Recent developments in delivery
of maternity care
7. It is impossible to elaborate about staffing
levels without first referring to major developments in the NHS
since the early 1990s. Over this time policy changes which have
impacted on the delivery of maternity services have been underway
including the Calman Report and the "New Deal" for junior
doctors. However the major policy which affected midwifery services
was the identification of the need for maternity services to achieve
a truly woman centred approach. As a result of the implementation
of "Changing Childbirth" in England and parallel documents
in Wales and Scotland a number of service aspects were highlighted.
They are detailed in Appendix 1 of this submission. Midwives were,
in many places, required to make major changes in their working
and professional lives to accommodate some of these "indicators
of success".
8. One example of such change would be a
new requirement to work on a "rotational basis". Whereas
previously midwives may have been largely based in one area, for
example labour ward, and concentrated their skills on the particular
aspect of care related to that area, the implementation of women
centred care meant important changes on two fronts. Professionally
midwives were required to develop their skills in areas of midwifery
practice they had not previously concentrated on. A midwife who
had long been based in the labour ward, for example, would have
been required to also give care in the community setting, acquiring
new expertise in areas such as working within a multi-disciplinary
approach to care. Continuity of care also impacted on working
practices. Whereas midwives have always functioned across a range
of settings, they were traditionally based in either the hospital
or community. Women centred care required midwives to work across
both settings (hospital and community) on a daily basis, in order
to individually provide total care to their women.
9. A second example of such change involves
a redefinition of midwives' working relationships. Instead of
the traditional ward based approach to staffing, midwives have
in recent years joined together into teams. The size and working
arrangements of these "teams" are very variable. However
the basic underlying principle remains that of a "caseload
of women" being cared for within a designated group of staff
who, between them, ensure that she is familiar with all the midwives
with whom she will have contact and that those midwives take responsibility
for the full range of her care. The nature of this care means
midwives working on a more intensive basis—in particular
being available "on call" outside of normal working
hours for their "caseload" of women.
10. No extra resourcing was identified within
the NHS to deliver "women centred care"; the Government
indicating it should be delivered on a cost neutral basis. As
a result no adjustment was made at national level to the staffing
requirements and skill mix of midwives charged with delivering
this new focus on care. (Note: skill mix is used in the sense
of ratio of qualified to unqualified staff and the combination
of different grades). While some of the "indicators"
relate to relatively straightforward alterations to service, others
have significant staffing implications. As this submission will
later identify, special research which has been commissioned by
the RCM will illustrate how successful outcomes on these indicators
are related to staffing considerations.
11. There are also ongoing national policies
which affect maternity services, in particular to do with audit
and risk management matters. Current audits include: records,
induction of labour, antenatal guidelines, breast-feeding and
standards. Actioning these audits and in particular dealing with
the implications of their recommendations impacts upon both management
issues, such as putting systems in place and the provision of
in-service training. These in turn affect staffing requirements.
12. Finally the Government has signalled
its intention to further improve public health and therefore the
health services to the population. Policy documents such as:
— The New NHS: Modern and Dependable
continue to raise the expectation of the population
and will inevitably impact on the staffing requirements within
midwifery services.
Summary Point
13. The NHS identified a major policy change
in the delivery of maternity care in the early 1990s. Major changes
were incorporated into their working lives by the majority of
midwives. No extra resourcing was made available. Neither were
any other changes made at national level to facilitate delivery
of the new, nationally defined, policy objectives. Further important
policy developments are in the pipeline which will also impact
upon staffing levels within maternity services.
