House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Evidence submitted by the Royal College of Midwives (WP 54)

The Royal College of Midwives (RCM) represents over 95% of the UK's practising midwives, and is the world's oldest and largest midwifery organisation. It works to advance the interests of midwives and the midwifery profession and, by doing so, enhances the wellbeing of women, babies and families.

The RCM welcomes the opportunity to contribute to the Health Committee's inquiry into workforce needs and planning for the health service, particularly given the continuing shortage of midwives in the NHS and the high dropout rate for student midwives.

SUMMARY OF RECOMMENDATIONS

The RCM recommends that to reduce the excessive amounts of stress and the workload of midwives, the Department of Health (DH) must urgently seek to recruit significantly more midwives whilst retaining those currently in post. To achieve this, the DH must use the Birthrate Plus workforce planning tool to assess workforce needs, set new and ambitious targets for increasing the size of the midwifery workforce and ensure sufficient funding to achieve that is in place, increase the number of places for student midwives and give those student midwives better financial assistance.

The RCM recommends that the DH publish without delay the plan of how it will implement not only the maternity standard of the National Service Framework for Children, Young People and Maternity Services but all other relevant commitments made on maternity services, including its manifesto commitments.

The RCM recommends that the DH act to reduce unnecessary intervention, particularly caesarean sections, increasing home births and births that take place in midwife-led units and birth centres. This will cut unnecessary demands on the midwifery workforce and aid retention.

The RCM recommends that the national tariffs relating to maternity services be developed that reflect all additional costs associated with providing maternity care to women and babies with diverse clinical and social needs.

The RCM recommends that providers of NHS maternity services should be prevented from establishing schemes aimed at income generation that detract from their ability to provide high-quality and equitable maternity care for all women and families.

The RCM further recommends that commissioners should explore the potential for contracting with midwifery group practices to provide antenatal and postnatal care services in deprived areas or in the event of GP practices opting-out of providing such services.

The RCM recommends that current NHS deficits should not be addressed by cutting maternity services budgets or by cutting the number of places for student midwives. Given the continuing chronic national shortage of NHS midwives, the number of places for student midwives must actually be increased.

The RCM recommends that the impact of the European Working Time Directive is taken into clearly into account when planning future workforce requirements.

The RCM recommends that to readjust the age profile imbalance of the midwifery workforce more student midwives are trained and brought into the profession.

The RCM recommends that trusts are required to provide sufficient support to NHS staff to allow them to undertake continuing professional development.

The RCM recommends that Agenda for Change be implemented in full if the retention benefits flowing from it are to be realised. The current NHS deficits are no justification whatsoever for any further delay in implementation or for attempts to water down the agreement. Moreover, three Secretaries of State for Health are on the record as stating that Agenda for Change is fully funded.

The RCM recommends the urgent introduction for all student midwives of an annual non-means-tested £10,000 bursary to replace all existing financial grants and bursaries.

The RCM recommends an induction and support programme for all midwives in their first year of NHS practice.

The RCM recommends that—given the lack of places offering adaptation programmes to midwives coming from other countries because of our midwife shortage—funding is in place to ensure that places offering such adaptation programmes are available to midwives able and willing to work in the NHS in England.

The NHS midwifery workforce

Current midwife numbers are insufficient to deliver a universally first-class service to women and these numbers have only crept up very gradually since 1997.

Using the Department of Health's own non-medical workforce census, which provides a snapshot of staffing in England as at 30 September each year, the number of whole-time equivalent (WTE) midwives in England's NHS has risen by a little over 4% from 18,053 in 1997 to stand at 18,854 in 2004 (the latest year for which figures are currently available). The headcount figure is better—rising by 11% from 22,385 in 1997 to stand at 24,844 in 2004. However with increased part-time working, it is the WTE figure that more accurately reflects staff availability.

This is in the context of a greater workload, more screening tests to be carried out, more first-time mothers, a higher caesarean section rate and other factors that place greater demands on midwives.

Moreover, the equivalent increases in the overall nursing, midwifery and health visitor workforce were much higher: the combined WTE figure for all the professions combined was up 23% and the headcount up 25% over the same period.

In addition to the NHS figures, the Royal College of Midwives itself produces an annual staffing survey. The latest—a snapshot as at 1 July 2005—revealed that:

— 74% of maternity units in the UK (78% in England) were experiencing vacancies;

— 59% of all these vacancies had been unfilled for more than three months; and

— in England, vacancies represented 5% of actual establishment (in London this was 12% and for the South East it was 9%—the two most problematic areas).

It is in this context that the RCM makes its submission.

Recent policy announcements

Recent policy announcements such as those contained in the National Service Framework for Children, Young People and Maternity Services and indeed in the Labour Party manifesto 2005 compel every trust to meet certain commitments regards minimum level and standards of care in maternity services.

The Labour manifesto promises that: "by 2009 all women will have choice over where and how they have their baby and what pain relief to use. We want every woman to be supported by the same midwife throughout her pregnancy."

Currently, although England's maternity services are safe, the chronic national shortage of midwives means that we do not yet have the kind of first-class service that women, the NHS and the Government clearly want and deserve. More midwives are needed before this high-quality service can be delivered.

This is a position supported by the Department of Health Minister the Rt Hon Jane Kennedy MP, who in her recent oral evidence to the Committee on NHS Charges confirmed the impact the shortage of midwives is having on delivery of first-class care:

"one-to-one midwifery support is part of the National Service Framework, it is a commitment we made in our manifesto. The brake on us delivering that is the lack of midwives and we are working hard, as in other areas, to increase the numbers of people in that area. I think it has increased by 2,200. Progress is being made on that score but it is slow . . . The only reason they are not getting it is because we do not have enough midwives to be able to provide it and that is why we are increasing the numbers and trying to raise the profile of midwifery as a career and promoting it as a career."

Technological change

Birth is an increasingly interventionist and medicalised practice; as a result, postnatal hospital stays are longer, which places additional demands on the midwifery workforce.

The percentage of spontaneous births, for example—as opposed to instrumental or caesarean—fell from 76.5% in 1980 to 66.5% in 2003-04. At the other end of intervention spectrum, the%age of caesarean deliveries has more than doubled from 9% in 1980 to 22.7% in 2003-04.

This increased level of intervention leads directly to longer postnatal hospital stays for the mother. Figures for 2003-04 show that where the onset of labour was spontaneous, 94% of women whose babies were born spontaneously—ie without any intervention—and mothers were out of hospital within three days; this fell to 86% of those whose babies were delivered with the use of an instrument, such as forceps; and of women whose babies were delivered by caesarean, only 57% were out of hospital within three days. These numbers were roughly the same for those women whose labour was induced.

With intervention in birth increasing, that places more and more demands on the midwifery workforce.

The shift towards greater intervention and medicalisation is not however inevitable, provided that there are sufficient numbers of midwives to support women during pregnancy. In our written evidence to the House of Commons Health Committee Maternity Services Sub-Committee's inquiry into Provision of Maternity Services in 2003 we were able to cite evidence that at some trusts intervention can be kept to a minimum by intensive midwifery support of women during pregnancy and birth.

Moreover, the additional burden resulting from elevated levels of intervention comes at a time when the overall number of births is also increasing: there was a 5% growth in the number of births in England in 2003-04 compared to the previous year. This places yet more demands on midwives.

An ageing population

Increasing numbers of older women are becoming pregnant and they are making up a growing proportion of all pregnant women. Midwifery care for such women is more demanding and this has a direct impact on what is required from the midwifery workforce.

Between 1991 and 2003 the number of women in England aged 40 or over conceiving almost doubled from 11,497-20,128. That is a 75% increase in 12 years. This happened at the same time as the overall number of conceptions to all women in England actually fell.

It is also noteworthy that over this period the abortion rate for women aged 40 or over fell (from 41.8%-34.9%), so not only were more women in this age bracket conceiving but a greater proportion were also having babies.

The 2003 figures also show that in England—and indeed throughout the UK—the highest rate of babies born with congenital anomalies were those born to women aged 40 or over. These are the women whose pregnancies will require the most from midwives.

It is also relevant to midwifery not only to look at older mothers but also at pregnant teenagers, who need additional help from midwives. Again, a comparison between 1991 and 2003 shows a rise in England in conceptions in this group. Conceptions to those aged under 16—the youngest teenagers requiring the most assistance—actually rose by 529 over that period despite the overall number of conceptions to all women falling by 41,183.

The ageing of the profile of pregnant women and the increased numbers of the youngest teenage mothers have a direct effect on care that midwives must provide.

Increasing use of private providers of services

The provision of private maternity services in England is very limited.

Around 593,600 births took place in England in 2003-04, of which about 0.5% occurred in private hospitals.

Additionally, a total of only 407 births (out of a total of around 593,600) were attended by an independent midwife. That amounted to less than 0.07% of the total.

As suggested by the number of births attended by an independent midwife, their numbers are limited. In May 2004, for example, the stated total membership of the Independent Midwives Association was 47. As a comparison, in September 2004 there were, according to the Department of Health, 24,844 midwives working in the NHS in England alone.

So, the current non-NHS provision of maternity services is largely irrelevant to the question of workforce needs and planning, and indeed many of the very small number of deliveries attended by an independent midwife end up using NHS—and not private—facilities.

There is of course the possibility that an international company could "enter the market" and set up maternity units in England. This could happen as part of a contracting out of GP provision to a private company, which might very well include traditional GP functions in antenatal and postnatal care. This could then lead to the trusts commissioning private companies to operate maternity units. Such a process would not be easy however. Even European companies would not find it easy to set up here: in February 2006 the European Parliament voted to exclude healthcare from the scope of a European Directive that aims to make it far easier for EU companies to set up in other countries. The European single market in services, especially in healthcare, is far from complete. Nevertheless, this remains a possibility, however this process would not create any new midwives and it is the ongoing chronic national shortage of midwives that is the central problem.

Should this happen, the RCM would want such companies to be bound tightly by the very same rules and regulations that apply to NHS providers. Of paramount importance would be the quality of care provided to women.

Very recently we have witnessed the emergence—in the Jentle Scheme at Queen Charlotte's Hospital—of what might be described as a kind of NHS/private hybrid. As the Committee knows from the evidence it took in its recent inquiry into NHS Charges, the Jentle Scheme offers one-to-one midwifery care throughout pregnancy to women able and willing to pay £4,000 to the trust. The College does not support this scheme because by linking one-to-one care with wealth it will undermine totally attempts to reverse health inequalities. The RCM believes that care should be free at the point of need. This is not a model we would advocate other NHS trusts follow nor is it a blueprint for the future of the NHS.

Financial constraints

Most maternity units are facing static or falling budgets and over a quarter are being asked to reduce midwife numbers or use cheaper, less qualified staff to care for women as a result of budget pressures. This will inevitably limit the ability of maternity units to meet demands placed upon them.

As part of our latest annual survey of Heads of Midwifery (HOMs), the RCM asked all HOMs whether their budget had increased over and above inflation: 28% said it had increased; 19% said it had decreased; and 54% said that it had stayed the same.

It is surprising that in a time when the demands on midwives are increasing, almost three-quarters of units have a static or falling budget.

For the first time this year we also asked HOMs whether they had been asked to reduce their staffing numbers or alter the skill mix as a result of trust-wide budgetary constraints. 26% reported that they had; 29% that they had not; and 44% gave no answer.

Further evidence from HOMs revealed that maternity care assistants/maternity support workers were being used to combat budget pressures rather than as a way to improve care. This was not the reason these new roles were created and we fear that budget pressures are leading to reductions in the quality of care in this way. The RCM supports the use of such staff as a part of the team supervised by midwives to enhance continuity of care and subject to ensuring that statutory requirements are met.

The European Working Time Directive

As a part of the same survey, we asked HOMs who felt that they had an inadequate number of midwives what factors contributed to that. One third identified a reduction in junior doctors' hours as contributing to that situation. It is therefore identifiable as a factor for many maternity units in trying to meet the demands placed upon their midwives.

The RCM recommends that the impact of the European Working Time Directive is taken into clearly into account when planning future workforce requirements.

Early retirement

A clear desire amongst midwives to retire over the coming years and an ageing profession point clearly to a workforce problem on the horizon that must be addressed sooner rather than later.

In December 2005, the RCM surveyed 6,000 of its members. The survey revealed that when asked in which year they plan to retire, more than half stated a year that fell between now and 2017, which is a little over a decade away.

One factor behind this may well be the ageing of the midwifery workforce. By comparing the age profile of midwives given in the last four statistical analyses of the Nursing and Midwifery Council (NMC) register (from the 2001-02 analysis through to 2004-05), a picture of the situation emerges. In the age profile given for 2001-02, 44.1% of midwives were aged under 40 but by 2004-05 this had dropped substantially to 31.6% (down 12.5%). The age profile of NHS midwives is now significantly older than even four years ago.

The RCM recommends that to readjust the age profile imbalance of the midwifery workforce more student midwives are trained and brought into the profession.

Changing the roles and improving the skills of existing staff

The position of the midwife as the primary carer for women experiencing normal pregnancy and birth has remained essentially unchanged for many years. Over the years however midwives have proved themselves very adaptable to the changing NHS environment.

Moreover every midwife is responsible not only for maintaining their existing skills but also ensuring that they become competent in any new skills required for practice.

Both the adaptability that midwives possess and the requirement to keep their levels of competency up-to-date are demands on midwives' time and the RCM is concerned that insufficient support is being given to midwives to enable them to do this.

For example, research commissioned by both the RCM and the Chartered Society of Physiotherapy into the attitude and experiences of both midwives and physiotherapists in relation to NHS reforms and their working lives revealed that: 69% of midwives received none or less than two days' formal on-the-job training; and 36% of midwives had received time off for education and training that they had organised and paid for themselves [Wilkinson F (2006) NHS Reforms and the Working Lives of Midwives and Physiotherapists: an interim report].

The RCM recommends that trusts are required to provide sufficient support to NHS staff to allow them to undertake continuing professional development.

Better retention

An important aim of the Agenda for Change pay system was better retention of NHS staff, including midwives. This was achieved by, for example, lengthening pay bands so that an individual's pay did not plateau so soon after being placed on a pay band. The effectiveness of Agenda for Change as a tool for improving retention is evidenced by NHS Employers who consider a 25% improvement in retention rates over the next 25 years to be reasonable.

In addition it is know from work commissioned by the RCM that where midwives are able fully to utilise all their skills—for example in midwife-led units—retention is greatly improved.

The recruitment of new staff in England

As the age profile in particular shows, there is a clear need to recruit into midwifery more and younger midwives to ensure the ongoing sustainability of the profession. The chief route to delivering that inflow of new and younger midwives is through training more student midwives and ensuring more of them make it into NHS practice and have a post to go to on qualification.

The present dropout rate amongst student midwives is around 20%. This is making it very difficult to deliver the extra midwives the NHS needs as too many training places are taken up by individuals who will not finish the course and will not therefore go on to practise as midwives within the NHS.

To reduce the proportion of student midwives who drop out of their studies we must see greater financial support for student midwives to keep them in their studies and lead them through to qualification and into NHS practice. Indeed, financial hardship was the main reason cited by student midwives who have dropped out of their studies.

Financial support for student midwives is currently a hotchpotch of bursaries and grants with some means-tested and some not. With student midwives more likely to be older and therefore more likely both to have pre-existing financial commitments and with three-quarters having dependent children, and with their spare time taken up with clinical placements, these financial pressures can become acute.

To address this the RCM has consistently called for an annual non-means-tested bursary of £10,000 for all student midwives. An EDM (number 197) calling for just such a bursary has—as of 15 March 2005—secured the support of 170 MPs, including over 100 Labour MPs; more than half of all LibDem MPs; over half the members of the Health Committee; the entire Plaid Cymru and Democratic Unionist parliamentary parties; and overall more than a quarter of all MPs.

In addition, all new midwives should have an induction and support programme for their first year of practice to assist them in consolidating the skills and competences they have on qualification. This will assist them to be able to cope with the stresses and strains of employment in today's overworked maternity units—for example, simultaneously caring for two or more women in labour.

The RCM recommends the urgent introduction for all student midwives of an annual non-means-tested £10,000 bursary to replace all existing financial grants and bursaries.

The RCM recommends an induction and support programme for all midwives in their first year of NHS practice.

International recruitment

International recruitment of staff is not as great for midwives as it is for other NHS professions, such as nursing, and so provides limited scope for meeting future workforce requirements. Genuine solutions must be homegrown.

Our HOMs survey, for example, showed a slight increase in the number of units reporting that they recruited from overseas "very frequently" compared to last year (up from 6.5% to 11%). The number of units who have recruited "occasionally" from overseas however has remained at 9% whilst the number of units who have recruited on a "seldom" basis is just 1.4%. Those who have "never" recruited from abroad is now 75%, compared to 73% last year. Three-quarters of units therefore are unaffected.

Whilst it may be relatively straightforward to recruit nurses from overseas, midwives from outside the European Economic Area wishing to practise in the UK as a midwife must complete an adaptation programme which varies depending on the preparation programme they have already gone through in their home country. This can require strong resource commitments from HOMs and senior staff but it can be shown that where these resources are committed rewards can be achieved as the overseas midwife stays in practice.

Royal College of Midwives

March 2006