In this blog, Clea Harmer Chief Executive at Sands sets out what we mean when we talk about reforming the system and why it is a necessary first step to enable improvements in maternity and neonatal services. 

Introduction

In our evidence to the maternity and neonatal investigation, Sands set out the need for whole-system reform rather than local service-level fixes, if maternity, neonatal and bereavement care in England are to be improved.

As Baroness Amos acknowledged in the final report on the National Maternity and Neonatal Investigation, “if we don’t reform the system, efforts to change it will fail.” 

For too long leaders have insisted that issues in maternity and neonatal care are limited to ‘dark corners’ of the NHS, to one or two ‘failing' Trusts. But with 65% of units rated unsafe by the CQC in 2024, an increase in maternal death rates, and little progress in saving babies’ lives, we know this hasn’t been the experience of many families. 

Families are suffering avoidable harm and loss because the current system is broken.  

Baroness Amos suggests that the eight recommendations she makes will address the systemic problems identified in the report and improve quality and safety. These follow a set of immediate and essential actions published by Donna Ockenden’s review into maternity and neonatal services in Nottingham University Hospitals NHS Trust in June, and over 700 recommendations that have come before these two reports. 

One of the tasks of the National Maternity and Neonatal Taskforce is to prioritise and sequence these recommendations into a deliverable action plan. However, for any action plan to be effective there must be a system which can support and enable it. 

To the question ‘why have recommendations to date been ineffective?’ it is important to consider the environment and structures in which maternity and neonatal care operate. This system has been the single biggest barrier to change, and without addressing these issues first, all attempts to introduce transformational change through separate well-meaning initiatives will fail. 

It’s vital we acknowledge this, and the National Maternity and Neonatal Taskforce has a once-in-a-generation opportunity to deliver the transformational system-wide change required to make care safer. 

What does system change look like?

To deliver the scale of change required, there must be a clear vision which is shared by everyone from Government to regulators and NHS staff. And there must be the energy, will and determination to make the shared vision a reality. 

This vision must enable:

Women, birthing people and parents to be placed at the centre of care 

If women, birthing people and families are put at the centre of the care being given, if they are listened to, respected, and ‘seen’ for the individuals they are, then they will receive safe, personalised care. 

A safe system is one which listens to families, which supports people to make the decisions that are right for their personal needs, and which is accessible to everyone. A safe system respects the fact that women and birthing people may have different approaches to, and make different choices around, risk. Personalised and safe care understands how to tailor care to meet the needs of an individual. Safe care is both an outcome-based metric and also an experience measure.

A just and fair culture 

As highlighted by Baroness Amos, the current culture within maternity and neonatal care is a critical safety issue. It is damaging women, families, babies and staff, it is driving inequalities in outcomes, and in the worst cases it is leading to avoidable deaths. 

Sands' submission to the Amos review set out how there is a need for a just culture which places an emphasis on accountability, fairness, justice and learning. 

In the current system there are staff who feel unable to raise concerns; there are staff who do raise concerns which are then not acted on; there are families who try to raise the alarm after their baby’s death but are blocked and ignored. Racism and discrimination are embedded in the system. 

No training course, leadership programme or single regulatory change will fix cultural issues that run this deep. It requires complete system reform.

A system which supports accountability  

Accountability should operate at different levels in a system. There is a need for personal accountability but also organisational and governance accountability. 

In a system where the difference between these is blurred or unclear; where there is no encouragement to take responsibility; and where there is no robust external assurance, it is likely that accountability fails. 

In a system where hospitals are able to ‘mark their own homework’ during reviews and investigations, where they self-assess returns to the Maternity Incentive Scheme, and where Boards may have poor and inadequate oversight, the conditions for robust accountability are clearly missing.            

What is needed is a system which encourages and rewards personal responsibility, and which supports organisational responsibility through robust external assurance provided by those who are truly external to maternity and neonatal care.

A genuinely independent Maternity and Neonatal Commissioner might be able to deliver this external assurance, but only if the role has true separation from healthcare, and the resource and funding required to truly hold the system to account. 

Reflections and what comes next

The publication of the Maternity and Neonatal Investigation report must be the catalyst for the changes needed to save babies’ lives. 

This is the opportunity for the Taskforce to envisage and plan for a system that supports safe and personalised care. To ensure that changes are fully costed and funded, and that changes are supported by monitoring and evaluation to ensure effectiveness.  We are calling on the new Prime Minister and the new Secretary of State for Health to make this their priority. 

This is the moment for transformational change, and Sands is ready to be a part of it.

Read more about Baroness Amos' recommendations 

Sands has done a deep dive into the eight recommendations from Baroness Amos' report into maternity and neonatal care in England.