Health CommitteeWritten evidence from the Royal College of Midwives (ETWP 77)

The Royal College of Midwives

1. The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of practising midwives in the UK. It is the only such organisation run by midwives and for midwives. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and we also provide professional leadership for one of the longest established of all clinical disciplines.

Summary of Main Points

The RCM broadly welcomes devolving policy direction.

The RCM is, however, concerned that national, strategic oversight might be lost.

The Government must maintain effective workforce intelligence; achieving this should include providing the Centre for Workforce Intelligence with the resources it needs to do its job properly.

Central funding for some national education and training initiatives—such as Return to Midwifery practice programmes—(which have proven their worth and for which the need remains) need to be maintained.

Health Education England must reflect the whole healthcare workforce.

Any new structures should initially be run in tandem with existing structures so that the best of the old can be maintained.

Mechanisms must be in place to ensure that continuing professional development (CPD) is not further eroded, and it should also be ensured that midwives and other professionals mix with their colleagues from across the country not just their local area to ensuring sharing of best practice.

Policies should be brought forward that enable midwives to move more easily and more frequently between positions in midwifery education practice to boost the turnover of staff within education and bring other practice benefits.

Overview of Policy Direction

2. The RCM broadly welcomes the direction of policy on education, training and workforce planning towards greater professional ownership. We recognise that this will necessitate some devolution of current arrangements but we are concerned that the drive to local determination will, as happened in the past, lead to a short-termist approach and a lack of coordination, to the detriment of future healthcare provision.

Losing Strategic Oversight

3. Devolving responsibility for education, training and workforce planning will make it harder, for example, for politicians to deliver on promises they make to the general public, such as the one made by the Prime Minister (the then Leader of the Opposition) in January 2010 to recruit an extra 3,000 midwives. The Prime Minister remains committed to wanting to see more midwives in post—telling MPs in November 2010 that, “We do want to see an increase in the number of midwives”1—but a hands-off policy on education, training and workforce planning runs totally contrary to being able to deliver on it.

4. Not being able to deliver on political pledges is not the only inherent problem with this approach. Simply maintaining an adequate workforce may become a challenge. A policy of devolving decision making runs the risk of repeating the mistakes of the 1990s, the last occasion on which workforce planning was devolved, when midwife education programmes were subject to severe and damaging cuts. The logic of this outcome is sensible enough. At a time when savings have to be made, it might seem reasonable for a local health employer to decide to avoid the expense of training a new midwife by simply “poaching” a newly-trained midwife from somewhere else; in short, becoming a free rider. This is not on its own a strategic problem, but if a sufficient number of employers take this approach, and such an outcome does not seem to us to be unlikely, then the number of new midwives drops precipitously. This is the RCM’s experience of how a devolved approach operated in the 1990s.

5. It is for these reasons that the RCM strongly recommends that the Government ensures that strategic oversight and governance of education, training and workforce planning is not lost when strategic health authorities (SHAs) are abolished. This is critically important in ensuring the continuing availability, training and development of a skilled workforce able to provide high quality, safe and effective care to women. Retaining national oversight of workforce intelligence and of the needs of the service in different parts of England is fundamental to ensuring that the system is sufficiently responsive and flexible to changes in demand for services. We hope that the lessons of the 1990s, mentioned above, will be learnt and that localisation of arrangements is not purely at the expense of national strategic considerations.

6. A national and strategic view of the knowledge and education of practitioners such as midwives is critical in ensuring a skilled workforce able to provide a high quality, safe and effective level of care to women, their babies and families through the continuum of pregnancy, labour and the postnatal period, including early support for parenting. Midwives are the only professionals who have access to women and their families at a crucial window in their lives, with a unique opportunity to influence the present and future health choices for them and their families.

7. Having specific and effective measures for workforce intelligence, and being clear on the numbers of workers at all levels being prepared throughout England, and indeed the UK, is fundamental to balancing the ebb and flow of the workforce in relation to providing new jobs for those completing their education and training, and to replacing those who are leaving the service either for other roles, or through retirement or career breaks. Even the current system does not always address this, in that some newly-qualified midwives, trained at public expense, have been unable to obtain immediate employment or have had to take part-time posts immediately after their programme. This is frequently a result of local financial strictures unrelated to clinical need. The RCM is aware of research that indicates that not being able to practise after qualification will often cause those practitioners to never practise, and this is a shameful waste of public money and talent. Some midwives who have not been able to obtain employment immediately after qualification have applied to complete the RCM Return to Midwifery Practice programme, having been in that situation.

8. Some programmes and educational initiatives need a national strategy, including protected and targeted funding; the RCM would recommend that the Government reviews what these programmes should be. An example is the Return to Midwifery programmes, which allow midwives to update their theory and practice in order to be competent and indeed confident enough to return to NHS practice. This is a cost-effective route usually taking anything from four weeks to one year to bring back an experienced practitioner. There remains considerable interest from midwives who have left the NHS to undertaken these programmes, but it is often difficult to identify funding to support the course fee, bursary, and clinical placement. The experience of the RCM has been that initiatives such as that used by NHS London have streamlined the process, and ensured that monies are available to facilitate this return. This is a huge benefit to local maternity services.

The New Structures

9. The Centre for Workforce Intelligence (CfWI) will clearly have an important role to play in developing workforce intelligence and supporting local providers and Health Education England (HEE). It is vital that the Government ensures that the CfWI has the requisite resources to undertake these responsibilities.

10. Structures and the architecture of any new system will of course be of vital importance. The proposed new system requires the design and development of new structures, including the clinical networks and HEE. This will require robust new governance, systems and processes to oversee the whole education and training system, including an effective legal framework. HEE must reflect the whole healthcare workforce, with equal representation across the professions, including colleagues from nursing, midwifery and the allied health professions (AHP). There is considerable experience and expertise within these groups that will add to the work of this group. The chair of the group could usefully be an independent person, with the appropriate expertise to contribute to the work. There are significant concerns that as HEE will be a successor to Medical Education England, it will follow a medical model. This would not be acceptable as midwives, nurses and AHPs provide the vast majority of hands-on care within the NHS and independent sectors.

11. The RCM believes that the Government should consider whether it might be possible for any new system to be set up and run in tandem with the existing system to enable any teething problems to be identified and addressed before closing the old system. The RCM would recommend that in preparation for this change, a careful review and evaluation is undertaken clearly to establish what systems and processes can be translated or utilised in the new system. We are concerned in particular that existing expertise of those at the SHA level might be lost, and this will adversely affect the commissioning of education and training.

12. The RCM supports the principle that healthcare providers have a duty to cooperate on planning the healthcare workforce and providing professional education and training. Where there is a strong and effective partnership between education and service providers, students are more likely to have a rewarding educational experience, and be confident entering practice as new midwives.

13. The RCM welcomes the establishment of HEE and expects that the commitment to promoting multi-professional education and training is reflected in the participation in its governance systems and processes of representatives from all sectors of the healthcare workforce. When it comes to the development of training and education programmes for midwives, we would strongly recommend accessing advice from a wide range of professional representation, including the Nursing and Midwifery Council (NMC), the RCM, and midwives in a Supervisor of Midwives or Local Supervising Authority role.

Continuing Professional Development

14. The RCM is concerned that proposals for localising the funding of continuing professional development (CPD) risks further eroding the opportunities for midwives and others to update their knowledge and skills. The midwifery profession has a long history of CPD—dating back to 1936—and this has allowed midwives to maintain and develop their knowledge and skills in line with changes to women’s expectations and needs, technological developments and emerging research and evidence. Many midwives find their development opportunities are now largely confined to mandatory training only. Whilst training in, for example, an update on lifting and handling, is of course useful, it is also imperative that midwives and other practitioners should meet and learn with colleagues from other areas, as this can be an important means by which they learn and share good practice, and generate new ideas and approaches to care. Any new arrangements must be predicated on the principle that all groups within the NHS workforce are dealt with equitably and are able to access sufficient education and training opportunities, including access to CPD.

Midwife Teachers

15. The RCM is also unclear how the future development needs of midwife teachers will be addressed under the proposed new arrangements. Experienced midwifery lecturers are essential for teaching and facilitating learning, and assisting in the development of students as reflective, effective decision-making practitioners, and support of qualified staff. Regrettably, the midwife teacher workforce is ageing, turnover is stagnant, and class sizes on the rise. HEE and other bodies concerned with education and training will need to address this issue as a matter of urgency.

16. The RCM believes that there needs to be greater emphasis within the education sector on recruiting skilled and experienced midwives into lecturing roles at universities. To achieve this, there will need to be an improvement in the conditions in which they work, including pay and access to clinical practice. Employment conditions for midwife teachers are often less appealing than for those in practice roles, such as consultant midwives.

17. All midwifery lecturers are practising midwives and spend a proportion of their time working clinically, alongside student midwives and also qualified midwives. This provides an ideal opportunity to support clinicians, and also identify issues that might need inputting into parts of the midwifery curriculum, for example record keeping skills, or communication. The RCM would welcome a system that enabled the clinical service providers to work in tandem with higher education colleagues, enabling the education and practice of students and qualified staff to be supported and developed, enriched by research and evidence that academic colleagues can bring to their service partners. It is also important to recognise the huge contribution of service providers to the support and nurturing of student midwives. Especially at this time with significant pressures on the system it would assist if arrangements were made to reimburse employers so that they could “back fill” for the clinical time expended on student support.

18. Mechanisms need to be developed to facilitate movement of midwives between the NHS and Higher Education Institutions, as this would encourage secondments, and shared working between both to the benefit of the NHS and to students and qualified staff.

19. The NMC’s Midwives in Teaching (MINT) project (2011) demonstrated the value of clinical practice in midwifery education. For example, students were able to develop competence and familiarity with clinical settings and build confidence with early practice placements and where lecturers effectively integrated practice and theory. This highlights the critical importance of the link between education and practice which is easily lost as academic institutions increasingly focus on research excellence.

20. The RCM would also highlight that there is a need for further research and evaluation work into the sphere of education, training and workforce planning, in order to ensure that good practice is identified and built upon, and evidence based practice is truly imbued into all spheres of the health service.

December 2011

1 HC Deb, 17 November 2010, c 882.

Prepared 22nd May 2012