NHS Resolution’s Maternity (Perinatal) Incentive Scheme found to strengthen Board engagement with safety

NHS Resolution has published an evaluation of the Maternity (Perinatal) Incentive Scheme (MIS), covering the first six years of operation from 2018 to 2024. The evaluation provides an assessment of the scheme’s contribution to maternity and neonatal safety across England.

Published alongside the evaluation are the MIS Year 8 Core standards and Supplementary guidance, which incorporates a transitional reset informed directly by the evaluation findings and feedback from NHS trusts and system partners.

MIS was established by NHS Resolution in 2017 to incentivise improvements in maternity and neonatal safety and care across NHS trusts in England, in line with government ambitions and priorities. It offers a financial incentive for trusts that demonstrate they have implemented a set of core safety actions, agreed and refined, in collaboration across the health system. Trusts contribute an additional 10% on top of their Clinical Negligence Scheme for Trusts (CNST) maternity contribution. Those achieving compliance with all safety actions receive their contribution back, along with a share of any unallocated funds. The scheme aims to address the significant human, clinical and financial impacts of avoidable harm in maternity and neonatal services.

The evaluation has been augmented by independent mixed-methods analysis undertaken by experts at The Healthcare Improvement Studies Institute (THIS Institute) at the University of Cambridge. The research combined quantitative analysis of scheme data with qualitative research based on interviews with stakeholders, including national bodies, and those working locally to deliver services including: NHS trust staff, integrated care boards, Local Maternity and Neonatal Systems, and Maternity and Neonatal Voices Partnerships.

Key findings

Strengthened Board engagement and prioritisation: The scheme has been effective in strengthening Board engagement with maternity and neonatal safety. The financial incentive raised the profile of safety at trust Board level and provided leverage for staff to secure resources and prioritise safety improvements. Stakeholders reported that without MIS, maternity and neonatal safety might not receive the same visibility at Board.

Improved compliance with safety standards: Compliance with the 10 safety actions has steadily improved over time, rising significantly from 53% of trusts in year one to 84% in year six. The scheme has enhanced compliance with safety standards and practices led by system partners (such as the Perinatal Mortality Review Tool), which are expected to support better outcomes over time.

Supporting national programmes: MIS has reinforced national maternity and neonatal safety priorities and supported implementation of key programmes including Avoiding Term Admissions into Neonatal Units (ATAIN) and the Saving Babies’ Lives Care Bundle (SBLCB). By consolidating requirements into 10 standardised safety actions, MIS has helped trusts focus efforts and reduce confusion from competing recommendations.

Enhanced assurance processes: The introduction of external verification for Safety Actions 1 (National Perinatal Mortality Review Tool (PMRT)), 2 (Maternity Services Data Set (MSDS)) and 10 (Reporting to MNSI and Early Notification Scheme), along with the reverification framework, has strengthened the credibility of the scheme. Over time, there has been a reduction in the volume of downgrades following reverification, indicating improved understanding of requirements, more effective local governance and more accurate declarations.

Supporting local improvements: The opportunity to apply for discretionary funding is an important element of MIS to help reduce a widening gap between ‘high performing’ trusts and those needing more support.

This evaluation demonstrates MIS’s valuable role in raising the profile of maternity and neonatal safety at Board level and supporting implementation of evidence-based safety practices. While directly attributing safety outcomes to individual actions remains complex, the scheme has strengthened Board engagement, reinforced national priorities, and supported NHS staff with their local business cases for improvements.

We are committed to evidence-based, data-driven decision-making, and this evaluation is an important step in ensuring MIS continues to add value. The transitional changes in year eight reflect our commitment to reducing administrative burden on the frontline while maintaining robust assurance, bringing a greater focus on supporting outcomes rather than process, and remaining responsive to the evolving maternity and neonatal landscape.

Megan Bidder, Director of Safety & Learning and Chair of the MIS Collaborative Advisory Group, NHS Resolution

Evaluating improvement programmes in healthcare is essential, enabling the system to identify what is working, what needs to change, and where best to concentrate efforts and resources. NHS Resolution’s commissioning of an independent rigorous evaluation of the Maternity Incentive Scheme is therefore very welcome. It’s great to see NHS Resolution’s commitment to engaging openly with these findings and listening carefully to feedback. The willingness to use the findings of the evaluation to inform the future direction of the scheme reflects the kind of learning culture that sustained improvement will require.

Professor Mary Dixon-Woods, Director of THIS Institute and Health Foundation Professor of Healthcare Improvement Studies at the University of Cambridge

Understanding impact on outcomes

As widely reported, it is challenging to directly attribute improvements in maternity and neonatal safety to individual initiatives. Safety results from numerous interconnected, system-wide efforts including transformation programmes, workforce development, technological advances, and collaboration across sectors. Despite this complexity, the evaluation identified some correlation, although not a statistically significant relationship, between MIS compliance and external trends such as stillbirth and neonatal death rates. This was primarily due to high overall compliance and limited data variability. While data limitations have made establishing direct causality between MIS compliance and improved clinical outcomes challenging (which is as expected), overall the scheme appears to have contributed effectively to system-wide efforts to enhance perinatal safety and quality.

During the period since the announcement of the National Halve-it Ambition in 2015, which is broadly synchronous with MIS operation, some national indicators have shown positive trends:

• Perinatal mortality rates in England have declined
• Neonatal admissions for term babies have reduced
• There has been modest improvement in maternity workforce stability
• In 2023, there were 1,500 fewer families experiencing stillbirth and neonatal death compared to 2013

However, areas of concern remain, including limited improvement in hypoxic ischaemic encephalopathy rates (noting recent data reporting a fall in reported cases to MNSI[1]), with too much unexplained variation at unit level, and longstanding inequalities in outcomes by ethnicity and socioeconomic status. The wider challenges within maternity and neonatal safety have been recognised through the establishment of the National Maternity and Neonatal Investigation and National Maternity and Neonatal Taskforce, which will report during Year 8 of MIS and will inform further scheme developments over time.

Addressing administrative burden
Feedback from earlier years of the scheme indicated that the growing complexity of requirements had been challenging for trusts. In response, the number of MIS sub-actions was substantially reduced from 155 in year 5, to 84 in year 6, focusing on those agreed by system stakeholders to add the most value. This change was well received and has helped mitigate unintended consequences identified in the research, such as increased reporting burden. Additional streamlining for year 8 will result in a further reduction to 36 sub-actions.

Regional patterns
The evaluation identified some regional variation in MIS compliance. However, trust size (by birth rate) and financial contribution were not associated with MIS compliance, suggesting that all trusts, regardless of their size or financial contribution to the scheme, have an equal opportunity to meet the core safety actions.

Downloads

• MIS evaluation report (in full)
• MIS evaluation ‘at a glance’ summary
• THIS Institute quantitative analysis
• THIS Institute qualitative evaluation
• MIS Year 8 Core standards
• MIS Year 8 Supplementary guidance

For more information about the Maternity (Perinatal) Incentive Scheme, visit our Maternity Incentive Scheme homepage.

Notes to editors:

1. NHSR administers MIS on behalf of the Secretary of State of Health and Social Care under powers associated with its administration of the Clinical Negligence Scheme for Trusts, and specifically Section 5 of the Safety and Learning Directions of 2019 – which direct NHSR to take appropriate steps to encourage parties indemnified under any of its schemes to ‘improve the quality and safety of services provided’. Section 5(2) indicates that one such step ‘may include the provision of a financial incentive’.
2. The evaluation covers MIS years one to six (January 2018 to March 2025). Year seven was still underway at the time of drafting publication and results for year seven will be published in April 2026.
3. The Collaborative Advisory Group (CAG) was expanded in year five to include fuller representation of the patient and service user voice, and was further updated in ear seven to formalise participation of a broader range of organisations.
4. In 2024/25, 51% (£2.5 billion) of the total clinical negligence cost of harm (£4.9 billion) related to maternity.
5. The Healthcare Improvement Studies Institute (THIS Institute) is based at the University of Cambridge and conducts independent research into healthcare quality and safety improvement.
6. ATAIN (Avoiding Term Admissions into Neonatal Units) is a quality improvement programme aimed at reducing admissions of term babies to neonatal units. The Saving Babies’ Lives Care Bundle is an evidence-based package of care designed to tackle stillbirth and early neonatal death.

About the MIS
MIS was established by NHS Resolution in 2017 to incentivise improvements in maternity and neonatal safety across NHS trusts in England. The scheme offers a financial incentive for trusts that demonstrate they have implemented a set of core safety actions, defined at system level through the CAG, which brings together national maternity and neonatal system partners including DHSC, arm’s length bodies, Royal Colleges, professional bodies, and service user representatives.

MIS Year 8: Transitional changes
The findings of this evaluation have informed the development of MIS Year 8 (April 2026 to March 2027), which will serve as a transitional year.

Year 8 Reset
Year 8 of the Maternity (Perinatal) Incentive Scheme has been redesigned following extensive engagement with the CAG, provider organisations, regional maternity teams and senior national nursing and midwifery leaders. Feedback from the MIS evaluation highlighted that the scheme have shaped changes to the scheme for Year 8, which have been co-designed with support of the cross-system CAG and tested at regional level.

Key changes introduced in Year 8

• Streamlined structure: Safety Actions reduced from ten to six, consolidating overlapping requirements and removing unnecessary prescription. Sub-actions have been significantly reduced.
• Outcome focused standards: Clearer expectations centred on core themes – workforce and capacity, training, learning from investigations, clinical care bundles, service user voice and equity, and Board level governance.
• Greater flexibility for trusts: Operational detail has been moved to supportive guidance, enabling trusts to demonstrate compliance in ways suited to local population needs and governance arrangements.
• Strengthened governance and accountability: More equitable routes for evidencing compliance, alongside clearer Board responsibility for oversight and improvement.
• Updated assurance model: A proportionate assurance approach is proposed for Year 8.

Overall impact
These changes represent a strategic reset of the MIS. The revised scheme aims to maintain rigour while increasing feasibility, transparency and impact, and establishes a more agile platform for further development in Year 9 and beyond.

Looking ahead
Future scheme development will align with findings from the National Maternity and Neonatal Investigation and the National Maternity and Neonatal Taskforce, both expected in 2026. MIS will continue to evolve, informed by stakeholder feedback and emerging national priorities, to sustain progress and address ongoing challenges in maternity and neonatal care.

[1] MNSI data show a fall in reported cases of HIE in England