England needs more midwives: but legal services are fine

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I was interviewed on Radio 5 Live yesterday, in relation to the news coverage of the National Audit Office revelations of maternity care.  The report confirmed the fact that England IS short of midwives, and revealed that the NHS spends nearly £700 on clinical negligence cover for each live birth in England. I wonder how many times audits and reports will confirm what we midwives have known and shouted about for years, and how long the message will continue to fall on deaf ears.

The Royal College of Midwives,  National Childbirth Trust, AIMS,  Women’s Institute and other organisations have campaigned long and hard for more midwives, needed urgently for the rising birth rate and increasing complexity in caring for mothers and babies. But there is something else going on here. The financial implications of England’s current negligence insurance scheme (Clinical Negligence Schemes for Trusts) mentioned above are bad enough, but associated processes also significantly increases the workload of maternity care staff, and adds to the growing culture of fear in maternity services.

In an attempt to increase safety through implementing standards of compliance, activity related to the scheme potentially increases risk by putting extra pressure of individual members of staff. ‘Tick box’ activity, extra form filling, and duplication of records add to the human cost and potential for mistakes. In many organisations midwives are taken out of generic posts to work as ‘risk midwives’ or governance leads. Usually these midwives are highly competent clinically, and their absence in the clinical area is missed-adding to the risk.

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However, an important impact of our legal system is related to practitioner’s fear of recrimination, and fear of litigation. Defensive practice or ‘covering your back’ ‘just in case’ is a recognised symptom of fear of litigation-and subsequent over treatment increases the risk of iatrogenic harm.  The increased and often duplicated recording of information becomes the focus of ‘care’, as practitioners complete patient records which are audited for insurance purposes. What the carer writes becomes more important than what she/he does, and women and families increasingly experience this distraction negatively.

The medical negligence solicitor who took part in the radio programme with me yesterday, said midwives and doctors need to increase their skills, and he suggested that England’s medical negligence processes were the envy of the world. I have a different opinion. Ensuring safety through appropriate skills is crucial, and whilst mistakes will happen, there is no excuse and we should continually work on improving services. Along with others, I believe improvements will only come if NHS workers are sufficient in number to have time to care, and that they are supported and nurtured enough to feel safe themselves. Where fear prevails and defensive practice in normal, women and families will continue to suffer. Radical but carefully planned changes are needed. Malpractice claims are rising, and there is little evidence that safety is improving, despite the laborious and bureaucratic systems and process imposed in the name of such. Our negligence claims insurance schemes aren’t working, and midwives are on their knees. Even though politician Dan Poulter is an obstetrician by profession, his responses to the NAO report reveal limited insight into the detail underpinning the facts that matter. We’ve said it before many times. If we don’t get it right for mothers and babies at the beginning of life, the impact can last a lifetime.

Childbirth has far reaching public health implications. This specilist medical negligence solicitor reveals the fact that many of the claims she sees are the result of pressures within the maternity systems, and calls for more resources to be invested.  Maybe it’s time to revisit a no-fault compensation scheme, the attempt in 2003 was never taken forward. Scotland has pursued this in light of the success in other countries.

Whatever we do, we can’t continue in the same vein. I would love to know your thoughts.

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23 comments on “England needs more midwives: but legal services are fine

  1. Oh dear, Sheena. Your words have reduced me to tears. This last fortnight I have felt like I am running on empty. Stillbirth. Removal of baby by social services. Sitting on women’s sofas to hear yet again the words ‘ it was at this point that I wanted to die!’. Four on-calls and four call-outs. An obstetric emergency where I’m required, there and then, to fill in yet another form. And there’s more. This is all on top of a new computerized record system, more form filling, more boxes to tick, and re-tick. There is no time for re-fueling, physically or emotionally.

    I often describe myself as working for women, and being paid for by NHS. I am a Midwife, and I have to fight long and hard to do the job I love, but I’m tired. The paperwork and defensive practice, now expected of us, will be the death of Midwifery as we know it.

    What you’ve written, Sheena is a great description of the problem we face. Thank you for sharing.

  2. Wonderfully written, and I whole heartedly agree we need more midwives rather than more paper tick box exercises for midwives. The cnst scheme has been highly criticized by The Kings Fund for not improving maternity services, and trusts who create risk midwife roles spend unnecessary funds to achieve level 2 cnst, when in fact maternity services would be improved greatly if the investment was made by increasing the number of clinical midwives. The Kings Fund further criticise by acknowledging that those trusts with level 2 don’t invest the monetary incentive back into maternity.

  3. Having experienced the ‘no fault litigation’ in NZ, I can see the benefits of it Sheila. I find it so sad returning to UK and seeing how the situation is even worse than when I left the national R & R post at the end of 2004 😦

  4. My 15-minute antenatal visits earlier this year and those of several other pregnant mums in my street result in stressed, anxious, depressed mums-to-be who feel totally unsupported at best and under attack at worst. As over-stretched midwives give more attention to form-filling (and handwriting computer records – WHY???!) during these all-too-brief appointments than speaking to us as human beings and finding out how we are, it didn’t occur to me it was all about litigation at the time but I suppose that is probably the root cause. Regrettably, the overall antenatal experience is marred severely by the fear of litigation that seems to underpin NHS midwifery services. I feel sure it’s not what most midwives entered the profession to do.

    • I was saddened to read how you and other mums-to-be felt following your antenatal check ups. I wonder how many more women in the UK feel the same? I am a Midwife of 16 years and can bare witness to the changes in practise over that period. As highlighted in news coverage this week £1 out of every £5 spent on maternity services is to cover litigation costs! I am an active member of the Royal College of Midwives, the RCM has been lobbying local MPs and the government for years to increase the number of Midwives rather than putting systems in place (form filling, tick box exercise, CNST) and have they been listening? I think not! We need women such as yourselves to speak up by contacting your local Hospitals, MPs etc to highlight your concerns. Since the recent Keogh Report where 14 hospitals in the UK were been put on special measures this has created a change in how patient complaints are dealt with by Hospital Trusts. Ask the Midwives at your doctors who and how you can contact a Supervisor of Midwives and Head of Midwifery services so you can discuss your concerns. If you know other women with similar experiences get together and highlight your concerns together. I hope you can move forward with this and get the care and support you deserve. Wishing you well x

    • Thank you for sharing your thoughts Rebecca, and I am so sorry you feel unsupported and stressed during your pregnancy. It would be good to talk to a Supervisor of Midwives where you plan to give birth as Alison suggested; they will be keen to help you, and to get feedback. It’s important to let the staff know as I believe change WILL happen, though women and communities making it clear when things aren’t right. Mothers (to be), midwives and doctors with others will influence the future together, but right now it’s just about you and your family. Good Luck, and thank you again. Let me know if I can help in any way 🙂

  5. Thanks so much Sheena, this so hits the nail on the head. The more risk processes there are the less the system trusts midwives. Trusting relationships are what is needed, both from top down – trust engenders trustworthiness. The system must learn to trust midwives. And from bottom up – wouldn’t it be even better if women could be given a midwife who knows and trusts them – and vice versa – a midwife they can get to know and trust. This would led to less fear-driven practice and less litigation. And of course oxytocin is the hormone of trust!

  6. Absoloutely to the point and yes midwives globally are working with a system where when the midwife works in partnership with the woman and respects her human rights. provides holistic care and even with celebrated birth the system fails the midwife and with that many excellent midwives leave the profession. fear driven practices by establishments are taking away women’s choice and with that there will be more trauma after childbirth as women will lose trust in the institutions that provide care. midwives are the heart and soul of childbirth and women are the driving force of childbirth and both deserve respect for they have the ability to birth well without fear.

  7. The shortage of midwives and at times doctors impacts on quality of care given – end of! Removing experienced highly skilled midwives from clinical practice to roles such as Risk Assessment and Clinical Governance only decreases the availability of circulating Midwives on the shop floor in order to give one-to-one care to women and their families. I am a highly skilled experienced midwife who gives 100% each and every day but this just doesn’t seem to be enough! And to be told by managers to better manage ones time or to multi-task isn’t in the slightest helpful or supportive! I understand pressure comes from line managers and higher management and feel this is where we need to breakdown barriers and change behaviours to encourage a more nurturing and caring management team so Midwives, Midwife Support Workers and Doctors are listened to and are fully supported. Communication is floored in many areas within the NHS structure, which was highlighted in the Keogh Report. Midwives need to empowered and truly supported so they can become central in service delivery. Our Midwifery Co-ordinators are ideally placed within the service to drive forward this change. However dependant on their personal ethos of management maybe the first stumbling block. A ‘do-as-I-say’ mindset disempowers Midwives. A a more open, positive, empowering and supportive culture is crucial to have a beneficial impact on maternity care delivery. Why are our leaders not encouraging and permitting Midwives to leader? Some staff are very disillusioned and feel that are not given the opportunity to express concerns without reprieve – again highlighted in the Keogh Report! This is where my heart lies – breakdown old ways of working to stamp out controlling and restrictive behaviours and replace them with openness and honesty together with a caring and supportive culture to empower our Midwives to create a maternity service to truly care for those we serve – who is with me??

    • Brilliant Allison! I think you have hit the nail on the head. Fear ‘of above’ underlies ALL of the defensive practice and negative culture. Every part of the team, be it management, midwives, NQMs, HCAs, Drs, are watching their backs and often more concerned with being seen to be working effectively (i.e. quickly and following protocol to the letter) by their own superiors and CNST audits than actually providing truly empathetic and compassionate care. I would say the majority of us do genuinely care deeply and want to provide the best care we can, but It’s just not possible. We are all caught up in this web and it’s all driven by lack of staff, lack of time and fear. Staff feel undervalued which leads to low morale and the behaviours of an ‘underdog’ profession…backbiting, negativity, bullying etc.

      I would hate midwifery to become a soul-less profession, women deserve better…and us midwives, HCAs and Drs deserve better too.

    • Thanks Alison, it’s worth remembering that the leaders and managers are stuck in a sandwich of bureaucracy and cost cutting dilemmas…and they need support and encouragement too, especially from those willing to change. External reviews aren’t always the best thing for morale; try reading Time to Care by Robin Youngson- you’ll find it here, with some inspirational videos http://heartsinhealthcare.com There’s answers and tools in there to help practitioners to deal with stress and concerns.

      Whilst I highlight issues in my blog, I truly believe ion the NHS and want to influence for change…most mothers and midwives use it, and it needs help. Brilliant that you feel passionate enough to comment; thank you! Sheena x

  8. Neighbourhood Midwives is with you Alison! We have set up as an employee owned organisation by midwives for midwives to nurture and grow exactly the sort of culture you are describing – one in which everyone looks after each other and midwives are trusted and empowered to work autonomously but with the governance structures to support them not restrict them.
    As a social enterprise we are not the ‘greedy private sector’ – we want to be and could be an integrated part of the NHS but working in a truly innovative way collaboratively with other Trusts and organisations to give seamless care – a return to relationship based midwifery with, as Margaret says, trust at its core. That could be one way to start to address the litigation time bomb – ideally combined with a fresh look at no fault compensation, which could be trialled in one small area (neurological damage for example) and then evaluated properly to see if it works. CNST as far as I am aware has never been evaluated…..

  9. Things have certainly changed since I left the NHS in 2002. Sad to say, but the defensive practice strategies only impact safe clinical practice. They do not improve it. I know this, because I moved from the NHS to the USA where maternity care is appalling. Women have little to no choice. Most care is provided by obstetrician’s who work according to volume. The more people they see the more money they earn. If a woman see’s her OB for more than 5 minutes she’s doing well. Education and advice on best practice is negligible. When the women arrive in Hosp, they are all treated as high risk ‘just in case’ scenario. Interventions take place for all except those who arrive with their baby crowning.

    Many hospitals won’t permit VBAC’s and I’ve sadly, sickenly witnessed women who are fully dilated upon arrival to the hospital being told that they need a C/S because of their prior C/S. Women who question this decision are often told by the OB that if they don’t consent to a C/S their baby will DIE! Yes. That’s what they are told. So their choice is stripped from them!

    Others have told nursing staff that they do t want their patient’s to be educated, as they can not do what they wish to them, which means a longer working day.

    Access to midwives is minimal & insurance coverage is a joke! It is so difficult and expensive for the women that midwifery support can be unrealisable for many.

    Please UK, don’t destroy what you have. Cherish it. Enrich the service. Hire more midwives and don’t continue following the USA on its obstetric path. It’s not worth it. Lead by example. Best practice!

  10. Unfortunately we are following the USA into being a litigious society and as usual, the only winners are the insurance companies who sell these policies. At £700 per live birth, and 20% of the NHS maternity budget, I can’t help but think the premiums are exorbitant and the NHS is not getting value for money. I don’t know of any private industry that would not challenge such costs. Our government should not be allowing private insurance companies to rip off the NHS so blatantly.

  11. Thank you Annie Francis! So glad I am not alone! Your enterprise sounds like you are encompassing everything I want for NHS maternity care! Where are you based? I would love to meet with you together with a couple of my colleagues and see what you are achieving. Do you feel this would be possible? Ali

  12. I have been so frustrated with defensive midwifery, investing so much time complying with CNST and trust standards and guidelines. I long to get back to caring for ‘our women’ 100% as we used to. So much stress is put on us now. I was thinking of going back to basics, simply by discussing with the women how they would like their care in labour to be, getting her to sign our agreement and then freely look after her to the best of my abilities! This agreement would include a discussion about whether she’d like me to attend to her needs or have my back to her filling in the electronic partogram!
    I agree with your article wholeheartedly Sheena, keep up the campaign!

  13. I have only just read this. I agree with you. I remember many times our manager threatened us with disciplinary action if we didn’t fill in our cnst forms. This was so wrong, and is why you are right we must have no fault compensation.

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