Evidence submitted by North East London
Strategic Health Authority (WP 02)
Please find attached notes in response to your
Inquiry—please note my response is for maternity services.
A summary of my responses are:
National recognition and acceptance
of a maternity specific workforce tool. Nationally agreed and
accepted midwife to births ratio.
Payment by Results and Practised Based
Commissioning offers an opportunity for maternity services to
be commissioned independently and for funding to follow the woman
rather than become part of the general funding within the acute
Trust as happens currently.
Investment in maternity IT system and
the development of competencies for data input clerks is essential
if Payment by Results is to be successful.
The possibility of Independent Midwifery
Practices providing a home birth service for London should be
explored and considered.
At the current funding levels the opportunity
for maternity services to achieve Standard 11 in the Children's
National Service Framework 2005 is seriously compromised.
Career pathways for "branches"
of midwifery practice should be established to ensure that not
all senior midwives are encouraged to practice as "mini doctors"
rather than "maxi midwives" due to greater status and
financial reward. The European Working Time Directive may adversely
effect junior doctors training.
Clinical leadership within midwifery
and obstetrics should be strengthend along with the availability
of flexible retirement options.
Midwifery leadership and the position
of the Director of Midwifery within an organisation must be strengthened
along with the development of the maternity support workers role.
A clear career structure and recognition
of mandatory training days along with good affordable housing
for rent/purchase to address the problem of retention.
The funding of midwifery training programmes
require review and a 10 year plan developed to ensure adequate
training to match increased birth projections and the planned
retirement of existing midwives.
The Nursing and Midwifery Council are
currently reviewing their recommendations for overseas qualified
midwives.
Centralised planning for physical capacity
would ensure greater flexibity within the maternity services.
I hope that these comments are useful and I
am very happy to provide further information should you require
it.
1. HOW EFFECTIVELY
WORKFORCE PLANNING,
INCLUDING CLINICAL
AND MANAGERIAL
STAFF, HAS
BEEN UNDERTAKEN
AND HOW
IT SHOULD
BE DONE
IN THE
FUTURE
Currently the only maternity specific workforce
tool recognised by the Department of Health, The Royal College
of Midwives and the Royal College of Obstetrics and Gynaecology
is the Birth Rate Plus audit tool, which has been in use since
1988 (formerly Birth Rate audit tool). The tool assists the maternity
unit to plan their service and commissioning based on their current
service model and provides a baseline for midwifery staffing.
Many maternity units have commissioned this audit at some considerable
cost to the organisation; however the recommendations from these
audits have never been fully accepted by the commissioning PCT's
and midwifery establishments remain largely historical in their
agreed level. This results in the ratio of midwife to births varying
from 1:26 in some parts of the country to 1:45 in others, irrespective
of the dependency level of the women accessing the maternity service.
Future planning must be based on an agreed national ratio of midwife
to births, which are mandatory for providers to comply with. This
could be enforced through the Clinical Negligence Scheme for Trusts
(CNST) which already includes medical staffing levels within its
criteria. Service models across London should be reviewed, with
the view to identifying non-midwifery tasks currently being provided
by midwives that could be provided by appropriately trained and
supervised support workers eg London postnatal services could
be provided by maternity support workers with midwives providing
targeted services for eg vulnerable women.
2. IN CONSIDERING
FUTURE DEMAND,
HOW SHOULD
THE EFFECTS
OF THE
FOLLOWING BE
TAKEN INTO
ACCOUNT
2.1 Recent policy announcements
Practised based commissioning (PBC—maternity
services have historically suffered from the practice of being
funded from block contracts. PBC offers a unique opportunity for
maternity services to stand alone, independent of the acute Trust
with the possibility of an alternative provider (eg maternity
network) commissioning maternity services. Organisations such
as maternity networks commissioning maternity services and Payment
by Results (PBR) could ensure that funding flowed directly back
into maternity services, leading to far greater flexibility within
the service and ability for organisational accountability, quality
and standards to be obtained.
2.2 Technological change
The Department of Health is currently working
on a national maternity data set. However the level of IT support/infrastructure
within some maternity units is below acceptable standards and
investment is required if PBR is to be effectively managed. Crucial
to the success of PBR will be the standard and accuracy of the
information entered therefore it is imperative that data input
clerks are well trained and competent. A competency framework
should be identified and training commissioned which is nationally
recognised to allow transferability of skills from one Trust to
another.
2.3 The increasing use of private providers
of services
Many maternity units report a reluctance of
midwives to provide homebirth's within their sector due to the
unsocial hours required for midwives to be on-call from home.
It can also prove difficult for some Trusts to comply with family
friendly initiatives and provide a 24 hour homebirth service.
However, many midwives who enjoy this model of working prefer
not to work within the NHS, therefore the possibility of Independent
Midwifery Practices providing a home birth service for London
should be explored and considered.
3. HOW WILL
THE ABILITY
TO MEET
DEMANDS BE
AFFECTED BY:
3.1 Financial constraints
Without significant investment in to maternity
services the opportunity for services to develop to meet the requirements
of Standard 11 of the Children's National Service Framework 2005
will be seriously compromised for the majority of London providers
of maternity services.
3.2 The European Working Time Directive
There is a downward trend in the number of junior
doctors undertaking obstetric specialist training. To cover the
gaps in the obstetric service senior midwives may be encouraged
to take on the role of junior doctors. This role may bring with
it a greater incentive in the form of status and financial reward
and may lead to devaluation in the role of the senior midwife
who remains within midwifery, with the most innovative and creative
midwives being encouraged to become "mini doctors" by
taking on the junior doctor role. This would lead to a greater
drain on maternity provision. It is therefore imperative that
a clear and defined career pathway is established for midwives
to encompass both "branches" ie those who remain within
the midwifery sphere and those who branch into formerly obstetric
practice. The ability of the Trust to provide 24 hour consultant
Obstetrician cover and comply with EWTD may prove difficult for
some Trusts, and impact negatively on the training of junior doctors
within obstetrics.
3.3 Early retirement
Mavis Kirkham's work Why Midwives Leave (2003)
identified a culture of bullying and harassment leading to high
stress levels in many maternity units. Clinical leadership both
in midwifery and obstetrics, team working and transparency in
clinical practice must be actively promoted to reduce the rate
of leavers along with the availability of flexible retirement
options.
4. TO WHAT
EXTENT CAN
AND SHOULD
THE DEMAND
BE MET,
FOR BOTH
CLINICAL AND
MANAGERIAL STAFF,
BY:
4.1 Changing the roles and improving the skills
of existing staff
Maximum deployment of existing midwifery staff
to ensure that productive time is maximised should be assured.
This will necessitate protection of the professional role of the
midwife, greater administrative and clerical support for maternity
services and reallocation of some parts of service to assistant/support
workers eg postnatal care could be provided by maternity assistants
with midwives providing care to targeted groups such as vulnerable
women. Midwifery leadership and the position of the Director of
Midwifery within an organisation must be strengthened.
4.2 Better retention
Agenda for Change payment banding should be
the same across London including that offered by Foundation Trusts.
At present newly qualified midwives are offered band 5 in some
areas and band 6 in other areas of London. Good standard affordable
housing within London should be available both for rent and purchase.
A clear career structure and recognition of mandatory training
(provided within the working day) would provide greater job satisfaction
too.
4.3 The recruitment of new staff in england
An uplift in midwifery WTE establishments is
required across London. In response to this an increase in midwifery
training commissions is required for both 18 month and 3 year
midwifery training programmes.
Three year midwifery students currently receive
either a bursary or a loan depending on whether they are completing
a diploma or a degree programme. The issue of student poverty
should be addressed in relation to the attrition rates of students
within Higher Education Institutes.
18 month midwifery students are currently paid
at AfC band 5 with shared funding of 80% by the local Strategic
Health Authority and 20% by the employing Trust. This arrangement
means that the employing Trust is responsible for paying all "on
costs" such as weekend working, night duty etc which are
an essential part of the students experience during training.
Trusts are reporting that, due to financial restraints, they can
no longer afford to support 18 month midwifery students. However
these students are gaining a second registration as they are already
registered nurses, and therefore bring with them skills in acute
nursing that are essential to ensure that the midwifery workforce
reflects the case mix of women accessing maternity services. This
problem needs to be addressed nationally to ensure that the option
of midwifery training is not closed to trained nurses.
4.4 International recruitment
This is currently under review by the Nursing
and Midwifery Council, and new recommendations are expected later
in 2006.
5. HOW SHOULD
PLANNING BE
UNDERTAKEN:
5.1 To what extend should it be centralised
or decentralised?
Planning physical capacity within maternity
services should be centralised for London and the practise of
`capping' within each Trust stopped due to the repercussions for
the surrounding maternity units when one maternity unit closes
to bookings. A more shared approach would lead to greater flexibility
and removal of bottle necks which can occur due to reactionary
measures being adopted by one Trust.
Debbie Graham,
Lead Midwife, NE London SHA
21 February 2006
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