub of the problem is. It isn’t necessarily about the knowledge of how to deal with a particular situation or condition, it’s actually how you understand each other’s role and who should be doing what and when. [Midwife]70
Crucially, this must also include students, who often aren’t invited to in-house or emergency training, and to visiting teams like anaesthetists and theatre staff. One anaesthetist described providing basic training to midwives about pain relief options, reporting that it had greatly improved the multi-professional relationships, and, consequently, the service provided to patients.71
51.Another attendee highlighted to us the importance of midwives and doctors training together from very early on:
I think there is some kind of future in thinking about how midwives and doctors train together but from an early stage in their career. The reason I say that is I think our speciality is really unique in terms of there is no other specialty where a women could go through right from booking, right to having a baby without seeing a doctor for example or doing the whole process with a doctor. And sometimes that baton is passed very quickly, and in quite difficult circumstances, and I don’t know if we work together enough to allow that to happen as seamlessly as it should do because when things go wrong this is one of the problems that happens. So going forward I guess, yes we need to do the MDT training and all the multi-disciplinary stuff, life skills and drills, human factors all of that needs to be a priority, and it is it’s part of the incentive scheme it’s something that all trusts need to do, but I think we need to go a little further in trying to understand the relationships that the professionals have in the first instance and nurturing them from a very early stage rather than just in a training setting. [O&G Trainee Doctor]72
52.The 2016 Maternity Safety Training Fund was widely welcomed by healthcare professionals and it is clear to us that the Fund delivered positive outcomes. However, for those positive outcomes to endure, more funding is required to embed on-going and sustainable access to training for maternity staff.
53.Training is essential for staff to deliver safe care. Evidence submitted to our inquiry highlighted that insufficient staffing is not only impacting the number of healthcare professionals available to deliver care for mothers and their babies but also the ability of staff to participate in vital training.
54.We recommend that a proportion of maternity budgets should be ringfenced for training in every maternity unit and that NHS Trusts should report this in public through annual Financial and Quality Accounts. It should be for the Maternity Transformation Programme board to establish what proportion that should be; but it must be sufficient to cover not only the provision of training, but the provision of back-fill to ensure that staff are able to both provide and attend training.
55.While it is encouraging that 93% of trusts are meeting the training objective set out in the Maternity Incentive Scheme, it is disappointing that only 8% of units across the UK are meeting the very highest standards of training, as set out in the Saving Babies Lives Care Bundle. It is also disappointing to hear the implementation of training still described as ‘variable’.
56.We recommend that a single set of stretching safety training targets should be established by the Maternity Transformation Programme board, working in conjunction with the Royal Colleges and the Care Quality Commission. Those targets should be enforced by NHSE&I’s Maternity Transformation Programme, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and the Care Quality Commission through a regular collaborative inspection programme.
26 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, page 6
27 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, pages 5; 63–77
28 Letter from the Minister of State for Patient Safety, Suicide Prevention and Mental Health on the maternity workforce gap
30 Q228 Minister of State for Patient Safety, Suicide Prevention and Mental Health, Department of Health and Social Care, Q168 Edward Morris
34 Bamber JH, Lucas DN, Plaat F, Russell R. Obstetric anaesthetic practice in the UK: a descriptive analysis of the National Obstetric Anaesthetic Database 2009–14. Br J Anaesth. 2020 Oct;125(4):580–587. doi: 10.1016/j.bja.2020.06.053. Epub 2020 Jul 28. PMID: 32736825
36 Letter from the Minister of State for Patient Safety, Suicide Prevention and Mental Health on the maternity workforce gap
39 Letter from the Minister of State for Patient Safety, Suicide Prevention and Mental Health on the maternity workforce gap
40 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
41 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
42 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
43 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
44 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
45 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
47 NHSE&I, Letter - Investment in Maternity Workforce and Training, April 2021
48 NHSE&I, National Response to the First Ockenden Report, March 2021
50 NHS Providers, Letter from NHS Providers on maternity workforce expansion, June 2021
52 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
53 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
55 HM Treasury, Spending Review 2020
56 NHS Resolution, Maternity Incentive Scheme. The 10 safety action actions for 20/21 include demonstrating: the use of the perinatal mortality review tool, submitting data to the Maternity Service Data Set (MSDS), transitional care services to avoid term admissions to neonatal units, an effective system of clinical workforce planning, an effective system to midwifery workforce planning, compliance with the 5 elements of the Saving Babies’ Lives care bundle, a mechanism for gathering service user feedback and coproduction using Maternity Voices Partnerships, 90% of maternity staff have attended multi-professional emergencies training, that Trust safety champions are meeting bimonthly with Board level champions and 100% of qualifying cases are reported to HISB and to NHS Resolution’s Early Notification scheme.
57 NHS Resolution, Maternity incentive scheme year two national results
59 Saving Babies Lives Care Bundle (SBLCB) is guidance developed to improve stillbirths and early neonatal deaths. This initially included four elements are care widely recognised as evidence-based and/or best practice including: reducing smoking in pregnancy, risk assessment and surveillance for fetal growth restriction, raising awareness of reduced fetal movement and effective fetal monitoring during labour. Version 2 of SBLCB was launched in March 2019, including an additional element to reduce preterm birth.
64 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
65 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
66 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
67 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
68 NHSE&I, Letter - Investment in Maternity Workforce and Training, April 2021
69 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
70 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
71 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
72 Health and Social Care Committee, Safety of Maternity Services in England Inquiry Transcript from Roundtable with Maternity Clinicians, January 2021
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