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 thatgiven the lack
of places offering adaptation programmes to midwives coming from
other countries because of our midwife shortagefunding
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 betterrising 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 latesta
snapshot as at 1 July 2005revealed 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.
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.
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."
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.
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 exampleas
opposed to instrumental or caesareanfell 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 spontaneouslyie without
any interventionand 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.
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.
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 Englandand
indeed throughout the UKthe 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 16the youngest teenagers
requiring the most assistanceactually 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.
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.
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 NHSand
not privatefacilities.
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 emergencein
the Jentle Scheme at Queen Charlotte's Hospitalof 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.
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.
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 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 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
skillsfor example in midwife-led unitsretention
is greatly improved.
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 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 hasas of 15 March 2005secured 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 unitsfor 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.
The RCM recommends thatgiven the lack
of places offering adaptation programmes to midwives coming from
other countries because of our midwife shortagefunding
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.
Royal College of Midwives
March 2006
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