A Maternity and Neonatal Commissioner for England
Following the recommendations of the Independent Investigation to Maternity and Neonatal Services led by Baroness Valerie Amos, the UK Government has committed to appointing the first statutory Maternity and Neonatal Commissioner for England.
With the right structure and safeguards in place a national Commissioner could become an important voice for women, parents and families and help ensure that maternity and neonatal services act on what is already known.
Creating the role, however, is only the first step, because what matters now is whether the Commissioner will have the independence, authority and resources needed to make a real difference. The role must be designed with sufficient independence and powers, otherwise, it risks becoming a symbolic figurehead in an already complex system.
Below we explore what the role of the Commissioner could include, and the powers may require to be part of the transformational change needed in maternity and neonatal care.
Turning learning into change
England already has many organisations responsible for different parts of pregnancy, maternity and neonatal care which may be confusing and complicated for families to navigate when things go wrong. Some provide services whereas others develop policy, inspect care, review deaths, analyse national data, consider complaints, establish professional standards or support improvement. Each has an important role, but the connections between them are not always clear.
When something goes wrong, one organisation may identify a concern, another may examine what happened, but responsibility for making changes might sit somewhere else entirely. Recommendations can be accepted without it being clear who will implement them, how progress will be measured or whether care has improved as a result.
For women, parents, families and staff, this can make it difficult to see:
- who is responsible for acting on concerns;
- whether recommendations have been implemented;
- whether changes have made care safer and more compassionate; and
- where risks or concerns remain unresolved.
Over many years, women, parents and families have contributed to reviews, investigations and inquiries; they have repeatedly described what happened to them, asked difficult questions and helped identify what needs to change.
Over 700 recommendations to improve maternity and neonatal care have been made since 2015, and yet the problems have been identified time and time again have not been resolved. The challenge is therefore not to produce more recommendations; instead, it is to connect that learning, protect it from being lost when organisations or leaders change, and show meaningful impact as a result.
The role of the Commissioner
The Amos report recommends that the Commissioner provide independent national leadership, holds the system to account for implementation, champions the voices of women, babies and families, helps drive urgent change and co-chairs the National Maternity and Neonatal Taskforce.
The Commissioner would not run maternity or neonatal services, and it should not replace the organisations that already inspect, regulate, investigate or respond to individual complaints. Instead, the Commissioner could help make the whole system easier to navigate for women, parents and families; more understandable, accessible and accountable.
The role could bring together evidence from reviews, investigations, complaints, national data and the experiences of families and staff. It could identify repeated concerns, gaps between organisations and national risks that remain unresolved.
Most importantly, the Commissioner could ensure that national learning leads to action, and ask not only whether a recommendation was accepted but:
- who was responsible for acting;
- what they did;
- when they did it;
- whether the change was sustained; and
- what difference it made to care.
New policies, updated guidelines or training programmes can all be useful, but completing an action is not the same as demonstrating improvement. Learning and recommendations must be able to show whether anything became safer, fairer or more compassionate for women, parents and families as a result
The role must have meaningful powers
A Commissioner would struggle to hold the system to account through goodwill and persuasion alone. Statutory powers would help the role obtain information, publish findings independently, make formal recommendations and require organisations to respond.
This would not need to mean creating another regulator with powers to inspect hospitals, issue fines or direct clinical decisions, or duplicating where these responsibilities already sit elsewhere. The purpose of the Commissioner’s powers should be to strengthen transparency, learning, implementation and accountability.
These powers should be based on a “comply or explain” model. When the Commissioner makes a recommendation, the organisation responsible could be required to say publicly whether it accepts it. If it does, it would explain what it plans to do, by when and how it will know whether the action has worked. If it rejects all or part of the recommendation, it must explain why. After an agreed period, organisations must return to show what they had done and what difference it had made.
A clear point of follow-up would help prevent recommendations from remaining ‘in progress’ indefinitely, disappearing into action plans or being marked as complete without anyone knowing whether the original problem has been resolved.
Families should not have to hold the system together
The Commissioner should be able to consider evidence from individual families where it reveals a repeated concern, a gap between organisations or a wider national problem. Families often hold information that is not visible in clinical records or national data, they may also identify failures in communication, continuity, escalation, compassionate care, cultural safety or bereavement care. Their knowledge should be treated as a core part of the evidence needed to understand care.
At the same time, families should not carry the burden of making the system learn. They should not have to repeatedly recount traumatic events to different organisations, work out which body is responsible for what, connect conflicting findings or pursue the impact of recommendations for years.
It is not enough to record that a family was contacted or invited to contribute to a review of their care. Families should be told how their questions and concerns were considered, what influence they had and what action followed. Some families experience several overlapping processes after pregnancy loss or the death of their baby. Others, particularly following first or second trimester pregnancy loss, or termination for medical reasons, may find that no nationally standardised review applies at all.
The Commissioner should be able to examine both problems: where families are repeatedly drawn into a maze of disjointed processes and where their care and concerns remain almost entirely outside formal learning.
Pregnancy loss and bereavement care must be included
The Commissioner’s remit must cover the whole maternity pathway, including early pregnancy, pregnancy loss, termination for fetal anomaly or medical reasons, labour, birth, neonatal care, maternal and baby death, harm and bereavement because safety, quality and experience cannot be neatly separated. Bereavement care includes how families are communicated with, supported, involved in reviews and told what happened.
A Commissioner intended to understand whether the system is learning must be able to care, communication, culture, inequality, family involvement and bereavement together.
Independence must be real
Calling a role independent does not make it so. Whether the role is truly independent depends on how the Commissioner is appointed, who provides the funding, whether the role has a dedicated team, whether it can obtain information directly and whether it can publish findings without approval.
The Commissioner may need to question or challenge the Department of Health and Social Care, NHS organisations, regulators and other national bodies. This presents a strong case for establishing the role outside DHSC, rather than asking the Commissioner to scrutinise the same department responsible for sponsoring and supporting it.
Whatever arrangement is chosen, the Commissioner would need to be able to ask difficult questions and publish uncomfortable findings without its priorities, budget or public statements being controlled by the organisations it is examining.
Part of a wider programme of reform
The Commissioner role alone will not deliver the transformational system reform required to deliver safer maternity and neonatal care. Alongside the role, the Government has also announced a national action plan, investment in maternity and neonatal buildings, national standards for maternity triage, expanded work to address discrimination and inequality, temporary roles for newly qualified midwives and the extension of Martha’s Rule to maternity and neonatal services.
The National Maternity and Neonatal Taskforce will play an important role in developing and delivering this programme and so, the Commissioner’s relationship with the Taskforce must be clear. If the Taskforce will lead the reform programme, the Commissioner must be able to provide independent scrutiny of whether that programme is being delivered and whether it is working.
Without a clear distinction between delivery and independent oversight, there is a risk that the same structures will be responsible for designing the reforms, reporting their progress and deciding whether they have succeeded.
Shaping the success of the role
The commitment to establish a statutory Maternity and Neonatal Commissioner is an important opportunity. Designed well, the role could connect evidence, protect learning from being lost, make responsibility visible and ensure that organisations explain what they have done. It could help move maternity and neonatal safety away from a repeating cycle in which harm is followed by review, recommendations and another promise to learn.
Designed poorly, it could become another national voice with an important title but limited ability to follow learning through to action, whilst adding another organisation for families to navigate into an already overly complex system.
Baroness Amos recommended that the statutory powers behind the Commissioner role be created through the Health Bill. However, the work to recruit, resource and design the role does not need to wait for legislation.
One option would be to appoint a Commissioner-designate who could begin shaping the role, building the team around it and working out the relationship to the National Maternity and Neonatal Taskforce. That could also mean the Commissioner has a hand in shaping the national action plan from the start, rather than being asked to scrutinise plans that are already well under way.
Women, parents and families need to know that their concerns will be heard, responsibility will be clear, promises will be followed through and the system will be able to show what has changed. A Commissioner designed with care and intention could be an important first step towards making that happen.