Current midwifery supervision and regulation – the Nursing and Midwifery Council’s role
The Nursing and Midwifery Council (NMC) is the independent statutory regulator of nurses and midwives in the UK. The NMC is required by the Nursing and Midwifery Order 2001 (the Order) to establish and maintain a register of all qualified nurses and midwives eligible to practise in the UK, to set standards for their education, practice and conduct, and to take action when those standards are called into question.
For historical reasons, midwifery has an additional framework of statutory supervision. When midwifery was provided outside the health sector, additional safeguards were deemed necessary. Today, the overwhelming majority of midwives work in the health service, where there is clinical governance, appraisal and performance management.
The Order gives the NMC powers to set rules for the regulation of the practice of midwifery (article 42). The Order requires the establishment of a Local Supervising Authority (LSA) for Midwifery in every area and requires midwives in that area to give notice of their intention to practise. Each LSA must ensure supervision of midwives in their area and investigate any concerns about midwives' practice.
The Order also requires the NMC to set rules and standards for midwives and the LSAs who are responsible for the statutory supervision of midwives. These are contained in Midwives rules and standards 2012.
For midwifery, supervision is a statutory responsibility which provides a mechanism for support and guidance to every midwife practising in the UK. The stated purpose of supervision of midwives is to protect women and babies by actively promoting a safe standard of midwifery practice.
Roles and responsibilities
With the abolition of SHAs in April 2013, responsibility for the LSA moved from SHAs to the NHS Commissioning Board (now NHS England). Previously, SHAs were responsible for discharging the role of the LSA, ensuring that statutory supervision of all midwives was exercised to a satisfactory standard within its geographical boundary.
The functions of the LSA include:
- providing a framework of support for supervisory and midwifery practice;
- receiving intention to practise data for every midwife practising in that LSA;
- ensuring that each midwife meets the statutory requirements for practice;
- assessing initial and continuing education and training for Supervisors;
- leading the development of standards and audit of supervision;
- determining whether to suspend a midwife from practice;
- being available to women if they wish to discuss any aspect of their midwifery care that they do not feel has been addressed through other channels; and
- investigating cases of alleged misconduct or lack of competence.
These duties are discharged through an appointed LSA Midwifery Officer.
LSA Midwifery Officer (Midwifery Officer)
The Midwifery Officer carries out the functions of the LSA and develops and audits standards of supervision within the LSA boundary. Each Midwifery Officer is a practising midwife with experience in statutory supervision, and provides a focus for issues relating to midwifery practice within each area. The Midwifery Officer does not represent the interests of either the commissioners or providers of NHS maternity services. The Midwifery Officer reports to the statutory regulatory body, the NMC. Although the Midwifery Officer is selected and employed by the LSA, the person specification and role criteria are specified by the NMC.
Supervisor of Midwives (Supervisor)
The Supervisor provides support and advice to midwives to ensure their practice is consistent with the regulatory framework. Supervisors are accountable to, and appointed by, the Midwifery Officer. They are practising midwives, with at least three years' experience. Each midwife within the LSA's geographical boundary must have a named Supervisor, selected from those appointed as Supervisors by the Midwifery Officer. Supervisors must meet with each midwife for whom they are a named Supervisor at least once a year. Midwives must have 24-hour access to a Supervisor.
How supervision works following a serious untoward incident
The role of the Supervisor is to monitor and support the practice of each midwife for whom they are responsible, including development needs, whilst at the same time discharging their own duties as practising midwives. Their role is also to investigate untoward or serious incidents and determine whether action is required. This might include recommendations for how the relevant midwife might improve their practice (for example, through further training), or whether her fitness to practise should be called into question. The Midwifery Officer must be notified when an investigation is being carried out and the Supervisor must notify the Midwifery Officer what action is required (if any) upon completion of their investigation and seek further advice. In fulfilling this role, Supervisors are independent of their employers.
How it works in other areas of clinical practice
The difference between the LSA process for investigating incidents and how this works in other areas of clinical practice, is that the clinical governance process is dependent on the organisation's own procedures for investigating serious untoward incidents. This means that, generally, the practitioner's employer will be responsible for deciding to investigate, carrying out the investigation, and ensuring that actions are taken to improve the practitioner's practice, or refer him/her to external organisations if there are serious concerns about his/her fitness to practice. A decision on whether an investigation is required will not be taken by the practitioner's peer – in other words, there is no equivalent supervisor for doctors. Instead, the decision will likely be taken by a clinical director, or be mandated by a policy or procedure which the specific organisation has in place, for example, to investigate all elective surgery deaths. Furthermore, there are also additional legal requirements which might mean that certain incidents (such as deaths) need to be reported to a coroner independently of the Trust's internal process.
Changes to statutory supervision
The NMC undertook extraordinary reviews of the Morecambe Bay NHS Foundation Trust in 2011 and 2012. In response to the learning from events at Morecambe Bay and other failings of care, it revised its Midwives rules and standards in 2012. These changes might be described as moves to mitigate any risks inherent in the Supervisors' dual role for support and regulation. In particular, a new rule strengthened the requirements on the LSA for investigating, reporting and information sharing about adverse incidents and complaints. The changes were designed to reduce the possibility of poor handling of cases because of confusion or a lack of awareness between the LSA and the employer/service provider.