Maternal Safety Strategy — House of Lords, 2017-11-28
Topic: Health
James O’Shaughnessy (Conservative, Centre-right): My Lords, with the permission of the House, I shall repeat a Statement made by my right honourable friend the Secretary of State for Health in the other place on the maternity strategy. The Statement is as follows: "Giving birth in England is the most common reason for admission to hospital. Thanks to the dedication and skill of NHS maternity teams, the vast majority of the roughly 700,000 babies born each year are delivered safely with high levels of satisfaction by parents. However, there is still too much avoidable harm and death. Every child lost is a heart-rending tragedy for families that will stay with them for the rest of their lives. It is also deeply traumatic for NHS staff involved. Stillbirth rates are falling, but still lag behind many developed countries in Europe, and when it comes to injury, brain damage sustained at birth can often last a lifetime, with about two multi-million pound claims settled against the NHS every single week. The Royal College of Obstetricians and Gynaecologists said this year that 76% of the 1,000 cases of birth-related deaths or severe brain injuries that occurred in 2015 might have had a different outcome with different care. So in 2015 I announced a plan to halve the rate of maternal deaths, neonatal deaths, brain injuries and stillbirths. Last October, I set out a detailed strategy to support this ambition. Since then local maternity systems have formed across England to work with users of NHS services to make maternity services safer and more personal. More than 80% of trusts now have a named board-level maternity champion, and 136 NHS trusts have now received a share of an £8.1 million training fund. We are six months into a year-long training programme and, as of June, more than 12,000 additional staff have been trained. The maternal and neonatal health safety collaborative was launched on 28 February; 44 wave 1 trusts have attended intensive training on quality improvement science and are working on implementing local quality improvement projects with regular visits from a dedicated quality improvement manager; and 25 trusts were successful with their bids for a share of the £250,000 maternity safety innovation fund and have been progressing with their projects to drive improvements in safety However, the Government’s ambition is for the health service to be the safest, highest-quality care available anywhere in the world, so there is much more work that needs to be done. Today I am therefore announcing a series of additional measures. First, we are still not good enough at sharing best practice. When you fly to New York, your friends do not tell you to make sure you get a good pilot. But if you get cancer, that is exactly what they ask about your doctor. We need to standardise best practice so that every NHS patient can be confident they are getting the highest standards of care. So when it comes to maternity safety, we are going to try a completely different approach From next year, every case of a stillbirth, neonatal death, suspected brain injury or maternal death that is notified to the Royal College of Obstetricians and Gynaecologists Each Baby Counts programme—about 1,000 incidents annually—will be investigated not by the trust at which the incident happened, but independently, with a thorough, learning-focused investigation conducted by the Healthcare Safety Investigation Branch, or HSIB. The new body started this year, drawing on the approach to investigations in the airline industry, and has successfully reduced fatalities with thorough, independent investigations whose lessons are rapidly disseminated around the whole system. The new independent maternity safety investigations will involve families from the outset, and will have an explicit remit not just to get to the bottom of what happened in an individual instance but to spread knowledge around the system so that mistakes are not repeated. The first investigations will happen in April next year, and will be rolled out nationally throughout the year, meaning we will have complied with recommendation 23 of the Kirkup report into Morecambe Bay Secondly, following concerns that some neonatal deaths are being wrongly classified as stillbirths, which means a coroner’s inquest cannot take place, I will be working with the Ministry of Justice to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law, giving due consideration to the impact on the devolved Administration in Wales. I would like to thank the honourable Member for East Worthing and Shoreham for his campaigning on this issue Next, we will do more to improve the training of maternity staff in best practice. Today we are launching the Atain e-learning programme for healthcare professionals involved in the care of newborns to improve care for babies, mothers and families. The Atain programme works to reduce avoidable causes of harm that can lead to infants born at term being admitted to a neonatal unit. We will also increase training for consultants on the care of pregnant women with significant health conditions such as cardiovascular disease We also know that smoking during pregnancy is closely correlated with neonatal harm. Our tobacco control plan commits the Government to reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less by 2022, so today we will provide new funding to train health practitioners, such as maternity support workers, to deliver evidence-based smoking cessation according to appropriate national standards The 1,000 new investigations into Each Baby Counts cases will help us transform what can be a blame culture into what needs to be a learning culture. But one of the current barriers to learning is litigation. So earlier this year I consulted on the rapid resolution and redress scheme, which would offer families with brain-damaged children better access to support and compensation as an alternative to the court system. My intention is that in incidents of possibly avoidable serious brain injury at birth, successfully establishing the new independent HSIB investigations will be an important step on the road to introducing a full rapid resolution and redress scheme in order to reduce delays in delivering support and compensation for families. Today, I am publishing a summary of responses to our consultation, which reflect strong support for the key aims of the scheme: to improve safety, patient experience and cost effectiveness. Going forward, I will look to launch the scheme, ideally from 2019 Finally, a word about the costs involved. NHS Resolution spent almost £500 million settling obstetric claims in 2016-17. For every pound the NHS spends on delivering a baby, another 60p is spent by another part of the NHS on settling claims related to previous births. Trusts that improve their maternity safety are also saving the NHS money, allowing more funding to be made available for front-line care. In order to create a strong financial incentive to improve maternity safety, we will increase by 10% the CNST maternity premium paid by every trust, but refund that increase, possibly with an even greater discount, if they can demonstrate compliance with 10 criteria identified as best practice on maternity safety Taken together, these measures give me confidence that we can bring forward the date by which we achieve a halving of neonatal deaths, maternal deaths, injuries and stillbirths from 2030 to 2025, which I am today setting as the new target date for our ‘halve-it’ ambition. Our commitment to reduce the rate by 20% by 2020 remains and, following powerful representations made by voluntary sector organisations, I will also include a reduction in the national rate of preterm births from 8% to 6% within this ambition. In particular, we need to build on the good evidence that women who have continuity of carer throughout their pregnancy are less likely to experience a preterm delivery, with safer outcomes for themselves and their babies Mr Speaker, I would not be standing here today making this Statement were it not for the campaigning of numerous parents who have been through the agony of losing a treasured child. Instead of moving on and trying to draw a line under their tragedy, they have chosen to relive it over and over again. I have often mentioned members of the public such as James Titcombe and Carl Hendrickson, to whom again I pay tribute. I also want to mention Members of this House who have bravely spoken out about their own experiences, including the honourable Members for Colchester, for Eddisbury, for Lewisham, Deptford, for Washington and Sunderland West, for Banbury and for North Ayrshire and Arran. The passionate hope of bereaved families outside this House as they stand shoulder to shoulder with those Members inside this House is that by drawing attention to what may have gone wrong in their own case, mistakes are not repeated and others are spared the terrible heartache that they and their families endured. We owe it to each and every one of them to make this new strategy work, and I commend this Statement to the House".