The 3-year delivery plan for maternal and neonatal services in England has been released, aiming to make care safer, more personalised and more equitable for women, babies and families (NHS England, 2023a). The plan sets out a strategy for delivering change by bringing together the actions and recommendations from a range of policies and reports into one cohesive document.
A key strength of this plan is engagement with the stakeholders in maternity care, including service users, frontline staff, leaders and a dedicated working group chaired by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists (RCOG). This engagement is hugely important to ensure that the voices of those whose experiences of maternity services has been less than acceptable have been heard.
The accompanying letter from senior leadership at NHS England (2023b) makes it clear that the plan is aimed at frontline staff and leadership, and summarises the contribution that different NHS departments will make to delivering the plan, which incorporates four key themes:
- Listening to, and working with, women and families with compassion
- Growing, retaining and supporting the workforce with the resources and teams that they need to excel
- Developing and sustaining a culture of safety, learning and support
- Standards and structures that underpin safer, more personalised and more equitable care.
An ambitious target of 3 years is set out to embed these four themes in order to improve care for the benefit of women, families and staff. The document offers a comprehensive presentation of how the themes were derived. Doubtless, anyone accessing or working in maternity services would find it hard to dispute that these are key areas for improvement, with women, service-users and staff front and centre, offering hope that maternity services will start to improve.
Arguably, the plan does not go far enough to show how exactly the themes will be delivered. There is some clarity required about how this will be resourced. Theme two, regarding the maternity workforce, will be fundamental. The success of the other three themes hinges directly on a clear commitment to invest in growing, retaining and supporting the workforce.
A number of policies have acknowledged the challenges faced by maternity services in terms of adequate staffing, from the NHS (2019) long term plan to the people plan (NHS England, 2020). Critics have argued that the principles are sound, but that investment is needed to achieve the goals set out by these plans (Alderwick and Dixon, 2019; Bailey, 2020).
Bodies such as the Independent Maternity Working Group (IMWG, 2023), the RCOG (2023) and the National Childbirth Trust (NCT, 2023) have all released statements in response to the most recent delivery plan. The message of these statements has been that while the plan is welcomed, there is concern at the absence of commitment to properly fund these initiatives.
The RCOG (2023) stated it was ‘concerned that an already overstretched NHS will not be able to implement this plan. This will be another missed opportunity to ensure compassionate, personalised and safe maternity care for everyone’. The NCT (2023) is also clear that these ambitions ‘can only be achieved with adequate staffing and a skilled and motivated workforce’, while the IMWG (2023) will continue to call on the government for funding.
As a midwife who works in the higher education sector, I was particularly interested in the plans for growing the workforce. Figures show that the number of midwives on the NMC (2022a) register grew by 3% in 2022 compared to 2021, which is encouraging but still modest.
The NHS (2023) delivery plan discusses boosting the midwifery workforce through undergraduate programmes, apprenticeships, postgraduate conversion, return to midwifery programmes and international recruitment. It appears that the initiatives that have been applied to addressing the nursing shortage have been transferred to midwifery, but the standards for midwifery education differ to nursing and this may create some challenges:
Undergraduate programmes
One glaring issue that is not discussed is the removal of tuition fees for undergraduate midwifery programmes. The government restored funding for healthcare programmes in the form of a maintenance grant between £5000 and £8000 in 2020 (Department of Health and Social Care, 2019). However, there appears to be a sustained lack of acknowledgement that many prospective healthcare students remain uncomfortable with accruing debt for the payment of tuition fees through a student loan, despite evidence suggesting this is a key factor (Marketwise Strategies, 2019).
Applications from mature students in particular have seen a drop in England, compared to Wales and Scotland who retain the NHS bursary model. Figures from pre-2017 showed that only 29% of students on nursing and midwifery courses were under 21 years of age compared with 51% in 2022 (Universities and Colleges Admissions Service, 2022).
In terms of widening participation and equality, diversity and inclusion, this particular policy has done little to address either, attracting more school leaver students to the detriment of mature students. While school leaver students clearly have lots to offer in maternity services, and should be nurtured to develop and hopefully remain in the profession, the mature student brings a wealth of life experience, communication skills, resilience and commitment, and makes a valuable contribution to a profession that requires all of the above. However, they also are more likely to have caring responsibilities for children and/or older relatives and need financial stability that a bursary and removal of tuition fees would support. This would require significant investment, but has the potential to increase applicants and address this particular facet of the 3-year delivery plan at scale.
‘Apprenticeships have the potential to address workforce shortages… but they…are not a quick solution, and this must be factored into long-term workforce planning.’
When the bursary was withdrawn in 2017, the aim was to focus these funds to increasing capacity for an additional 10 000 training places, as the cap on university places for healthcare students was removed (Foster et al, 2017). However, as anyone working in the education sector will attest, this aim was not realised. Capacity is limited by the provision of placements in clinical areas. There is also growing concern over adequate practice assessment and supervision, as staffing levels are increasingly depleted.
The NMC (2023a) standards for nurse education have been amended to include up to 600 practice hours through simulation, which takes some pressure off the clinical placement provider capacity (although this does present other challenges to higher education institutions). However, the same alteration has not been applied to midwifery standards. This ensures that every practice hour is on clinical placement but does remove some flexibility on how practical skills and knowledge can be facilitated.
A slightly more flexible approach to midwifery education is evident in the new standards. There is now an allowance of a minimum of 30 births with the opportunity to care for an additional 20 women in labour, rather than the previous stipulation of 40 births (NMC, 2023b). However, the focus on minimum numbers for births, antenatal and postnatal checks remains a contentious area.
A 3-year undergraduate programme should be able to offer a range of rich learning experiences that enable the development of well-rounded midwives with a focus on woman-centred care at the point of registration. The current standards, which are rigid in their application of quantitative measurement of skills, may not be the optimum way to achieve this.
Overall, the undergraduate route has the potential for delivering a high standard on a larger scale, but requires significant changes in the funding models, as well as flexibility in curriculum design.
Apprenticeship programmes
Apprenticeship programmes are an excellent way to increase numbers of skilled, qualified professionals. Currently, there are limited institutions that offer apprenticeships from nurse associate or maternity support worker to midwife, and the stipulation for a 3-year midwifery degree programme remains for those who are not registered as adult nurses.
Apprenticeships have the potential to address workforce shortages in midwifery, but they do differ from nurse degree apprenticeships, which are completed in 18 months. They are not a quick solution, and this must be factored into long-term workforce planning. As one facet of a composite approach to growing the profession, they are of value.
Postgraduate conversions
Postgraduate conversions, where registered adult nurses are able to undertake a shortened (18 months to 2 years) programme, hold promise. Salary support at agenda for change band 5 is offered, as well as tuition fee support, which makes this an attractive offer to registered nurses who might otherwise leave the NHS altogether. They are a relatively quick way to grow the midwifery workforce with already skilled professionals, albeit expensive. There are only a small number of higher education institutions currently offering this option, so the scale at which this can be implemented is self-limiting at present. Additionally, the backfill for nursing vacancies that this will create may pose a considerable challenge for already stretched NHS trusts.
Moreover, there may be a case for expanding the maternity workforce, with adult nurses undertaking care for women in appropriate settings while midwives focus on midwifery-specific care. For example, the care for women post-caesarean section can be provided by nurses. High dependency care for women both antenatally and post-birth can also be provided by nurses with requisite skills, with support from midwives when required. As midwifery is experiencing shortages, there is a need to seek solutions that both expand the workforce and ensure that care for women is not compromised.
International recruitment
International recruitment has made an important contribution to compensating for shortages of UK-trained healthcare workers. It has also led to a welcome increase in ethnic diversity in the NHS workforce, creating opportunities for personal and professional exchange.
There are ethical considerations around depleting healthcare workers in poorer countries, creating a disproportionate disadvantage to their healthcare system (Moriarty et al, 2022). This notwithstanding, the success of international recruitment in midwifery has not matched that of nursing. By 2022, there were 23 367 internationally trained nurses joining the NMC register (representing more than half of new registrants), compared to 76 midwives in the same time period (NMC, 2022b). International recruitment is not a panacea; there are fewer countries who have midwives and the transferability of key skills, education and standards for pre-registration is much more of a challenge.
Return to midwifery
The number of midwives leaving the NMC (2022a) register has continued to rise in recent years, with an increase of 13% compared to the number of leavers in the previous year. When asked, leavers cite too much pressure, poor workplace cultures, increased workloads and a lack of staff as reasons for leaving. To attract midwives back to the profession, there needs to be a clear plan as to how they will be supported, as well as a notable improvement to workplace culture in the NHS. The 3-year plan does acknowledge this, and has set out plans for trusts to implement local evidence-based retention action plans. However, there is no commitment to investment over and above what was promised following the Ockenden (2020) report, before the impact of COVID-19 had been felt on staffing levels.
Conclusions
The 3-year delivery plan sets out sound principles for improving maternity services and enhancing the care experienced by women and their families. It pulls together a range of recent policies and reports and places women and frontline staff at the centre of the discussion.
However, what is required now is a firm commitment to proper investment in order for the goals to be achieved. This article has focused on the objective of growing the workforce from an education perspective. The composite approach to growing the workforce is commendable, but true growth in the workforce will not be seen until the prospect of being a midwifery student becomes more accessible and financially viable to a broader range of the UK population. It is acknowledged that this is just a small part of theme 2, as well as the plan overall, and each component requires a robust and comprehensive exploration of the key issues in order to move forward and ensure that this plan is deliverable.