Health Management and Policy Alert

Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20

MBRRACE-UK -
This report finds that pregnancy remains very safe in the UK. In 2017-2019 191 women, of the 2,173,810 giving birth, died during or up to six weeks after pregnancy; 495 during or up to one year after their pregnancy. This is a small, but not statistically significant, decrease in the overall maternal death rate. It outlines a need for recognition that women can be placed at additional risk by clinician behaviours which focus on concerns over a woman’s pregnancy rather than concerns over a woman herself. It also highlight the gaps that remain in mortality rates between women from deprived and affluent areas, women of different ages and women from different ethnic groups.

• Report
• MBRRACE-UK - publications

Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation

Department of Health and Social Care - 

Following concerns raised about the quality and outcomes of maternity and neonatal care, an independent investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust was commissioned. The primary reason for this report is to set out the truth of what happened, so that maternity services in East Kent can begin to meet the standards expected nationally, for the sake of those to come. The report identifies four areas for action. The NHS could be much better at: identifying poorly performing units; giving care with compassion and kindness; teamworking with a common purpose; and responding to challenge with honesty.

• Report
• More detail

Safer care for all: solutions from professional regulation and beyond

Professional Standards Authority - 

This report highlights some of the biggest challenges affecting the quality and safety of health and social care across the UK today. It describes a ‘fragmented and complex’ patient and service user safety framework and calls for action to address the safety issues. The report's main recommendation is the appointment of an independent Health and Social Care Safety Commissioner (or equivalent) for each UK country. These commissioners would identify current, emerging, and potential risks across the whole health and social care system, and bring about the necessary action across organisations. The report goes on to consider four important themes: tackling inequalities; regulating for new risks; facing up to the workforce crisis; and accountability, fear and public safety.

• Report
• Press release

Guidance for emergency departments: initial assessment

NHS England - 

This guidance makes recommendations for models of initial assessment of patients arriving at emergency departments and provides standard definitions of the processes that classify as initial assessment: streaming, triage, and rapid assessment and treatment. It recognises that initial assessment and flow from the front door of a hospital are a crucial first step on a patient’s journey.

• Guidance
• More detail

Interim report

Infected Blood Inquiry - 

This report recommends that an interim payment of no less than £100,000 should be paid, without delay, to all those infected and all bereaved partners currently registered on UK infected blood support schemes, and those who register between now and the inception of any future scheme.

• Report
• More detail

System on a cliff edge: addressing challenges in social care capacity

NHS Confederation -
This report, based on a survey of NHS leaders across England, says staffing gaps and a lack of capacity in social care are putting the care and safety of patients in the NHS at risk. More than nine in ten NHS leaders warn of a social care workforce crisis in their area which they expect will get worse this winter. Almost all NHS leaders say that the most impactful solution would be better pay for social care staff and call for the Government to increase investment in social care as a priority.

• Report
• NHS Confederation - news

NHS Providers: new hospital programme survey

NHS Providers -
To understand trusts' experience and progress to date, NHS Providers carried out a survey of trusts currently included within the new hospital programme covering questions around funding, delays and the value of the programme. Nearly two in three leaders who responded said delays to the programme affected their ability to deliver safe and effective patient care, with all those facing delays reporting cost implications.

• Briefing
• NHS Providers - news

Re:Birth summary report

Royal College of Midwives -
This project worked with representatives from across maternity care, including staff, advocacy groups and service users. It advises that midwives and obstetricians put the needs and wishes of women at the heart of all conversations about their care. It recommends that maternity staff should follow the five As: acknowledge, ask, affirm, avoid and annotate.

• Summary report
• Royal College of Midwives - press release

Compensation and redress for the victims of infected blood: recommendations for a framework

Cabinet Office - 

This study by Sir Robert Francis QC looks at options for a framework for compensation for the victims of the infected blood tragedy. Sir Robert will give evidence about his work to the Infected Blood Inquiry in July 2022. Before then, it is important that the Inquiry, and recognised legal representatives of its infected and affected core participants, have an opportunity to consider his work. The Minister for the Cabinet Office has published a statement about the study.

• Study
• More detail

Nursing under unsustainable pressures: staffing for safe and effective care in the UK

Royal College of Nursing - 

In March 2022, the RCN invited nursing and midwifery staff from across the UK to give their experiences of the last time they were at work. There were 20,325 responses to the survey. Eight in ten (83 per cent) said there weren’t enough nursing staff to meet all patient needs safely and effectively on their last shift. Just a quarter (25 per cent) of shifts had the planned number of registered nurses. Less than one in five (18 per cent) said they had enough time to provide the level of care they’d like.

• Report
• Press release