When the final Ockenden report (2022) was published on 30 March this year, the same day also saw a report disclosing that satisfaction with the NHS had dropped to a 25-year low (Wellings et al, 2022). Satisfaction with the NHS, overall, fell to 36% – an astonishing 17 percentage point decrease on 2020. This is the lowest level of satisfaction recorded since 1997, when satisfaction fell to 34%. More people (41%) were dissatisfied with the NHS than satisfied (Wellings et al, 2022). Key reasons for this dissatisfaction were waiting times for GP and hospital appointments (65%), followed by staff shortages (46%) and a view that the government does not spend enough money on the NHS (40%).
The scale of the Ockenden review is unprecedented in the history of the NHS. The report makes clear that there can be no excuses for the incidents that have happened in what has become known as the Shropshire maternity scandal. This review has to signal a turning point for all those who offer maternity services. The actions recommended must be acted upon with speed.
Seven years ago the Morecambe Bay investigation report was published (Kirkup, 2015). This report, covering the period January 2004 to June 2013, concluded that the maternity unit at Furness General Hospital was dysfunctional and that serious failures of clinical care had led to the unnecessary deaths of mothers and babies. It appears that the 44 recommendations of this report have not been implemented universally.
Even now, there remain concerns that NHS maternity services and their trust boards are continuing to fail to adequately address and learn lessons from serious maternity events.
It is acknowledged that maternity services have serious workforce challenges and this has to change. Workforce challenges that have existed for over a decade cannot be put right overnight. This is accepted. But how can maternity services find themselves so depleted of staff? For many years, there has been no investment in services. Attempting to run a quality maternity service on a shoestring is destined to lead to adverse outcomes for mothers and their babies. The Ockenden review (2022) is of the belief that if the ‘whole system’ that underpins maternity services is committed to the implementation of all the immediate and essential actions within the report, along with the provision of necessary funding, then this has the potential to lead to far-reaching improvements for all families and all of those staff who work in NHS maternity services. This has to be heeded by government and those who commission services.
In its response to the review, the Royal College of Midwives (RCM) noted that poor culture and leadership have to be challenged if NHS maternity services are to be the safest place for women to give birth (RCM, 2022). A seismic cultural shift is needed. A working culture where staff are afraid to raise concerns was cited by the report as a key factor in many of the cases described.
After numerous investigations and inquiries, our NHS is still failing to be a service that is devoted to continual learning. Consistently, lessons are not learned, mistakes in care are repeated and the safety of people to whom we have the privilege to offer care and support is too often unnecessarily compromised as a result. We all have a responsibility to speak out about poor behaviours and poor care in the places where we work. Working environments with toxic working cultures will lead to a lack of appropriate escalation, this in turn threatens patient safety and this has to stop. The lessons from Ockenden have the real potential to be transferable to the whole of our NHS – but will they?