It was 1980.

Big John, as he was affectionately known to his friends, stepped out of the air-conditioned diner into the blinding Texan-heat, bouncing off the main-street through Camel Back.

He pulled-out the keys to his F-100 pickup, looked across at where it had been parked. It was gone.

At that moment Big John had become another victim of the ‘phantom-park shifter’.

The upshot; Ford recalled 21 million vehicles with an issue… cars shifting out of parking mode and running away.

Ford first responded by issuing each owner with a special warning-sticker. As you might imagine, that didn’t go down too well.

Eventually, they were forced into one of the biggest recalls in history.

In 1999, Ford again… forced into another recall… 15 million vehicles… a faulty cruise control switch that caught fire.

If things keep going wrong, there must be something wrong with the way we do things.

Quality control, supply-chain, training, design… dunno.

The NHS? Well… think maternity;

1993, Changing Childbirth Report: Department of Health, highlighted the need for a woman-centred service… changes in service delivery.

2015, Kircup review: examined serious failures in maternity, neonatal services and maternal harm.

2016, Learning from Tragedy: Keeping Patients Safe: highlighted lessons learned from investigations into serious incidents, plus recommendations for improving safety and the investigation process.

2016, National Maternity Review: aimed to improve the safety and quality of maternity care.

2016, Better Births: Improving outcomes of maternity services emphasising personalised care, continuity of carer, and choice.

2017, Saving Lives, Improving Mothers’ Care; confidential enquiry into maternal deaths.

2018, Independent Review into deaths of children in Northern Ireland’s hospitals due to fluid mismanagement

2019, NHS Long Term Plan: included commitments to improve maternity services and expanding perinatal mental health support.

2022, The Ockenden Review; identifying significant failings in care and making recommendations for improvement.

2022, Care Quality Commission reports deteriorating substandard care at 39% of maternity units… the same concerns ‘emerging again and again’.

2022, Independent investigation by Kirkup on maternity and neonatal services in East Kent.

2023, MBRRACE, lessons learned from Confidential Enquiries into Maternal Deaths and Morbidity.

2023, NHS England; Three year delivery plan for maternity and neonatal services.

2024, ongoing review; into maternity issues, Nottingham.

2024, House of Commons Research; Quality and Safety of Maternity Care, ‘reasons for… disparities are not fully understood’.

Add to that; complaints against maternity services and midwives have grown year-on-year in 2021/22; a 10% rise. Complaints against maternity departments only; grew by 16%, from 3,970 in 2020/21 to 4,610 in 2021/22…

… and it is safer to give birth in Bulgaria than Britain.

£1.1 billion was paid in compensation for negligence in maternity and neonatal care, roughly a third of the total NHS spend on maternity services in 2021/22.

And… add to all that, the recent report from the All Party Parliamentary Group on Birth Trauma… seven chapters and twelve recommendations.

It was stupid for Ford to issue drivers a sticker telling them their car might be dangerous and it is just as stupid for the NHS to keep publishing reports telling mums and families maternity care might not be safe.

If things keep going wrong, there must be something wrong with the way we do things.

The All-Party report adds little to what we know, other than, this time the issues have been articulated by women, themselves.

The recommendations are pretty much a repeat of what all the other reports have said. With the exception…

… this report calls for an overarching strategy document to spell out what ‘maternity services are supposed to look like’ and a ‘maternity commissioner’, who would be required to report to the Prime Minister every year.

No, no, no!

The Commissioner will spend most of the year trying to think-up new ways to explain to the PM why, ‘maternity services don’t look like what they’re supposed to look like’.

What are the issues?

There are lots of factors; deprivation, age, women’s health, training, staffing, investment, listening, management… the upshot… the NHS can be very good and very bad at maternity services.

If the NHS was the Ford motor company it would probably decide not to ‘do maternity’. I’m sure the shareholders would agree.

The NHS isn’t a car company and we can’t not ‘do maternity’ but we must find ways to do it consistently better and I’m convinced the people doing the best they can, want to do it better and…

… they don’t need another report.

This is about opening our minds, honest reflection, looking at where it’s done safer and better, sharing the best from here and overseas.

None of these reports have made us safer, but attitudes will.

News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.