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Select Committee on Health Minutes of Evidence

Memorandum by the Royal College of Midwives

FUTURE NHS STAFFING REQUIREMENTS (SR 46)

B. STAFFING LEVELS IN MATERNITY UNITS

Current arrangements—NHS Trust establishments

14. Historically there has been no framework for defining staffing levels or skill mix (the ratio of qualified to unqualified staff and the combination of different grades) within maternity units. As a result there is great variability in both staffing levels and grade mix across the UK. This disparate approach is also ad hoc, in other words there is no match between these staffing levels and the flexible patterns of care referred to above.

15. To help illustrate this point for the Select Committee the RCM carried out a survey of 60 Heads of Midwifery. This, combined with the annual survey we carry out each year in preparation for RCM "evidence" to the Pay Review Body (PRB), indicates the following points:

— The annual RCM survey of 158 Heads of Midwifery for the PRB revealed that in both 1997 and 1998 these service managers do not believe the funded midwifery establishment for their Trust has been adequate for the level of activity undertaken. Particular concerns have been expressed about the inability to meet new initiatives because of inadequate staffing. (See para 20 below) Anecdotal evidence from these surveys also indicates that there are some maternity units where establishments have not changed in 20 years, despite a change to a holistic role for the midwife.

— Of the 60 Heads of Midwifery who have specifically provided material for this submission to the Select Committee, initial analysis reveals that the majority regularly (eg annual/bi-annually) review their establishment. However the criteria or "tool" used varies hugely and includes the following: midwife/delivery ratios, "past experience", comparisons with other units, midwives to beds, "Birthrate", dependency levels, "regional norm" and "money available". In addition, a number of Heads of Midwifery, indicate that they never review their establishments. These varied approaches no doubt reflect, in part, the lack of national indicators for staffing levels. (See Appendix 2) As we will elaborate below, however, the varied and flexible nature of maternity care would make it difficult to put rigid criteria in place for setting establishments.

16. Midwifery grade mix throughout the NHS is also hugely varied. The reason for this is in part historical. On the one hand the implementation of the clinical grading structure in 1988 gave rise to widespread discontent within the profession as midwives in roughly similar jobs found themselves on differing grades depending on which part of the country they worked and also, even more regrettably, whether they worked full or part time. In 1995 and in response to the implementation of "women centred care" (see above) the NHS Executive reached a specific agreement with the Royal College of Midwives on the grading of midwives working in this way. While the basic premise of this agreement was a minimum grade of "F" for such midwives, no provision was made for its implementation on a national basis. The RCM has endeavoured to progress the matter throughout the UK but has only been able to achieve limited success. As a result only a small number of maternity units, (less than 30 out of total of 280) employ midwives on a minimum of grade "F". The use of the lower grade "E" therefore remains widespread. An unpublished survey by the NHS Executive over the summer (1998) reveals that over 50 per cent of the midwives in some units, notably in the north of England, are graded below "F". This result accords with the RCM's own monitoring information which also reveals intensive use of the lower grade in many units, notwithstanding the fact that the work carried out by these midwives is closely comparable to that carried out by midwives elsewhere who are on the higher grades of "F" and "G".

Summary point

17. It is impossible to establish a coherent picture of the levels of staffing within maternity units, the extent to which these are reviewed and the basis upon which this is done. The approach currently used within the NHS is completely piecemeal and frequently irrational. While midwives have been charged with delivering national policies in maternity services, no corresponding measures have been put in place with regard either to the numbers of staff needed to deliver the required services or the appropriate grade mix.

Current arrangements—midwifery education

18. Places on midwifery degree programmes and training for practising midwives (which will be dealt with in Section C of this paper) are commissioned by local education consortia. These bodies determine the number of degree places according to criteria which includes: availability of clinical placements and skill mix. In recent years there has been a major reduction in the number of midwifery training places commissioned. Between 1992 and 1996 midwifery training commissions in England were cut by 20 per cent. Although there has subsequently been a modest increase in training places, the English National Board (ENB) has recorded a 7 per cent fall in the midwifery training population, from 3,521 to 3,263 students in the last year. Put simply, there are just not enough newly qualified midwives entering the profession to enable Trusts to meet the demands of the service.

Summary Point

19. Responsibility for determining the future staffing needs of midwifery services belongs to local educational consortia. In recent years there has been a fall in the numbers of training places.

Identified problems with current arrangements

Users of maternity services

20. Thus far we have identified several major changes that have taken place in maternity services over recent years and the lack of a coherent approach to staffing. The inadequacy of this situation has far reaching implications for service delivery. It affects service users, in particular women and their babies, and relationships within the "health team".

21. Effects on service users can be separated into two areas: the scope of choice available to women and their perceptions of the quality of care they have received. Two further pieces of research in these areas we would like to bring to the attention of the Select Committee are unpublished work specially commissioned by the RCM, based on a survey of 121 maternity units, and a report earlier this year by the "Audit Commission", "Women's Views of Maternity Care".

The following table 1A, drawn from the RCM's survey of Heads of Midwifery, sets out six national indicators of success for women centred care and the Heads of Midwifery assessment of the extent to which these have been met.

Table 1A

Indicator of Success Indicator met No. of units

Every woman should know one midwife who is responsible for continuity of maternity care 36 121

30 per cent of women have the midwife as the lead professional 31 117

Every woman should know the lead professional responsible for the planning and provision of care 40 119

75 per cent of women should know the person who cares for them during their delivery 10 120

Midwives should have direct access to some beds in the maternity unit 62 117

All women should have access to information about the services available in their locality 56 120

22. It is clear from the above that those indicators least dependent upon staffing input, such as access to information and, for midwives, access to beds—are those where Heads of Midwifery consider the most progress has been achieved. On the other hand minimal progress has been made towards the target of women knowing the midwife who delivers them. In order to deliver a degree of "continuity of care", in other words ensuring women know their midwives, working arrangements have to be redefined in such a way that the women and midwives are in regular contact. A variety of models now exist within midwifery services to provide continuity of care/carer: various team approaches (both large and small), group practices and "one to one midwifery". All of these models, however, have implications for staffing levels.

23. The RCM's evidence to the Pay Review Body in 1998 also deals with this matter. As we have already identified (para 13), the Heads of Midwifery we have surveyed do not consider their establishments adequate to meet the level of activity undertaken. Table 1B, below, identifies those factors which these senior midwives believe contribute to inadequate midwifery establishments:

Table 1B


Factor	No of Heads of Midwifery

Impact of woman-centred care	72
Levels of sickness/maternity leave	64
Reduction in junior doctors hours	48
Reduction in midwifery budget	32
Changes in delivery rates	29
Social/demographic change	19
Other factors	16

In other words, these senior midwives are saying that their establishments are not adequate to delivery women centred care, although other factors also impact on staffing shortages.

24. The Audit Commission has dealt with the perceptions of women in terms of their choice. The majority of the women surveyed on this matter felt that they had no option as to where their baby was born or that their "choice" was down to only one hospital in particular. (Page 53 "First Class Delivery"). Staffing shortages are also referred to by the Commission: "Two-thirds of women (68 per cent) said that they . . . were left without professional support at some time during labour. One in four of these said this happened at a time when it worried them to be alone".

Summary point—service users

25. It is clear from a number of research projects that national polices for the delivery of maternity services are not being delivered due to staffing shortfalls. It is, we believe, wrong for the Government to lift the expectations of the population in such a profound experience as child birth and then fail to review, let alone make the necessary adjustments, to ensure delivery of such policies. In other words, the future staffing requirements of the NHS cannot be examined to the exclusion of policy development and implementation in the wider health care field.

Providers of the Service

What about midwives themselves?

26. While there are no easy answers, we are in no doubt that a silent revolution has been taking place for midwives—both in terms of their professional and working lives. On the one hand midwives report that the implications of women centred care have been to make their professional lives more rewarding. Getting on for half of the midwives who took part in our unpublished research (paragraph 18 above) indicated that they exercised more skill and discretion in their role. Examples of role extension provided by Heads of Midwifery cover an enhanced clinical role for midwives: for example suturing, carrying out ventous deliveries and engaging in complex scanning routines. All of these procedures have training implications which are additional to midwives' existing responsibilities. Midwives have a long and developed history of continuing professional and educational development. However whereas doctors are reimbursed for training costs, should they choose to undertake these, midwives are legally required to maintain and develop their competence and to acquire new skills. There is no automatic entitlement to reimbursement of the costs involved, with the result that midwives are increasingly having to continue their professional development in their own time and/or with their own funds. They are also paid significantly less than doctors.

27. On the other hand, hours of work among midwives have increased substantially since 1991, in just under half of the 121 units we surveyed. Of these midwives 62 per cent indicated they occasionally worked longer hours than their basic working week. Just over one-third—36 per cent—regularly worked longer hours. Around half of the midwives working in this way were doing five or more extra hours per week. A small number (6 per cent) were doing an extra 10 to 15 hours a week! The overtime worked indicates one of two things: either their units are not up to full establishment or, while their unit does not suffer from staffing shortages, the establishment is inadequate to deliver the care expected.

28. The message from midwives is shared by their managers. The following table, from the RCM's research (paragraph 18), summarises the perceptions of Heads of Midwifery.

Table 1C

CHANGES IN MIDWIVES' JOBS SINCE 1991 (% OF UNITS)


Changes in:	Large Increase	No. of Units

Responsibility in the job	35	120
Effort required (Intensity of Work)	30	121
Pace of work	45	121
Provision of training	21	120
Promotion opportunities	1	120
Job security	1	117

29. "A Review of Midwifery Led Care" published in the Midwifery Digest "MIDIRS" in 1997 concluded:

"A picture emerges over the last six to seven years of a major shift in clinical workload from obstetricians to midwives yet there has not been a corresponding shift of resources from obstetric to midwiferyservices . . . In the post "Changing Childbirth" climate where the demand for midwifery led services is growing, a debate about the appropriate allocation of resources for obstetrics and midwifery has been conspicuously absent."

Summary point—service providers

30. Midwives have made a huge increase in their professional contribution to the NHS since the national policy of women centred care was implemented in 1991. However, because the matter of resources was never addressed, the increased expectation of service users—pregnant women—is being met on a patchy basis. This patchy service directly relates back to failure to consider staffing implications. Midwives themselves are working longer hours than ever before—and at an increased pace. In other words, what progress has been achieved on the national policy objectives of women centred care has been resourced almost exclusively by midwives themselves.

Frameworks on which to base establishment

31. This submission has identified that there is no regular tool for assessing the establishment of midwives. If and when they are reviewed, a range of ad hoc measures are used. As a result establishments vary hugely across the country. There is often no relationship with the services offered and the outcome for both staff and service users is, to say the least, unsatisfactory.

32. A number of Heads of Midwifery responding to our "Select Committee" survey identified a further constraint: the requirement to find "savings" from the maternity budget in order to comply with Trust cost restraints. Typically these have tended to be in the region of 2-3 per cent of their budget and inevitably impact on staffing. Some units have "restructured" in order to find savings, most frequently by downgradings or freezing vacant posts, especially the more senior "career" midwifery posts (eg, Grades "G' and above). Others, in particular in the south of England, report that the difficulties they are experiencing in recruiting midwives translate into "savings" on vacant posts, thereby possbibly precipitating a downward spiral in their establishment in the longer term. Safeguards on staffing levels are therefore urgently needed within the system to arrest this process.

33. Nearly all the Heads of Midwifery responding to our survey indicated that maternity services would benefit from the "identification of parameters" which could be used to work out staffing levels. The need for flexibility with such "parameters" is paramount. Not only is there variability in the ways midwives deliver care, there is also a degree of unpredictability in the activity levels within maternity units at any particular time. It is not always possible to get a perfect match between numbers of women in labour and staff on duty! Numerous other features were also identified by Heads of Midwifery as impacting on staffing levels. Included among these were: the reduction in junior doctors' hours, role of "core staff" especially in intra-partum care and needs of local populations. One senior midwife reported that preliminary work she had been engaged on at regional level on this matter had identified no less than 40 different factors! The danger, in other words, is that the exercise becomes wholly unmanageable.

34. A number of Heads of Midwifery identify a way forward which entails a two track approach: nationally set parameters to indicate minimum "safe" staffing levels combined with scope to adapt the model locally. Local factors could include: location of the population (rural areas necessitate higher staffing levels for example), specific local health care needs, innovative models of care and working relationships between midwives and medical staff, in particular obstetricians.

35. The potential benefits of such an approach would be that:

— safeguards would be put in place at national level which would preclude staff being forced to practice unsafely because of financial constraints;

— flexibility would be ensured through local indicators;

— the impact of national policies, in particular "women centred care", quality and changes to the working practices of other medical colleagues (eg reduction in junior doctors' hours) would need to be fully thought through, before their implementation;

— service users and providers would benefit from a more rational and consistent approach.

Summary point

36. While changing patterns of maternity care have made it difficult to work to a tightly prescribed ratio on staffing levels, the absence of any indicators at all can result in staffing being heavily influenced by financial constraints. This, in turn, can result in midwives having to practice unsafely because of staffing shortages. An approach to staffing which identifies nationally determined minimum "safe staffing levels" for maternity units combined with a range of "indicators" to accommodate local circumstances and the need for flexibility offers a solution.

Improved Interface with Education Commissioning

37. Because the consortia take account of current staffing when determining numbers of placements, it is logical to conclude that the inadequacies of establishment settings will have a knock-on effect. The interface with education also need to include the following:

— The midwifery services should have identified in its budgets, time for the teaching and supervision of student midwives, student nurses and medical students who are gaining experience in the clinical areas.

— Newly qualified staff needs support to enable them to become confident in their practice. They need the support of preceptors. The staffing levels should reflect the time which the preceptors will be spending with the newly qualified staff.

— Evidence based care is an important part of clinical governance. In order for midwives to provide this type of care, the staffing levels should be such that midwives can spend time understanding the new technology and research which would supply the evidence.

— Midwifery services with a high level of women who need special social, medical or language support should have a higher ratio of midwife to women so that the educational needs of the women and the midwives are met.

Other means of improving recruitment and retention rates

38. For several years now, the RCM's evidence to the Pay Review Body has indicated serious midwifery recruitment difficulties in many parts of the UK. However, and as we have pointed out in our 1998 PRB evidence, there is a large pool of midwives who are choosing to remain outside the profession. For the year ending UKCC figures show that as of 31 March 1999 there will be 93,776 registered midwives, but only 32,803 are currently practising—ie almost certainly working as midwives within the NHS. Thus for every midwife currently at work, there are another three who are choosing to remain outside the profession. The problem is likely to be exacerbated in view of the decline in the number of practising midwives, which stands at its lowest point this decade.

39. Two final pressures on the system come from midwives themselves. The RCM welcomes the current move within the NHS to promote family friendly policies, including flexible working. Midwives are increasingly choosing to work part time, the total number of such midwives has increased from 38 per cent in 1991 to 48 per cent in 1998. The cumulative number of hours worked by midwives is therefore declining and the age of the midwifery workforce is moving ever upward. An analysis of the UKCC data by age breakdown reveals a continuing decrease in the proportion of practising midwives aged less than 40 years. Up until 1998, the proportion of midwives under 40 was decreasing by around 1 per cent per year, but in the last 12 months there has been a noticeable acceleration in this trend. We are greatly concerned that the rising age profile of the midwifery workforce is yet another indication of the difficulties Trusts are having in attracting new entrants to replace those midwives who are leaving the profession.

40. Within such a climate the importance of the NHS retaining and attracting back its midwives becomes paramount. While a lot of work is currently underway with regard to equal opportunity matters, for example family friendly policies, the NHS cannot afford to continue to disregard the question of pay. Table A20, cited earlier in this submission, identified that while midwives were working harder and more intensively their reward for doing so was minimal. The RCMs own internal research of Heads of Midwifery on the main ways of preventing loss of midwives indicates that "better pay" comes out top—receiving the support of the clear majority. Other approaches indicated by Senior Managers responding to the survey for this submission include:

— improve staff facilities;

— enhance recognition and remuneration;

— better promotion opportunities;

— encourage and support "return to practice"

— salary that fully reflects the responsibilities of midwives;

— guaranteed support for training;

— minimum grade "F"; and

— separate pay spine from nurses.

Summary Point

41. On a variety of fronts, including current recruitment and retention rates and demographic changes the NHS is seeing a serious reduction in the number of midwives. While it is essential that future staffing levels are determined on a more rational and consistent basis, this will not in itself wholly solve the problem. Unless the NHS starts to value its midwives in a way which recognises their worth in the time honoured way—eg pay and career opportunities—the RCM does not believe the current situation of midwife shortages will significantly improve.



© Parliamentary copyright 1999	Prepared 3 March 1999