The final report from the Independent National Maternity and Neonatal Investigation has pointed to challenges with fragmented digital systems, continued reliance on paper, and prolonged underinvestment in digital infrastructure, putting forward suggestions for capital investment, an updated modern service framework, AI, and data.
The investigation conducted reviews of maternity and neonatal services in 12 NHS trusts, aiming to identify systemic issues and to develop a series of national recommendations. It also incorporates the lived experiences of 450 families, 10,500 responses to a public call for evidence, feedback from more than 9,000 staff, and engagement with advocacy groups, national stakeholders, and NHS leaders.
Baroness Amos, chairing the investigation, said: “It is clear to me that the maternity and neonatal system is not set up to deliver consistently safe, high-quality and compassionate care and this must be rectified. It is fragmented, overly complex and too slow to learn and improve. The consequences of this can be seen in the tragic experiences we hear about. The recommendations I have made should deliver long-term, sustainable change, create a system that learns from harm, and help women to receive safer care, justice and accountability in the future.”
Fragmented care was one of the major themes raised, with identified variations dependent on location, the individual receiving care, or the type of service provided; a lack of connectivity between GPs, antenatal, and postnatal care; and patients reporting having to repeat, sometimes very traumatic, information over and over again in different settings. Staff highlighted fragmented governance, outdated service models, workforce pressures, lack of multidisciplinary training, and poor infrastructure with “weak” digital systems lacking interoperability.
Maternity and neonatal services currently operate within “a mixed landscape of paper-based and digital record systems”, the investigation notes, with reliance on paper or hybrid approaches remaining common, and around two-thirds of maternity services and 79 percent of neonatal services still using paper in some form. Digital documentation was reportedly “frequently described as taking longer than paper-based systems”, it goes on, with families talking about midwives spending significant time on computers, and staff feedback suggesting it can be difficult to build a relationship with a family when having to input information into a digital system.
Also considered were the impacts of digital systems in reinforcing inequalities or barriers to care, and a “misalignment” with digital infrastructure not keeping pace with the needs of modern maternity and neonatal care, or with wider advances in the use of digital and AI across society. Noted are government plans for the single patient record, which the investigation states “must deliver for maternity and neonatal services”; and safety systems like the Maternity Outcomes Signal System, which it adds “cannot work as effectively as intended” without good quality data.
A total of eight recommendations are put forward, including creating a statutory national maternity and neonatal commissioner, improving how the system responds and learns when things go wrong, creating a modern service framework with national standards for high quality maternity and neonatal care, and delivering digital systems fit for modern service needs.
“DHSC/NHSE must deliver estates and digital systems that are fit for modern maternity and neonatal care with 12-month, five-year and 10-year investment commitments and implementation deadlines,” the investigation finds. “Estates and digital infrastructure are the foundations of safe care, and they have been eroded by sustained underinvestment.” Clear and enforceable standards for estates should be set out with plans for long-term capital investment, taking into account immediate maintenance and refurbishment backlogs, it continues.
The investigation further recommends that a clear national implementation timeline be set out for the roll out of interoperable digital maternity and neonatal systems, including mandating national datasets, to ensure every woman and baby has one single, digital record that follows them wherever they receive care. This should include, it outlines, a unified national dataset covering public health and epidemiological data to allow for trend and performance monitoring. Investment in digital should also extend to emerging technologies supporting quality and safety in clinical interactions.
Wider trend: Digital in women’s and children’s health services
A national assurance assessment of maternity and neonatal care and services in Wales has made a series of findings and recommendations around the role of digital and data, noting in particular the requirement for better real-time data availability and coordination, and further investments in digital and infrastructure. For quality of care and service user outcomes, key findings included variability in data availability across health boards, with all health boards reporting a need for increased national focus, support, and oversight. “Teams were unable to describe an aligned long term digital strategy to enable improvements across Wales,” the panel noted. “They described more specific streams of work to include a Beacon dashboard and implementation of BadgerNet® Maternity individual digital health records across Wales. However, even with such a nationally driven initiative to implement BadgerNet® Maternity, there remained confusion over which modules were being used to drive the necessary change in digital alignment.”
NHS England has announced the roll-out of an online system designed to identify patterns and trends in data routinely recorded in maternity services and send warning signals when a critical safety check is required. The Maternity Outcomes Signal System (MOSS) is being introduced in response to the “Reading the Signals” report that followed an independent investigation into maternity and neonatal services in East Kent. According to NHS England, analysis demonstrated that it “would have detected signals in maternity units that later experienced serious incidents, including East Kent, Shrewsbury & Telford, Leeds, and Nottingham”. Upon detecting a pattern or trend in data that indicates something unusual is happening, the MOSS system produces a warning signal, making it mandatory for maternity units to carry out a critical safety check within eight working days. Actions taken in line with these signals are also to be shared with regional and national teams.
NHS England has published a preliminary market engagement notice with a total value of up to £110 million, hoping to inform the future of children’s digital health services. Ambitions are to modernise services including the child health information service, antenatal and newborn screening programmes, and a digital alternative to the Red Book. The wider vision, according to NHSE, is to develop a suite of digital and data services to support preventative health and care services for children, requiring “an approach that does not just digitise processes, but rethinks healthcare delivery to support changing behaviours and lifestyles through information, advice and support, drawing on understanding of motivations and behaviours, and tapping into the potential of new technologies, including artificial intelligence”.
