Well thank you, Ranee for your welcome, and thanks to the College for giving me this opportunity to address you today, and a warm welcome to those of you who’ve travelled from across the world to be here.
The National Health Service began with a literal birth, Aneira Thomas, named after my predecessor, and Aneurin Bevan was born at one minute past midnight on the 5th of July, 1948.
Since then, tens of millions of babies have been delivered by the NHS. Bringing new life into the world is a wonderful thing, and it’s great to be in a room full of the people who spend their professional lives supporting it. You know better than most that this is also a moment of risk and jeopardy for women and their babies, and that that risk is considerably higher than it should be because of the state of the crisis in our maternity and neonatal services here in the UK.
Within the past 15 years, we’ve seen appalling scandals that blew the lid on issues ranging from care, safety, culture and oversight. Morecambe Bay, Shrewsbury and Telford, East. Kent, Nottingham. The last government responded with initiatives like Better Births in 2016 and the Maternity Transformation Programme. But despite improvements on some metrics, inequalities in maternal and neonatal outcomes have become more visible, not less.
The rate of maternal deaths has been consistently rising. Babies of black ethnicity are still more than twice as likely to be stillborn than babies of white ethnicity, and black women are still 2 to 3 times more likely to die during pregnancy or shortly after birth than white women. Tragically, that gap is closing slightly, but partly because more white women are dying in childbirth. In September, the Care Quality Commission’s National Review of Maternity Services in England found that almost half of all trusts were rated as requiring improvement on safety. Another 18% were rated as inadequate.
There is a widespread lack of staff and in some places a lack of potentially life-saving equipment, and some services don’t even record incidents that have resulted in serious harm. Taxpayers who are footing the bill for our failure to get a grip with everything else I’ve just said, it’s no wonder clinical negligence payouts have reached an all-time high £2.8 billion last year, with maternity accounting for 41% of all the money paid out.
These are the facts. But behind these alarming statistics are people and the lives that have been taken from them. I spent a lot of time with victims of NHS maternity and neonatal scandals and failures during the last year. Listening. Listening to them share with a total stranger the most personal, painful accounts of their experiences and the trauma that occurs when we fail them. When I say we, I don’t just mean the maternity units that failed them. I mean NHS leaders and managers that put protecting their reputations over protecting patients. Or when we put legal advice that says do not admit liability over doing what is right by families. I mean the regulators who failed to hold them to account. And I mean politicians, including me, because the first step in putting this right is being honest about our own mistakes and failures.
And the truth is, we’re not making progress fast enough on the biggest patient safety challenge facing our country. And I know what that means. Because of the many hours I’ve spent with families left completely traumatised by our failure to get it right every time. When I visit the Nottingham families they arranged themselves around the horseshoe table in date order, with those whose experience goes furthest back, sat to my left and the most recent sat to my right. The most recent was just last year, and I honestly dread the prospect of going to another meeting with another family arriving at that end of the table with another story to tell. This time, one that has happened on my watch.
Across all of the meetings I’ve had every story is unique, but there are common themes. Some are there because their children died, some because their children suffered injuries that have left them with lifelong complications and disability. Others are women who suffered terrible life changing injuries during childbirth, or fathers left traumatised and unsupported with severe mental health challenges. I’ve seen photographs of their children. I’ve seen the ashes of their children in the tiniest little boxes, and I’ve also seen more courage than I could ever imagine mustering if I had to walk a day in their shoes. Carrying the weight of their trauma. All of them have had to fight for truth and justice. They describe being ignored, gaslit, lied to, manipulated, and damaged further by the inability for a Trust to simply be honest with them that something has gone wrong. They talk to me about the trauma that they experience compounded time and time again. When a hospital Trust or regulator simply turns their back on them, when all they’re searching for is answers.
It’s their bravery that has brought me to the place that I am today. I want to say publicly how sorry I am sorry for what the NHS has put them through. Sorry for the way they’ve been treated since by the state. And sorry that we haven’t put this right yet. Because these families are owed more than an apology. They’re owed change, they’re owed real accountability, and they’re owed the truth. So today I’m setting out a different approach to the one that’s failed before. We’re going to do it with, rather than to these families. And we’re going to put the voices and experiences of mums, dads and children at the heart of our approach to improving quality, safety and accountability. Maternity safety will become the litmus test for all safety in the NHS. I’m taking personal responsibility for it as Secretary of State and as the staff leading maternity and neonatal services. I need your help because we’re a team and I can’t do this without you. I know the majority of births in England are safe, and I urge all women to engage with their maternity service and raise any concerns they may have about themselves or their baby.
But for too long, those cases where things do go wrong have been swept under the carpet, and this cannot continue. I know I’m talking to an audience that will embrace this challenge. You will come to work every day to care for people. You are tired, tireless and dedicated in your work. I suspect you’re tired too, with the pressures you’re under. You go to work to do the right thing, and every day there are healthy babies being delivered safely, with moms receiving great care. But we also know that staff are being put in an impossible position far too often. It’s the moral dilemma I’ve heard from midwives, obstetricians and neonatologists across the country. They feel conflicted because they don’t feel their maternity ward or neonatal unit is delivering a safe service every time, and they don’t want to work in an unsafe environment. So they consider leaving. But they also tell me that if they walk away, they’d be letting it down even further.
This is not a choice any member of staff should have to face. And I’m aware that there’s a risk that we further demoralize a workforce that’s already been on its knees and felt battered working in an NHS in crisis. I also worry about the risk of causing unnecessary fear or anxiety among mums going into labour, and the dads and loved ones holding their hands through the experience is a dilemma I wrestle with all the time. But I won’t do any of us any favours if we’re not honest about the scale of the challenge, so that we can provide a response able to meet it.
Over the last year, I’ve been wrestling with how we tackle the problems in maternity and neonatal units. And I’ve come to the realization that while there is action we can take now, we have to acknowledge that this has become systemic. It’s not just a few bad units up and down the country. Maternity units are failing. Hospitals are failing. Trusts are failing. Regulators are failing. There’s too much obfuscation, too much passing the buck and giving lip service too much shrugging at a cultural problem that we fail to address. Because of that, we have enormously wide race and class inequalities in maternity care. Women, especially black, Asian, and working class women, are not listened to or given the chance to be advocates for their own health. We have an implicit message from the system that tells women not to have a miscarriage at the weekend. We have women who are classed as having a normal birth, still leaving, traumatised and scarred. And most concerning of all, we have the normalization of deaths of women and babies. We must stop and stop now with the mindset that these things just happen. Our inability to deal with this goes wider than maternity, in fact wider than our health service.
It goes to the very core of how Britain responds to state failure. I should give a little context for my own outlook. I don’t have a conventional background for someone whose title is Right Honourable. I was born not far from here, actually, at the Mile End Hospital to teenage parents. I experienced poverty growing up and beside a loving family. The reason I’m stood here today is a member of the British Cabinet is because the state got it right, in my case, council housing. A great state education. A welfare state that clothed and fed me.
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But I also saw the way the state often treats people from backgrounds like mine. The way the DSS, the social security staff talk to my mum like she was dirt at the bottom of their shoes. The fights my grandmother used to have with Tower Hamlets Council when she ran the local tenants union. So I came into office with a healthy degree of cynicism and skepticism about the state. That doesn’t often come naturally to those of us with left wing politics who fundamentally believe in an active state.
I’ll be honest with you, as I’ve listened to these family’s experiences of the state and NHS failure, that cynicism has boiled over into hot tears and real anger about what they’ve been put through and what they’re still living with. From the Horizon Post Office scandal to the infected blood scandal, the degradation of responsibility and trust in our institutions is compounding a cynicism and malaise at the ability of British politics, or even democracy, to deliver for people. This is a dangerous place for a country to be. If we do not admit the scale of the failure in maternity services, we’re condemning ourselves to etching that mistrust deeper. If we cannot admit openly that we as institutions and as a state have got this wrong, we will never be able to fix it or rebuild that trust. Too many children have died because of state failure, and I will not allow this to continue under my watch.
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So to face up to this, we have to change two fundamental things. First, we must ensure real accountability when things go wrong and give justice to those who’ve been wronged. Second, we must drive real improvements in maternity and neonatal care, which will require clear direction, a change of culture, and for all of us to mobilise as a team to get this right.
Today I’m announcing a rapid national investigation of maternity and neonatal services, co-produced to include the families who have suffered the worst injustices of maternity care, modelled on the Darzi investigation into the state of the NHS. This will be an evidence-based investigation setting out what’s going wrong and priorities for action. It will look in detail at up to ten maternity units that are giving us greatest cause for concern. And it will report directly to me by Christmas.
Crucially, the investigation team and terms of reference will be co-produced with the victims of maternity scandals. The investigation will also pull together the recommendations from the other reviews that have taken place to assess progress and provide clarity and direction for the future, so that everyone in the system knows what they’re working to.
I’m currently discussing with Leeds families the best way to grip the challenges brought to light in that trust by their campaigning reports in the media and the latest CQC report, and I’ll be ordering an investigation into nine specific cases identified by families in Sussex who are owed a thorough account of what happened in those cases.
I’m also establishing a National Maternity and Neonatal Task Force, which I will chair, bringing together experts, staff, campaigners and representatives of families to help me drive improvement across the NHS.
We will call on international colleagues so that we understand what works and how to learn from the best and take to the rest, and the Royal College will have a really important role to play in that. I will also continue to meet families throughout the year, to give them a chance to hold me to account and provide them with a direct route to feedback.
To me, the taskforce will answer some of the most pressing issues the families have put at the top of the list, namely, how can we ensure that women and their partners are always listened to when they raise concerns about their pregnancy or labour? What else should we be doing to save babies and women from dying or being severely harmed? How do we get better at spotting when things go wrong in units, and how do we tackle this before it grows?
We’ll also bring in a package of measures to start taking action now, increasing accountability across the board and bringing in the cultural change we need to see within the next month. The NHS chief executive, Jim Mackey, and Chief Nursing Officer Duncan Burton will meet the trusts of greatest concern including Leeds, Gloucester, Mid and South Essex and Sussex to hold them to account for improvement working with the NHS leadership. I will set strong and consistent expectations for Trust Chairs, Chief Executives and Boards with overhauled oversight and performance framework and a new performance dashboard. We’ll roll out the new MOSS digital system to flag potential safety concerns and trust much earlier, and support rapid action and roll out a national maternity and neonatal inequalities data dashboard.
Our ten year plan and upcoming Dash review will look to tackle this safety crisis at its root with an overhaul of the wider patient safety landscape. We will work to declutter this crowded landscape so that the patient experience works for patients again. I brought Mike Richards back to the CQC as chair to turn around that failing organisation, and I will work closely with him to make sure that the Commission is working effectively on behalf of patients and the public.
Together, these measures will create real accountability, cut through the noise to prevent patterns spiralling and work towards tangible improvements for women and babies. I’m also going to do this with you, as well as the Royal College of Midwives and the other colleges and professional bodies. The Royal College has a reach across the globe and there are maternity professionals from many, many countries here today. These challenges and maternity care are not just in our country. I want to learn from the best systems internationally, and then to showcase how we are taking on the challenge of tackling inequalities across pregnancy and birth head on. Strong clinical leadership really matters. I can’t do this without you. I’m committed to doing this with you, not to you.
So I know some of what I’ve said today will have been tough to hear, especially for people who give up their time early on a Monday morning to be here because you care about delivering safe and high quality care, and you take pride in your profession. Together, we’ll make sure that women and their partners feel heard and listened to, to make every birth a safe birth, to make high quality the hallmark of maternity services in this country, and to banish avoidable maternity and baby deaths to the history books. So I’m looking forward to working with you in that endeavour.
Thank you very much.
