Introduction
In the context of strategic health management and governance, maternity care within the National Health Service (NHS) represents a critical area where policy development directly impacts patient outcomes, resource allocation, and organisational efficiency. This essay discusses the ‘Better Births’ policy, introduced in 2016 as part of the National Maternity Review, which aims to enhance the safety, personalisation, and continuity of maternity services in England (NHS England, 2016). From the perspective of a student in strategic health management, this policy is examined for its organisational challenges, drawing on theoretical literature related to policy implementation. Furthermore, the essay explores how a change management model, specifically Kotter’s eight-step model, could be applied to understand the policy’s success or failure. The discussion highlights key arguments supported by evidence, while acknowledging limitations in implementation within the NHS framework. By analysing these elements, the essay underscores the complexities of governing health policies in a resource-constrained environment.
The ‘Better Births’ Policy in NHS Maternity Care
The ‘Better Births’ initiative, formally known as the National Maternity Review, was commissioned by NHS England in 2015 and published in 2016. It seeks to transform maternity services by promoting safer, more personalised care, with an emphasis on continuity of carer, better postnatal support, and improved mental health provisions for mothers (NHS England, 2016). This policy emerged in response to ongoing concerns about maternal mortality rates and inconsistencies in care quality across NHS trusts. For instance, it recommends that women should have a dedicated midwife throughout their pregnancy, birth, and postnatal period, aiming to reduce complications and enhance patient satisfaction.
From a strategic health management viewpoint, ‘Better Births’ aligns with broader NHS governance goals, such as those outlined in the NHS Long Term Plan (NHS, 2019), which prioritises preventive and personalised care. However, its implementation has faced scrutiny. Evidence from official reports indicates that while the policy has led to some improvements, such as increased access to perinatal mental health services, progress has been uneven (House of Commons Health and Social Care Committee, 2021). This policy is particularly relevant in the UK context, where maternity care is delivered through a publicly funded system, making organisational challenges a key governance issue. Arguably, the policy’s focus on personalisation reflects a shift towards patient-centred models, yet it requires significant organisational restructuring, which introduces complexities in strategic planning.
Organisational Challenges in Implementing ‘Better Births’
Implementing ‘Better Births’ within the NHS has encountered several organisational challenges, primarily related to staffing, funding, and cultural resistance. One major issue is workforce shortages, which hinder the continuity of carer model. The Royal College of Midwives (RCM) has highlighted that midwife vacancies in England stood at around 2,500 in recent years, exacerbating burnout and turnover (RCM, 2020). This shortage directly impacts the policy’s goal of assigning dedicated midwives, as trusts struggle to reallocate limited personnel without compromising other services. From a governance perspective, this reflects broader strategic mismanagement in human resource planning, where demand for maternity services outpaces supply.
Funding constraints further compound these challenges. The policy requires investment in training, digital tools for care coordination, and infrastructure for community-based services, yet NHS budgets have been strained by austerity measures and the COVID-19 pandemic (King’s Fund, 2021). For example, a report by the Health Foundation notes that maternity services received insufficient ring-fenced funding, leading to patchy implementation across regions (Health Foundation, 2020). This uneven distribution raises equity issues, as rural or under-resourced trusts face greater difficulties, potentially widening health inequalities.
Additionally, organisational culture presents barriers. Resistance to change among staff, due to entrenched hierarchical structures, has slowed adoption. Theoretical literature on organisational behaviour, such as that from Schein (2010), suggests that cultural inertia in large institutions like the NHS can undermine policy initiatives. In practice, this manifests as reluctance to shift from hospital-centric models to community-focused care, as evidenced by audits showing variable compliance rates (Care Quality Commission, 2022). These challenges illustrate how strategic governance must address not only policy design but also the practicalities of execution in a complex, multi-layered organisation like the NHS.
Theoretical Literature on Policy Implementation
Theoretical literature provides valuable insights into the implementation of policies like ‘Better Births’. Implementation science emphasises that successful policy rollout depends on factors such as stakeholder engagement, resource availability, and adaptability (Nilsen, 2015). For instance, Damschroder et al. (2009) in their Consolidated Framework for Implementation Research (CFIR) highlight domains like intervention characteristics, outer setting (e.g., policy environment), and inner setting (e.g., organisational culture), which are directly applicable to NHS maternity care. In this framework, ‘Better Births’ scores well on intervention adaptability but falters in the inner setting due to staffing issues, as discussed earlier.
Furthermore, literature on health policy implementation underscores the role of governance structures. Hill and Hupe (2014) argue that multi-level governance in public health systems often leads to ‘implementation gaps’ where national policies dilute at the local level. This is evident in ‘Better Births’, where national directives from NHS England clash with trust-level autonomy, resulting in inconsistent outcomes. Generally, these theories reveal limitations in top-down approaches, suggesting that bottom-up strategies might enhance buy-in. However, the literature also acknowledges applicability issues; for example, CFIR is more suited to research settings than real-time governance, limiting its direct use in strategic management.
From a student’s perspective in strategic health management, these theories highlight the need for evidence-based planning, yet they sometimes overlook the political dimensions of NHS funding, which can override theoretical ideals.
Applying a Model to Understand Success or Failure
To better understand the success or failure of ‘Better Births’, Kotter’s eight-step change management model (Kotter, 1996) can be applied. This model, widely used in organisational studies, includes steps such as creating urgency, building a guiding coalition, and anchoring changes in culture. In the context of ‘Better Births’, the initial step of establishing urgency was achieved through the 2016 review, which used data on maternal deaths to highlight the need for reform (NHS England, 2016). However, failures emerge in later steps; for instance, forming a powerful coalition has been weak due to fragmented leadership across NHS trusts, leading to inconsistent implementation.
Kotter’s model helps evaluate why the policy has partially succeeded in areas like mental health integration but failed in achieving full continuity of care nationally. Evidence shows that where trusts have ‘generated short-term wins’ (step six), such as pilot programmes in London, outcomes improved (House of Commons Health and Social Care Committee, 2021). Yet, sustaining momentum (step seven) has been challenged by external factors like the pandemic. Theoretically, this model reveals that ‘Better Births’ lacks robust mechanisms for institutionalising changes, contributing to its mixed results.
Applying Kotter’s framework underscores governance lessons: strategic health management requires proactive change leadership to mitigate organisational challenges. Indeed, it could inform future policy development by emphasising iterative evaluation, though its linear nature may not fully capture the dynamic NHS environment.
Conclusion
In summary, the ‘Better Births’ policy represents a pivotal effort in NHS maternity care to prioritise personalised and safe services, yet it faces significant organisational challenges including staffing shortages, funding limitations, and cultural resistance. Theoretical literature on implementation, such as CFIR and governance theories, illuminates these issues, while Kotter’s model provides a structured lens to assess the policy’s partial success and ongoing failures. From a strategic health management perspective, these insights emphasise the importance of adaptive governance to bridge implementation gaps. Implications include the need for enhanced resource allocation and stakeholder involvement in future policies, ultimately aiming to improve maternal outcomes. Addressing these challenges could strengthen NHS resilience, though further research is required to evaluate long-term impacts.
References
- Care Quality Commission. (2022) Maternity Services Survey 2021. Care Quality Commission.
- Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A. and Lowery, J.C. (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science, 4(50).
- Health Foundation. (2020) Understanding the drivers of variation in maternity care. Health Foundation.
- Hill, M. and Hupe, P. (2014) Implementing public policy: an introduction to the study of operational governance. 3rd edn. Sage.
- House of Commons Health and Social Care Committee. (2021) The safety of maternity services in England. House of Commons.
- King’s Fund. (2021) The NHS budget and how it has changed. King’s Fund.
- Kotter, J.P. (1996) Leading change. Harvard Business Review Press.
- NHS. (2019) NHS Long Term Plan. NHS.
- NHS England. (2016) Better Births: Improving outcomes of maternity services in England. NHS England.
- Nilsen, P. (2015) Making sense of implementation theories, models and frameworks. Implementation Science, 10(53).
- Royal College of Midwives. (2020) State of maternity services report 2020. RCM.
- Schein, E.H. (2010) Organizational culture and leadership. 4th edn. Jossey-Bass.
