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3. Functional limitations

3.1 Need for action

The lack of implementation and evaluation work following the Each Baby Counts findings was frequently mentioned as being a limitation of the programme.

There was a real sense that the findings had shone a light on many of the factors that are present in the local investigations as needing attention, yet the recommendations were lacking in advice for local services to action them or indeed any wider follow-up of the Each Baby Counts programme findings in order to improve outcomes.

“We know what goes wrong; what we’ve not been so good at is understanding why that is [. . .] the difficulty is how does a service actually implement it, and that is not really in there [in the EBC reports].” (Executive Director – Midwife)

“I’m concerned about what’s going to happen with the recommendations, how are they going to be implemented, if anything is going to change from this.” (Parent representative – Campaign for Safer Births)

There was acknowledgement, however, that perhaps one reason why the programme had not achieved everything it could have done was the quality of local investigations.

The whole premise of the programme was reliant on the integrity and content of local investigations.

As noted earlier, in some instances they were comprehensive enough for review, but for many that was felt not to be true and so, while a number of important insights were identified, there was a sense that the impact could have been greater.

“We just did not realise how poor investigations were, so I don’t think the aims of EBC have been able to be met because we’ve been thwarted by the poor-quality reviews that haven’t led to the outcome as intended, but nonetheless has provided invaluable insights for the system.” (Head of Maternity and Neonatal Safety, NHS England and NHS Improvement)

3.2 The Each Baby Counts ambition

The ambitious aim of Each Baby Counts to reduce these incidents by 50% by 2020 was noted by some as a worthy goal but ultimately one that was not well resourced or planned in terms of the methods to achieve it.

That said, there was an overarching feeling from those interviewed that, while the goal had not been achieved, the fact that maternity safety was ‘on the map,’ the profile of these cases had been raised and the professions involved had come together with a shared purpose to improve care were all worthwhile outcomes of this programme.

“I think they’ve [maternity professionals] felt empowered to talk about safety and I think that it [Each Baby Counts] has very firmly put maternity safety on the map.” (Each Baby Counts Quality Improvement Lead)

“EBC has hastened the breaking down of barriers there [with multidisciplinary team working], which I think is important.” (Professor of Neonatal Medicine)

A further limitation pertained to the time lag in Each Baby Counts being able to report findings. The reports published were describing data from two years previously which were not necessarily representative of the current picture. Having more contemporaneous data would have been valuable.

That said, there was an acknowledgement of the resource required, particularly on the part of Each Baby Counts reviewers to complete the tasks needed, meaning there was a level of understanding of why the outputs were timed as they were.

There was frequent mention that the programme was fully reliant on the ‘goodwill’ of those participating and that no additional funding or resource was available to those reporting or reviewing, highlighting an area of importance for any work going forward.

Recognition of the need for protected time in particular, but also funding, for staff undertaking this type of work was seen as key to being able to implement long-term sustainable changes.

“It’s really hard to get them to concentrate in an area where they’re simply just trying to keep rotas going and to keep the service relatively safe [. . .] I think for anybody to make a really big change, for example if they think that there’s an issue with the culture, they need protected time to be able to stand back and concentrate on that.” (Consultant in Public Health)

3.3 Data collection and timeliness

Further to the issues of data lag, data anonymity within the programme was discussed.

Each Baby Counts did not collect or review identifiable data, and while some stakeholders were not aware this was the case, for those who were, the response to the issue was mixed.

For some there was strength in the data being anonymous, allowing for deeper and unbiased investigation, and for others the programme had not been designed to collect data on the individuals involved in the case as such, but rather the focus was on the quality of the review conducted.

That said, for others the lack of demographic information was seen as a missed opportunity.

“The point of EBC was not to collect quantitative data, it was to look at the reviews and to draw out new themes about where we could make changes rather than contributing to surveillance.” (Researcher)

“It’s about ethnic inequalities, and also about inequalities due to social deprivation. It is critical both are part of whatever happens next.” (Research and Prevention Lead, Sands)

While the original programme never set out to explore individual demographic factors, many respondents felt that it would have been useful to collect ethnicity and socioeconomic status in order to add to the narratives of other national initiatives such as MBRRACE-UK.

Having a conscious attention to diversity and inclusion was certainly highlighted as needing an essential presence from the outset in future work, and other areas of practical recommendations for future work are included in the next section.