Under-motivated, Under-skilled and Under Threat

ISSN 0256-5004 (Print)

AIMS Journal, 2000, Volume 12 No 4

When midwifery skills are in decline, the quality and safety of women's experience of birth is also under threat. AIMS' Chair Beverley Beech argues that proposals for a new Nursing and Midwifery Council can only cause the deterioration of an increasingly deskilled and undermotivated profession.

For 40 years AIMS has been pressing for better maternity services at both local and national level. Almost twenty years ago, in response to the Briggs Bill, AIMS joined with concerned parents, midwives and other concerned professionals, to protest at the proposal to combine the Central Midwifery Board with the nurses within the UKCC.

AIMS' position was that combining midwifery with nursing would result in a diminution of midwifery skills and would adversely affect the quality of care for mothers and babies. We were assured that these proposals would be reviewed in ten years time. They never were and our anxieties have been proven correct.

The new council

Recently we were sent a draft of the proposals and a questionnaire which gave us the opportunity to provide input and comment on proposals for a new Nursing and Midwifery Council. The way the consultation was conducted was less that acceptable and only served to confirm our worst fears for the profession.

AIMS' members believe that the present plans for a new Nursing and Midwifery Council are unacceptable and those aspects of the plan which are concerned with midwifery are totally unacceptable. Token acknowledgement is made of midwifery as a separate profession from nursing, but the proposed structure does not support this and, as a framework supposedly designed to fulfil the obligation to protect mothers and babies, it is a failure.

Without a strong, separate, Midwifery Board with clear aims midwifery practice will continue to decline. A Midwifery Board should, therefore:

  • Provide an effective regulatory system;
  • Protect the public from sub-standard and negligent practitioners;
  • Provide a framework which will support and strengthen midwifery practice.

The best interests of mothers and babies will only be achieved by a Midwifery Board which is totally separate from a Nursing Board. To do otherwise implies that midwifery is merely a branch of nursing.

These Boards could be supported by a structure which provides for an umbrella executive which would be responsible for maintaining the register and administering professional conduct procedures etc. A Midwifery Board would enable the midwifery profession to be entirely responsible for education, standards and accountability and would be responsible for the Midwives Rules and administering the Supervisory structure.

The public expects real accountability and involvement in the provision of maternity care and to fulfil this the Board should comprise equal numbers of lay representatives and midwives.

A weakened and deskilled profession

Since the NHS Re-organisation Act, implemented in 1976, the midwifery profession has been weakened and de-skilled. AIMS' members strongly believe that the present proposals will continue that trend, and will further diminish the high standards of care women and babies are entitled to expect.

AIMS' members are increasingly concerned about the loss of midwifery skills. A soon-to-be published survey of normal birth is expected to reveal that less than 14% of first time mothers, and only 24% of second and subsequent birth mothers had normal births in the five large centralised obstetric units surveyed.

Many of our calls from concerned women reveal the reluctance of many midwives to attend birth at home, as they no longer have the experience. Women who wish to have a normal, physiological birth of a baby presenting by the breech, or twins, are experiencing considerable difficulty in finding sufficiently skilled midwives, or even midwives willing to gain these skills.

Such women are condemned to unnecessary surgical deliveries. AIMS members who have served on the UKCC and Midwifery Committee reported continual examples of the UKCC's failure to understand and strengthen the midwifery profession, or address the above issues. A great deal of time was wasted on the midwifery committee discussing nursing issues instead of addressing midwifery practice and women's concerns.

Response to specific questions

Although we responded to the questionnaire there were important issues which this questionnaire fails to address. The final question, for example, which had the potential to be open ended, is restricted. It is yet another example of conducting a survey with questions which have been carefully selected, worded in ways which limit responses, are not open ended, and do not have even a section for additional comments.

We find it unfortunate that the 'consultation' was conducted in this way, and it made us reluctant to reply. AIMS members have been involved in many 'consultation' meetings and discussions. There is a consensus of opinion between the lay groups and professionals involved in maternity care and these were presented to JM Consulting in a previous consultation exercise. In common with other consumer groups we are disappointed that little notice has been taken of these views and await with interest the response to this particular exercise.

For the benefit of our members we reproduce our answers to the questionnaire below.

Do you think that any specific measures are necessary to ensure effective communication and collaboration by the NMC with each part of the UK, or should this be left to the Council to determine?

We are already greatly concerned at differing and in some cases inferior standards in midwifery in both Northern Ireland and Scotland. Midwifery has been eclipsed to a greater extent in Northern Ireland and Scotland and has moved more towards obstetric nursing. Our members in both countries are greatly concerned.

The standard of education which is making midwifery an increasingly evidence based profession should help. However, the ethos of midwifery has been so eroded in some parts of the UK that we are not optimistic about early success. AIMS' members believe that it is not in the interests of mothers and babies for there to be separate regulatory functions, standards and education in each country.

What do you think of the proposed initial composition of the Council 12 practitioners and 11 lay members?

To cover all the activities required of a Council with representation from each country it appears to us that these numbers are cutting it very fine. Furthermore, the proposed structure of 12 practitioners (4 midwives and 8 nurses) ensures midwifery remains in a minority.

What steps do you think are needed to ensure that the distinctive contribution of each profession is properly acknowledged?

We object to the wording of this question. It is not a question of a 'contribution', midwifery is a different profession with a different skill base and different responsibilities, since a midwife is a practitioner in her own right - a nurse is not. Although the nursing role has been greatly extended, most nurses operate under the supervision and guidance of doctors.

The present structure of the UKCC has failed properly to acknowledge the contribution and needs of the midwifery profession and the new proposed Council will continue that failure. The difficulties experienced by the current Midwifery Committee reflect this.

To acknowledge properly the distinctive contribution of the midwifery profession a separate Midwifery Board must be established on the lines indicated in the pre-amble to this response. Furthermore, the present Act states that" A person other than a registered midwife or a registered medical practitioner shall not attend a woman in childbirth."

It is illogical for the midwifery profession to be combined with a profession whose members would be prosecuted should they attend a woman in labour, other than in cases where there is an emergency.

Furthermore, it is most worrying that in Section 3 "Keeping the Register" paras 3.1 and 3.2(b) the Secretary of State has the power to close the Midwifery Register by Order of Councillor otherwise. This is absolutely unacceptable especially as the current proposals leave midwives as a minority on Council.

In the past, the unanimous views of midwives have been over-ruled by the Council and we see no reason why this could not occur again in the future. Since the Midwifery Committee meets three times a year it cannot possibly make an effective contribution and serve the needs of its clients. There has to be an increased frequency of meetings in any future committee.

What is the maximum NMC membership compatible with a strategic and flexible framework and with the overriding aim of public protection?

We do not have an answer to this question.

Do you think the President should be elected by NMC members or appointed by Government?

The President should be elected.

Do you have any other views on the size and composition of the new NMC?

The Council should have equal numbers of lay members from groups representing users of midwifery and nursing services. Furthermore, how can the range of midwifery practice be reflected when only four midwives will be represent community, hospital, independent, case-load, education and research midwives? All the lay members on the Midwifery Board should be appointed by consumer groups involved with maternity care.

How can the aim of facilitating the new ways of working described in para 20 best be secured?

By having a separate Midwifery Board and facilitating the implementation of case-load midwifery practice.

What is the best way of ensuring that appropriate professional and consumer advice is available to the NMC?

By taking notice of the advice that has been given to date, otherwise consumers will consider exercises similar to this, and the JM Consultation, have been a waste of time, money and energy. Fifty per cent consumer representation on the Midwifery Board will encourage greater liaison and co-operation.

What are your views about membership of the committees dealing with fitness to practise?

Midwives currently have an excellent system of supervision which, one presumes, largely accounts for the low numbers of midwives who come before the Professional Conduct Committee.

Our members who have been appointed to this committee have found their skills and knowledge wasted as the few cases they have been invited to judge have involved nursing issues. A more appropriate use of their time and skills would have been to restrict their involvement to maternity cases and ensure that practitioners are judged by their peers and practitioners who practice in the same area e.g. community midwives judged by a majority of community midwives.

What other sanctions should be available for unfitness to practise?

Our main concern is with the fact that many serious allegations progress no further than the initial screening and the public is not being protected. We frequently see cases of very bad care, unable to be dealt with by the local Supervisors, which should be criticised and dealt with but are not being referred.

We feel this is a serious shortcoming of the procedures and should be addressed by the new structure. In appropriate cases there should be re-training followed by an examination. There could also be a required period of close supervision plus suspension.

No effective disciplinary mechanism can work properly unless the professional body has an investigation unit, as was recommended by the Merrison Committee for the General Medical Council.

What are your views on an independent appeals process?

In view of our experience of the way complaints are handled by the UKCC we feel an independent appeals process would be welcome. Complainants, and the public, might have more confidence in it.

How can the assessment of good health and good character in the interests of public protection best be reconciled with fairness to individual registrants and prospective registrants?

We have no comment.

How do you think the arrangements of the quality assurance of professional education and the statutory responsibilities of the new Council can best be integrated?

It is essential that there is a separate statutory Midwifery Education Committee and Professional Development Committee.

How do you think continuing competence to practise can best be determined, monitored and maintained?

The midwifery profession already has statutory supervision and PREPP and this could be further developed.

What role should the NMC have in developing standards of the preparation, supervision and performance of staff working with registered professionals?

The Midwifery Board will need to determine this.

What are your views about the early appointment of a " Shadow Council"? How should it be constituted and what method of appointment should be used?

We hope this will be seen as an opportunity to involve new people, both lay and professional. A number of places should be retained for lay members and the lay groups should conduct their own election and appoint the necessary number.

What are your views on the composition and methods of appointment to the first (statutory) Council?

The Midwifery Board should be elected by the midwifery profession and the lay membership should be selected by the relevant lay groups following an election which they arrange.

What should the functions of the first Council be, and how should they be performed?

The new council should commission the Policy Studies Institute to look at the way complaints from the public are handled, similar to the study they did on the General Medical Council. Look at a means of improving ease of access by the lay public to the register and enable them to check more easily whether or not practitioners are on it.

Have you any further comments about any of the issues raised?

It is essential that if the interests and safety of mothers and babies are to be protected and midwifery practice enhanced and encouraged a separate Midwifery Board is created. Over twenty years amalgamation with nursing has had seriously detrimental effects on midwifery practice and it is time this was addressed.

The current administration within the UKCC does not inspire confidence and has been criticised in the past for its poor standards and administrative skills. Skilled administrators should be appointed from outside after national advertisements.

Download Modernising Regulation - The New Nursing and Midwifery Council - consultation document from the Department of Health Website
[No longer available - for further details on consultation outcomes please see https://www.gov.uk/government/consultations/changes-to-nursing-and-midwifery-council-governing-legislation]

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