Mixed-methods evaluation of the Maternity and Neonatal Independent Senior Advocate (MNISA) pilot in England

The MNISA role was introduced by NHS England in 2023 in response to an Immediate and Essential Action in the independent Ockenden Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust (2022). The role was established to ensure “families’ voices are heard, listened to and acted upon” following adverse outcomes such as the death or serious injury of a baby or the mother during NHS care. 

MNISAs were piloted across 16 Integrated Care Boards (ICBs) to offer independent support and advocacy for families, aiming to amplify their voices, navigate complex systems, and promote learning and system-wide change.

This independent mixed-methods evaluation was conducted from October 2024 to June 2025 by the NIHR Rapid Service Evaluation Team (RSET). It aimed to assess the implementation, impact, and value of the role. The evaluation included interviews with families, MNISAs, and staff at Trust, regional and national level; documentary analysis; a national MNISA survey; and analyses of costs and budget impacts and caseload data.

Findings

• Families overwhelmingly valued the MNISA role, describing it as instrumental in feeling heard and supported, particularly during distressing investigations  and reviews. Independence from the hospital where the adverse outcome happened was key to fostering trust. MNISAs provided practical and emotional (empathetic and parent-centred approach) support, facilitated communication with services, and enabled families to move forward psychologically. Families strongly advocated for the continuation of the role and expressed concern about the absence of similar support for those outside the pilot.

• Staff recognised the MNISA role as valuable for supporting families, improving communication, and enhancing system responsiveness. Challenges noted included concerns about role duplication, lack of clarity in the scope and boundaries of the role, and additional demands on governance and clinical teams. Access challenges were described, especially for non-English speakers, and some eligible families were unaware of the service or unable to engage due to trauma or process barriers.

  Caseload

• The MNISA caseload is only a proportion of all families experiencing eligible adverse outcomes within the Trusts to which they are connected. For example, MNISAs’ support was requested for around 18% of all neonatal deaths and stillbirths.
• The caseload is weighted towards families from less deprived areas and where the mother is of white ethnicity.

• There is no clear relationship with the age of the mother and the likelihood of a family being taken on as a case.

  Costs

• On the assumption that all eligible adverse outcomes (approximately 7,154 in 2023) receive MNISA support, based on the same delivery model as the pilot, the total one-year budget impact would be £41.8m (477 MNISAs, receiving a maximum assumed annual caseload of 15 referrals each), at a total cost of £5,841 per referral (SD £1,383).
• Employing 100 MNISAs across England could cover approximately 21% of all families experiencing an eligible adverse outcome, with a one-year budget impact of £8.7m.

Areas for consideration for future implementation

Access: Removing variation in families' access to the service 

Ensure universal and equitable access through standardised referral pathways, multilingual and accessible materials, and repeated offers of support in a variety of formats. It is recommended to better consider how best to support families not currently accessing the service, particularly those from ethnic minorities, to prevent existing inequalities being widened further.

Role: Clarifying the scope of the role

Develop and clarify a national MNISA job description, with mandatory training requirements (e.g. clinical literacy, advanced safeguarding, professional advocacy), and boundaries to distinguish from related roles and ensure effective collaboration.

Service: Clarifying the scope of the service 

Provide national-level guidance on service parameters, national communication to help foster a receptive culture for change and visibly embed the role in local systems while protecting its independence.

Change: Embedding robust and sustainable wider change

Create formal mechanisms for the insights gathered by MNISAs (individually and collectively) on areas for improvement to be acted on by the system.

• There is uncertainty around MNISA caseload capacity and therefore the total budget impact (which assumed 15 caseload) due to a lack of data on the distribution of MNISA case mix and duration of support. Further review is recommended to understand relationships and remove overlaps with similar existing roles to prevent duplication, and whether MNISAs should be a national resource distributed by need or equally distributed across ICBs.
• The MNISA role has demonstrated early value to families and services but requires strengthened infrastructure, clearer definition, and more consistent integration into local and national systems to achieve its full potential. Future evaluation should focus on long-term outcomes, including equity of access, safety and quality of care, and sustained system learning.
• In light of the recent government announcement on 23rd June 2025 of a national investigation and Taskforce to drive urgent improvements to the safety of maternity and neonatal care, these evaluation findings indicate the MNISA service is uniquely placed to make a valuable contribution to enabling families' voices to be heard, and their concerns acted upon.

Read the full slide set report for further detail