Making Modern Service Frameworks: methodology, methods and transparency - a view from maternity

By Catherine Williams, on behalf of the AIMS Campaigns Team

Introduction: the Amos Review and the prospect of a Modern Service Framework for maternity

The recommendations of the Maternity and Neonatal Service Review chaired by Baroness Amos (‘the Amos Review’) include (pp.17–19) the creation of a ‘modern service framework’ (MSF) which sets out new national standards for maternity care ‘developed in collaboration with women, families, staff and experts’ with the goal of achieving high quality maternity and neonatal care.¹

The report specifies that there must be "a set of unified national standards for clinical, professional and operational guidance for maternity and neonatal services... This must be developed in partnership with national professional organisations, including the National Institute for Health and Care Excellence (NICE), Royal Colleges and professional bodies".

A Maternity and Neonatal Taskforce² has been set up to create a new national action plan based on the findings of the Amos Review, which is expected in December 2026. While a letter from the NHS CEO to NHS organisations on 1 July 2026 did not state explicitly that a Maternity MSF would be created, saying only that ‘operational guidance’ is coming, published Taskforce minutes confirm that an MSF for Maternity and Neonatal Services will be part of the new action plan.

This article explores what an MSF is, whether ‘how’ they are made and ‘who’ makes them is clear (it isn’t), and what we can learn from the National Service Frameworks (‘NSFs’) of the early 2010s, a model which they ‘modernise’. Focusing on my area of interest, maternity care, I call for transparency about methodology and methods (and about who is involved and why) when NHS England acting as a regulator³ of the NHS, here as joint publisher with the government, specifies and publishes (actual or de facto) mandatory⁴ clinical, professional and operational standards for the NHS - standards against which NHS England, the Care Quality Commission and other regulators will be assessing quality of care.

What is a Modern Service Framework?

The promise of MSFs to come is made in Fit for the Future, the government's 10-year health plan for England (‘the 10-Year Plan’)⁵ . Explicitly referencing the National Service Frameworks (NSFs) published between 1997 and 2010⁶, described as ‘a clinically led and authoritative tool that supported sustained improvement to major condition outcomes, including by narrowing inequality and reducing unwarranted variation’, the government promises a new wave of MSFs ‘which are accessible and transparent to all’.

Each MSF will define ‘an aspirational, long term outcome goal’, specify interventions supported by the best evidence of likely success while driving up value and equity, and set standards for use of the interventions along with a clear implementation and oversight strategy.

A new feature (compared to the old NSFs) is the specification of ‘challenge areas’ in care in which NHS England believes significant progress will be possible if innovative interventions are developed.

Transparency claims and the two first MSFs

With the 10-Year Plan commitment to the NHS being the most transparent healthcare system in the world, recently repeated in the new NHS Quality Strategy⁷, we might expect clarity about how clinical standards and related policy guidance are made. The first couple of MSFs published, however, do not demonstrate this. Both are jointly published by NHS England and Department of Health and Social Care (DHSC).

Turning to the MSF Cardiovascular Disease⁸ (‘CVD MSF’)(Annex C, p.70), I see terms of reference for a task and finish group whose chairs and members are listed. It is stated that "the task and finish group will help to shape a national CVD MSF for NQB [National Quality Board] and ministerial consideration and approval. Co chairs will oversee the framework and any supporting documentation to be written and managed by DHSC and NHS England officials." No detailed explanation is given about how 'best' available evidence’ (p.71) to inform the MSF is defined, how evidence was selected and used, nor how advice was weighted.

The CVD MSF states (p.49) that it "establishes a clear set of evidence based national priorities, standards and metrics which form the basis of system oversight and accountability." But it is not clear exactly who made the priorities, on what basis, or how the standards and metrics were decided.

The new MSF for sepsis⁹ is currently available only as web pages (possibly a pdf version will follow, with details of ‘how it was made’ included in that). There is nothing at all to say who wrote this MSF nor how it was made. (Information online indicates that Dr Ron Daniels of the UK Sepsis Trust sat on a steering committee, but that is the only information I have been able to find.¹⁰) Hardly a case of transparency.

Looking back: National Service Frameworks (1997–2010)

Do the earlier National Service Frameworks (NSFs) provide a model of clear method, explanation, and evidence use? (These were made by DHSC before NHS England became a non-departmental public body in 2013.) Depressingly, having reviewed eight NSFs, the answer is largely, ‘No’.

With the exception of the 2001 NSF for older people’s services¹¹, which sets out a plausible (if sketchy) method and lists members of an Expert Reference Group (ERG), the NSFs I have reviewed vary from

• saying nothing about how they were made, to
• listing some values and principles, without explaining exactly how the final document was arrived at.

(Rather fun to come across the present Archbishop of Canterbury, Sarah Mullally, in several documents in her capacity - back then - as Chief Nurse.)

The older people’s NSF is encouraging as a model of ‘making a service framework’, which might be adapted and improved on today, because it sets out explicit ‘parameters’ for setting standards. These parameters are ‘current policy’, available resources, value for money, and the need to be "evidence based where possible, or if not to be based on the consensus of best clinical practice". A typology (quality/status grading system) for evidence is set out (one was also used in the NSF for mental health in 1999).^{12, 13}

What about maternity? The NSF Children, Young People and Maternity (2004) is documented in several parts, with different ERGs for different sections. The Standard 11 (Maternity)¹⁴ expert reference group is listed at the end of the relevant document but not mentioned in the contents list. There is no explanation of how the standards statements in it were written. Which leads me to reflect on how naïve I was when I first read that standard back in 2004 - about the questions one should ask about who is making national standards, precisely how, and with what parameters.

From innocence to experience – learning about policy making

It was in 2004 that I joined a Maternity Services Liaison Committee¹⁵ as a service user rep, baby in my arms, and read NSF Standard 11 (Maternity) with enthusiasm. Only later, working in a regulator’s policy team, did I begin to think about the mechanics of government and (in contrast) regulator-level policy making.

Training briefly with the Civil Service Fast Stream as an external student sent along by the regulator I worked for, in 2008, I discovered that young civil servants spent lots of time on ‘stakeholder mapping’ and creative exercises involving many post-its and pictures cut from magazines.¹⁶ This puzzled me as a regulatory policy professional used to thinking at every turn in terms of field-defining legislation, codes of conduct, evidence suitable to inform institutional decision-making, and the need to reference these parameters in my everyday work shaping and documenting that decision-making.

Later, as a formally qualified group facilitator involved in co-production in health and social care, I came to value creative working methods. But I also became deeply committed to the NHS being guided by the best available research evidence, particularly in maternity care.

The idea that national quality standards in maternity could be written without a clear method setting out step-by-step how the drafting would proceed, who would be doing it, and making explicit reference to women’s legal rights, the Equality Act 2010, the ethical duties of healthcare professionals, and evidence in the form of NICE guidance would worry me greatly.

Looking forward: what do we know about how MSFs are made?

Not much, at the moment. While NSFs were purely government-made policy guidance, MSFs will (while NHS England, slated for abolition, still exists) be made, it seems, jointly by DHSC with an ‘arm’s length’ public body, which is formally a regulator for providers of NHS services, able to set and enforce service standards.¹⁷

We should therefore expect to see, given the current bold policy commitments to transparency and quality in relation to the NHS, a ‘boundaried’ process in which a clear methodology and methods statement sets out the parameters for the making of each framework with reference to relevant law, government policy, use of evidence, and step-by-step exactly how it was developed and written.

The NHS England Medium Term Planning Framework¹⁸ for 2026 to 2029 says that "The criteria and methodology [for making MSFs] are being tested through the development of a first set of 3 MSFs, focused on CVD, serious mental illness and sepsis, with further MSFs on dementia and frailty to follow. Task and finish groups are being set up for each, and the frameworks will be co-designed in partnership with clinicians, people with lived experience and system partners." [emphasis added]

Key questions remain unanswered, particularly as we consider the Maternity and Neonatal Services MSF in prospect:

• what is the methodological approach (theory and values underpinning the ‘how’ of doing the work) and what methods (what has actually been done) have been used?
• How are expert reference group (ERG) members selected? Was there open advertisement and criteria-based selection?
• How are service users involved?
• Does the ERG ever write draft wording? Is actual wording of Framework statements and standards ever discussed or do officials ask general questions and listen to ERG members discussing the topic, to inform what the officials then draft?
• Or are NHS England officials doing the drafting? DHS officials? Both? If so, are they clinically qualified, or not? (The answers to these questions define and refine other questions we have e.g. about how NICE guidance and research evidence are being used, or not; e.g. about the structure and governance of the policy-creation process in its entirety - is policy being made in a transparent manner which any informed citizen can understand and critique, and what questions should one ask?)
• Who are the clinical staff within NHS England (and within DHSC?) overseeing drafting?
• What exactly is the process? Does drafting come first before any ERG discussion? How are ERG comments made, recorded, weighted, actioned?
• Is there a literature review? How and by whom is it specified and carried out? Who sees it and when? How is evidence from such a review weighted and used in the drafting process?
• Is there public consultation when scoping the MSF or on the final draft of the wording before publication?

It is as impossible to tell for the new MSFs as it is for almost all of the old NSFs.

Transparency, governance and the risk of GOBSAT

If the NHS is to be the most transparent healthcare system in the world, transparency must extend beyond ‘data’ (figures). If citizens are to ‘mark its homework’, NHS England and DHSC must set out clearly:

• who is appointed to advise and how
• who drafts service frameworks and what their qualifications are
• precisely how, step by step, each MSF is developed
• how evidence is selected, weighted and used.

Otherwise, what we may legitimately fear is GOBSAT¹⁹: Good Old Boys Sat Around a Table using evidence they prefer in an opaque process.

Without transparency about method and people involved, it’s impossible to ‘mark the homework’. Was this a rigorous and sensibly-boundaried exercise with a good-enough output? Or is it one in which bias and ‘being the right person in the right place at the right time’ meant getting points into the framework/standards?

Challenge after the event is essential if the process was not rigorous and is only possible where there is a clear statement of what was done and by whom and why.

National-level governance tensions over quality - who should be in charge?

Can we rely on the newly ‘revitalised’ National Quality Board²⁰ to sort this out, to ensure proper methodology and transparency about it?

Tracking back through NHS England board papers, it appears to me that the National Quality Board had to ‘muscle in’ and take responsibility for the new NHS Quality strategy, after NHS England had set up its own task and finish group to write the strategy.^{21, 22}But it’s difficult to follow what happened, and I can find no clear public statement about how the strategy was developed and by whom - the statement about transparency in the published strategy therefore seems meaningless. But things can improve. We must hope.

The 2026 NHS Quality strategy mentions NICE nineteen times, particularly highlighting its role in making quality standards. NICE was set up to take decisions about which drugs to fund in the NHS , and which not, away from politicians.²³

Based on my recent reading, I realise now that in the 2010s, civil servants - possibly clinically qualified, possibly not - were writing standards in national service frameworks, with an unclear role for, and degree of involvement of, ‘advisory’ ERGs, at least in the published documents (whatever civil service practice guidance at the time might have suggested) and generally no clear methodology statement and note of methods used.

Here we are again in 2026, it seems, with NHS England and DHSC jointly doing standards and guidance-making work which perhaps NICE can do better, process-wise^{24 ,25}with the NHS then directed by NHS England as regulator to use those standards. NICE guidelines are not a ‘textbook’ for care, so the question then remains how gaps in the guidance they provide are to be filled; and if this work of ‘integrating guidance sources and filling gaps, to describe how care will be provided’ will be done by NHS England and/or DHSC, then methodological clarity and rigour seems essential, if the promises of the 10-Year Plan and the Quality Strategy about service quality are to be met.

In maternity, we already have the detailed maternal care bundle published earlier this year by NHS England in its capacity as a regulatory, standards-setting body for the NHS. Expert reference groups are listed, but it is not possible to see how the standards in the bundle were made (see Appendix A).26

With NHS England winding down to closure, we have the prospect of DHSC in future specifying dense clinical detail in government-made national quality standards for clinical and operational matters. Is this a good idea?

A call for transparency

Whoever is making quality standards for the NHS, I have more confidence in the detail and rigour of the NICE manual than in vague ERG ‘terms of reference’ of variable quality in service frameworks old and new. NICE, it seems, is keen to be involved.²⁷ We need to see more detail when an MSF is published. NHS England and DHSC, meanwhile, collaborating with the academic partnership known as the Health Equity Evidence Centre, seem more interested in quality of MSF implementation than in methodological rigour up front.^{28, 29}

Transparency means, ‘everyone can mark your homework,’ not ‘these lovely, competent people we have listed were invited along (and we may have said we would use best available evidence) - so just relax and assume we, the public servants involved, advised or helped by them, will have done a good job.’

We might listen to a warning from the year 2000:

"The external reference group responsible for the NSF had 41 members. Of these, three were cardiologists, and eight might loosely be called clinicians with other interests. This may explain why the standard of the medical aspects of the NSF approximates to the level one might expect in a final MB viva of a student of poor to moderate ability." Hampton, J.R. (2000) ‘The National Service framework for coronary heart disease: the emperor’s new clothes’³⁰

And look at NHS England practice when it is specifying and commissioning specialised services³¹ (such as complex home respiratory assistance for adults or cystic fibrosis care for children): there we see a process specified in great detail, for anyone to read, think about, and comment on.

AIMS calls on NHS England and DHSC to make sure in future that precisely why and how quality standards in Modern Service Frameworks are being made, and by whom, is fully transparent. We look forward to seeing this approach taken for the Modern Service Framework for the Maternity and Neonatal Services. Women, babies and families deserve no less.

Catherine Williams, October 2026

Further reading

National maternity and neonatal service improvement efforts in England: what has been happening/ what’s going on? - AIMS Campaigns Team here

Appendix 1 Extract from Fit for the Future – the 10-year health plan for England (2025) - about introducing MSFs in the NHS [here]

Appendix 2 Extract from the Final report of the Amos Review (2026) - Recommendation 4 - about introducing an MSF for maternity and neonatal services. [here]