What defines a safe service? The Care Quality Commission's (CQC) key lines of enquiry can be said to encapsulate the main issues. However, their published provider reports are now often so old as to be unreliable, with changes being made at pace to address this and other regulator woes.
The new, single assessment framework (Care Quality Commission, 2024a) looks set to remain, albeit with a number of simplifications and changes agreed, but yet to be made. At the time of writing, the key lines of enquiry for ‘safe’ are little changed from those of the outgoing framework. These cover safeguarding, risk management, the environment and infection control, safe staffing, medicines optimisation, learning from incidents and safe systems, pathways and transitions. The latter point, focusing on effective action to keep people safe when they move between services, is the only significant addition made to this section of the new framework, moved from a different section.
One stream of CQC's work to address slow re-inspections, as well as concerns raised by a series of investigations highlighting failings at NHS trusts, is the national maternity inspection programme. This focused on ‘all hospital maternity locations that had not been inspected since before March 2021’ (CQC, 2024b).
The good news is that excellent practice was found. However, this was in pockets, and CQC's firm conclusion was that services are not up to standard. Almost half of the 131 services inspected were rated ‘requires improvement’ (36%) or ‘inadequate’ (12%) overall. For the ‘safe’ key question, no services inspected were rated ‘outstanding’ and just over a third were ‘good’. More than two-thirds were rated as ‘requires improvement’ (47%) and ‘inadequate’ (18%).
How do these, largely systemic, failings affect women and their families? They may not receive a safe and timely assessment. There are no national standards or targets for maternity triage, although guidance has been issued since the inspection programme by the Royal College of Obstetricians and Gynaecologists (2023). In some cases, inspectors found the triage phone went unanswered and some women discharged themselves before being seen, as their wait was so long.
The quality of their care may not be as expected. Too few midwives may be on duty, possibly supplemented by bank and agency staff less familiar with local systems and procedures. Chronic staffing shortages in health and care services have been a general feature for some time and apply equally to midwifery. CQC (2024b) concluded that ‘high numbers of midwives [are] being driven away from the profession by current pressures’. Fewer are entering the profession. University applications for midwifery are at a 6-year low.
Care of Black and Asian women and staff may not be equitable. There are no national guidelines that NHS trusts can use to evaluate their efforts to address health inequalities. Issues identified by data make these initiatives imperative. For example, ‘Black women are still 2.8 times more likely to die during or up to 6 weeks after pregnancy compared with women in White ethnic groups … and Asian women are 1.7 more times likely to die during the same period’ (MBRRACE-UK, 2024). The CQC also found both services users and staff had identified discrimination because of their ethnicity or because English was not their primary language.
Women may receive insufficient information and support following a serious incident. CQC (2024b) were concerned at ‘the potential normalising of serious harm in maternity’. While midwives were experienced at dealing with such incidents, the regulator emphasised that this is not the case for individual women, whom they felt needed more help in processing these often significant events and making decisions about future pregnancies. On a positive note, the CQC found that most trusts reported and learnt from patient safety incidents well.
After the high-profile reports on maternity care in recent years, it is useful to be able to set these in context against CQC's national inspection programme. However, this confirms that the overall picture is far from rosy, with a long way to go before maternity services are routinely offering safe care to all women.