• Call us now: 0300 303 0444
  • Call us now: 0300 303 0444

Supervision: Maternity's safety net

11 March, 2014

Supervision: Maternity's safety net

Statutory supervision purports to protect the public. But high-profile cases showing an apparent lack of supervision seem to highlight shortfalls in the system. Are midwives walking a tightrope without a safety net? Helen Bird investigates.

Midwives magazine: Issue 2 :: 2014 Statutory supervision purports to protect the public. But high-profile cases showing an apparent lack of supervision seem to highlight shortfalls in the system. Are midwives walking a tightrope without a safety net? Helen Bird investigates.

Supervision 250x200


Litigation in maternity care is rising. With a record birth rate and chronic understaffing comes the inevitably heightened scope for error, and the figures seem to confirm this. The National Audit Office’s report, Maternity services in England (2013), states that trusts paid out £482m for maternity clinical negligence cover in 2012-13; the equivalent of around a fifth of spending on maternity services.

Surely it is at times like these that a robust and effective system of governance is needed more than ever within maternity units. But it seems that a huge question mark has been placed over the statutory function of supervision since the occurrence of, and subsequent media attention around, serious untoward incidents (SUIs) in recent years.

At the end of last year, the Ombudsman’s report (PHSO, 2013) highlighted three such incidents, ‘in which local statutory supervision of midwives failed’. It is thought that one of these is the well-documented case of baby Joshua Titcombe, whose death in 2008 at Furness General Hospital, part of Morecambe Bay NHS Trust, arguably prompted a much closer look into supervision.

Indeed, on conducting a review of professional standards within the trust in 2011, the NMC made a total of 18 recommendations, 11 of which concerned supervision. While the three units at the trust have rebuilt standards, practice and public perception since this time, the concern over supervision has not faded.

So much so, in fact, that its very existence under the structure of the modern NHS has been called into question. But the RCM continues to champion the statutory function of supervision, believing its place in midwifery to be crucial. Jacque Gerrard, RCM director for England, says: ‘The RCM supports the statutory structure of supervision of midwives as part of governance. This is because it provides support to midwives, ensuring practice is safe and consistent within the regulatory framework, while protecting women and their families.’

According to the first of two key principles set out by the Ombudsman’s report (PHSO, 2013), a clear distinction between the regulatory and supervisory aspects of midwifery practice must be made. The second states that ‘the NMC should be in direct control of regulatory activity’.

To that end, the NMC is soon to launch a review of supervision in midwifery, which, on the Ombudsman’s recommendations, will be divided into two parts. Jackie Smith, NMC chief executive and registrar, tells Midwives: ‘What we’re most concerned with is the extent to which the system is currently protecting the public, and that’s why we’ve decided to undertake this review.

‘The first part will look at the system for investigation and regulation; the second part will look at supervision.’

Jackie agrees that, based on the evidence presented by the Ombudsman’s report, ‘there are questions that need to be answered’. It should be noted, however, that the three SUIs documented by the report took place within the same trust in England, and that systems of supervision vary across the UK.

In Wales, for instance, a new initiative will be implemented over the next few months with the aim of ‘future-proofing’ supervision. This will involve the appointment of full-time supervisors, who will undertake the role for a period of 18 months.

‘It is considered that this model will enable more efficient and proactive management of investigations, external to employing health boards, and ensure timely, remedial support for midwives,’ says Helen Rogers, director for RCM Wales.

This is a system that appears to be working well in parts of England, too. Jessica Read, local supervising authority midwifery officer (LSAMO) for London, reports that three trusts across the capital are benefiting from dedicated, full-time SoMs. ‘They’re working 150 hours a month, so in a sense it’s equivalent to 10 supervisors,’ she says. ‘This suddenly impacts on their ratios, which is something that we’ve always been challenged with in London, but the quality of the function that the supervisory team is able to deliver is also improved dramatically.’

The other result, Jessica adds, is that supervisors who also hold managerial positions are freed up from this potentially conflicting role. As Jackie notes, ‘the way in which the system is constructed means that supervision and investigation can be done by the same person’.

But is this the way it should be? Based on the account of a labour ward coordinator who spoke to Midwives, it blurs the lines and makes for a difficult working environment. She even claims that it is compromising safety on her ward. The Ombudsman’s report (PHSO, 2013) also highlights this as a ‘weakness’ of statutory supervision, stating: ‘The dual role of a supervisor, providing support but also a regulatory function, allows for an inherent conflict of interest.’

Since supervision is unique to midwifery, has it become an entirely redundant concept under the new NHS structure? Jessica argues that ‘to remove this integral element to our profession would be extremely short-sighted’.

She also points out that the Ombudsman focuses heavily on investigation processes in her report, whereas supervision serves a far broader function. ‘Investigation probably forms about 25% of what we do,’ she says, ‘but 75% is the provision of a robust system for revalidation of midwives and establishing proactive, woman-centred, innovative schemes to support women in their pathway’.

Jean Watson, who was part of this year’s RCM award-winning team of SoMs (see box), adds that the profession is fortunate to have such a system in place. ‘I think our nursing colleagues are quite envious of supervision in the form that we have it,’ she says, adding that the clinical director at her trust is looking into ways of adapting the peer-review system, which she helped to implement, for nurses.

Perhaps another important point to note is that, while the Ombudsman’s report (PHSO, 2013) casts a shadow of concern over supervision, the cases on which it focuses occurred some five years ago, and the system ‘has changed hugely’ since, reports Jessica.

She goes on to state that, certainly in London, the number of maternity SUIs has reduced significantly in the most recent reporting year. ‘Of course, we can’t prove that supervision prevents serious incidents from occurring and damage to babies, because the impact is so difficult to measure,’ she says. ‘So, although it’s very difficult to get a robust link between the two, I would like to suggest that proactive supervision is making a difference.’

With the first part of the NMC’s review of supervision about to start, the coming months are sure to shed more light on whether it is, in fact, making enough of a difference to maternity care. The council is also calling on midwives to contribute to its consultation on revalidation, whereby midwives and nurses will demonstrate their fitness to practise; a process that will no doubt be supported by a robust system of supervision.

In the meantime, it is perhaps timely to remind ourselves that, in the early 1900s, midwives fought for a system of self-supervision, having previously been overseen by doctors. Surely now is the time to, once again, take control of the profession, to keep the safety of women and babies at the forefront and to remember why it is worth fighting for.

‘We can’t be seen to be closing’
Claire*, a labour ward coordinator, describes the situation at her trust which, with the increased birth rate, is working beyond capacity.

‘We’ve got quite a lot of supervisors, but only one is neither a manager nor a matron. We have a really high-risk population and a hugely complex caseload.

‘They seem to want to keep the unit open regardless, because of bad press we’ve had recently. We can’t be seen to be closing the unit as we’d get a fine, and we can’t afford a fine because we’re in financial deficit. They’re not thinking like supervisors, they’re thinking like managers.

‘A neighbouring hospital will divert to us at least twice a month. Their supervision seems to be working – they don’t close the unit, they divert, whereas we just close. It probably happens two or three times a year, but it is unsafe more frequently.

‘I would like the supervisors to be the clinical midwives that work on the shop floor, rather than managers who, in some cases, haven’t set foot in a delivery room for 10 years. I’m not saying that no managers should be supervisors but, if we had a larger proportion of midwives working on the floor, I think there would be more safety in numbers and it would set a precedent.

‘It’s worrying that supervision does not seem to be working. I’d like to know whether other trusts are having the same problems that we are.

‘I want something to be done that’s going to change supervision so that it’s back to what it used to be – that is, looking after the women and the midwives looking after them.’
*Name has been changed

‘The midwives have embraced it’
Jean Watson, SoM and part of the winning team of the RCM award for supervisors of midwives, tells of the successful system* of supervision implemented within NHS Lanarkshire:
‘We were challenged with trying to improve the documentation of the midwives within Lanarkshire. The situation beforehand was probably like it is for all midwives – that written documentation is their evidence of care provided. And, when it’s not up to standard, it becomes like a jigsaw puzzle with pieces missing.

‘As SoMs, our ultimate aim is to protect the public, but we’re also trying to protect midwives by saying: “You’ve got to write it down, it doesn’t matter how busy you are.” The message wasn’t getting across very well from us as supervisors, so we tried a different angle, which is where the peer-review system came in.

‘The midwives have embraced it and taken it on board. The small teams within the community areas or the bigger ward areas are now reviewing each other’s documentation.

‘They’re picking up good points, such as: “I like the way you’ve written that plan of care, that’s something I might use,” so it’s picking up the positives as well as the negatives. What’s worked so well is that we had clinicians on the shop floor helping to implement it, and there were also academics on the periphery offering advice, so it was a real team effort.

‘Obviously it will take time to see if this is actually making a difference to women and babies and their care, which is the whole aim of it.’

Meanwhile, at North Lincolnshire and Goole NHS Foundation Trust, which was shortlisted for the RCM supervisors of midwives award, the team successfully modified supervision. The result of this was improved outcomes and, significantly, a reduction in stillbirth rates.

Ann Lilley, who nominated the trust, says: ‘By embracing the need for change, the SoM team demonstrated relentless dedication and commitment to improving outcomes for women and their babies, while showing support for midwives.’

*An article on this system of supervision will appear in a forthcoming issue of Midwives.




National Audit Office. (2013) Maternity services in England. HMSO: London. See: www.nao.org.uk/wp-content/uploads/2013/11/10259-001-Maternity-Services-Book-1.pdf (accessed 25 February 2014).

Parliamentary and Health Service Ombudsman. (2013) Midwifery supervision and regulation: recommendations for change. HMSO: London. See: www.ombudsman.org.uk/__data/assets/pdf_file/0003/23484/Midwifery-supervision-and-regulation_-recommendations-for-change.pdf (accessed 25 February 2014).


Printer-friendly version