The Ockenden Maternity Report: A Wider NHS Perspective by Bernie Bentick
Bernie Bentick calls for an Independent Regulatory Body for NHS Managers, adequate funding and prioritisation of Safety over Activity in the NHS, a National Well Being Guardian and more effective scrutiny of Shropshire's Health Providers.
The Ockenden Report, published yesterday, was commissioned by former Secretary of State for Health Jeremy Hunt in 2017 after the parents of babies who died in the care of Shrewsbury and Telford NHS Hospital Trust (SATH) were distraught about the uncaring response of Staff to their bereavement. Concerns were also raised about the numbers of preventable baby deaths.
Initially 23 families were involved but this ultimately grew to 1486 and an Ockenden Interim Report was published in December 2020, describing details of the first 250 cases examined, listing 27 Local Actions for Learning for SATH and 7 Immediate & Essential Actions (IEAs) for all NHS Maternity Units in England.
The Final Ockenden Report, covering 1486 cases, was published on 30th March 2022 in 15 Chapters and contained distressing descriptions of mothers' and families' experiences.
I was deeply saddened to read the stories and my heart bleeds for the bereaved mothers and families. The Report provided a forensic examination of the standards of care across the clinical and management teams, but not the levels of funding for SATH Maternity Services, which were widely recognised as inadequate by those Staff working within it.
The principal themes of the report were inadequate safety systems, including poor investigation of and learning from the deaths of babies and mothers, not listening to mothers and families, a zeal for maintaining historically low Caesarean deliveries, persistent understaffing, the failure of both internal and external Investigations to identify the problems and a culture of bullying, blame and fear.
The reader is directed to the Final Report for details, but significantly, it states that although SATH Perinatal statistics were above (worse than) average, they were comparable to many similar Maternity Units, implying that there may be similar problems elsewhere, hence the imperative to issue 7 Immediate and Essential Actions for all Maternity Units in England within the Interim Report in December 2020.
This Press Release sets out the wider context for the failures at SaTH and makes recommendations for improvements to the way that care and safety is managed across the whole of the NHS, not just Maternity Services.
Over several years, there have been frequent reports of catastrophic failures and scandals within NHS Trusts, the most recent including the East Kent Hospitals University Trust, Liverpool University Hospitals NHS Trust, the University Hospitals Birmingham Foundation Trust and most recently the response and hand-over times in the West Midlands Ambulance Service.
Many of these scandals have their roots in 7 actions of former Governments:
• The NHS and Community Care Act 1990 separated purchasers and providers of NHS & social care, setting up competition between providers and creating an NHS Internal Market for health care.
• The Health and Social Care Act 2003 Act intensified competition to win Healthcare Contracts, with the establishment of Foundation Trusts which controlled their own budgets.
• Since 2004, with the introduction of the Payment by Results System for NHS Activities and the imperative to reduce waiting lists, procedures (including Operations) have commonly been favoured for funding. In 2014, a national tariff payment system was introduced, introducing a specific fee for many procedures and investigations, resulting in further prioritisation of those activities.
• The American concept of 'managerialism' was adopted by the Department for Health and NHS management in the 1980s and is now the standard for NHS Management.
In this culture, Senior NHS trust managers who had little or no experience of front-line NHS activities were appointed. The concept of profit for investment within NHS care flourished. Simultaneously, some excellent clinical staff were promoted to managerial posts without the training or support to perform their new roles.
• The decade of austerity, starting in 2009/10, resulted in stagnation of NHS funding. Clinical and other services were forced to take annual budget cuts of 3% - so-called cost Improvements - to fund favoured developments. Some services lost up to 25% of their budget. However, NHS activity increased significantly during this decade, with inpatient admissions increasing by almost 30%.
• The costs of some surgical treatments, particularly 'key-hole' Endoscopic procedures rose considerably, including new expensive equipment, replacing the traditional open procedures.
• Novel investigations & treatments adding to the drain on resources.
The result was promotion and generous funding of some services, especially surgical procedures, while at the opposite end of the spectrum, Cinderella services, principally non-surgical ones such as Maternity, Emergency, Mental Health and Care of the Elderly, withered and eventually collapsed due to dwindling resources and priority, as staffing frequently dropped to unsafe levels.
Vital equipment & Facilities were not maintained or replaced, with the development of Risk Registers, where only items of highest priority were repaired or replaced.
By 2019, the deficit in the NHS Estates maintenance budget was £6.5 billion, of which half presented a high or significant risk to patients or Staff.
In these circumstances, several Trusts or services within Trusts developed a highly corrosive culture of bullying, undermining & blame, coercing staff into working beyond safe levels and blaming individuals for resource deficiencies, to avoid taking responsibility for those deficiencies. A search of the Heath Service Journal recently on the topic of bullying produced 1,194 results.
This led to an NHS epidemic of disciplinary investigations, staff dismissals, early retirements and resignations. A constant barrage of scandals in many trusts led to several public inquiries including those at the Mid-Staffordshire NHS Foundation Trust (Francis Report), Morecambe Bay NHS Foundation Trust (Kirkup Report), the Christie Inquiry and the Shrewsbury and Telford NHS Hospital Trust (Ockenden Report).
These malignant regimes were allowed to grow and spread to other services & trusts. Failing NHS executives moved to different positions but without any mechanism to control the spread of the dysfunctional culture.
Modern matrons were created from the Francis Report to ensure adequate standards of care but they were quickly diverted into 'bed managers' in many hospitals, losing Trusts a valuable resource for maintaining standards.
The Care Quality Commission has demonstrably failed to achieve its objective of maintaining acceptable levels of patient care, governance, staff well-being and financial competence in SATH and elsewhere.
In Shropshire, the local Joint Health Overview and Scrutiny Committee appeared to have no clear understanding of the issues in SATH and currently struggles to even meet, due to depletion of Officers serving the Committee.
In the Shrewsbury and Telford NHS Hospital Trust (SATH), a corrosive bullying, undermining and blame culture developed. This led to increased staff disciplinary investigations and dismissals, early retirements and resignations, with high staff turnover and progressive increases in unfilled vacancies.
I and others reported the bullying culture and safety issues to senior SaTH managers and the regulators, including the Care Quality Commission, NHS Improvement and The National Guardian between 2016 and 2018, including over 50 specific incidents involving over 100 Members of staff. Maternity staff were included in those who were reported as bullied.
A management appointed Employment Law Team carried out a superficial and inadequate Investigation, which was never published (Ibex Gale Report).
SATH issues have continued until recently, when external support from The University Hospital Birmingham and Sherwood Forest Trusts, plus the appointment of a Trust Board of previously successful NHS Senior Managers, has begun to stabilise SATH.
However, this has not yet eradicated the bullying problem, still suffered by 15.2% of staff from Managers (down by 0.4%) and 26.4% from colleagues (up by 2.2%) in the 2021 NHS Staff Survey for SATH, which was also published yesterday.
There are six reforms which would resolve or improve the current Health Care Crisis in England and would complement the Ockenden Report recommendations:
1. The government should implement one of the most important recommendations of Sir Robert Francis in his report of the inquiry into the Mid-Staffordshire NHS Trust in 2013. This is the establishment of a Statutory Regulatory Body for all NHS managers, with specified training, accreditation and a code of conduct, with sanctions for non-compliance. This could be called The Health Management Council, would bring NHS managers into line with all other NHS professionals and should
Result in high quality, open, transparent Leadership at all levels of NHS Management.
2. The NHS should prioritise 'Safety' over 'Activity', as happens in the Aviation Industry.
This was a key theme in The Ockenden Report and should be implemented right across the spectrum of healthcare.
3. There needs to be adequate NHS and social care funding to the levels in the best western countries (UK current spend is the second lowest in the G7 Group).
4. An NHS National Wellbeing Guardian should be established by the government, to lead the army of local Wellbeing Guardians, recently appointed in all NHS Trusts.
5. The traditional Safety Nets within NHS Trusts should be re-established, including Senior Medical and Allied Professions Committees, with representation at Trust Board Level.
6. The newly established Integrated Care Systems and the Health Overview and Scrutiny Committees should comprise Professionals with clear understanding and experience of Health and Social Care provision and should ensure that NHS Trusts meet their safety as well as activity targets. Public Health should be well represented on these Committees.
Bernie Bentick 31st March 2022
Retired Consultant in Gynaecology, Reproductive Medicine & Obstetrics at SATH.
Shropshire & Shrewsbury Town Councillor for Meole Ward.
www.gov.uk/government/publications/final-report-of-the-ockenden-review