WF 15

Ymchwiliad i gynaliadwyedd y gweithlu iechyd a gofal cymdeithasol

Inquiry into the sustainability of the health and social care workforce

Ymateb gan: Coleg Brenhinol y Bydwragedd

Response from: Royal College of Midwives




The Royal College of Midwives

8th Floor, Eastgate House, 35-43 Newport Road, Cardiff, CF24 0AB


The Royal College of Midwives’ response to Welsh Assembly Inquiry on the sustainability of the health and social care workforce




1.       The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of practising midwives in the UK. It is the only such organisation run by midwives for midwives. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and provide professional leadership for one of the most established clinical disciplines.


2.       The RCM welcomes the opportunity to respond to this consultation and our answers to the consultation topics are set out below.


3.       Q: Do we have an accurate picture of the current health and care workforce? Are there any data gaps?


4.       Successive Welsh governments have supported a midwifery specific workforce planning tool (Birthrate Plus) and have maintained midwife numbers which has helped to prevent a serious shortage of midwives. The principles of prudent healthcare provide numerous opportunities for midwives and midwifery services. They support a focus on normality and a decrease in unnecessary intervention.


5.       However, many challenges remain. The RCM has remained concerned for some time about the age profile of our workforce. Looking at midwifery numbers alone, the picture looks rosy: There were more midwives working in the NHS in Wales in 2015 than there have been since at least 2009. The increase during that time was around eight per cent. This has outpaced the changed in the number of births, helping to reduce the ratio of births per midwife.[1]


6.       However, this situation is under threat.  37 per cent of midwives working in the NHS in Wales are in their fifties or sixties. Without investment in our workforce, before too long we could see a dwindling number of midwives available to staff our maternity units, with an insufficient number of younger midwives in place to replace those set to retire. So while we have an accurate picture of our workforce, we need to take action on the basis of that picture.



7.       Q: Is there a clear understanding of the Welsh Government’s vision for health and care services and the workforce needed to deliver this?


8.       There are three key documents used by Health Boards across Wales to describe the vision for health care given to women and families: the Maternity Strategy, Midwifery 20:20 and the Birthplace study. Between them these documents spell out what needs to happen in order for us to have a maternity service that promotes pregnancy and childbirth as an event of social and emotional significance, where women and families are treated with dignity and respect.  All Health Boards are currently required to report on progress made in relation to the targets set out in the Maternity Strategy. And we now have a huge raft of evidence from the Birthplace study which suggests that lower-intensity birth locations (such as midwifery-led units and women’s own homes) are safe and sustainable options for many women.[2] In addition the adoption of the principles of Prudent Health care has meant that there are opportunities for less unnecessary intervention, lower caesarean section rates and fewer low risk women receiving care in obstetric units unnecessarily. The RCM was a key player in the development of the Maternity Strategy and Midwifery 20:20 and supports their aims. We believe that the evidence provided in the Birthplace study can radically change the way that care is provided and contribute hugely to the prudent health care agenda.


9.       What is less clearly articulated in national policy is the workforce needed to realise these ambitions. The RCM has made our views clear in our Welsh election manifesto, our Caring For You Charter and our response to the NHS workforce review in 2014. We support the recommendations coming from the Prudent Healthcare resource.[3]


10.   Unlike other parts of the UK, Wales is fortunate in that it appears  to currently have enough midwives to meet its birth rate. However this is only in relation to birth rate numbers.  It is our view that the current structures do not support a cohesive approach to workforce planning, development and commissioning of training across NHS Wales. We would like to see a long-term commitment to continuing to have the required number of midwives, especially as this will be prerequisite to meeting the requirement of having 45% of births taking place in midwifery-led units. Further, we believe that in order to meet the public health challenges above, we must strengthen community midwifery, and there is an opportunity for further development of maternity support workers (MSWs).


11.   Q: How well-equipped is the workforce to meet future health and care needs?


12.   The maternity workforce has changed to meet the changes in service demand. Whilst the number of Consultant Midwives had remained static there is now a move to have at least one Consultant Midwife in each Health Board. The RCM supports this move and welcomes the recognition of the contribution that these roles bring to maternity services, especially in areas such as normality and public health. There has also been an acknowledgement of the vital role that Maternity Support Workers can play in Maternity services. The development of the Maternity Support Worker Curriculum has meant that the role and responsibilities of MSW’s are clearly defined.


13.   We would also support the establishment of systems whereby on going training and development and continuous improvements become the norm. We support a greater emphasis on the use of multi-disciplinary teams in the planning and delivery of healthcare and believe that multi professional training programmes have a role to play in encouraging respect and understanding for other roles in the provision of service. As before, effective team-working across disciplines is vital to quality maternity care.


14.   The role of the Midwife in delivering the public health agenda is now well established. The 2011 Strategic Vision for Maternity Services in Wales stated, ‘Pregnancy is a powerful motivator for change. It is a time when women and their partners, often for the first time, make positive lifestyle changes and choices in order to provide the optimal conditions to ensure the health and wellbeing of their unborn baby’.[4] Each contact with a midwife is an opportunity to improve the health not only of the woman and her baby but that of her wider family. Midwives are also the frontline professionals who can signpost women to other specialist services, such as for smoking, weight loss, domestic violence and drug abuse. They are also involved in cases of safeguarding and mandatory reporting of FGM.


15.   Q: What are the factors that influence recruitment and retention of staff across Wales? This might include for example:

a.       the opportunities for young people to find out about/experience the range of NHS and social care careers;

b.      education and training (commissioning and/or delivery);

c.       pay and terms of employment/contract


16.   In 2016 the RCM launched a major campaign to improve RCM members’ health, safety and wellbeing at work so they are able to provide high quality maternity care for women and their families. The asks of Caring For You are based on the startling results of a survey of RCM midwife, student and maternity support worker (MSW) members.[5]


17.   The results from the survey show that maternity units are overworked and understaffed and many midwives, maternity support workers and student midwives are feeling under intense pressure to be able to meet the demands of the service. This is creating high levels of stress and burn out which is impacting on the care that is provided to women and their families.


18.   RCM members’ shift working has a negative impact on their health, safety and wellbeing, in particular restrictions to work flexibly; working long shifts; shift patterns; missing breaks; and working beyond hours cause frequent problems. Some workplaces have dysfunctional cultures, resulting in workplaces that have high levels of bullying, harassment and undermining behaviours.


19.   The following quotes are from welsh midwives and we urge the committee to think about retention and recruitment in the context of these experiences:


20.   “The organisation runs on goodwill, staff working extra shifts on top of their contracted hours, staying on after shift end-times etc. Not a great deal of appreciation for this apparent from senior management”.


21.   “Short staffed and made to feel guilty about this, therefore struggle to go to work when unwell. Currently pregnant, awful morning sickness and sciatica. No support and no sickness absence as feel guilty”.


22.   “If things go wrong we do not feel supported even though management say there is a no blame culture. We are also expected to attend people [in the community] even if there are health and safety concerns and management do not want to pay two midwives to attend for the whole labour [at home] due to paying overtime. Some colleagues are scared to be called because they do not want to be out alone at night in a strange environment”.


23.   The research also found that 69% of our members said they had caring responsibilities. This gives us a good indication about the balance that many members (and NHS staff overall) have to find in their daily lives. While 35% of respondents had made a request to change their shifts in the last two years, unfortunately 37% of these said their request to change their hours was rejected. Many respondents reported that they were not given the reason for why their request was rejected but many said it was due to staffing and workload.


24.   Part time work is common and clinical midwives are experiencing a higher level of stress and burnout than ever before. Service demands can make higher-banded positions less attractive, which means the talent pool can shrink. We must focus not only on ensuring raw numbers of midwives are sustainable but also think about how to support midwifery careers for life and support emerging leaders.


25.   While at times this report makes for troubling reading about the level of burn out and stress amongst midwives and maternity support workers it does offer solutions too. The evidence we present shows that when Heads of Midwifery and RCM Health and Safety Representatives work in partnership and take action on health, safety and wellbeing it does make a difference. Stress levels are lower, health and wellbeing is better and importantly, care for women and their families improves.[6] We are thrilled that Powys Teaching Health Board was the first health board in Wales to sign up to the RCM’s Caring for You Charter and they have been joined by three other boards in recent weeks. We hope all the boards will sign up to the Charter to improve health and wellbeing of staff which will help create happier and healthier workplaces, with positive working cultures that always deliver quality care for women and families.


26.   In regards to pay and terms and conditions, the Royal College of Midwives is committed to UK wide pay bargaining, through the NHS Staff Council, and the independent Pay Review Body. We believe that Agenda for Change is the most transparent, fair and equal system as it is underpinned by the job evaluation system which is based on equal pay for work of equal value. Our expectation is that this will continue.


27.   The independent NHS pay review body makes recommendations to the Welsh Government on the pay of midwives, nurses and other staff employed by the NHS, with the exception of doctors, dentists and very senior managers. Unlike the Scottish Government, which has consistently followed the pay body’s recommendations, the Welsh Government has failed in the past to honour them in full. This is a shame, and has left midwives in Wales out of pocket and they continue to be paid less than their Scottish equivalents.


28.   Midwives are drawn into the profession for many reasons, they may have had children themselves, they may follow family members into the profession but mostly they are driven by a desire to work with women and families and to provide the best care possible. Financial reward is frequently not the primary driver; however, it is unrealistic to expect them to work without adequate financial reward. Midwives have bills to pay just like everyone else. That is why it is important that they are paid a fair salary for the work they do, and the fairest way of determining that salary is through an independent process like the one we have. It is so important that all sides honour the pay review body’s recommendations even when midwives might think it is too low or employers think it is too high.


29.   Q: Whether there are there particular issues in some geographic areas, rural or urban areas, or areas of deprivation for example.  


30.   The latest statistics on breastfeeding in Wales show the massive variation between areas which the RCM believes must urgently be addressed to tackle life-long health inequalities.


31.   The highest breastfeeding rates were seen for babies of women resident in Powys Teaching Local Health Board (72%) and lowest for those in Cwm Taf University Local Health Board (50%). There is a clear need for more breastfeeding support, especially for young mothers, and midwives must be able to have the time to work with women to enable them to breastfeed safety and comfortably. Breastfeeding lays the foundations for an individual’s future health and wellbeing. It brings great benefits for society as a whole in terms of reduced spending on ill health. Previous surveys into our members views on postnatal care found there is not usually enough time our resources to support new mothers with important aspects of breastfeeding, according to 25% of our members.[7] With the increase in complex care needs the labour ward has often been seen as the priority for midwifery staffing with the result that post natal care has not been given the value/attention that it should have had.


The Royal College of Midwives

August 2016

[1] Royal College of Midwives. State of Maternity Services Report 2015.

[2] Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, McCourt C, Marlow N, Miller A, Newburn M, Petrou S, Puddicombe D, Redshaw M, Rowe R, Sandall J, Silverton L, Stewart M. ‘Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study’. British Medical Journal. 2011;343.

[3] Design the future workforce – ensuring that the future workforce is in line with service and financial planning; Develop the future workforce – includes education commissioning, staff development, and recruitment and retention process; Deliver the future workforce – ensuring plans are delivered, processes are effective, clinicians are engaged and best practice is shared’. See Making Prudent Healthcare Happen.

[4] Welsh Government (2011). A Strategic Vision for Maternity Services in Wales.

[5] The RCM’s Caring for You survey was conducted during March 2016 with RCM members using Survey Monkey. In total there were 1,361 responses. The survey asked questions about midwives’, maternity support workers’ and student midwives’ health, safety and wellbeing at work.

[6] Royal College of Midwives.  Caring for You Campaign: Survey Results. May 2006.

[7] Royal College of Midwives. Pressure Points: Infant feeding, Supporting parent’s choice. May 2014.