Real changes to the NHS require real changes to NHS inquiries
Preliminary findings in a rapid inquiry into NHS maternity services are due this month. 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 who 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don’t bring is recent experience of delivering babies at 3am with inadequate staffing, conflicting protocols, and outdated equipment.
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.
How these recommendations are 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.
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.
Many of the units identified as underperforming serve deprived areas. 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.
Such 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.
What would help?
Frontline staff know what would improve care, but they’re rarely asked, and when they are, their answers don’t fit the inquiry framework.
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.
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.
We should 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.
We need to 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.
We must 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.
We should 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.
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.
Further information can be found here
- Why inquiries into NHS maternity care are failing - 9th December 2025
