Improving maternity and neonatal care in England: a survey to evaluate the implementation of the core competency framework to improve multi-professional practice

Abstract

Background

The NHS England-led Core Competency Framework (CCF) aims to address significant safety concerns and national variations in maternity practice. The CCF defines minimum safety training requirements for all maternity and neonatal services in England. It emphasises the importance of service user involvement, local incident learning, multi-disciplinary team training and network learning. Successful national implementation may reduce variation in training and competency assessment across England, but the CCF has not been subject to evaluation.

Aims

To explore CCF implementation in maternity and neonatal units in England including factors affecting implementation and investigate staff views regarding the acceptability, appropriateness and feasibility of implementing the CCF.

Methods

A national online survey of organisational leads responsible for planning, delivering and implementing the CCF across NHS Trusts in England. Survey questions were informed using the TIDieR framework and acceptability, appropriateness and feasibility of the CCF were measured using the Weiner validated scale. Proportions were calculated for each response by individual and by Trust with corresponding confidence intervals using Stata version 19 and open text responses were analysed using thematic analysis.

Results

The survey contained 82 completed responses covering 66 (54.7%) NHS Trusts across England. Survey respondents considered the CCF acceptable 4.4/5, appropriate 4.2/5, but feasibility scored just 3.7/5 with lack of resources cited as a common implementation barrier. Multi-professional Education Teams were reportedly in place at 68.2% of Trusts (55.8–78.4%, 95% CI), although responsibility for the development and planning of training was mostly undertaken by midwives. Respondents reported delivering multi-professional maternity and neonatal training, however, there was variation in the number of days training that each professional group received. The survey found 54.5% (42.3–66.3 95% CI) of Trusts provided midwives 3–4 days and 31.8% (21.6–44.2 95% CI) 5–6 days. Whilst 47.0% (35.1 - 59.2 95% CI) of obstetricians, 45.5% (33.7–57.7 95% CI) of neonatologists and 87.9% (77.3- 93.9 95% CI) of anaesthetists were provided only one to two days of CCF training. Maternity service user involvement was reported at 68.2% (55.8–78.4 95% CI) of Trusts, whilst neonatal service user involvement was reported in 39.4% (28.2 -51.8 95% CI) of Trusts. Involvement consists mainly of routine feedback rather than encouraging active user engagement.

Conclusion

Whilst the CCF is generally considered to be acceptable and appropriate it is reportedly less feasible. There remains variation in the implementation of Multi-Professional Education Teams, the number of days of training available to professionals and involvement of service users across represented NHS Trusts. Insufficient resources and staffing impacted on the delivery of the framework.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15013-z.

Background

There is substantial concern regarding the quality and safety of maternity services and existing variation in its delivery across England. Previous high-profile investigations have found evidence of systemic failures in the provision of safe maternity care within certain

National Health Service (NHS) Trusts [1, 2]. NHS Trusts are the legal entities in England that provide healthcare goods and services, including hospital services, community services and/or other aspects of patient care [3].

A Health and Social Care Committee report (2021) examining maternity safety also found significant limitations to the training provided for maternity staff and that effective, multi-professional learning was not always occurring [4]. In 2024, the Care Quality Commission reported that 48% of NHS maternity services were rated as inadequate or requiring improvement [5].

In response to these challenges, the Maternity Transformation Programme, within NHS England, led the development of an initial Core Competency Framework (CCF), in collaboration with the Royal Colleges and Nursing and Midwifery Council (NMC) [6]. The CCF sought to address known variation in training and competency assessment across England. It ensures that training to address significant areas of harm are included as minimum core requirements for all maternity and neonatal services. The CCF was updated to CCFv2 in 2023, and now sets out six modules for training, but stops short at providing materials or stipulating qualifications for trainers. Within the framework, there are some training modules that mandate which professional groups must attend (e.g. obstetric emergency training). These modules are regulated by the NHS Maternity Incentive Scheme which is a financial incentive programme designed to enhance maternity safety within NHS Trusts by rewarding organisations for demonstrating core safety actions [7]. For the other modules, it is the responsibility of maternity units to justify who should attend, by using local priorities (e.g. audits, incidents) and adhering to professional regulations [8].

The CCF ‘How to Guide’ published alongside CCFv2 assumes multi-professional education teams exist within each Trust to plan and implement CCF training programmes. It identifies four key principles that underpin the framework which are supported by work focusing on safety within maternity and neonatal care [9]. These principles are:

1. Service user involvement in developing and delivering training.

2. Training is based on learning from local findings from incidents, audit, service user feedback, and investigation reports. This should include reinforcing learning from what went well.

3. Promote learning as a multi-disciplinary team.

4. Promote shared learning across a Local Maternity and Neonatal System.

Research highlights the importance of actively involving the public and patients and putting them at the centre of healthcare [10, 11]. Incorporating the service user voice within maternity services provides a clearer understanding of safety problems from multiple perspectives, helps with the creation of solutions within the clinical setting, and ultimately contributes to improved patient choice and outcomes [12, 13]. The CCF also emphasises the importance of local and shared learning. The Ockenden (2020) and Kirkup (2022) reports that investigated significant safety failings in maternity services within particular NHS Trusts, highlighted the need for clinical incidents, including maternal deaths, to inform delivery of the local multi-disciplinary training plans [1, 2]. The World Health Organization (WHO) sets out similar guidelines to improve patient safety globally [14]. Several reports have also highlighted the potential for services to establish links with other ‘partner’ Trusts to support shared learning opportunities [1, 15]. Finally, the CCF emphasis on incorporating multi-disciplinary training is based on recommendations from multiple national reports and international research outcomes. For example, training in the form of PROMPT (PRactical Obstetric Multi-Professional Training) which supports multi-professional relationships and collective team competence can improve patient care and outcomes [16–19].

The overall aim of the CCF is to reduce national variation in training and competency assessment across England. To date there has been no formal evaluation of how the CCF has been received by healthcare organisations, the fidelity of its implementation, or the impact that it has had on staff competence, safety and quality of care. The study reported in this paper forms part of a larger evaluation project titled The CORE Study, to explore and enhance the implementation and impact of the CCF in England as it seeks to reduce variation in maternity and neonatal care [20].

Methods

Aim

This paper describes the findings of a national online survey which aimed to explore:

1. How the CCF has been implemented in maternity and neonatal units in England.

2. Staff views of the acceptability, appropriateness and feasibility of implementing the CCF.

3. Contextual factors affecting the implementation of the CCF.

Study design

We conducted an online national survey of all NHS Trusts in England to investigate the implementation of the CCF since its inception in 2020. Ethics approval was obtained from HRA Northwest – Greater Manchester East Research Ethics Committee & HCRW (IRAS project ID: 337,557; REC reference: 24/NW/0384). The survey was undertaken to determine the extent to which those responsible for the implementation of the CCF consider it acceptable, appropriate and feasible. Regarded as leading indicators of intervention implementation success [21, 22]; Weiner’s Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure were included. In line with Weiner’s handbook one question from each of Weiner’s three validated scales were chosen, based on their discriminant content validity (0.8, 0.7 and 0.9 respectively) [21, 22]. For the purposes of this study, the acceptability of the CCF referred to a respondent’s perception that the framework was agreeable or satisfactory. Appropriateness questions evaluated the perceived fit and relevance of the CCF to both the setting and to meet stipulated goals or address identified problems. The questions regarding feasibility evaluated the degree to which respondents felt that the CCF could be successfully implemented as intended.

The design of the survey was informed using the TIDieR (Template for intervention Description and Replication) framework which aims to improve published descriptions of interventions, to enable clinicians and patients to reliably implement those that are shown to be useful, and to ensure research findings can be replicated and built on. Questions were designed to establish and report accurately implementation of the CCF in different maternity units across England in terms of ‘who, what, where, why and when’ [23]. Fixed response questions used a five-point scale (agree, somewhat agree, neither agree nor disagree, somewhat disagree, and disagree). Qualitative open text items were included to allow participants to elaborate on their answers or to highlight any areas not already covered by the survey. The questionnaire was piloted with three midwives, and some questions were removed to eliminate repetition. The final 51 item questionnaire explored the respondents’ views on topics including if Trusts had established a multi-professional education team, how they implement the four training principles, and the implementation and delivery of the CCF over time (see Additional File 1 for full survey). The online survey was managed and completed through Qualtrics software [24].

Recruitment

England’s Chief Midwifery Officer and the seven Regional Chief Midwives (who lead the transformation of maternity services in each of the seven English regions) shared the online survey with maternity and neonatal clinical leaders in the local NHS Trusts (Fig. 1). The Royal College of Midwives also shared the survey link within their midwifery leaders’ network. The online survey was then distributed within each NHS Trust (n = 121) to the organisational leads of the CCF these roles could include the practice development midwife, the safety and quality lead midwife, obstetric consultant or anaesthetic consultant. At the start of the survey a participant information sheet and consent form was included. It was made clear participation was voluntary and responses were anonymous. Every study participant provided consent prior to completing the survey.

Fig. 1.

Regional response rate from 66 Trusts responding to survey in England. Percentage of NHS Trusts responding in each region % (as a percentage of England’s overall response rate %)

Data collection

The survey was live for eight weeks (March - April 2025) and email reminders were sent out via the same networks at 4 and 6 weeks. Respondents were asked to identify the maternity and neonatal units in which they worked to establish the reach and response rate of the survey. As each Trust had several organisational leads who were eligible to complete the survey, individuals were not asked to provide their name or demographic details, their IP address was not collected, and participants remained anonymous. Participants were also informed in the information letter not to include any personal or identifiable information about themselves, other staff members, or service users within the free text areas of the survey. Respondents were required to mark a consent box before submitting the form and were assured that their data would be treated confidentially and stored securely.

Data analysis

Descriptive summary statistics were uploaded to a password protected server. For the purposes of analysis, we distinguished between data about a Trust’s provision of training and the views and opinions of lead implementers on the CCF. Data about the provision of training was analysed per NHS Trust. Where more than one survey from the same Trust had been submitted, individual answers were compared. When the responses to the questions differed, they were coded as split or mixed. Proportions were calculated for each response by individual and by Trust with corresponding confidence intervals using Stata version 19. All respondents’ views about the training were analysed by individual response (and not by Trust). Weiner’s three implementation measures were analysed in line with the Weiner instruction manual, coding ‘completely disagree’ as 1 and ‘completely agree’ as 5, with average scores generated across each of the three domains. Cut-off scores for interpretation are not yet available; however, higher scores indicate greater acceptability, appropriateness, and feasibility [21, 22]. Thematic analysis using inductive coding was used to analyse qualitative data captured in open text fields [25]. Data were coded independently by SG and RW, having familiarised themselves with the data. Initial codes were developed and then collated into broader themes jointly before being finalised. Any discrepancies were discussed at the time they arose and resolved.

Results

The survey received a total of 116 responses. One respondent did not include qualifying data required for analysis and was therefore excluded. All other excluded responses had not progressed past the initial qualifying questions and as such had self-excluded (n = 34). There were 82 complete surveys from CCF lead implementers that were included in the analysis, of these 82 responses twelve Trusts gave two survey responses, and two Trusts gave three survey responses. In total, 66 out of the 121 NHS Trusts with maternity and neonatal services responded (54.7%). With no overall difference in the response and nonresponse rate of better and poorer performing Trusts based on their independent regulator ratings (CQC); and with good geographical representation across England. The East of England had the highest response rate (76% of NHS Trusts responded) compared to the Northeast and Yorkshire (33.3%) (Fig. 1).

Staff views on the acceptability, appropriateness and feasibility of the core competency framework

All respondents completed questions regarding the acceptability, appropriateness and feasibility of the Core Competency Framework. Each question generated a score from one to five (one being completely disagree and five being completely agree). The CCF is considered acceptable (4.4/5), appropriate (4.0/5) and feasible (3.7/5) finding that whilst the CCF is considered acceptable and appropriate it is less feasible to implement (Table 1). Of the 82 respondents who completed the survey just 46 (56.1%) agreed that management supported the delivery of the CCF and 28 (34.2%) agreed somewhat (Table 3).

Table 1.

Weiner the acceptability of intervention Measure (AIM), intervention appropriateness Measure (IAM), and feasibility of intervention Measure (FIM)

	I completely agree (5)	I agree (4)	I neither agree nor disagree (3)	I disagree (2)	I completely disagree (1)	Weiner Score (mean scores 1–5)
I welcome the CCF	39/82 47.6%	33/82 40.2%	7/82 8.5%	2/82 2.4%	1/82 1.2%	4.4
The CCF seems suitable	24/82 29.3%	44/82 53.7%	8/82 9.8%	5/82 6.1%	1/82 1.2%	4.0
The CCF seems easy to use	16/82 19.5%	42/82 51.2%	12/82 14.6%	10/82 12.2%	2/82 2.4%	3.7

Table 3.

Respondent’s views on the planning and delivery of CCF training

	Agree	Somewhat Agree	Neither Agree nor Disagree	Somewhat Disagree	Disagree
Multi-professional education team have a shared understanding	32/57 56.1%	17/57 29.8%	3/57 5.3%	5/57 8.8%	0 0.0%
Those planning training have appropriate skills	43/57 75.5%	10/57 17.5%	2/57 3.5%	2/57 3.5%	0 0.0%
Those delivering training have appropriate skills	43/57 75.5%	10/57 17.5%	2/57 3.5%	2/57 3.5%	0
Local learning meaningful	61/81 75.3%	18/81 22.2%	1/81 1.25%	0	1/81 1.25%
Local learning is good quality	56/81 69.1%	25/81 30.9%	0	0	0
Multi-professional learning is meaningful	61/82 74.4%	18/82 22%	2/82 2.4%	1/82 1.2%	0
Multi-professional learning is good quality	58/82 70.8%	21/82 25.6%	2/82 2.4%	1/82 1.2%	0
Shared learning is meaningful	30/73 41.1%	35/73 47.9%	5/73 6.8%	2/73 2.8%	1/73 1.4%
Shared learning is good quality	33/73 45.1%	30/73 41.1%	7/73 9.6%	2/73 2.8%	1/73 1.4%
Management adequately supports delivery of CCF	46/82 56.1%	28/82 34.2%	5/82 6.1%	2/82 2.4%	1/82 1.2%

Thematic analysis of open-text responses found the CCF supports implementation leads to justify, organise and deliver the programme. Further CCFv2 provided more direction and structure than the original version, gave greater clarity on the training topics required and more helpful details regarding the training content:

Better structure, more thorough range of topics covered and a large increase in the non-clinical elements such as human factors and escalation training. (Participant: 21)

Conversely analysis found the training required by the framework was too resource intensive:

I like the concept of the CCF in aiming to ensure a national standard to training, however meeting the standards are almost impossible in terms of what staff groups attend and how many hours are required. (Participant: 15)

Further qualitative thematic analysis found partial implementation of the CCF (i.e. three out of the six modules), prioritising the three modules included in the Maternity Incentive Scheme over others in the context of insufficient resourcing.

What is difficult is that only 3 topics are parts of the submission (maternity emergencies, fetal surveillance and NLS) and therefore gaining commitment for the other elements is a challenge. We use the documents as a tool and evidence to back up why we need support but only submitting against the 3 topics makes the others seem less important. (Participant number: 59)

Multi-professional education team

Across all 82 responses MET teams were reportedly in place in 69.5% of cases (Table 2). When analysed by Trust 68.2% of Trusts (55.8–78.4%, 95% CI) have METs in place. Three Trusts had mixed responses indicating there may be METs in place at individual maternity and neonatal units and not at others within the same Trust (1.4%-13.4%, 95% CI). Just 56.1% of respondents felt their METs had a shared understanding, whilst 75.5% felt those planning and delivering training had the appropriate skills to do so (Table 3). Of the 57 respondents that reported a MET at their Trust 96.5% included a PDM, 87.7% a consultant obstetrician, 73.7% a consultant anaesthetist. Strikingly just 39% a neonatal nurse, 24.6% a neonatologist and 29.8% a service user lead was reportedly included in MET teams.

Table 2.

Implementation of the five key CCF elements in England’s NHS trusts

	Individually reported			By Trust
	N out of 82	Percentage of total	(95% CI)	N out of 66	Percentage of total	(95% CI)
MET Team
no	25	(30.5%)	(21.4, 41.4)	18	(27.3%)	(17.8, 39.4)
yes	57	(69.5%)	(58.6, 78.6)	46	(69.7%)	(57.4, 79.7)
mixed	-	-	-	2	(3.0%)	(0.7, 11.6)
Maternity Service Users
no	22	(26.8%)	(18.3, 37.6)	12	(18.2%)	(10.5, 29.6)
yes	60	(73.2%)	(62.4, 81.7)	45	(68.2%)	(55.8, 78.4)
mixed	-	-	-	9	(13.6%)	(7.2, 24.4)
Neonatal Service Users
no	45	(54.9%)	(43.9, 65.4)	31	(47.0%)	(35.1, 59.2)
yes	37	(45.1%)	(34.6, 56.1)	26	(39.4%)	(28.2, 51.8)
mixed	-	-	-	9	(13.6%)	(7.2, 24.4)
Local Learnings
no	1	(1.2%)	(0.2, 8.4)
yes	81	(98.8%)	(91.6, 99.8)	65	(98.5%)	(89.7, 99.8)
mixed	-	-	-	1	(1.5%)	(0.2, 10.3)
Multi-Professional Training
yes	82	(100%)		66	(100%)
Shared Learning
no	9	(11%)	(5.8, 19.9)	6	(9.1%)	(4.1, 19.0)
yes	73	(89%)	(80.1, 94.2)	58	(87.9%)	(77.3, 93.9)
mixed	-	-	-	2	(3.0%)	(0.7, 11.6)

Although many Trusts had, to some extent, implemented a multi-professional education team, qualitative analysis identified a lack of multi-professional engagement within the planning and delivery of the CCF. There was further evidence that the efforts to implement the CCF had been driven largely by the midwifery teams:

The Midwifery Education Team do the planning, but anaesthetic and obstetric colleagues contribute to the obstetric emergency day, the fetal monitoring day and some of the other sessions. (Participant number: 74)

Further analysis found having other professions who were not currently part of the multi-professional education team would be likely to help training course attendance by those professions:

We need a medical staff representative for the CCF so that this is also valued and recognised as important by medical staff. (Participant number: 63)

Service user involvement in training

Despite being one of the four key underpinning principles, service user involvement in the planning and delivery of the CCF is not well adopted across the NHS in England. Respondents (45/66 Trusts) 68.2% (55.8–78.4 95% CI) reported they had involved maternity service users in the development and delivery of training, and 26/66 reported neonatal service user involvement 39.4% (28.2 -51.8 95% CI) (Table 4). However, respondents reported routinely collected data, such as the NHS Friends and Family questionnaire for patient feedback or the Patient Advice and Liaison Data, as the most frequently cited as examples of involving service users. Where ‘other’ was selected by respondents, the most common involvement was through incorporation from incident reporting feedback and the use of local case studies. Deeper engagement activities which included co-designing training or observing training sessions were less well used 43.9% (29/66) and 30.3% (20/66) respectively. This was also apparent from the qualitative data.

Whilst we don’t involve service users face to face with training planning, we do incorporate Datixincident actions, complaints feedback and feedback from birth afterthoughts into training programmes. (Participant number: 73)

Table 4.

Survey results demonstrating ‘how are service users involved in training’

How are service users involved in training – y/n	Yes (%)
Develop the training needs analysis/ 3-year training plan	28/66 (42.4%)
Develop the aims and objectives of each training module	15/66 (22.7%)
Develop training materials	29/66 (43.9%)
Facilitating, participating, or observing training	20/66 (30.3%)
Providing feedback on the quality of training sessions	15/66 (22.7%)
Use local Patient Advice and Liaison Service data	28/66 (42.4%)
Use local patient feedback data e.g. friends and family questionnaire	46/66 (69.7%)
Other	18/66 (27.3%)

Qualitatively the study found some evidence that the CCF was contributing towards a greater incorporation of service users, especially through collaboration with local maternity and neonatal voice partnerships where people with lived experience work together with staff to transform care:

The CCF prompted us to use the maternity and neonatal voice partnerships in order to gain their views on our training programme. This is a relationship that we are continuing to develop and has led to us planning quarterly meetings with our maternity and neonatal voice partnerships leads so we can discuss any relevant training issues. (Participant number: 66)

Multi-professional training

Respondents from all 66 Trusts reported that they delivered multi-professional maternity and neonatal training (Table 2). 74.4% (61/82) of individual respondents agreed that this training was meaningful, and 70.8% (58/82) felt that it was of good quality (Table 3). Variation was reported, between Trusts and between professions, in terms of allocated time for CCF. The survey found substantial variation in the number of training days made available to staff working in maternity and neonatal services in England. 54.5% (42.3–66.3 95% CI) of Trusts provided midwives 3–4 days and 31.8% (21.6–44.2 95% CI) 5–6 days (Table 5). For medically trained professionals, the required days were fewer, with 47.0% (35.1 - 59.2 95% CI) of obstetricians, 45.5% (33.7–57.7 95% CI) of neonatologists and 87.9% (77.3- 93.9 95% CI) of anaesthetists provided one to two days of CCF training. The number of training days neonatologists and neonatal nurses receive was not provided (missing or not known) in around half of the survey responses (Table 5).

Table 5.

Training time by profession

	Individually Reported			By Trust
	N out of 82	Percentage of total	(95% CI)	N out of 66	Percentage of total	(95% CI)
Midwife
1–2 days	7	(8.5%)	(4.1, 17.0)	4	(6.1%)	(2.3, 15.3)
3–4 days	49	(59.8%)	(48.7, 69.9)	36	(54.5%)	(42.3, 66.3)
5–6 days	26	(31.7%)	(22.5, 42.7)	21	(31.8%)	(21.6, 44.2)
mixed	-	-	-	5	(7.6%)	(3.1, 17.2)
Maternity support worker
1–2 days	49	(59.8%)	(48.7, 69.9)	35	(53.0%)	(40.8, 64.9)
3–4 days	26	(31.7%)	(22.5, 42.7)	20	(30.3%)	(20.3, 42.6)
5–6 days	3	(3.7%)	(1.2, 10.9)	3	(4.5%)	(1.4, 13.4)
I don’t know	1	(1.2%)	(0.2, 8.4)
mixed	-	-	-	6	(9.1%)	(4.1, 19.0)
missing	3	(3.7%)	(1.2, 10.9)	2	(3.0%)	(0.7, 11.6)
Obstetrician
1–2 days	42	(51.2%)	(40.4, 62.0)	31	(47.0%)	(35.1, 59.2)
3–4 days	32	(39.0%)	(29.0, 50.1)	24	(36.4%)	(25.5, 48.8)
5–6 days	2	(2.4%)	(0.6, 9.4)
I don’t know	3	(3.7%)	(1.2, 10.9)	2	(3.0%)	(0.7, 11.6)
mixed	-	-	-	7	(10.6%)	(5.1, 20.9)
missing	3	(3.7%)	(1.2, 10.9)	2	(3.0%)	(0.7, 11.6)
Anesthetist
1–2 days	74	(90.2%)	(81.5, 95.1)	58	(87.9%)	(77.3, 93.9)
3–4 days	2	(2.4%)	(0.6, 9.4)	1	(1.5%)	(0.2, 10.3)
I don’t know	3	(3.7%)	(1.2, 10.9)	2	(3.0%)	(0.7, 11.6)
mixed	-	-	-	3	(4.5%)	(1.4, 13.4)
missing	3	(3.7%)	(1.2, 10.9)	2	(3.0%)	(0.7, 11.6)
Neonatologist
1–2 days	40	(48.8%)	(38.0, 59.6)	30	(45.5%)	(33.7, 57.7)
3–4 days	3	(3.7%)	(1.2, 10.9)	2	(3.0%)	(0.7, 11.6)
7–8 days	1	(1.2%)	(0.2, 8.4)	-	-	-
I don’t know	33	(40.2%)	(30.1, 51.3)	25	(37.9%)	(26.9, 50.3)
mixed	-	-	-	7	(10.6%)	(5.1, 20.9)
missing	5	(6.1%)	(2.5, 14.0)	2	(3.0%)	(0.7, 11.6)
Neonatal nurse
1–2 days	40	(48.8%)	(38.0, 59.6)	29	(43.9%)	(32.3, 56.3)
3–4 days	3	(3.7%)	(1.2, 10.9)	2	(3.0%)	(0.7, 11.6)
7–8 days	1	(1.2%)	(0.2, 8.4)	-	-	-
I don’t know	34	(41.5%)	(31.2, 52.5)	27	(40.9%)	(29.6, 53.3)
mixed	-	-	-	6	(9.1%)	(4.1, 19.0)
missing	4	(4.9%)	(1.8, 12.5)	2	(3.0%)	(0.7, 11.6)

The CCF recommends multi-professional emergency training include psychological safety, civility, human factors and escalation process education. Whilst civility (80.5%), human factors (85.4%) and escalation processes (90.3%) are reported included widely in training, only 68.4% of respondents agreed that psychological safety training was included (Table 6).

Table 6.

Inclusion of safety elements with multi-professional emergency training

	N out of 82	Percentage of total	(95% CI)
Psychological safety
I disagree	1	(1.2%)	(0.2, 8.4)
I somewhat disagree	4	(4.9%)	(1.8, 12.5)
I neither agree nor disagree	1	(1.2%)	(0.2, 8.4)
I somewhat agree	20	(24.4%)	(16.2, 35.0)
I agree	56	(68.3%)	(57.3, 77.5)
Civility training
I disagree	1	(1.2%)	(0.2, 8.4)
I somewhat disagree	1	(1.2%)	(0.2, 8.4)
I somewhat agree	14	(17.1%)	(10.3, 27.0)
I agree	66	(80.5%)	(70.3, 87.8)
Human factors
I somewhat disagree	1	(1.2%)	(0.2, 8.4)
I somewhat agree	11	(13.4%)	(7.5, 22.8)
I agree	70	(85.4%)	(75.8, 91.6)
Escalation process
I neither agree nor disagree	2	(2.4%)	(0.6, 9.4)
I somewhat agree	6	(7.3%)	(3.3, 15.5)
I agree	74	(90.2%)	(81.5, 95.1)

Shared learning across the local maternity and neonatal system

Of the 82 respondents 73 (89%) reported they incorporated shared learning from across their local maternity and neonatal system into their training (Table 2). When analysed by Trusts 87.9% (77.3–93.9 95% CI) incorporated shared learning. Examples of shared learning include observing partner Trusts training, the sharing of training materials and trainers with specific expertise. However, only 30/73 (41.1%) of respondents thought the shared learning was meaningful and 33/73 (45.1%) thought it was of good quality (Table 3).

Qualitative analysis found some evidence that implementers were using regional maternity and neonatal networks and national forums to support the implementation of shared learning. However, respondents described the challenges in implementing shared learning due to differences in identified needs across the network:

There is more work to do in this - but as each Trust has different learning priorities and guidelines …. It can be challenging as the focus can be different at different points. (Participant number: 57)

Resource issues associated with implementing the core competency framework

Thematic analysis of the qualitative data found resourcing of training challenging which included issues with physical infrastructure within the hospital, such as not having enough space to run teaching sessions and lack of appropriate equipment. The lack of sufficient funding for the CCF was also highlighted in the survey with reports of staff having to complete Trust mandated training in their own time.

Increased time required to attend training but sadly not supported and expected to complete a large portion in own time. Additionally, supplies to provide training is lacking.” (Participant number: 80)

The volume of training required has increased beyond our staffing uplift allocated for study leave and training. With the financial pressures within the NHS at present, increasing that uplift to incorporate further training is putting Trusts under huge strain and pressure to comply with the Core Competency and safety training. (Participant number: 9)

There were also resource issues in terms of insufficient staffing. Hospitals were challenged with not enough staff to cover both clinical care and training:

Staffing shortages difficult to allocate staff to training. Very large groups to train and makes learning environment not effective. Very little access to rooms for training, no adequate training facility venues, not appropriate for training” (Participant number: 2)

Discussion

The findings of this study show that organisational leads implementing the CCF within maternity and neonatal units broadly consider the framework to be acceptable and appropriate, that is, they considered it to be satisfactory and perceived that it addresses training needs, but not always feasible to implement in practice. Only around half of the respondents felt management adequately supported efforts to implement the CCF which has likely impacted on the feasibility of delivering the training framework. Further findings show that there were insufficient staffing levels to support training attendance and that a significant barrier to supporting the implementation of the CCF was a lack of appropriate resourcing, including financial resourcing. The Health Select Committee supported implementation of the Ockenden national training recommendations adopted via the CCF [4]. The Department of Health and Social Care invested an additional £95.9 m into maternity and neonatal services (2021–22) of which £80 m was distributed as a targeted System Development Funding [26]. The Local Maternity and Neonatal System were given budgetary oversight, however the extent to which funds were ringfenced for CCF training, including sufficient staffing levels to facilitate training at Trust level is unclear. The impact of reduced funding in the 2024–2025 budget on maternity and neonatal training is yet to be established. [27]. Survey respondents reported that the cost of delivering the three modules covered by the Maternity Incentive Scheme was prioritised, thus deprioritising delivery of the remaining modules – an unintended policy consequence. The financial incentive structures around MIS delivery therefore shaped partial implementation of the CCF. The extent to which issues around the feasibility of delivering the CCF impacts on its effectiveness as an intervention requires further investigation.

This study has found that if a multi-professional education team was in place within a Trust, it tended to comprise a core team of professionals including a practice development midwife, consultant obstetrician and consultant anaesthetist. The minimal involvement of neonatology teams was notable. Neonatologists were seldom cited as members of the multi-professional education team and neonatal service user involvement was poorly embedded. The lack of data around the number of days training the neonatal team received indicates this framework may not be being adopted by neonatal services alongside maternity services which requires further investigation. Around a third of Trusts included in the survey did not have a multi-professional education team in place, in those with a MET only half of respondents felt the MET had a shared understanding in relation to training with qualitative responses suggesting a culture whereby the planning and responsibility of the CCF is inevitably left to the midwives. The extent to which the absence of METs and a shared understanding within METs impact on the effectiveness of CCF training requires further investigation.

The misalignment between the number of days of training midwives receive (3–6 days) compared with doctors (1–2 days), suggests that Trusts and possibly professional groups do not view the entirety of the CCF as necessary for the multi-professional team. Reports by Ockenden [2] and Kirkup [1] commented on the presence of a ‘them and us’ culture between midwifery and obstetric staff, and the fact that training in silos still exists demonstrates a lack of psychological safety in the NHS workplace [1, 2]. The recent national review of maternity services in England also recognised poor relationships between obstetric and midwifery teams which affect the safety of some maternity services [5]. Relatedly, our results show that psychological safety was not embedded into multi-professional training to the same extent as other aspects of emergency training. Building psychological safety in teams is now widely recognised in health settings as being critical to fostering cultures in which staff can speak up to admit errors, question, and suggest ideas for change, free from recrimination, that ultimately improves patient care and safety [28].

One of the safety actions under the Maternity Incentive Scheme is that there is dedicated time allocated for a lead obstetrician to teach fetal surveillance [7]. However, there are no other such mandated requirements for the CCF which may hinder Trusts attempt to embed a diverse multi-professional education team and engender a collaborative multi-professional culture. In addition, the CCF itself does not define or go into detail regarding what multi-professional team training should comprise. Given that multi-professional team training has multiple definitions such as ‘individuals drawn from different disciplines’ [29] and ‘a group of professionals from one or more clinical disciplines’ [3], using the words ‘multi-disciplinary team training’ within the CCF may lend itself to confusion, ambiguity and variation. As such survey data reporting the occurrence of multi-professional team training should be treated with a degree of caution. Nonetheless, inequities in professional training, evidenced by the disparities in the planning or attendance of training reveal a concerning trend. Liberati et al. [16] found that one of the features of high-performing (safe) maternity units was staff learning together across disciplines to produce competence across teams, in turn providing, “an ethos of collective endeavour and mutual respect across roles and disciplines” (p.66). When disparities exist between professions in the planning and attendance of training, the potential of the CCF to achieve its ambition of reducing harm across maternity and neonatal units is severely restrained: the ability of multiple professions to work collectively, particularly between midwives and obstetricians, is restrained without opportunities to train together, failing to address hierarchies and ultimately impacting the safety of maternity and neonatal service users. Greater detail may be warranted with regards to the attendance of multi-professional team members at each CCF module.

Despite being one of the four key underpinning principles, service user involvement in the planning and delivery of the CCF is not well adopted across the NHS in England. Our survey found many Trusts were not involving maternity and service users in their training and where they were Trusts mainly relied on indirect service user voices such as patient feedback forms and risk incidents. This is despite evidence that direct service user input can improve outcomes including clinical reasoning, communication skills and empathy [30]. Further, whilst NHS England considers indirect service user voices to form part of service user involvement, it also recommends that involving MNVP team members in designing and delivering CCF modules can ensure that service user voices are deeply embedded within the CCF [9]. The underlying reasons for the lack of involvement of service users in the development and implementation of training is not known, although across healthcare facilities barriers to service user involvement include power differences between healthcare professionals and those in a lay capacity. However, inconsistency in Maternity and Neonatal Voice Partnership resourcing has been identified as a challenge for its functioning [31]. The shortage of resources, user concerns about voicing negative attitudes, and a resistance from healthcare professionals are also cited barriers [13, 31]. Additionally, organisations may choose just one or two ‘appropriate’ representatives and exclude service users from minority ethnic populations who may have more complex lived experiences [13, 15]. Using an evidence-based framework [32] or employing key principles for Patient and Public Involvement engagement [13] may better enable service user involvement in developing and delivering training as set out in the framework.

The results showing that shared learning across Local Maternity and Neonatal Systems (LMNS) was being incorporated in training in most of the Trusts, yet with low levels of meaningfulness and quality indicates the need for further work in this area. A key function of an LMNS is to bring together regional leads working in maternity and neonatal services to drive strategic change, focusing on, among other things, improvements in safety and quality of services. However, the fact that many respondents did not find value in the incorporation of shared learning, citing different local learning priorities and guidelines within the same network, draws attention to the need for further investigation into the extent to which LMNSs are the most appropriate structure to facilitate shared learning that can be embedded in local CCF training. Further investigation can help to uncover the mechanisms at play within LMNSs that either foster or stymie true collaboration. Martin and Dixon-Woods [33] point out that the existence of networks does not automatically lead to meaningful collaboration and that managed clinical networks can quickly shift from a focus on education to becoming performance driven. The conceptual framework of Communities of Practice, where learning is a social activity, is supportive of improving patient safety and includes elements such as a shared interest, mutual engagement, and shared repertoire may foster greater shared learning efforts [34], may be a structure better suited for this purpose.

Strengths and limitations

This paper reports on the first national survey of multi-professional maternity and neonatal training in England. It provides insights into the implementation of a national programme to improve the organisation of post-registration training. These results can be applied to other countries looking to design and implement a similar national training plan. The results of the survey have been strengthened by using validated scales [21, 23].

The survey contained 82 completed responses covering 66 NHS Trusts across England (57% response rate). The findings do not therefore represent the views of all lead implementers, nor do they establish the extent to which the CCF has been adopted across all of England’s maternity and neonatal units. We acknowledge that surveys are by nature self-selecting which will have introduced self-reporting bias, influencing our survey findings [35]. Whilst the survey had good representation across the English regions, improving the generalisability of the findings, some regions were under-represented in responses which may have limited our insights into regional variation. A further limitation is that by targeting this survey at lead implementers of the CCF only, the findings offer insights from the perspectives of a single group only – other professionals involved in planning or implementing the CCF or those who receive CCF training may have varying perspectives and opinions on it. Following pilot testing feedback, only one item out of four were selected from Weiner’s three implementation measures. Although chosen for their discriminant content validity, the single item approach prevented reliability (Cronbach’s alpha) assessment. Additionally, this survey captured data at only one specific time-point and therefore does not provide any insight into how implementation of the CCF changes over time. Finally, we recognise that this survey cannot provide any evidence to link training with improved outcomes. Additional quantitative and ethnographic research is being undertaken by the study team in seven maternity and neonatal units across England with which this survey data will be integrated to provide greater in-depth analysis and understanding of the implementation of the CCF across England.

Implications for policy and further research

There is a mismatch between the policy initiative to roll out the CCF and the reality of implementing this policy – introducing national multi-professional training standards without providing the necessary structures in place to support has led to only a partial adoption of the CCF. It is imperative that there is adequate aligned funding and workforce capacity resourcing to support implementation. Furthermore, unlike MIS compliance that is enforced through a range of measures such as financial penalties and refunds for Trusts, there is no such enforcement of the CCF. The resourcing of the CCF was identified as a pressing issue for those working to deliver it in England’s NHS Trusts. The substantial reduction in maternity and neonatal funding and the removal of its ringfencing [27] is likely to create further challenges in addressing the immediate and essential actions to deliver multi-professional training set out in the Ockenden report [2]. The planned second survey and mixed method research being carried out as part of the wider Core Study is likely to capture the impact of these changes. The ongoing research will also seek to understand in more detail the barriers and facilitators to implementing the CFF including establishing a multi-professional education team and embedding service users in these teams as well as delivering multi-professional training. The role of the Local Maternity and Neonatal System in the delivery of effective CCF training will also be investigated. Finally, the study will identify local level implementation strategies that have improved maternal and neonatal outcomes to inform future national training strategies.

Conclusion

The CCF is considered by MET leads to broadly speaking be a helpful means of addressing multi-professional training needs across maternity and neonatal services but is inadequately resourced and incentivised to be fully implemented in practice. There remains variation in the implementation of multi-professional education teams, the number of days of training available to professionals and involvement of service users across England’s NHS Trusts. The survey identified insufficient resources and staffing to deliver the framework effectively. Further research is required to establish the impact of the framework on maternal and neonatal care and the barriers and facilitators to its implementation in different contexts.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

CCF

Core competency framework

NHS

National health service

NIHR

National institute for health and care research

NMC

Nursing and midwifery council

Author contributions

RW, GR, JD, SA, HB, SB, MP, TA, SG, GZ all contributed to the original NIHR HS& DR research grant application and have therefore made substantial contributions to the conception and design of the work. SG, JD and RW designed the survey, SG conducted the survey with analysis from SG, RW SC and JD. All authors reviewed and revised the manuscript.

Funding

This study has been funded through Health and Social Care Delivery grant awarded by the National Institute of Health and Care Research, [NIHR159486] and is sponsored by King’s College London.

Data availability

All data will be stored securely on a password protected computer within the research data repository at Kings College London for five years. The datasets generated and/or analysed during the current study are not publicly available because this survey is part of a wider ongoing study but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by HRA Northwest – Greater Manchester East Research Ethics Committee & HCRW (IRAS project ID: 337557; REC reference: 24/NW/0384). Participants were informed of their right to withdraw at any time without reprisal.

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.