Conclusions and recommendations
We brought together leaders in the field of midwifery and regulation to discuss the strengths and weaknesses of the current system and what needs to change to enhance the safety of mothers and babies.
The strengths of statutory supervision for midwives include:
- It provides support for midwives through 24-hour access to a Supervisor;
- The independence of the LSA should ensure that the LSA's Midwifery Officer and Supervisors of Midwives can comment freely on the safety and quality of midwifery services, which could be said to be in the public interest.
- The LSA can protect the public by taking immediate action to suspend a midwife pending referral to the NMC.
- Midwives' entitlement to supervision and support is protected by its statutory framework.
- Where investigations are conducted well by Supervisors, this makes for a more effective and cost-effective investigation stage on the part of the NMC following a referral.
The weaknesses of statutory supervision include:
- The dual role of a Supervisor, providing support but also a regulatory function, allows for an inherent conflict of interest.
- The fact that the Supervisor can be a peer allows for a further conflict, because of a natural desire to support and protect a colleague while at the same time fulfilling an important regulatory role.
- The confidentiality of the Supervisor of Midwives' role can impede hospital investigations and can prevent potentially valuable information coming to light. This can be particularly problematic in root cause analysis because it can stop issues to do with team effectiveness coming to light, as it focuses on the role and actions of midwives.
- Midwifery Officers are appointed locally rather than by the NMC. This means the NMC has limited control over the quality of the Midwifery Officers.
- There is a risk that the presence of supervision allows the employer/provider to have less control over the quality of maternity services and staff performance than they do for other services. This is not in the public interest because the public has a right to expect the provider to be responsible for quality and safety.
- The NMC is not a system regulator and therefore it is in the uncomfortable position of setting requirements, and receiving information, relating to systems (such as ratios) without powers of enforcement.
- There is a weak evidence base in terms of risk for the continuation of an additional tier of regulation for midwives.
In conclusion, we can see that midwifery supervision may have real merits in the support it provides for midwives across the country on a daily basis. However, those strengths do not extend to the regulatory role of supervision. In fact, any value added by supervision as a mechanism for regulationis outweighed by its weaknesses for regulatory purposes. It does not achieve desired safety objectives and the continuation of statutory supervision begs the following questions:
- Is this the most effective and cost-effective regulatory model for this profession?
- If statutory supervision did not exist, would it be proposed, just for this group of health professionals?
Health and care professionals are subject to a number of mechanisms to ensure safe practice, from frameworks put in place by employers or service providers, to professional regulation. The case for an additional tier of regulation for midwives is not clear. Moreover, other health and care professions benefit from supervision without it being a statutory right, or an aspect of their professional regulation.
We cannot tell from the evidence in these cases what the emotions and motivation of the individuals involved were. We also found no direct evidence of a conflict of interest in these cases. However, the cases do clearly illuminate a potential muddling of the supervisory and regulatory roles of midwives. We think this exemplifies the weaknesses in the current regulation arrangements at a local level.
The conflicts of interest we can see may or may not have been the reasons behind the failures we have observed – we simply cannot say. However, they do mean that the current arrangements are not in the interests of, and potentially pose a risk to, the safety of mothers and babies.
This is sufficient reason for change.
Principles for the future of regulation and supervision
We have worked with the NMC, the Professional Standards Authority, NHS England and the Department of Health. We have identified two key principles that will form the basis of proposals to change the system of midwifery regulation.
The two principles are:
- that midwifery supervision and regulation should be separated;
- that the NMC should be in direct control of regulatory activity.
We recommend that these principles inform the future model of midwifery regulation.
We recognise that the regulatory framework for midwifery is a UK-wide framework and changes need to be negotiated with stakeholders across the UK. We undertake to share our conclusions and reasoning with the other UK ombudsmen and we look to the Department of Health to convey these recommendations to its counterparts in Northern Ireland, Scotland and Wales.
We recommend that the NMC works together with NHS England and the Department of Health to develop proposals to put these principles into effect. This will include developing and consulting on proportionate approaches to midwifery supervision and midwifery regulation. We recommend that this is done in the context of the anticipated Bill on the future of healthcare regulation. We also recommend that the Professional Standards Authority advises and reports on progress.