By Lorin Lakasing, author of “Delivering the truth: Why NHS maternity care is broken and how we can fix it together”
Preliminary findings in a rapid inquiry into NHS maternity services are out this month (December 2025). It’s the latest in a series of investigations stretching back twenty-two years. All have been well-intentioned, but somehow, again and again, they fail. Why?
Missing the mark
The people who run these inquiries are accomplished professionals – senior healthcare figures, policy experts, data analysts. They bring expertise in systems, processes, and governance. What they typically don’t bring is recent experience of delivering babies at 3am with inadequate staffing, conflicting protocols, outdated equipment and working in a hazardous working environment.
The recommendations produced make perfect sense in theory: more training; better protocols; enhanced oversight; increased transparency. But on the ground, these translate into more boxes to tick, more time away from patients, more fear of getting something wrong. Each layer of bureaucracy added to “improve” care actually makes providing good care harder.
The carrot and stick problem
The way these recommendations get implemented reveals another fundamental misunderstanding. Managers receive carrots – more funding for achieving targets, better ratings for compliance, career advancement for hitting metrics. They then use sticks to motivate frontline staff – threats of unit closure, special measures, blame for poor outcomes, criticism for missing targets.
This creates a perverse dynamic. Managers become experts at chasing carrots, developing vast teams devoted to meeting targets and improving ratings. Meanwhile, clinicians become adept at dodging sticks, following protocols defensively rather than using clinical judgement while avoiding difficult conversations that might lead to complaints.
Actual patient outcomes become almost incidental. A unit can tick every box, meet every target, achieve an “Outstanding” rating, yet have clinical outcomes no better that another rated “Inadequate”. Conversely, a unit providing excellent clinical care might be rated “Inadequate” because they prioritised patients over paperwork.
Take the Shrewsbury and Telford case . The trust had been praised for achieving low caesarean rates: around 16% – close to the ill-conceived 15% target set by commissioners at the time, and consistently 8% to 12% below the average in England. Meeting this target brought funding and recognition.
But achieving it meant delaying necessary interventions, pressuring mothers into vaginal deliveries when the risk benefit analysis was clearly in favour of Caesarean delivery and prioritising the metric over mothers and babies.
When senior clinicians raised concerns, they were seen as obstacles to achieving targets. Many left rather than compromise their clinical judgement. Those who remained learned to work within a system that rewarded hitting numbers rather than healthy deliveries. The inevitable tragedy that followed wasn’t due to individual failures but systemic pressures that made poor outcomes almost inevitable.
Missing the local context
National inquiries, by their nature, seek national solutions. But maternity services face vastly different challenges depending on location, demographics, and resources. What works in rural Gloucestershire won’t necessarily work in inner London, yet inquiries produce one-size-fits-all recommendations.
When Health Secretary Wes Streeting selected underperforming units for special attention in his rapid inquiry, it was widely reported that many served deprived areas. The assumption was that these units are failing due to poor practice. However, these units might actually be performing miracles given their starting point, but that nuance is invisible when you’re only looking at standardised outcomes.
Similarly, inner-city units face unique staffing challenges. The cost of living means salaries don’t stretch as far. Experienced staff move to areas where their pay provides better quality of life. These inner-city units constantly train new midwives only to lose them once they gain experience. Yet inquiries recommend more training programmes without addressing why staff don’t stay.
These local contexts are key to understanding why issues arise and yet they don’t fit neatly into sweeping national reforms and new tick-box targets, so they are missed or dismissed.
The transparency paradox
Prompted by patient complaints about concealment and collusion, most recent inquiries have emphasised “transparency” and “openness”. The idea is compelling: if we’re honest about problems, we can address them; if we involve patients more, we’ll build trust. In practice, this well-intentioned approach has created new problems.
The Lucy Letby case illustrates this paradox perfectly. When consultants raised concerns about unexplained deaths, they were initially dismissed by management and even asked to apologise to Letby. Managers were operating out of fear in a system that prioritises perception over actual patient care. They knew that any investigation would become public, that media coverage would be devastating, and that their ratings and funding were at risk.
A recurring theme across NHS trusts is senior managers placing reputational damage limitation ahead of patient and staff safety. The pressure for transparency, paradoxically, incentivises hiding or white-washing problems until they become undeniable crises.
Staff learn quickly that raising concerns brings scrutiny, blame, and career consequences. Better to keep quiet, follow protocols, document everything defensively. The very transparency meant to improve care creates a culture of fear that prevents honest discussion of problems before they become tragedies.
Rather than building trust with patients, quite the reverse happens. Patients arrive hypervigilant, looking for fault, and expecting to be let down and all too ready to seek information from alternative online groups. Staff cannot provide confident reassurance without fear of reprisals or accusations of failing to listen to patients. Ultimately, these factors combine to create an environment where clinicians are squeezed into impossible situations and end up in either adversarial relationships with patients or disengaging with them. No one wins.
What would help change this
The solutions aren’t rocket-science. Whilst the patient voice is clearly important, it is frontline staff who know what would improve care. But they’re rarely asked, and when they are, their answers don’t fit the inquiry framework.
First, we need clinicians involved in designing and implementing solutions. Not former clinicians long lost to management, but practising professionals who understand current realities. Their insights about workflow, team dynamics, and practical obstacles are irreplaceable.
Second, we must reform the incentive structure completely. Currently, the carrot-and-stick approach means managers chase funding whilst staff dodge blame. Neither focuses on actual patient outcomes. We need to reward clinical excellence, staff retention, and team stability rather than tick-box compliance.
Third, recognise that different areas need different solutions. A unit serving a stable, affluent English-speaking population has different needs than one serving an impoverished transient, multilingual community with complex health needs. Stop pretending universal protocols solve local problems.
Fourth, optimise data collection and use it better. NHS maternity units already track comprehensive metrics through various software systems. Instead of fixating on a few specific targets that can be gamed, we should use this wealth of data to understand performance holistically. Trust that clinicians want the best outcomes for patients – they don’t need carrots and sticks, they need respect, appropriate resources, and a pay package that recognises their expertise and incentivises them to continue in clinical work.
Fifth, address why clinical work is undervalued. When moving into management or investigation work pays significantly more than delivering babies, we’re telling our best clinicians their expertise is worth less than bureaucracy. We need to value and reward the actual work of providing care.
Sixth, create psychological safety for staff. The constant fear of blame, investigation, and media scrutiny paralyses clinical decision-making. Staff need to know they can raise concerns without destroying their careers, make clinical judgements without defensive documentation, and learn from mistakes without punishment.
The question we must answer
At its heart, this is about deciding what the NHS maternity service is for. Is it a bureaucratic institution focused on compliance, targets and ratings? Or is it a service dedicated to providing safe, compassionate care to mothers and babies?
Currently, we’re trying to be both, and failing at both. We pour resources into achieving ratings that don’t correlate with clinical excellence. We create layers of management to oversee processes that make care harder to deliver. We investigate failures without addressing the systemic pressures that make them inevitable.
This isn’t about eliminating management or abandoning all oversight—of course we need some administrative structure and accountability—and neither is it about excluding patients from the debate. But we’ve lost the balance. The pendulum has swung so far towards acceding to patients’ demands and implementing bureaucratic processes that clinical care has become secondary. We need to rebalance the system to include the opinions of those actually providing care.
When the majority of resources, time, and respect flows to non-clinical activities whilst frontline staff struggle with inadequate support, we shouldn’t be surprised that care suffers. Every additional layer of bureaucracy that doesn’t directly support clinical work is a choice to prioritise appearance over outcomes. We need to consciously shift that balance back towards the people who actually deliver babies and care for mothers.
What this inquiry could achieve
Realistically, without having made fundamental changes in approach, this current inquiry will likely produce similar recommendations to its predecessors: more transparency; more patient involvement; more oversight; more protocols; more training; more targets. The cycle will continue.
But if this inquiry has done something revolutionary—genuinely listened to frontline staff, recognised local contexts, addressed perverse incentives, valued clinical work appropriately—it could begin real change.
The change wouldn’t be quick. We’re talking about reversing decades of bureaucratic accumulation, changing deeply embedded cultures, rebuilding trust between all parties. It would take political courage to admit the current approach isn’t working. It would take public patience to allow time for genuine reform rather than quick fixes. It would take professional commitment to stay engaged despite past disappointments.
Most importantly, it would require all parties—investigators, managers, staff, patients, media, politicians—to recognise their part in the current dysfunction. Not through blame, but through understanding that everyone’s responding rationally to a system that incentivises the wrong things.
The people running inquiries aren’t villains; they’re accomplished professionals trying to help. Managers aren’t deliberately obstructing care – they’re responding to the incentives placed before them. Staff aren’t being difficult – they’re trying to provide care under impossible conditions. Patients aren’t being unreasonable – they’re seeking support wherever they can find it.
Once we understand that the problem isn’t bad people but bad systems, we can begin designing better ones. Systems that reward clinical excellence rather than bureaucratic compliance, that value frontline expertise over administrative convenience, that recognise local contexts rather than imposing universal solutions, that support staff to provide the care they want to give rather than defending against blame.
Will this inquiry achieve that? History suggests not. But if enough people have recognised the pattern we’re stuck in, if enough voices have called for genuine change rather than more of the same, if we are finally ask the people who know what’s wrong and what would fix it—the frontline staff delivering babies every day—we might break the cycle.
ABOUT THE AUTHOR
Dr Lorin Lakasing is an NHS consultant in obstetrics and fetal medicine. She draws on her 30 years of clinical experience in maternity care to give an insider’s view of the current worrying situation and its development, and suggests how we might move towards the safe, effective NHS maternity service that everyone deserves. Her latest book, “Delivering the truth: Why NHS maternity care is broken and how we can fix it together” is about the stories behind the headlines, revealing the reasons why major stakeholders in this vital service have inadvertently been encouraged to pursue different agendas, and how that has made effective, collaborative working towards optimal clinical outcomes almost impossible.
Web: https://lorinlakasing.com/publications.html
Amazon: https://amzn.eu/d/g1dX9rh