Implementation Gap
Lasting improvements in maternity care depend on treating implementation as a long-term process, argues Evelyn Akoto
Britain is remarkably good at investigating failure. When things go wrong, we commission reviews, appoint respected experts and produce thoughtful recommendations. Few countries examine their mistakes with the same degree of honesty and rigour.
The Ockenden review and Baroness Amos’ review into maternity and neonatal services are the latest examples. Both are serious pieces of work, both contain important lessons, and both reinforce what many working across health and care already know: safer maternity services depend not only on clinical excellence, but on leadership, organisational culture, accountability and listening to women and families.
The uncomfortable truth, however, is that very little of the substance of either review is new. Many of the themes identified by Ockenden and Amos have appeared in previous reviews and investigations stretching back years. Britain no longer has a knowledge problem when it comes to maternity safety. It has an implementation problem.
Part of the problem lies in the realities facing modern public services. Maternity services are operating under enormous pressure and are often expected to respond simultaneously to recommendations from national reviews, regulators, investigations and local improvement programmes. Taken as a whole, the system is good at generating recommendations and bad at creating the space, capacity and infrastructure needed to embed them.
The ‘embedding’ point is key. Public services are often able to implement initiatives in the short term, but as leaders move on, teams change, and organisational priorities evolve, services can slide back into poor practice.
That is not a criticism of individual organisations or leaders; it is ultimately a question of institutional design. If we want different outcomes, we need to structure services differently.
First, implementation needs to be treated as a long-term process rather than a one-off event. One of the strengths of the Southwark Maternity Commission was that it deliberately built in annual reviews, including a three-year interim review and a five-year evaluation, in recognition of the fact that meaningful system change takes time to embed and sustain. We should consider whether major national reviews could adopt a similar implementation cycle, creating opportunities to assess not simply whether recommendations were accepted, but whether they changed practice, culture and outcomes over time.
Second, the system needs to become better at prioritisation. Not every recommendation can be delivered at once, particularly in already pressured services. National reviews should distinguish between immediate priorities, medium-term reforms and longer-term system change, allowing organisations to focus on embedding improvements rather than continually responding to the next set of recommendations.
Third, responsibility for implementation needs to be shared across the whole system. The Ockenden and Amos reviews reinforce that improving maternity care requires more than action from individual NHS trusts. Many of the issues they identify – including issues with leadership, culture, trust, and inequalities – extend beyond hospital walls. This is where local authorities have an important contribution to make, including through health and wellbeing boards, which bring together councils, NHS organisations and wider partners to provide leadership across local systems. Local authorities can also provide continuity that survives organisational restructures and leadership changes, helping to maintain focus once national attention moves elsewhere.
When I chaired the Southwark maternity commission, one lesson stood out above all others: complex public service challenges are rarely solved by one organisation acting alone. They require partnership and shared accountability. Most importantly, they require institutions capable of sustaining their focus after the headlines have disappeared.
This is the real challenge posed by Ockenden and Amos. It is not whether we can learn lessons – Britain has shown repeatedly it can – but whether we can build institutions capable of holding on to those lessons long enough to turn recommendations into lasting change.
