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Healthcare system reform and professional identity

02 June 2014
Volume 22 · Issue 6

Recently I have been reflecting on my experiences as an independent midwife from 2000 to 2001 and as part of a group practice between 2001 and 2003. While at times challenging and emotionally demanding, I found these roles tremendously fulfilling. I very much enjoyed participating in a model of care that initiated one-to-one contact. This personalised approach followed right through until mother and baby were offered health visitor services, usually 2 weeks after birth. The most rewarding aspect for me, was the prolonged and supportive relationship that could develop with a woman as she progressed along her mothering journey. I especially enjoyed the postnatal role, despite this period often being the trickiest of paths to negotiate, as a woman adapts to life with her new baby. I recall many instances where the pre-existing relationship enhanced my care and sensitivity during this profound, and highly individual, transition in a woman's life.

At risk of appearing nostalgic, it strikes me that today's maternity services are quite different from those of a decade ago. This is perhaps expected given the passage of time—‘plus ça change’. Yet one development, in relation to the direct and continuous model of care, is especially noticeable. It appears to have fundamentally altered certain beneficial aspects of our opportunities to engage with women. The restructuring of healthcare service provision established by New Labour's various NHS reform agendas has integrated extended roles for maternity support workers (MSWs) into the structure of UK maternity services. As a result, the clinical practice of midwives has altered considerably, due to the delegation of what are frequently referred to as midwifery ‘tasks’ to MSWs. These include certain clinical interventions, breastfeeding support as well as ante- and postnatal education/advice.

‘Within this current climate of under resourced postnatal maternity services, MSWs are almost universally considered a godsend’

The politically driven NHS reform processes underpinning this phenomenon began in 2000. The NHS plan was launched and the concept of ‘workforce planning’ expanded to incorporate the redefinition of roles relating to health professionals delivering front line services. Partly in response to anticipated staffing shortfalls, this change in direction of healthcare service provision was rationalised as being necessary to ‘modernise’ and achieve greater ‘interprofessional’ modes of working. As such, the expanding role of MSWs can be attributed to the extension of certain principals of governance expressed through the application of human resource management strategies (Hyde et al, 2005; Bosanquet et al, 2006). This initiative has culminated in a situation where the core skills of midwives as well as the boundaries of our profession have become radically altered. Emphasis in policy rhetoric is placed on the re-allocation of ‘tasks’ to support clinicians in order to: enhance the role of healthcare professionals, improve productivity and achieve patient-centered care. On the other hand, critics suggest workforce development policy aims to reduce the cost of labour by substituting skilled professional roles with ‘healthcare assistants’ who provide a protocol driven service (Stubbings and Scott, 2004). Clearly, NHS workforce development is most certainly a complex undertaking with success likely to be dependent on numerous factors including sufficient resources and retention of staff identities (Masterson, 2002; Macfarlane et al, 2011). In my view, what is of great importance for midwifery is the fact that many of the traditional emotional, social and caring aspects of our profession have also been delegated as a consequence of such healthcare service reform. This is especially notable in the almost universal use of MSWs to provide the majority of postnatal care services to women, including breastfeeding support when required, which has led some midwives to lament this outcome (Prowse and Prowse, 2008).

Of course I accept that many midwives welcome the extension of their roles and the delegation of certain key tasks to MSWs. Academic and professional debate surrounding the increased responsibility of support workers centers on how to: monitor efficacy, educate, regulate, ensure legal accountability and define their scope of practice (Hussain and Marshall, 2011; Griffin et al, 2012; Colvin et al, 2013). I appreciate that within this current climate of under resourced postnatal maternity services, MSWs are almost universally considered a godsend. The financial argument for the development of MSWs is compelling, yet it is important to remember that they were ideologically conceived in a very different era that did not face such resource challenges. Moreover, had either David Cameron or Nick Clegg fulfilled their pre-election pledge to employ more midwives, one wonders if MSWs would be quite so ubiquitous today. I recognise that they are highly regarded colleagues and the ‘emotional, social and caring’ features of midwifery roles can be shared with other healthcare practitioners. However, I am equally sure many midwives, if asked, would not wish to entirely relinquish these important elements of midwifery culture.

Furthermore, I suggest that the debate concerning the pros and cons of extended roles for MSWs detracts from the fact that these changes in workforce provision were politically and ideologically driven. They were implemented without consultation with either our profession or the general public. Therefore certain remits have been fundamentally changed by an act of political will. I would feel more certain that this was a step in the right direction if we, as a profession, had been engaged in that decision making process. The absence of debate as to whether or not the rise of MSWs is desirable in healthcare service provision, is tantamount to acceptance of this policy by healthcare practitioners (including midwives). Such deference to NHS reform is surely highly undesirable as it erodes our self-identity as a profession. This has real potential to generate unforeseen and irreversible consequences for core aspects of our future remit as midwives.

My reflections on the expanding remit of MSWs within maternity services and our consequent changing professional identity, I believe, has parallels with concerns for our professional authority in the face of the dominance of the medical model of care. It may be the case that our sense of professional authority and identity remain as elusive as ever owing increasingly to the forces of governance. This is in spite of our ‘enhanced’ roles in the newly redesigned NHS (et plus c'est la même chose’?). Yet I do not want to accept that we will remain immutable and that we cannot direct our own profession within the contemporary policy landscape. The way forward I believe is to comprehensively debate and critique healthcare system policy as a distinct professional entity. We must attempt to influence proposed reforms at inception, perhaps in conjunction with other health professionals, as opposed to perpetually adopting a position of concession and compliance towards the prevailing political will.