My Lords, I declare an interest as a vice-president of the Royal College of Midwives.
I read the Second Reading debate that the noble Lord, Lord Hunt, introduced on the regulation of health and social care earlier this month. I was disappointed not to be able to listen to it in the Chamber because it had some eminent speakers. I read Hansard and, as so often, I was impressed by the clarity and first-hand knowledge that noble Lords brought to that debate. This time, the noble Lord, Lord Hunt, concentrated on beaming down on one aspect of regulation concerning one profession—midwifery.
In Parliament a couple of weeks ago, the general secretary of the Royal College of Midwives enlightened parliamentarians on the state of maternity services in 2016. Professor Cathy Warwick told us that, in the last six years, we have seen the number of midwives increase by 1,560, but that the increase has massively slowed down in recent years. As noble Lords have said in this debate, the work has been changing. First, we have seen an increase in the number of mothers giving birth. Secondly, we know that teenage pregnancies have declined—something we have sought to achieve in this country. However, older mothers over the age of 40 are giving birth and they have increased in number. Many of these women have long-standing health complications. They are sicker and sometimes they have babies who are more vulnerable and need greater care.
As the noble Lord, Lord Hunt, has said, the midwifery workforce is also changing, with an increase in the number of experienced midwives nearing retirement—one in three is now in her 50s or 60s. It is not so much about the numbers; this is a body of midwives who are really experienced. We need experienced midwives to ensure that new students coming in can understand the service in which they are working and the different skills they need. So we have to try to maintain the
midwives that we already have and this order has a part to play. It is a new order and my noble friend the Minister gave a clear exposition of its value.
I want to probe some of its consequences a little. When we were carrying out the review of maternity services for England, the first thing we did was to ask the women, their partners and families what they wanted from maternity services. In this case, our constituency is the midwives. What do the midwives want? It was interesting that, when they were asked about statutory supervision going, they were very upset about it. Eighty-four per cent wanted to keep statutory supervision. They had keen concerns about patient safety and about the quality of assurance if supervision were removed from the law. They felt that the potential for the removal of support for midwives was considerable and they had concerns relating to the NMC’s ability to manage an increased fitness-to-practise referral rate.
These are genuine concerns and it is our duty to see that they are met as the roll-out of this new process takes place. I understand that the Secretary of State has commissioned another review of the NMC, again concerning Morecambe Bay. One case from there has still to be concluded after eight years. No wonder midwives are concerned about the NMC’s ability to manage an increased fitness-to-practise referral rate. The NMC has to step up to the plate. Look at how the GMC has evolved over years: the first thing its new chief executive did was ensure that it was an efficient organisation. I do not get that feeling of confidence with the NMC. Some work needs to be done on that, maybe on aspects brought up by the review.
In the five-year forward view, which was agreed between the DoH and NHS England, an ambition was laid out to make it easier for groups of midwives to set up their own NHS-funded midwifery services. We all agree that we need more midwives. Since the publication of Better Births, a small group of midwives called Neighbourhood Midwives has gathered together and managed to get a contract from the NHS. This gives us more midwives and women more choice, which is something we should applaud. However, it is important that midwives are subject to regulation, wherever they are working, and that has been the case since the European Union brought in its directive. There is a long-running saga about independent midwives and I declare my interest as a patron of Independent Midwives UK. The NMC has felt it right to ensure that independent midwives are suitably covered for clinical indemnity when delivering women giving birth, and it is right to do so. However, I cannot glean from the NMC what level of indemnity is required. I have asked five times what is the “appropriate”—the NMC’s word—cover that it requires for clinical indemnity for independent midwives. I get no answer. I do not know whether the NMC realises how difficult it is to get clinical indemnity to cover people working in different professions. Although a lot of the cases that are brought are actually systems failures, sometimes they are obstetric failures. It is right that the regulators should look at the safety record of those they are indemnifying and I am not sure that is understood by the NMC.
The first questions that any insurance company is going to ask are: “What is meant by appropriate? What size of pot is required?”. Again, we get no answers. The NMC has spent a very long time warning independent midwives that they could lose their registration. Four days before Christmas, the NMC sent a letter out telling independent midwives that they had lost their right to practise. Four days before Christmas, these trained midwives, who had spent a long time in the service, were in fear of losing their livelihoods, vocation and profession. Above all, they lost their right to attend in labour women whom they knew well. As the noble Baroness, Lady Walmsley, has said, that is so important. We know that if there is continuity in the person looking after the woman through antenatal, the birth and postnatal care, we reduce the number of premature births by 24%. Premature births are expensive, emotionally and in monetary terms. If we can reduce them by that percentage we should strive very hard to achieve it.
Since these independent midwives have sought clarity from the NMC, the NMC owes it to them, but they have received conflicting advice. In its values, the NMC states that it wants to be “fair”. My noble friend raised the question of fairness. The NMC says that it will be,
“consistent in the way we deal with people”.
I cannot see that consistency. All the midwives and women who have rung me up and sent me emails have said that they do not understand the consistency because it is not there. It seems to apply one way to one midwife and another way to another, depending on the relationships—sometimes family ones—with the women. I welcome the review of the NMC, not least to examine the level and content of communication provided to those registrants who are seeking clarity, so that they know where they stand. That is the least that a registration body should do.
Better Births, the report of the maternity review for England, has two central themes: choice and safety. As my noble friend said in his introduction to this debate, safety should be at the heart of the service. We agree with that and safety is attached to the order. In our travels during the review, we listened to countless women—lots of them—trying to find out exactly what they wanted from the service. One strong response was that women and their families are seeking a safer service. I will tell noble Lords, and particularly the Minister, about our visit to Sweden because we are waiting for a consultation paper and I hope my noble friend will put pressure on the Secretary of State and his colleagues to release it. Over the last five or so years, Sweden has reduced the number of serious birth injuries from 20 per 100,000 babies born to five. In England, our current rate is 30 per 100,000. Last year, the NHS Litigation Authority paid out £560 million to 130 families for children who had been damaged at birth, while another 70 families who were not able to establish clinical negligence in this country received no compensation at all.
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In England, it takes up to 10 years to settle such cases, and the costs are likely to rise to £1 billion by 2020. In Sweden, the test is whether the damage was
avoidable. It does not seek to establish blame; that is really important. The family is fully involved and the aim is to carry out a rapid investigation to determine what happened and to feed the learning back to the clinical teams, while providing rapid support for families. Our system means the learning is delayed. The people involved in the incidents have moved on after this period of time, so none of the learning is fed back.
We need a system like the one in Sweden. That is what we have proposed in Better Births through what we call a rapid resolution and redress system. The Government have agreed to consult on this scheme and we hope the consultation will be launched as soon as possible, because we have momentum going now. This is a once-in-a-generation opportunity to do a really good thing for families, for babies, for the country and for the Exchequer. Anything my noble friend can do to ensure its publication would be very welcome indeed.
One has only to read the superb series on midwifery in the Lancet to see the scope of practice for midwives and how it differs immensely from nursing. This addresses some of the points the noble Lord, Lord Hunt, made. The Royal College of Midwives makes the case clearly in its paper when it says:
“We would not treat doctors and dentists as if they were interchangeable”.
Nursing and midwifery should be treated like that—they are different. I understand what the noble Lord, Lord Willis, was saying about silos. We have to avoid them. Travelling around the country one sees silos, but one also sees magical things happening where there are no silos—where obstetricians, midwives, nurses, neonatal nurses and all the rest are working together. Within Better Births, we are introducing local maternity systems to try to make that happen.
Our concern is heightened by the fact that, as the noble Lord, Lord Hunt, was saying, there are no seats on the council set aside for midwives. Inevitably, the council is dominated by nurses. Therefore, with the best will in the world, the council can at times make decisions about midwifery with no midwife in the room. I do not think that is right. We are told about a panel, but a panel is not strong. We want something that has presence, that is respected and that can make a mark within the regulatory body, the NMC.
I will give my noble friend four questions—I should have given him notice of this, but I have been very busy on another Bill today—and I will perhaps seek a written answer to them. Could he give an assurance that, regardless of any removal of the legal requirement for a midwifery committee, the Government will continue to require the NMC to pay due regard to the midwifery profession, recognising that it regulates two separate, distinct professions? The NMC will be required to put in place robust systems to ensure that it seeks and obtains professional midwifery advice on all matters affecting midwifery. Will he agree to what I think is a very modest request?
Could my noble friend also confirm that the NMC will continue to be required to produce standards and guidance for midwives? This should include standards
pertaining to the care of mothers and babies and be based upon extensive consultation with the midwifery profession. Another value the NMC has is accountability. As the noble Lord, Lord Hunt, and the noble Baroness, Lady Walmsley, said, we need the NMC to be accountable. Her comment about knowing where the good places are that retain midwives is very important. My view is that it depends on the leadership and accountability of those looking after the service.
Thirdly, I ask my noble friend, regarding local supervision of midwives, to confirm that a robust system will be in place to monitor the rollout of the new system and, specifically, that the Department of Health will be required to report to Parliament—as has already been suggested in the debate—on the effectiveness of the new arrangements after their first year of operation.
Finally, I ask my noble friend to agree that there is a need for a senior midwifery voice within the UK Government. As has been said, we have a superb leader in NHS England on midwifery care, but that person needs a higher status. That person should be on the same level as the Chief Nursing Officer, because they are looking at different aspects. Can my noble friend consider having a chief midwifery officer at the national level, with directors of midwifery within the NHS England regional teams? We need that leadership. Over the years it has been much diminished, as the noble Lord, Lord Hunt, explained very well. We very much admire the lead maternity person in NHS England but they need to be called a “director”. She or he needs a higher status, and I do not think that such a request is impossible to respond to.