Three weeks into my new appointment as Deputy Regional Maternity Lead for Midlands and East, the Easter Bank holiday weekend prompted me to catch my breath and reflect on the dramatic changes and challenges that the midwifery profession—and my career—has faced over the past few months.
Friday 31 March 2017 was a memorable day for the midwifery profession as we said goodbye to statutory supervision, which had been an integral part of midwifery regulation since 1902. Seven days later, Professor Jane Cummings, Chief Nursing Officer for England, launched a new model of clinical supervision for midwives. The A-Equip (Advocating for Education and Quality Improvement) framework is an employer-led model of clinical supervision for midwives that aims to facilitate a continuous improvement process to value midwives, build their personal and professional resilience and contribute to the provision of high quality of care (NHS England, 2017). The framework is designed to implement a key recommendation of the regulations for change outlined by the Parliamentary and Health Services Ombudsman (2013), that supervision and regulatory procedures should be separated.
Following the legislative midwifery regulation changes, I was delighted to be appointed into the new regional maternity structure and am looking forward to working in partnership with direct commissioning organisations (DCOs), clinical commissioning groups (CCGs) and providers, embedding the ambitions of the national maternity review, Better Births (Department of Health, 2016a), the A-Equip model (NHS England, 2017), the Five Year Forward View (NHS England, 2014), and Leading Change Adding Value, a framework for nursing, midwifery and care staff (NHS England, 2016).
The end of statutory supervision
Within the midwifery profession, statutory supervision was very much like the well-known branded spread: you either loved it or you hated it. Quite simply, its function was to protect the public. In my opinion, the regulation model remained robust but, the principles went unchanged since it was established and there was lack of quantifiable evidence to demonstrate how much protection it provided (The Kings Fund, 2015).
‘Within the midwifery profession, statutory supervision was very much like the well-known branded spread: you either loved it or you hated it’
Sadly, through the failures identified by Parliamentary and Health Service Ombudsman (2013), Francis (2013) and Kirkup (2015), statutory supervision has been removed under a heavy black cloud; and although the Department of Health acknowledged that there were a number of non-regulatory elements of statuary supervision that were highly valued by midwives and women, these seem to have been forgotten or have not been embraced (Department of Health, 2016b).
I was very proud of my previous role as local supervising authority (LSA) midwife/supervisor of midwives (SoM) for the East of England, but was devastated and shocked by the failures that were—and continue to be—identified within statutory supervision. Clearly, radical changes needed to be made.
However, before I can move forward, my thoughts and reflection today centre around my previous role as an LSA midwife and SoM for the East of England.
Sample cases
As the doors close on statutory supervision, I would like to share a snapshot of reoccurring themes that were found in recent investigations.
Looking at the collaboration between three Trusts in the East of England throughout 2016, there were a total of eight LSA investigations. In all cases, the concerns involved midwifery practice issues relating to fetal monitoring, escalation and communication, and record-keeping. Other less common themes included medication errors and not following Trust guidelines.
Fetal monitoring issues were mainly around misinterpretation of the cardiotocograph (CTG) and lack of monitoring maternal pulse (as a cross reference against the fetal heart).
Escalation and communication concerns primarily involved midwives making a referral to a coordinator rather than an obstetrician, and coordinators not escalating to the obstetrician.
The poor standard of record-keeping by midwives essentially involved a lack of depth and detail in relation to conversations with parents (especially around making informed decisions) and/or missing information when a midwife had received advise from a coordinator. Likewise, many coordinators did not document their advice once it had been given.
Supervision in the Midlands and East
Many would argue that the peer-led investigations could not be described as truly open and transparent (although many management investigations are also peer-led). In my region, we were beginning to to look at how investigations would be completed by SoMs in neighbouring Trusts, which may have helped to overcome this problem. More importantly, we ensured that our investigations were based on factual evidence and not the SoM's opinion, to avoid issues when the investigating SoM knew or worked with the midwife under investigation. However, I would agree that not knowing the individuals makes the investigation process much easier.
Likewise, every investigation in the East of England was read and formally approved by the Local Supervising Authority Midwifery Officer (LSAMO) for Midlands and East, who ensured that the quality of the report was to a standard which would be approved by the Nursing and Midwifery Council (NMC). I was very proud that the feedback from the NMC on the depth and quality of our reports was always positive.
I never like to dwell on the past and one could argue that our investigations are now history. I feel strongly, however, that women and midwives should be reassured that not all investigations completed by the LSA were of an unsatisfactory standard.
I also think that it is important for women to be reassured that, when catastrophic events occur, they are rarely due to one individual midwife. My mantra is, and always will be, that midwives (and obstetricians and support workers) do not come to work to do harm. Their role is often a vocation; one that they feel passionate about. When the outcome is poor, they are often personally devastated and traumatised by the events. Midwives face challenges every day to balance their workload while providing safe and effective care, but things do go wrong, and, sadly, I do not have the answers as to why the same mistakes are made repeatedly.
Moving forward
I believe strongly in the importance of esnuring women's safety and quality of care, and it is my opinion that we are only in the infancy of learning lessons on safety, which needs to be explored in much greater depth. The recent media coverage of devastatingly poor outcomes for women, and the debate about the quality of investigations fills me with great sadness. Open, honest and impartial investigations are paramount and although investigations can be unimaginably painful, women and their partners should have the choice to be involved. Likewise, the poor standards of midwifery practice identified is concerning, and the root cause for this repeated behaviour must be understood and eradicated.
As I move forward into my new role with excitement and energy, I have engaged with all the heads of midwifery within the region, offering support to embed the A-Equip model. To date, the feedback has been very positive.
I am looking forward to forging new relationships within the region and using my experience and expertise, supporting Trusts to review serious incidents at regional and national level. The lessons learned from these incidents must be shared and robust mechanisms must be developed to stop them re-occurring.
As an individual, I always embrace change and I am excited about the future of midwifery. To move forward, we have to have a voice; I intend to be proactive and I hope that I can continue to make a difference in the profession I have loved for so many years.