I'll refrain from asking why none of these worthy Inquiries seem to address what, for me, looks like the core of the problem. That would be rude and uncouth ...
Instead I looked at this sentence again: "We have become exceptionally good at investigating failure and remarkably poor at learning from it." - and wondered how this could be. After all, aren't we told, again and again and again after every failure and catastrophe, be it in the NHS, be it in the country in general, that 'lessons will be learned'. doesn't it look as if the NHS and the whole of whitehall is constitutionally incapable of actually 'learning lessons'?
Well, I'll be rude then, and somewhat circumspect. The core of the problem, as I see it, is the preponderance of females who've grown up and been educated under a strict, feminist ideology. And, using another ancient slogan, 'I say this as a woman', so I do have, in lefty manager speak, 'lived experience'...
Maternity services began to struggle in the 80s when midwife training was cut markedly as a response to a falling birthrate ( just before population increased through immigration) ,Add to this the closure of smaller local maternity units and merging of even larger ones as happened in Sheffield. The result is a stretched hierarchy heavy service. I could go on about young relatives recent experiences but the reports already highlighted the reasons.
Staffing and closures undoubtedly contributed. But we’ve now had decades of reports describing the same failures. At some point we have to ask whether this is only a resource problem, or whether the assumptions behind the modern maternity system deserve the same scrutiny as its staffing levels.
Poor teamwork is mentioned in every one of these reports. A major issues in maternity care, which has been around at least since I was an Obstetric SHO (Junior Doctor) in the early 1980s, is the command structure (spoiler alert, there isn't one). Midwives are independent practitioners and only ask for help from Obstetricians (Doctors) when they feel they need it- there is no automatic supervision of the former by the latter. Together with the perceived imperative for normal deliveries this leads to delays in calling for help and to subsequent interventions with the inevitable consequence of avoidable harm to mothers and babies.
As well as the human costs, the outstanding provision for NHS maternity clinical negligence claims in England is approximately £37.5 billion, accounting for about 62% of the entire outstanding clinical negligence liability for the health service. (£60 billion).
This sounds remarkably similar to the argument made for decades—that more obstetric oversight inevitably improves outcomes.
Yet Britain once had a strong tradition of skilled community midwifery, and British observers criticized American obstetrics a century ago as “an orgy of interventions.”
Perhaps the question isn’t simply who is in charge, but whether we’ve forgotten that restraint is also a clinical skill.
I remember talking to a friend who worked in a smaller town in NZ years ago; he commented that an (Austrian) obstetrician came; a very caring and capable man; who was a "main de coucheur" obstetrician; meaning he could only deliver babies vaginally; a urologist taught this man how to do LSCS ("caesars"); seemingly the lady paediatrician in the town commented that the number of brain-impaired children fell dramatically after this;
" the outstanding provision for NHS maternity clinical negligence claims in England is approximately £37.5 billion, accounting for about 62% of the entire outstanding clinical negligence liability for the health service. (£60 billion)."
goodness; that suggests there are one or two issues afoot ............
If I might make a more general point, it seems that most "inquiries" fall into similar categories.
Readers of Trust the Evidence will immediately think of La Hallett & her KC Chums.
But then there is the Post Office Fujitsu Horizon IT case, the "Infected Blood" scandal, waiting for most of those affected to die before settling, Even the Covid "vaccine killed and damaged" victims are treated almost with derision (after Mark Steyn was forced out of GB News by Ofcom and incompetent management), whilst ennobled perpetrators stuff their boots with profits.
In my time, I have read a number of inquiry reports. I think the only one I could commend to anyone interested, is the "Report of the Tribunal appointed to inquire into the Disaster at Aberfan on October 21st, 1996". This, you might remember, was the spoil heap collapse in South Wales that buried alive 116 Welsh schoolchildren and 28 adults. Thanks to the honesty and determination of Sir Herbert Edmund Davies who chaired the inquiry, the report is very accurate and laid considerable blame on the then Chairman of the National Coal Board Lord Robens and other senior officials for their gross incompetence and neglect of any competent design and management of the construction of spoil heaps generally, not least at Aberfan.
I have to admit that one of the main attractions in 1976 of a job with the NCB as a newly Chartered Civil Engineer was the hope that I could help (even after 10 years!) in making these enormous heaps safe.
It should be noted however, that despite the excellence of inquiry report efforts of Sir Herbert Edmund Davies and his team, no-one was really held to account. And Alfred Robens, Baron Robens of Woldingham, a Labour politician, "went on selected by Barbara Castle to chair a committee on workplace health and safety. This led to the 1972 Robens Report which controversially championed the idea of self-regulation by employers. The Report itself led to the Health and Safety at Work etc. Act 1974 and the creation of the Health and Safety Commission and the Health and Safety Executive." (Wikipedia).
Maybe it's just my age, but I am exasperated how often I post something, or just send a text to someone only to find that the super duper magic "correction" software renders what I type (and usually carefully check!) into nonsense.
thanks for an excellent commentary Martin; somebody kindly pointed out to me a while back how to edit posts: click on the magic three dots at the right of the text; magic; you can then look perfect
What about highlighting the seeming complete absence of clinical ownership alongside clinical oversight in maternity units. These aspects highlight the now disastrous erosion of the fundamentals of medical and surgical method created by 'managerialism' across the NHS.
But I wonder whether “clinical ownership” is itself part of the problem in maternity. Birth isn’t analogous to most medical or surgical care.
Historically, the question wasn’t who owned labor, but who recognized when physiology was no longer protecting itself and assistance was genuinely needed.
That’s a very different model from one built around command, oversight and escalating intervention.
"Historically, the question wasn’t who owned labor, "
gosh; I would have sensed it was an ever-present dilemma; almost a tug of war in some places; I had cause to read Linda Bryder's 2009 book on the Cartwright inquiry in distant NZ in 1987; what I found interesting as one of the outcomes of the report; was that a more fiercely independent midwifery was established; because it seemed inherently (to some) that women would naturally do a much better job always for other women; doctors (assumed to be male) were essentially vilified; there seemed poorer outcomes in this brave new world; whereas years before, after a UK professor of obstetrics started in NZ in 1963, there had been new maternal mortality and perinatal outcomes data regularly and thoroughly collected; and new oversight; there were strong suggestions it seemed that there were concerning perinatal issues with the new expansion of midwifery; and that there was not allowed to be clear data made available; to judge the facts; it seemed ideology must triumph
I appreciate the clarification. I certainly agree that someone must accept responsibility when things go wrong.
But does not “ownership” unintentionally shifts the center of gravity away from the woman herself. Childbirth is unique in that the patient should remain the primary actor, with clinicians carrying responsibility for recognizing when physiology is no longer protecting itself and help is genuinely needed.
Your comment also reminded me of my aunt. She was a classic twilight sleep mother with her first baby in 1965, but by the time she began asking questions and had Lamaze births in 1974 and 1978, she often reflected on an English friend she had known in the early 1960s. She was struck by how calmly this woman approached pregnancy and birth compared with the fear-based, obstetrician-as-savior culture American women were immersed in.
She didn’t have the language for it then, but later realized she had witnessed two very different birth cultures.
I sometimes wonder whether that quiet confidence was one of the casualties of the NHS’s move toward centralized, hospital-based maternity care.
surely so much has changed; an "elderly primip" in 1970 was .. guessing .. 25; (please correct me as appropriate) but AI said
"The definition of "elderly primip" (short for elderly primipara)—a first-time pregnant individual—has shifted dramatically from the 1970s, when it meant anyone over 25. Today, the standard UK clinical definition is age 35 or older at delivery, though modern terminology heavily favors Advanced Maternal Age (AMA) over the outdated and stigmatizing "elderly" label"
many lasses delivering in the early 1970s in big city UK maternity hospitals; were late teens to early 20s; and weighing less than 70kg before pregnancy; having several children, it seemed common that 2nd or 3rd children were born more rapidly and easily; so data better overall?
quite a few girls will be having their first baby aged 38 or more; regarded as having more risk; much, much more T2 diabetes; much more obesity; and perhaps having only one child; so skewing data?
I would gently suggest the "apples" of 60 yrs ago, are not identical to today's apples
The maternity sector seems to be especially awful, but the NHS as a whole does have a problem with SOME - perhaps too many - staff; being cruel to patients, misunderstanding what's wrong with them and jumping to conclusions, making things up (even consultants do that) and telling huge fibs to cover up when things go wrong.
I won't plug my forthcoming book but it'll be full of all that sort of stuff.
Viv had hearing problems; I put in writing to ward staff that they should remove face masks when speaking to her and speak to her left ear. They refused to remove masks 'because of covid' (this was last summer) and then made a load of mistakes after not properly explaining what drugs etc they thought she should have. This sort of problem was mentioned on a Patients Association call I was on on Friday; a representative from one or other ICB said that hospital staff are required to 'make appropriate adjustments' for the disabled (of whom there are many in hospitals - arguably most patients are, in some way, disabled and the staff should be used to dealing with them), and patients or representatives should raise a formal complaint if staff fail to make an effort to communicate with them. I commented that I'd have been forever raising formal complaints; when something goes wrong in hospital patients and their carers look after the patient first. They often don't have time to complain (and it's b difficult to know who to complain to).
What comes out in the media is, I'm afraid, the tip of a very big iceberg.
I was also at a King's Fund conference last week which may have held a glimmer of hope for the future: the subject was Artificial Intelligence. I know what Tom and Carl think, but AI is already in halthcare (imaging especially), audio-to-text transcripts are being used at some GP surgeries (hooray, no more 'confusion' about what was said!), and one lady spoke about a knee replacement op being done by a robot. Today's stroppy doctors striking for huge pay rises could be the modern day equivalents of British Leyland toolmakers. (Who doesn't drive a car built by a robot now?)
Not sure that I'd want my child (or grandchild now) delivered by a robot though...?
I was in touch with Julie Bailey recently; you may know her, Mid Staffordshire issues etc. She worked tirelessly (to use the elites favourite b*llshit word) to chase up ministers and committees and trusts and all that; what happened? Nothing. As Vivian commented, our government is very good at failing to learn lessons.
And yet there are posters everywhere in the gp surgeries annd nhs hospitals, and on their answerphones imploring, YOU the patient, to be kind to the NHS staff!!!!! If you don’t laugh, you will cry.
I think I commented on the PA call that the NHS needs to ban 'zero tolerance' posters. If patients are angry it is because of frustration, despair, and perhaps pain too. The NHS has forgotten what it is there for, it's become a self serving stalinist bureacracy in which the patient is just, well, an inconvenience!
In his review into East Kent maternity services (October 2022), Dr Bill Kirkup states: ‘As indicated in Chapter 1, this chapter puts forward an approach that is different from the norm: in particular, we have not sought to identify multiple detailed recommendations. NHS Trusts already have many recommendations and action plans resulting from previous initiatives and investigations, and we have no desire to add to their burden with further detailed recommendations that would inevitably repeat those made previously, or conflict with them, or both. We take those previous recommendations and the resulting policy initiatives as a given.’
Or to put it more pithily, what is the point of saying the same thing again and again when it is still ignored?
Or perhaps it suggests we’ve reached the limits of what these inquiries can explain. If every report begins from the same assumptions about how maternity care should be organized, it’s hardly surprising they produce the same recommendations.
The question may no longer be why implementation fails, but whether the paradigm itself deserves examination.
Agreed. The author of this book is an obstetrician of considerable experience. She makes some excellent points, especially around the training and experience of today's midwives who have far less experience than the previous generation.
Dr Lorin Lakasing, Delivering the Truth – Why NHS maternity is broken, and how we can fix it together.
I’ll read it. But if it never questions the obstetric paradigm, it’s still trying to solve a failure of the paradigm from within the paradigm. That’s exactly what every one of these inquiries has done
The recurring inquiries don’t portray inexperienced midwives causing harm. They portray highly trained obstetricians, highly trained midwives, and highly trained institutions faithfully reproducing the same blind spots decade after decade as women and babies die. Reducing that to a training problem misses the point. It scapegoats midwives while protecting the obstetric paradigm and the institutional structures that have remained remarkably consistent throughout all these reports.
We don’t simply need more highly trained midwives working as junior obstetricians. We need more midwives practicing midwifery—a distinct model of care grounded in continuity, physiological birth, clinical judgment, and knowing when genuine pathology —rather than protocol —requires obstetric intervention.
Interesting answer. I think she does question the current paradigm. True, she discusses the (in her view) less than adequate training of current midwives, but emphasises that when things go wrong it is generally a systems, not a midwife failure, and she forensically analyses the failures of manager-led services.
Read it. I would be genuinely interested in your views.
When things keep going wrong in similar ways and reports are regularly ignored, I think you have to start looking for "root causes."
I have little experience with maternity services and so was surprised to see that midwives are "independent practitioners" who work alongside doctors that sometimes have limited training in teams described repeatedly as dysfunctional.
Are we facing an "emperor's new clothes" scenario here? Apart from managers who sit in offices, who is in charge here?
Added to the above, I find that midwives are not usually trained nurses, is this how the lack of listening and compassion enters the scene?
Given the independent practitioner role and the role of doctors I would expect constant friction and territory grabbing.
Looks to me as if the midwives have carved a niche that benefits them and not the patient.
Do they need to be trained as nurses and then convert, as a Nurse Specialist in other does RG diabetes, Dermatology, Asthma etc.
As a final point Dr Bill Kirkup resigns after Amos Report is amended after sign off. Amos is a politician, what's going on with the need to amend at such a late stage? Details of Kirkup's position from Gemini AI below
'A Danger to Patient Safety: Dr. Kirkup strongly disagreed with the final report's stance, which concluded that normal birth ideology was "not currently widespread." Having investigated past scandals where the pursuit of natural births "at any cost" led to avoidable baby deaths and maternal harm, he argued that pushing the issue "under the covers" presents a severe danger to patient safety. '
….incapable of learning lessons - indeed! Exactly mirroring the failure to learn lessons in the area of non accidental injury of children. Even in this era where clinicians have a duty of candour, we are still failing to stand up and be counted when it comes to ‘outing’ institutional and personal failures of care. Why is this? Is it a case of quis custodiet ipsos custodes? Who will stand up for you if you stand up to the blob? Many years ago, my mum reported an abuser in the children’s home where she worked. The attitude she got from her co-workers was ‘it’s all very well for you - you are married , you don’t need to work …’ OK. That was the early 1980s, but the pressures on people not to rock the boat are even stronger now, I feel, and the working environment is very complex and hidebound. Whistleblowing is as fraught with danger as ever, if not more so….
Matthew Syed's book 'Black Box Thinking' makes comparisons between healthcare and civil aviation and the different cultures of 'learning from mistakes'.
Richard Lyon has a substack and writes about the UK energy industries. He has created an amazing web platform that monitors energy subsidies in real time. It may be worth contacting him.
I remember talking to an ICU specialist; who had attended what was an Australasian course; run by anaesthetists; it is called EMAC
" The Effective Management of Anaesthetic Crises (EMAC) course is used to teach operating room teamwork and crisis management. The simulation-based course features a dedicated module on human factors designed to improve communication, non-technical skills, and leadership during medical emergencies."
This ICU specialist said to me he had repeatedly gone to emergencies in the ED; and they had not gone well; his response was to go and read more textbooks; he felt pure knowledge was the answer; the course "blew his mind": all the arcane concepts of "human factors", "teamwork", "communication" etc etc were acted on that course; scenarios given; the scenarios were videoed and audio recorded; people were gently taught how to debrief; how to reflect;
but if one embraces this stuff; then something must be given up; it requires less reverential memory of perhaps useless facts; a radical change to a curriculum; by an established medical hierarchy that sees an emergency as bringing someone back to a clinic in a week, as opposed to a month; and by changing radically, the creation of a more fluent new type of creature; one that intuitively can work better with others; and boy, is that deep; the Boston teaching seemed the best model for what to teach; Advocate/Inquire;
you tell people what you see; you blurt it all out and you tell them all that you think, because of that; then you ask them how they see it all; repeat and rinse
Airlines teach human factors to flight crew; it seems central; I remember hearing of an experienced airline simulator pilot coming to watch a constructed OR scenario; he could not believe the everyday .. unstructured stuff verging on chaos that was seemingly a part of that world; people just walking in and walking out; messages to various people; chats; calls; before even a real problem emerged; coping dynamically with an inherently changing situation; real life
our grand-daughter (UK) was born May 22; our daughter commented to me yesterday that as her daughter prepares to start class in Sept this year; that the cohort of that age-group seem substantially down; class numbers much smaller; seems widespread across the region that she can hear of; she seems to just accept this as curious; naturally my suspicions are aroused to something that could well be significant; that there were fewer births by total coincidence of course; in an era when new, life-saving medicines were being enthusiastically implemented. Pure coincidence. Those that can look more deeply into the data could perhaps inform this suggestion much better. Data would surely all help inform us.
"We actually think this could become a Trust the Evidence project in its own right. A simple annual dashboard could FOI every trust on metrics such as:"
sounds good; can you organise an appeal to fund that? aka a big DONATE button
you might have to involve AI to help you collate it
goodness; you say it so clearly "The answer is extremely uncomfortable: We have become exceptionally good at investigating failure and remarkably poor at learning from it."
I'll refrain from asking why none of these worthy Inquiries seem to address what, for me, looks like the core of the problem. That would be rude and uncouth ...
Instead I looked at this sentence again: "We have become exceptionally good at investigating failure and remarkably poor at learning from it." - and wondered how this could be. After all, aren't we told, again and again and again after every failure and catastrophe, be it in the NHS, be it in the country in general, that 'lessons will be learned'. doesn't it look as if the NHS and the whole of whitehall is constitutionally incapable of actually 'learning lessons'?
"looks like the core of the problem"
pray; enlighten us Vivian
we would all agree with you; the civil service always chants "'lessons will be learned" with the regularity of a liturgy; and we all laugh back loudly
Well, I'll be rude then, and somewhat circumspect. The core of the problem, as I see it, is the preponderance of females who've grown up and been educated under a strict, feminist ideology. And, using another ancient slogan, 'I say this as a woman', so I do have, in lefty manager speak, 'lived experience'...
Maternity services began to struggle in the 80s when midwife training was cut markedly as a response to a falling birthrate ( just before population increased through immigration) ,Add to this the closure of smaller local maternity units and merging of even larger ones as happened in Sheffield. The result is a stretched hierarchy heavy service. I could go on about young relatives recent experiences but the reports already highlighted the reasons.
Yes
Poor pay, poor morale, poor staffing levels, shifts and lack of support for midwives have to be part of the problem.
No midwife enters the profession with a negative attitude.
Medical students these days have had very little training including in obstetrics and this also applies to junior doctors in the maternity unit.
AI, algorithms and guidelines have displaced clinical judgement when a woman is in labour.
Staffing and closures undoubtedly contributed. But we’ve now had decades of reports describing the same failures. At some point we have to ask whether this is only a resource problem, or whether the assumptions behind the modern maternity system deserve the same scrutiny as its staffing levels.
Poor teamwork is mentioned in every one of these reports. A major issues in maternity care, which has been around at least since I was an Obstetric SHO (Junior Doctor) in the early 1980s, is the command structure (spoiler alert, there isn't one). Midwives are independent practitioners and only ask for help from Obstetricians (Doctors) when they feel they need it- there is no automatic supervision of the former by the latter. Together with the perceived imperative for normal deliveries this leads to delays in calling for help and to subsequent interventions with the inevitable consequence of avoidable harm to mothers and babies.
As well as the human costs, the outstanding provision for NHS maternity clinical negligence claims in England is approximately £37.5 billion, accounting for about 62% of the entire outstanding clinical negligence liability for the health service. (£60 billion).
This sounds remarkably similar to the argument made for decades—that more obstetric oversight inevitably improves outcomes.
Yet Britain once had a strong tradition of skilled community midwifery, and British observers criticized American obstetrics a century ago as “an orgy of interventions.”
Perhaps the question isn’t simply who is in charge, but whether we’ve forgotten that restraint is also a clinical skill.
I remember talking to a friend who worked in a smaller town in NZ years ago; he commented that an (Austrian) obstetrician came; a very caring and capable man; who was a "main de coucheur" obstetrician; meaning he could only deliver babies vaginally; a urologist taught this man how to do LSCS ("caesars"); seemingly the lady paediatrician in the town commented that the number of brain-impaired children fell dramatically after this;
thanks docross;
" the outstanding provision for NHS maternity clinical negligence claims in England is approximately £37.5 billion, accounting for about 62% of the entire outstanding clinical negligence liability for the health service. (£60 billion)."
goodness; that suggests there are one or two issues afoot ............
If I might make a more general point, it seems that most "inquiries" fall into similar categories.
Readers of Trust the Evidence will immediately think of La Hallett & her KC Chums.
But then there is the Post Office Fujitsu Horizon IT case, the "Infected Blood" scandal, waiting for most of those affected to die before settling, Even the Covid "vaccine killed and damaged" victims are treated almost with derision (after Mark Steyn was forced out of GB News by Ofcom and incompetent management), whilst ennobled perpetrators stuff their boots with profits.
In my time, I have read a number of inquiry reports. I think the only one I could commend to anyone interested, is the "Report of the Tribunal appointed to inquire into the Disaster at Aberfan on October 21st, 1996". This, you might remember, was the spoil heap collapse in South Wales that buried alive 116 Welsh schoolchildren and 28 adults. Thanks to the honesty and determination of Sir Herbert Edmund Davies who chaired the inquiry, the report is very accurate and laid considerable blame on the then Chairman of the National Coal Board Lord Robens and other senior officials for their gross incompetence and neglect of any competent design and management of the construction of spoil heaps generally, not least at Aberfan.
I have to admit that one of the main attractions in 1976 of a job with the NCB as a newly Chartered Civil Engineer was the hope that I could help (even after 10 years!) in making these enormous heaps safe.
It should be noted however, that despite the excellence of inquiry report efforts of Sir Herbert Edmund Davies and his team, no-one was really held to account. And Alfred Robens, Baron Robens of Woldingham, a Labour politician, "went on selected by Barbara Castle to chair a committee on workplace health and safety. This led to the 1972 Robens Report which controversially championed the idea of self-regulation by employers. The Report itself led to the Health and Safety at Work etc. Act 1974 and the creation of the Health and Safety Commission and the Health and Safety Executive." (Wikipedia).
Who said irony is dead?
In passing the report was 1966 not 1996. I still remember the TV black & white pictures reporting & the sheer devastation.
Absolutely.
Maybe it's just my age, but I am exasperated how often I post something, or just send a text to someone only to find that the super duper magic "correction" software renders what I type (and usually carefully check!) into nonsense.
Important not to get paranoid, but....
thanks for an excellent commentary Martin; somebody kindly pointed out to me a while back how to edit posts: click on the magic three dots at the right of the text; magic; you can then look perfect
What about highlighting the seeming complete absence of clinical ownership alongside clinical oversight in maternity units. These aspects highlight the now disastrous erosion of the fundamentals of medical and surgical method created by 'managerialism' across the NHS.
" the seeming complete absence of clinical ownership alongside clinical oversight in maternity units"
Seamus O'Mahony in I think "Can medicine be cured?" commented wryly
"Doctors practice in teams, and take the blame individually"
I agree about managerialism.
But I wonder whether “clinical ownership” is itself part of the problem in maternity. Birth isn’t analogous to most medical or surgical care.
Historically, the question wasn’t who owned labor, but who recognized when physiology was no longer protecting itself and assistance was genuinely needed.
That’s a very different model from one built around command, oversight and escalating intervention.
"Historically, the question wasn’t who owned labor, "
gosh; I would have sensed it was an ever-present dilemma; almost a tug of war in some places; I had cause to read Linda Bryder's 2009 book on the Cartwright inquiry in distant NZ in 1987; what I found interesting as one of the outcomes of the report; was that a more fiercely independent midwifery was established; because it seemed inherently (to some) that women would naturally do a much better job always for other women; doctors (assumed to be male) were essentially vilified; there seemed poorer outcomes in this brave new world; whereas years before, after a UK professor of obstetrics started in NZ in 1963, there had been new maternal mortality and perinatal outcomes data regularly and thoroughly collected; and new oversight; there were strong suggestions it seemed that there were concerning perinatal issues with the new expansion of midwifery; and that there was not allowed to be clear data made available; to judge the facts; it seemed ideology must triumph
'Ownership' is about ultimate responsibility, a genuine patient orientated commitment.
I appreciate the clarification. I certainly agree that someone must accept responsibility when things go wrong.
But does not “ownership” unintentionally shifts the center of gravity away from the woman herself. Childbirth is unique in that the patient should remain the primary actor, with clinicians carrying responsibility for recognizing when physiology is no longer protecting itself and help is genuinely needed.
Your comment also reminded me of my aunt. She was a classic twilight sleep mother with her first baby in 1965, but by the time she began asking questions and had Lamaze births in 1974 and 1978, she often reflected on an English friend she had known in the early 1960s. She was struck by how calmly this woman approached pregnancy and birth compared with the fear-based, obstetrician-as-savior culture American women were immersed in.
She didn’t have the language for it then, but later realized she had witnessed two very different birth cultures.
I sometimes wonder whether that quiet confidence was one of the casualties of the NHS’s move toward centralized, hospital-based maternity care.
surely so much has changed; an "elderly primip" in 1970 was .. guessing .. 25; (please correct me as appropriate) but AI said
"The definition of "elderly primip" (short for elderly primipara)—a first-time pregnant individual—has shifted dramatically from the 1970s, when it meant anyone over 25. Today, the standard UK clinical definition is age 35 or older at delivery, though modern terminology heavily favors Advanced Maternal Age (AMA) over the outdated and stigmatizing "elderly" label"
many lasses delivering in the early 1970s in big city UK maternity hospitals; were late teens to early 20s; and weighing less than 70kg before pregnancy; having several children, it seemed common that 2nd or 3rd children were born more rapidly and easily; so data better overall?
quite a few girls will be having their first baby aged 38 or more; regarded as having more risk; much, much more T2 diabetes; much more obesity; and perhaps having only one child; so skewing data?
I would gently suggest the "apples" of 60 yrs ago, are not identical to today's apples
The maternity sector seems to be especially awful, but the NHS as a whole does have a problem with SOME - perhaps too many - staff; being cruel to patients, misunderstanding what's wrong with them and jumping to conclusions, making things up (even consultants do that) and telling huge fibs to cover up when things go wrong.
I won't plug my forthcoming book but it'll be full of all that sort of stuff.
Viv had hearing problems; I put in writing to ward staff that they should remove face masks when speaking to her and speak to her left ear. They refused to remove masks 'because of covid' (this was last summer) and then made a load of mistakes after not properly explaining what drugs etc they thought she should have. This sort of problem was mentioned on a Patients Association call I was on on Friday; a representative from one or other ICB said that hospital staff are required to 'make appropriate adjustments' for the disabled (of whom there are many in hospitals - arguably most patients are, in some way, disabled and the staff should be used to dealing with them), and patients or representatives should raise a formal complaint if staff fail to make an effort to communicate with them. I commented that I'd have been forever raising formal complaints; when something goes wrong in hospital patients and their carers look after the patient first. They often don't have time to complain (and it's b difficult to know who to complain to).
What comes out in the media is, I'm afraid, the tip of a very big iceberg.
I was also at a King's Fund conference last week which may have held a glimmer of hope for the future: the subject was Artificial Intelligence. I know what Tom and Carl think, but AI is already in halthcare (imaging especially), audio-to-text transcripts are being used at some GP surgeries (hooray, no more 'confusion' about what was said!), and one lady spoke about a knee replacement op being done by a robot. Today's stroppy doctors striking for huge pay rises could be the modern day equivalents of British Leyland toolmakers. (Who doesn't drive a car built by a robot now?)
Not sure that I'd want my child (or grandchild now) delivered by a robot though...?
I was in touch with Julie Bailey recently; you may know her, Mid Staffordshire issues etc. She worked tirelessly (to use the elites favourite b*llshit word) to chase up ministers and committees and trusts and all that; what happened? Nothing. As Vivian commented, our government is very good at failing to learn lessons.
And yet there are posters everywhere in the gp surgeries annd nhs hospitals, and on their answerphones imploring, YOU the patient, to be kind to the NHS staff!!!!! If you don’t laugh, you will cry.
I think I commented on the PA call that the NHS needs to ban 'zero tolerance' posters. If patients are angry it is because of frustration, despair, and perhaps pain too. The NHS has forgotten what it is there for, it's become a self serving stalinist bureacracy in which the patient is just, well, an inconvenience!
Wow ! I think this an amazing project you are embarking on.
I’ll put out a couple of emails to see if I can find IT help.
In his review into East Kent maternity services (October 2022), Dr Bill Kirkup states: ‘As indicated in Chapter 1, this chapter puts forward an approach that is different from the norm: in particular, we have not sought to identify multiple detailed recommendations. NHS Trusts already have many recommendations and action plans resulting from previous initiatives and investigations, and we have no desire to add to their burden with further detailed recommendations that would inevitably repeat those made previously, or conflict with them, or both. We take those previous recommendations and the resulting policy initiatives as a given.’
Or to put it more pithily, what is the point of saying the same thing again and again when it is still ignored?
Or perhaps it suggests we’ve reached the limits of what these inquiries can explain. If every report begins from the same assumptions about how maternity care should be organized, it’s hardly surprising they produce the same recommendations.
The question may no longer be why implementation fails, but whether the paradigm itself deserves examination.
Agreed. The author of this book is an obstetrician of considerable experience. She makes some excellent points, especially around the training and experience of today's midwives who have far less experience than the previous generation.
Dr Lorin Lakasing, Delivering the Truth – Why NHS maternity is broken, and how we can fix it together.
I’ll read it. But if it never questions the obstetric paradigm, it’s still trying to solve a failure of the paradigm from within the paradigm. That’s exactly what every one of these inquiries has done
The recurring inquiries don’t portray inexperienced midwives causing harm. They portray highly trained obstetricians, highly trained midwives, and highly trained institutions faithfully reproducing the same blind spots decade after decade as women and babies die. Reducing that to a training problem misses the point. It scapegoats midwives while protecting the obstetric paradigm and the institutional structures that have remained remarkably consistent throughout all these reports.
We don’t simply need more highly trained midwives working as junior obstetricians. We need more midwives practicing midwifery—a distinct model of care grounded in continuity, physiological birth, clinical judgment, and knowing when genuine pathology —rather than protocol —requires obstetric intervention.
Interesting answer. I think she does question the current paradigm. True, she discusses the (in her view) less than adequate training of current midwives, but emphasises that when things go wrong it is generally a systems, not a midwife failure, and she forensically analyses the failures of manager-led services.
Read it. I would be genuinely interested in your views.
When things keep going wrong in similar ways and reports are regularly ignored, I think you have to start looking for "root causes."
I have little experience with maternity services and so was surprised to see that midwives are "independent practitioners" who work alongside doctors that sometimes have limited training in teams described repeatedly as dysfunctional.
Are we facing an "emperor's new clothes" scenario here? Apart from managers who sit in offices, who is in charge here?
Added to the above, I find that midwives are not usually trained nurses, is this how the lack of listening and compassion enters the scene?
Given the independent practitioner role and the role of doctors I would expect constant friction and territory grabbing.
Looks to me as if the midwives have carved a niche that benefits them and not the patient.
Do they need to be trained as nurses and then convert, as a Nurse Specialist in other does RG diabetes, Dermatology, Asthma etc.
As a final point Dr Bill Kirkup resigns after Amos Report is amended after sign off. Amos is a politician, what's going on with the need to amend at such a late stage? Details of Kirkup's position from Gemini AI below
'A Danger to Patient Safety: Dr. Kirkup strongly disagreed with the final report's stance, which concluded that normal birth ideology was "not currently widespread." Having investigated past scandals where the pursuit of natural births "at any cost" led to avoidable baby deaths and maternal harm, he argued that pushing the issue "under the covers" presents a severe danger to patient safety. '
….incapable of learning lessons - indeed! Exactly mirroring the failure to learn lessons in the area of non accidental injury of children. Even in this era where clinicians have a duty of candour, we are still failing to stand up and be counted when it comes to ‘outing’ institutional and personal failures of care. Why is this? Is it a case of quis custodiet ipsos custodes? Who will stand up for you if you stand up to the blob? Many years ago, my mum reported an abuser in the children’s home where she worked. The attitude she got from her co-workers was ‘it’s all very well for you - you are married , you don’t need to work …’ OK. That was the early 1980s, but the pressures on people not to rock the boat are even stronger now, I feel, and the working environment is very complex and hidebound. Whistleblowing is as fraught with danger as ever, if not more so….
Matthew Syed's book 'Black Box Thinking' makes comparisons between healthcare and civil aviation and the different cultures of 'learning from mistakes'.
Richard Lyon has a substack and writes about the UK energy industries. He has created an amazing web platform that monitors energy subsidies in real time. It may be worth contacting him.
The link to the report is bad?
I remember talking to an ICU specialist; who had attended what was an Australasian course; run by anaesthetists; it is called EMAC
" The Effective Management of Anaesthetic Crises (EMAC) course is used to teach operating room teamwork and crisis management. The simulation-based course features a dedicated module on human factors designed to improve communication, non-technical skills, and leadership during medical emergencies."
This ICU specialist said to me he had repeatedly gone to emergencies in the ED; and they had not gone well; his response was to go and read more textbooks; he felt pure knowledge was the answer; the course "blew his mind": all the arcane concepts of "human factors", "teamwork", "communication" etc etc were acted on that course; scenarios given; the scenarios were videoed and audio recorded; people were gently taught how to debrief; how to reflect;
but if one embraces this stuff; then something must be given up; it requires less reverential memory of perhaps useless facts; a radical change to a curriculum; by an established medical hierarchy that sees an emergency as bringing someone back to a clinic in a week, as opposed to a month; and by changing radically, the creation of a more fluent new type of creature; one that intuitively can work better with others; and boy, is that deep; the Boston teaching seemed the best model for what to teach; Advocate/Inquire;
you tell people what you see; you blurt it all out and you tell them all that you think, because of that; then you ask them how they see it all; repeat and rinse
Airlines teach human factors to flight crew; it seems central; I remember hearing of an experienced airline simulator pilot coming to watch a constructed OR scenario; he could not believe the everyday .. unstructured stuff verging on chaos that was seemingly a part of that world; people just walking in and walking out; messages to various people; chats; calls; before even a real problem emerged; coping dynamically with an inherently changing situation; real life
our grand-daughter (UK) was born May 22; our daughter commented to me yesterday that as her daughter prepares to start class in Sept this year; that the cohort of that age-group seem substantially down; class numbers much smaller; seems widespread across the region that she can hear of; she seems to just accept this as curious; naturally my suspicions are aroused to something that could well be significant; that there were fewer births by total coincidence of course; in an era when new, life-saving medicines were being enthusiastically implemented. Pure coincidence. Those that can look more deeply into the data could perhaps inform this suggestion much better. Data would surely all help inform us.
"We actually think this could become a Trust the Evidence project in its own right. A simple annual dashboard could FOI every trust on metrics such as:"
sounds good; can you organise an appeal to fund that? aka a big DONATE button
you might have to involve AI to help you collate it
goodness; you say it so clearly "The answer is extremely uncomfortable: We have become exceptionally good at investigating failure and remarkably poor at learning from it."