The COVID-19 pandemic has shone a bright light on the seriousness of health inequalities within England, exacerbating the significant discrepancy between healthy life expectancy that is known to exist between the least and most deprived areas of England. A national approach to reduce health inequalities and narrow the life expectancy inequality gap, has been developed by Dr Bola Owolabi and the Healthcare Inequalities Improvement Team at NHS England. This approach, known as ‘Core20PLUS5’, is to be implemented at both a national and system level. It defines target population cohorts – the ‘Core20PLUS’ and identifies ‘5’ focus clinical areas that require accelerated improvement as a priority due to their contribution to the life expectancy inequality gap.
This is the third in a series of five blogs, written by clinical fellows on secondment at NHS England and NHS Improvement and Healthcare Quality Improvement Partnership (HQIP), explore the ‘5’ focus areas, the links between health inequalities and the invaluable contribution of leadership to narrowing the life expectancy inequality gap. The ‘5’ focus areas are cardiovascular disease, cancer, chronic respiratory disease, maternity and mental health.
As an obstetrician I have read the maternal mortality Confidential Enquiries since early in my career, but didn’t attend my first MBRRACE-UK launch event until 2019. Health inequalities data had been collected and reported on in the past, but my lasting memory from the day was the shocking racial disparities in outcomes for birthing people in the UK, with Black women being five times more likely to die than White women.
The maternal mortality Confidential Enquiry is the longest running and most successful medical report in history and was established in 1952, shortly after the inception of the NHS, with a maternal mortality rate at that time of around 90 per 100,000 women giving birth in the UK. The key to success was confidentiality without fear of punitive action in order that full collaboration could occur and lead to valuable lessons. It has a long history of influencing positive change, and indeed discussions relating to learning from the first report led to a memorandum on antenatal care and toxaemia of pregnancy (eclampsia) published in the BMJ in 1956. Over the course of nearly 70 years the enquiry has evolved, and the current provider, MBRRACE-UK, reviews maternal and perinatal mortality, as well as learning lessons from severe morbidity in specific conditions. The maternal mortality rate in the UK is now 8.8 per 100,000 women giving birth, and whilst there is a 10 fold improvement since the 1950s, whether we have made progress on the 2015 target of reducing maternal mortality by 50% by 2025 is debatable. Maybe you think the target is too ambitious based on how far we’ve come, but consider this: our mortality rate is more than twice that of some of our European counterparts. The latest MBRRACE-UK report identified that improvements to care may have made a difference to the outcome in 37% of women, and when you start breaking down our data the differences in outcomes based on ethnicities and deprivation are stark, with a more than a four-fold difference in mortality rates amongst women from Black-ethnic backgrounds compared to White women.
The MBRRACE-UK reports have been pivotal in highlighting health inequalities, leading to the birth of campaigns such as Fivexmore and a Channel 4 documentary “The Black Maternity Scandal”. The RCOG has established a Race Equality Taskforce and Birthrights are conducting an investigation into Racial injustice in maternity care. These are just some of the actions that have arisen as a result of the work that MBRRACE-UK have done.
Where do we go next?
As a trainee I have completed my fair share of audits, but collecting the data is just the start of the story and the real challenge is acting on the findings to influence positive change. Health inequalities are far more challenging to address than writing the correct prescription, with many social determinants of health such as housing, education and employment outside the control of the NHS. In 2016 Better Births set out a vision for maternity services to become safer and more personalised, with the aim that all women can be offered continuity of carer. Continuity of carer describes receiving care from the same one or two midwives throughout the antenatal, labour and postnatal period, and has been shown to improve outcomes for women and their babies, including lower rates of preterm birth and baby loss. The health inequalities highlighted by MBRRACE-UK have identified the women for whom this is most important, leading to it becoming a focus area of the Core20PLUS5 approach by the National Health Inequalities team at NHS England, with the target of ensuring continuity of carer is provided for 75% of women from Black, Asian and minority ethnic communities and the most deprived groups.
Currently we face a midwifery staffing crisis like never before, with 60% of midwives considering leaving the profession. Changing the model of care that we are offering may feel like an insurmountable problem, however continuity of carer is associated with greater job satisfaction levels and longer term thinking will hopefully improve retention of our valuable midwifery workforce. Now more than ever we need effective clinical leadership to nurture and support our midwives, working collaboratively to build safer maternity services. Delivering on the Core20PLUS5 ambition requires leaders to have a strong vision of the needs of both the local population and NHS staff, finding the path forwards that manages both the short and long term problems. Leaders need to demonstrate the FMLM standards of organisational responsibility and strong system leadership, engaging teams to innovate to improve care for patients, whilst improving job satisfaction and retention of staff. Delivering on continuity of carer ambitions is an exceptional challenge, but this is a challenge that we need to rise to in order to improve care and outcomes for women, with the hope that one day we won’t be reporting that the colour of your skin impacts your risk of dying at what should be one of the happiest times of your life.
Dr Josie O’Heney
Dr Josie O’Heney is an Obstetrics and Gynaecology trainee in North-East London. She is currently a National Medical Director’s Clinical Fellow at Healthcare Quality Improvement Partnership (HQIP).
Josie is a passionate obstetrician with a special interest in obstetric medicine. Through her clinical practice she has sadly seen inequality in care and outcomes, and applied to the leadership scheme to gain understanding and experience that will empower her to influence positive change for women on a larger scale than her individual practice. At HQIP she is working with the National Clinical Audit and Patient Outcomes Programme (NCAPOP) team, liaising closely with NHSEI in areas that include national recommendations from reports, health inequalities, and the maternity programme. In addition to her role at HQIP Josie is also working with the National Guideline Alliance on the NICE guideline update to intrapartum care for healthy women and babies.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am a National Medical Director’s Clinical Fellow, working at Healthcare Quality Improvement Partnership (HQIP), commissioners of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).