3000 - the new magic number?
Following the health secretary’s announcement that 3000 more midwives are to be trained in England, Midwives takes a look at what is being promised, what it will take to deliver it, and how it fits into a bigger picture of midwifery workforce planning.
Health secretary Jeremy Hunt’s announcement that over 3000 more midwifery training places will be created triggered a chorus of enthusiastic press headlines: ‘Largest-ever increase’, ‘Women to have dedicated midwives’, ‘Plans to transform safety’.
With services under huge pressure and ever more reliant on midwives’ goodwill to make up for poor staffing levels (RCM, 2017), this is undoubtedly welcome news, and something that the RCM has lobbied for long and hard.
But with another seven or eight years to go before all the promised midwives are expected to be working in maternity services, and many questions still to be answered around how their clinical placements, mentorship and preceptorship will be supported, this announcement is far from the end of the story.
Indeed, with a multitude of factors – including retention rates, Brexit and the withdrawal of the student bursary – continuing to make an impact on midwife numbers, it is not the full story either.
Speaking at the ‘Maternity Transformation Programme: two years on’ event in March, the health secretary promised the ‘largest-ever’ increase in NHS midwives and maternity support staff, with a plan to train more than 3000 extra midwives over four years, kicking off with 650 more midwives in training next year, followed by increases of 1000 in the subsequent years.
He also set out his ambition that the majority of women will have continuity of carer throughout their maternity journey by 2021.
‘The statistics are clear that having a dedicated team of midwives who know you and understand your story can transform results for mothers and babies – reducing stillbirths, miscarriages and neonatal deaths, and the agony that comes with these tragedies,’ he added.
‘This profound change will be backed up by the largest-ever investment in midwifery training with a 25% expansion in the number of training places, as well as an incredibly well-deserved pay rise for current midwives.’
His announcement came in the same week that midwives were offered that pay rise – of between 6.5% plus a cash award of 1.1% and 29% – as well as a 12.6% uplift to the starting salary, which sees a newly qualified Band 5 midwife starting on £24,907 a year by 2020-21.
Jeremy Hunt also announced proposals to professionalise the MSW role, defining it and developing a national competency framework and voluntary accredited register.
Further to that, work is underway to develop new training routes into midwifery, to ‘allow talented support workers to become registered midwives’ and ‘help the midwifery profession attract and retain talented staff’.
Recognition at last
These steps are a welcome acknowledgement that ‘we need more midwives in England’, says Gill Walton, RCM CEO. ‘We’ve spent a long time saying it, and finally we feel there is recognition that midwifery shortage is real.
‘We have tried really hard to support continuity of carer – we know the evidence around it as a concept which develops safe and quality care – but we have also reflected how difficult it is to implement wholescale change within a service without the right number of staff. You can’t do it unless you have enough midwives – the two go hand-in-hand.’
Gill also warmly welcomes the plans to develop the MSW role ‘in a way that underpins the quality and effectiveness of the whole maternity team’, and proposals for new routes into the profession, including a new midwifery apprenticeship programme.
She adds: ‘It is really important there is not just one route into midwifery – not just applying to university and paying £9000 a year, which will put some people off. ‘We want to attract midwives from all walks of life who will bring valuable experience – and that might be those already working in maternity services as MSWs.’
Where are we now?
While the health secretary kept his announcement firmly future-focused, it’s no secret that today’s maternity services in England are facing a staffing crisis.
The RCM has argued over many years that services in England are operating with a shortage of around 3500 midwives, while the trend towards older mothers with more complex health conditions has continued (Kelly and Lee, 2017).
The resulting demands have been taking their toll on the health and wellbeing of the workforce, with midwives left feeling stressed, burnt-out and unable to give high-quality care to women and their families (RCM, 2016).
Staff retention has suffered: between October 2016 and September 2017, 27% more people left the NMC register than joined it, with many citing working conditions as the reason (NMC, 2017). And in the RCM members’ pay survey, over 60% of respondents said that they were considering leaving the service in the next one to two years (RCM, 2017).
The bigger picture
More midwives are clearly desperately needed – but commissioning additional training places is only part of the solution, says Richard Murray, director of policy at The King’s Fund.
‘There are so many broader issues around the current workforce which need to be addressed,’ he says. ‘You can train more people – but are they willing to apply? Willing to get through to the end of their training? And are employers offering them high-quality jobs so that people want to stay once they’ve started working in the NHS? Can the NHS retain them over time?’
He adds: ‘It’s not going to happen quickly, so as a consequence you have to look at issues around current employees – can we do things to help make their working lives better, to raise morale? The pay rise plays into that – but can we do something on return to work? And where are we with international recruitment?’
What Brexit will mean for international recruitment, traditionally the NHS’s ‘get out of jail free card’ as Richard puts it, has yet to play out – but early indications don’t look good.
The latest figures from the NMC show a significant rise in the number of EU midwives and nurses leaving the register – up 29% between April 2017 and March this year. To add to the woe, numbers joining from the EU fell dramatically – down 87% over the 12 months to March 2018 compared with the previous year (NMC, 2018).
And, contrary to the government’s rationale for removing the bursary, there has been no upsurge in students on midwifery and nursing courses. An analysis by The King’s Fund shows that the number of acceptances onto courses in England fell slightly in 2017, compared with the previous year – and the number of mature students fell sharply (Maguire, 2018).
Research by the RCM has also revealed that while midwifery courses are still oversubscribed, applicants are now down by over a third, having fallen not just last year, but every year since 2013 – with the biggest drop seen in applicants aged over 21 (RCM, 2018).
In light of how much ‘less attractive’ the midwifery profession has become, Gabrielle Bourke, RCM professional policy advisor, says: ‘For now, we need urgent measures to ensure that we will have enough students willing to become midwives so this vision can be achieved.’
Pressure on placements
After attracting students, the next step is keeping them, says Gill Walton. ‘Getting these midwives safely supported through their programme is the next piece of work. How do we ensure those additional midwives are supported through university practice placements, so that they come out of their training and want to stay midwives?
‘We need them to train and we need them to stay as midwives – to absolutely love it – so that they can help transform maternity services for the benefit of women and families.’
For under-pressure services, the additional student intake could be burdensome in the short term at least, and how clinical placements will be funded and supported is yet to be defined.
It is a point of concern for Alison Edwards, senior lecturer in midwifery at Birmingham City University, who says: ‘It isn’t as simple as recruiting thousands more students as this requires the infrastructure to support it.
‘You need more tutors, more on-site resources and, perhaps more importantly, more mentors and capacity in placement areas – which is currently under immense strain.’
Her view is reflected in a letter to Midwives from a student midwife (see here), who says: ‘We are easily forgotten. The clinics and hospitals often aren’t expecting us when we turn up to work, there are often not enough midwives to shadow and when we arrive we rarely get continuity.’
Amanda Wyatt, a community midwife in Oxford, agrees: ‘It will be very difficult to get enough experienced sign-off mentors for an increased number of students.
‘Students need time with a named mentor while on placement, and we already struggle to give students the continuity needed.’
Meline Turkington, a third-year student midwife at Bournemouth University’s Portsmouth campus says the potential for less support is worrying. ‘The training is so tough – attrition rates are already very high. When the supervision is not there, the mentorship is not there, people drop out.’
New midwives, new jobs?
While there are certainly many vacancies in the system, questions have been raised about whether jobs will be readily available for these additional midwives when they qualify.
It is something that perinatal mental health educator, physiotherapist and hypnobirthing practitioner Lynn Jackson-Taylor is deeply concerned about.
Lynn, an affiliated member of the RCM, recalls the challenges she and her physiotherapy cohort faced upon qualification in 2010, when a shortage of positions was so great that employers introduced a cut-off point for the maximum number of applications they would accept for available roles.
Some of her fellow graduates were forced to take assistant roles or move into other fields entirely.
‘They need to have jobs at the end of it or there are going to be unemployed midwives becoming deskilled and disenchanted, looking for work in the private sector or considering other options,’ she says.
As Richard Murray at The King’s Fund puts it: ‘If we are going to train people – particularly if they are going into debt to get trained – we need to get that right. What an incredible waste of time, effort and skills if we train people and there isn’t an appropriate job available for them at the end of it.’
But Professor Jacqueline Dunkley-Bent, head of maternity, children and young people at NHS England, is reassuring. While plans are ‘still in their infancy’, she says NHS England, Health Education England (HEE), the RCM, providers and other partners are working together to ensure that ‘the infrastructure in place to support students within organisations is appropriate, so that even with an increase in numbers they still get robust training and good outcomes at graduation, and that includes jobs
And while it’s the ‘right time to consider the workforce and workforce plans,’ she adds: ‘I wouldn’t want people to think that “now we have 3000 more midwives, we can implement continuity of carer”. It’s much more complex than that – it requires the transformation of services.’ She calls the announcement ‘a fantastic opportunity for maternity services and the midwifery profession’, and adds: ‘I think we need to acknowledge that this is a big commitment that’s been made and celebrate that in the first instance.’
As well as understanding the numbers coming in, getting to grips with the numbers leaving midwifery is crucial, says Richard Murray.
‘We need to know what factors are driving midwives to leave the profession. If we don’t confront those reasons, it’s like pouring water into a bag with a hole in – you can keep pouring in at the top, but the hole gets bigger and more pours out the other end.’
He believes what is needed is a more rounded approach that ‘looks in full at how you keep people and how you attract them’.
Work is already underway on that score: HEE, with NHS England, NHS Improvement, Public Health England and the Department of Health is currently drawing up a 10-year strategy for recruiting, training and supporting staff across the health service in England, set to be published this summer (HEE, 2018).
That has been underpinned by Theresa May’s recent promise of a ‘multi-year’ funding plan for the NHS in England, moving away from annual ‘cash top-ups’ to address its long-term financial needs (UK Parliament, 2018).
Hope for the future
While things won’t improve immediately – Gill Walton believes the additional training places and the recently announced pay increase will give midwives vital hope that ‘things are moving in the right direction’ and fuel their ambition to ‘work in a different way’.
‘While we are looking at getting new midwives into training, we also need to think about how we retain midwives. We don’t want to lose people going through this process, so the other piece is thinking about how we can support each other,’ she adds.
She says the RCM’s focus is now making sure promises are delivered on.
‘We have to embrace this opportunity. We have been asking for it, and now we have been given it, we need to be proactive about how we deliver it.
‘We are engaging with everyone to think of imaginative ways we can implement this. It might not be easy, but the alternative is not to do it and that would be ridiculous. We have to find solutions together.’
The Picture in Northern Ireland
Breedagh Hughes, the RCM’s director for Northern Ireland, says the midwifery workforce is in crisis with increasing numbers retiring – almost a quarter aged 55 and over – and others seeking employment elsewhere in the UK.
With the combined impact of sick leave, maternity leave and vacancies, she says: ‘Every single working day, every single week, 23% of the midwifery workforce in Northern Ireland is not available for work.’
Yet despite the deepening crisis, the political impasse in Northern Ireland means that, while the RCM has pressed for a substantial increase to commissioned training places, Breedagh says, ‘there is no government, no budget, no money, no one to approach, no one to sign it off’.
And that includes action on pay restraint: without fresh ministerial direction, civil servants are maintaining the 1% pay cap, creating a significant pay gap between midwives there and in the rest of the UK – bringing fresh fears that more midwives will be enticed elsewhere. ‘And with no unemployed midwives at all in Northern Ireland, there is no readily available workforce to fill vacancies as they arise,’ Breedagh adds.
This is particularly true for senior posts due to the high number of experienced retirees, leading to issues with skill mix, and ‘relatively inexperienced midwives working without the supervision of more experienced midwives’. Brexit too is set to have an impact, with some 40 midwives currently travelling from the Republic to work in services in the north.
Midwives here are ‘at the end of their tether’, adds Breedagh. ‘The service is running on goodwill and retired midwives are coming back to work on bank. Every week midwives are donating two or three hours each to keep the service running and that in the long term is not sustainable. The situation is dire – we are facing a really deep crisis.’
The Picture in Scotland
Mary Ross-Davie, RCM director for Scotland, says while shortages are not insignificant there, the real concern lies in the rate at which they are increasing: the vacancy rate has gone from 1.2% in 2013 to 4.8% in June last year.
This is largely due to the ‘retirement bubble’ in the midwifery workforce, with 41% of Scottish midwives aged over 50, and a large cohort eligible to retire over the next one to two years.
The RCM made ‘a very strong case’ to the Scottish Government, based on this, and on the potential need for more midwives in the ‘new maternity landscape set out in the Best start review’, adds Mary.
‘We have made the case and they have heeded it,’ she says. ‘In December they announced an 18% rise in the number of student midwife places in 2018-19, followed by incremental rises over the next two years. We’re hoping to get up to 250 places every year – up from 191 last year.’
Plans to address the supply of midwives also include the reintroduction of a two-year midwifery short course for nurses, and a significant number of new places at the University of the Highlands and Islands in Inverness to feed maternity services in some of the more remote parts of the country, says Mary.
‘It’s an improving picture. By the time we get to 2021-22, the higher midwifery student numbers will be beginning to come through, and the rate of retirement will be levelling off, she adds.
But she points out that more student midwives in need of mentorship, and more newly qualified midwives in need of preceptorship support will also mean ‘greater pressure on the system’.
The Picture in Wales
After a sharp decline in commissioning rates in recent years, last year saw a 40% increase in the number of midwifery training places in Wales, and that increase has been maintained in 2018-19, says Helen Rogers, RCM director for Wales. ‘That is obviously extremely welcome,’ she adds. ‘We have a Labour government in Wales that has put a huge amount of money into educational and training programmes for healthcare professionals in NHS Wales, and midwives have benefited from that.’
The Welsh Government supports Birthrate Plus, which health boards must be compliant with, although there are still issues with vacancies and an ageing workforce, adds Helen. A new vision for maternity services in Wales is set to be launched in the autumn which could also have implications for workforce planning.
‘But we have no problem attracting people into midwifery training in Wales,’ Helen says. ‘Every place is massively oversubscribed. We still have the bursary, and if someone from England comes to be trained in Wales, they have to commit to staying for two years afterwards or potentially face a financial penalty.’
‘We have done a lot of work to get midwifery workforce planning right and it is a lot better in the last few years – working much more in partnership with the services. There is certainly recognition by our cabinet secretary and the Welsh Government that if the NHS is going to deliver what it needs to deliver then it needs enough staff.’
Adding up the new plans
35% fall in applicants to midwifery courses in England in 2017 since 2013
45% fall in applicants over 21
5577 fewer people from the EU joined the NMC register in 2017-18 than the previous year
£9250 annual tuition fee for a midwifery course in England
76% of UK HoMs have vacancies in their unit
6/10 midwives in the UK are considering quitting in the next two years.
Illustration: Ben O'Brien