The publication of Baroness Valerie Amos’ Independent Investigation into Maternity and Neonatal Services in England (the Amos Review) comes less than a week after Donna Ockenden’s final report into maternity services at Nottingham University Hospitals NHS Trust, the largest maternity investigation in NHS history, and days after the Government confirmed that Martha’s Rule will be extended to all maternity services in England.
Together, these developments represent an important moment for maternity services. The Amos Review rightly focuses on how the system should improve nationally. For me, however, it also raises a more fundamental question.
How does national learning about patient safety become local change?
For more than a decade, maternity care has been the subject of investigations, reviews and inquiries. Morecambe Bay, Shrewsbury and Telford, East Kent, Nottingham and now Amos have each examined different organisations, different circumstances and different families. On reading through the subsequent reports, it was apparent that the geography was different, but the problems were the same. Women’s concerns were not recognised, staff felt unable to challenge decisions meaning opportunities to intervene were missed. Leadership, governance and organisational cultures failed to respond to warning signs, with tragic results.
The Amos Review concludes that England’s maternity and neonatal system requires fundamental reform and takes a system-wide view of how services can become safer, more equitable and more consistent. That national perspective is both necessary and welcome.
However, maternity care is not delivered nationally. It is delivered locally, in consulting rooms, assessment units and labour wards, where women and healthcare professionals make decisions together every day. Those decisions are often made under pressure, in circumstances that are uncertain, complex and constantly changing. They cannot be prescribed from Whitehall or NHS England.
Maternity services need to improve communication between everyone involved
That is why I do not believe the success of the Amos Review will ultimately be measured by the quality of its recommendations, but by whether those recommendations improve the quality of those conversations and, ultimately, the decisions that follow.
National standards can improve consistency. National leadership can strengthen accountability. National oversight can identify unwarranted variation and support improvement. But none of those things, on their own, determine what happens when a woman says, “Something doesn’t feel right.”
One concept that receives relatively little attention in discussions about maternity safety is psychological safety. Although the term is more commonly associated with workplace culture than patient care, I believe it has an equally important place in maternity services.
Psychological safety is not about avoiding difficult conversations or making people feel comfortable. It is about creating an environment in which women, families and healthcare professionals all feel able to raise concerns, ask questions, admit uncertainty and challenge decisions without fear of being dismissed, judged or blamed.
For a woman, that may mean feeling confident enough to say that her baby’s movements have changed, to question whether something is normal, explain that reassurance has not reassured her, or simply to return because something still does not feel right. Unfortunately, the findings of previous investigations have also repeatedly shown that it can mean being strong enough to pressure for further investigation when clinicians won’t listen to those concerns.
For a healthcare professional, it means feeling able to ask for help, escalate concerns, question assumptions or change course as new information emerges without worrying that speaking up will be viewed as criticism or failure by either senior leadership, or peers.
Psychological safety is not the objective, better decisions are
Joint decision-making is often discussed as a matter of patient autonomy or experience. It is both of those things, but it is also a patient safety intervention. Every clinical decision depends upon information, and that information comes from different sources. A woman brings knowledge that no clinician possesses. She knows what has changed, how she feels, what is normal for her pregnancy and what no longer feels right. Clinicians bring professional expertise, evidence, experience and an understanding of risk. Neither perspective is complete on its own.
When women do not feel able to contribute fully, or clinicians do not feel able to question, challenge or reconsider a decision, the quality of the information informing that decision is diminished. Patient safety is affected not because people lack expertise or information, but because they lack the conditions in which that expertise or information can be shared effectively. Psychological safety creates those conditions and enables the exchange of information on which meaningful joint decision-making depends.
Listening to women’s concerns is not just compassionate care, it is also clinical assessment
Seen through that lens, the relationship between the recent developments becomes much clearer. The Nottingham Ockenden Report demonstrates what can happen when local systems fail to hear women, support staff to speak up or respond effectively to emerging risks, and the extension of Martha’s Rule into maternity services provides an important national safeguard when those local conversations break down, recognising that women and families may identify deterioration that warrants a fresh clinical review.
Martha’s Rule should never become the primary mechanism through which women feel able to have their voices heard. The safest maternity services will always be those where concerns are recognised, explored and acted upon through everyday clinical encounters, long before formal escalation becomes necessary.
The Amos Review then asks a broader question. How can the maternity system become more consistent, so that safe, compassionate care is not dependent upon postcode or individual organisational culture? Its central premise is that variation in care should no longer determine variation in outcomes. That ambition is difficult to argue with. The challenge, as with every major maternity review before it, is translating that ambition into consistent practice where care is actually delivered.
That inevitably creates a tension between national consistency and local judgement.
National consistency should not mean uniformity of clinical decision-making. Every woman and pregnancy is different, meaning the risks are also different. What should be consistent is not that every woman receives identical care, but that every woman receives care that is safe, evidence-based, individualised and informed by meaningful joint decision-making.
National standards have an important role. They should establish clear expectations around governance, escalation, learning and accountability while leaving space for professional judgement and genuinely individualised care. Their purpose is not to replace local decision-making but to strengthen it. No national review, however comprehensive, can determine what happens in a delivery room at three o’clock in the morning. Only the people in that room can do that. The purpose of national leadership is to create the conditions in which better local decisions become more likely.
Perhaps this is where the greatest challenge now lies.
Much of the early commentary on the Amos Review has understandably focused on its recommendations. Those discussions are important, but they risk obscuring the wider question of how improvement is achieved. History tells us that publishing another maternity review is not enough, however well-intentioned or well evidenced it may be. Successive reviews have generated important learning and driven meaningful improvements, yet many of the same themes continue to recur across maternity services.
The NHS has become increasingly sophisticated at identifying what needs to change. Reviews are commissioned, which lead to recommendations. Those recommendations lead to action plans which the governance structure oversees the implementation of.
But implementation is not the same as improvement. It is relatively straightforward to ask whether a recommendation has been implemented, the harder question is whether it changed behaviour. Harder still is whether that change improved outcomes for women and babies.
That is where the real work begins.
For the Amos Review, and the many recommendations that have come before it, to deliver lasting change, it will need to be because women feel more confident to speak, professionals feel more confident to listen, question, challenge and change course, and every clinical interaction becomes a little more open, a little more collaborative and, ultimately, a little safer.
Because that is how national learning and system-wide recommendations become better local conversations, better local decisions and, ultimately, safer maternity care.
The next challenge for maternity services isn’t national. It’s local.
Katherine Pearce
Head of Medical Negligence
About the author
Katherine Pearce is Head of Medical Negligence at Davies and Partners Solicitors. Before qualifying as a solicitor, she worked in NHS governance, giving her a unique perspective on patient safety, organisational learning and the practical challenge of translating national policy into meaningful improvements in frontline care. She writes regularly on developments in clinical negligence, maternity safety and healthcare governance.
Related reading
- Amos Review: What the key recommendations mean for women and families
- Martha’s Rule
- Are maternity services getting worse? A look at recent maternity unit scandals
Read the Amos Review: https://www.matneoinv.org.uk/