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Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS


McGowan J, Attal B, Kuhn I, et al Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010–2023 BMJ Quality & Safety Published Online First: 29 November 2023. doi: 10.1136/bmjqs-2023-016606

Why it matters

Although they are a popular strategy for improving care, large-scale improvement programmes have often had mixed impacts in clinical services. Previous research has identified important features of improvement programmes that need to be optimised, but we don’t know how well these quality criteria are routinely met.

English NHS maternity services continue to be challenged, despite a large number of improvement initiatives over a long period, making this an important setting in which to study programmes that aim to improve quality and safety.  

The objectives of the UK government’s recently established Maternity and Neonatal Care National Oversight Group include “looking at work being carried out by a range of programmes set up to improve maternity and neonatal care […] to ensure they are joined up and effective.” It is vital that these programmes are well-designed, are informed by best available evidence, and are reported well. We aimed to identify large-scale improvement programmes implemented in English NHS maternity services in the period 2010-2023, and to carry out a structured quality assessment of those meeting our criteria.  

Our approach

We identified relevant initiatives from a range of information sources including grey literature, research databases, and other sources. Improvement programmes that focused on intrapartum care and had a publicly available evaluation report were subject to a structured assessment based on selected features of programme quality. We focused on programmes that sought to improve intrapartum (during labour) care, so didn’t assess programmes that focused on antenatal or postnatal care. Programmes that didn’t meet our definition of an improvement programme, and/or that didn’t have a retrievable evaluation report, were excluded from our review.

What we found

Many large-scale maternity improvement initiatives in England don’t have a publicly available evaluation report, representing a major barrier to learning and accountability.

Among those that do have an evaluation report, we found widespread weaknesses in design, transparency of reporting, and evaluation. We identified multiple problems including inadequate descriptions of implementation support for clinical services, variable use of evidence, lack of explicit commitment to reducing inequalities, and limited involvement of women and their families. We also identified some potential for programmes to contribute to widening inequalities between high- and low-performing services.

Our findings are both a cause for concern and unlikely to be unique to this clinical setting.

This study suggests key targets for improving the design, delivery, evaluation and reporting of large-scale programmes in healthcare to maximise their impact on quality and safety, ensure accountability (including for how resources are used) and better gather learning to improve care for patients. The first steps for policymakers and commissioners of improvement programmes are to:

  • commit to and incentivise high-quality reporting. This is crucial to providing transparency and enabling scaling of successful programmes.
  • commit to evaluation and public reporting of findings, which is fundamental to high-quality commissioning of large-scale programmes in healthcare, and key to securing learning and accountability.
  • identify the reduction of health and care inequalities as an explicit goal of healthcare improvement programmes.
  • close gaps between stated policy goals and programme design, for example in relation to the involvement of patients and the public.

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