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Midwifery supervision and regulation: recommendations for change

What we can learn from other professions – the Professional Standards Authority’s view

The Professional Standards Authority for Health and Social Care (the Authority) is an independent body, accountable to the UK Parliament, which promotes the health, safety and wellbeing of patients, service users and the public by overseeing and reviewing the work of the nine statutory bodies that regulate health professionals in the UK.  

There are few parallels or similarities to the supervisory arrangements for midwifery in the regulation of other professions. Perhaps the closest example is the role of the Responsible Officer within medical regulation, although this is a much more recent development for a different regulatory purpose. However there are important differences between the Responsible Officer role, which was established to help deliver revalidation, and the Supervisor of Midwives, not least that the Responsible Officer does not have a role in investigating untoward incidents on behalf of the General Medical Council (GMC).

The Authority raised concerns about the role of the Responsible Officer in revalidating doctors and the challenges this role presents to meeting its expectations of good regulation in response to the 2010 GMC consultation on revalidation, for example: 

  • The Authority believed the concept introduced a conflict of interest – as medical directors, Responsible Officers might be considered to have a vested interest in having their doctors deemed fit for revalidation; 
  • Lack of independence from the profession – whilst the decision whether to revalidate rests with the GMC, this is based on the Responsible Officer’s assessment. The role of assessing whether a doctor is fit to practise essentially remains with the profession; and
  • Opportunity for inconsistency – there is scope for considerable variation in the type, amount and strength of evidence submitted, and subjectivity in its interpretation. In addition, the number of Responsible Officers, the periods over which assessments are made and the resources required, added to potential weaknesses in the evidence, present a challenge to obtaining accurate and consistent judgments.

As has already been noted, these difficulties also arise in the Supervisor of Midwives’ role, although to a greater extent, given the wider regulatory function that the Supervisor role is intended to fulfil.

Other regulated professions do not have this confusion of roles or the potential for a conflict of interest with respect to investigating incidents on behalf of the regulator. The absence of clear comparators from other professions suggests that there may be difficulties in sustaining these supervision arrangements in their current form in the future. This position is supported if we examine the rationale for the regulatory reforms that arose following the Shipman Inquiry. These sought to change the balance of power and influence which professionals and non-professionals had in regulation. The White Paper Trust, Assurance and Safety (2007) described the reason for these reforms: 

… patients, the public and health professionals need to be able to take it for granted that the councils act dispassionately and without undue regard to any one particular interest, pressure or influence. This will ensure that the regulators are not only independent in their actions, but, just as critically, that they are seen to be independent in their actions. Doubts based on perceived partiality have threatened to undermine patient, public and professional trust in a number of regulators over many decades.’ (paragraph 1.3)

The most significant change in this respect was to create the General Pharmaceutical Council and establish a clear separation between the regulatory and professional leadership roles previously fulfilled by a single organisation (the Royal Pharmaceutical Society of Great Britain). Across other regulators, including the NMC, elections of professional representatives to regulatory councils were abolished and replaced by appointment of members based on evidence of merit and competence. Councils were reconstituted to give parity of lay and professional membership. These two steps removed the direct influence of the profession over their regulation, moving away from self-regulation to a shared approach that clearly prioritised the interests of patients and the public. 

Seen in this context, the Authority’s view is that these supervision arrangements are a clear candidate for reform, as they demonstrate a local manifestation of an older model of professional regulation – one that uneasily combines important regulatory and professional leadership roles. This combination of functions in one role creates circumstances that have the potential to undermine confidence in regulation. It would be far more appropriate, and it would better reflect the realities of current midwifery practice, and the role of professional regulation, if the Supervisor did not have such regulatory responsibilities. In essence, the regulatory responsibilities of an employer-based supervisory role should be adequately captured by the core standards for the profession issued by the regulator. 

If it is decided that a local professional leadership role in midwifery remains important, the new role could be developed by learning from supervision and clinical leadership in other professional groups such as social workers and psychotherapists.