Over the past year, I have received many emails and letters from maternity service users, midwives and nurses expressing their concerns and seeking clarity regarding rumours that midwifery supervision will be completely eradicated (Box 1). My consistent message has been that ‘midwifery supervision is here to stay’; however, the development of a future employer-led model of midwifery supervision in the UK is required.
Box 1.Concerns about supervision‘Supervision will become punitive and not restorative’‘Midwives will be referred to the Nursing and Midwifery Council at the drop of a hat’‘Without the law supervision will be difficult to enforce’‘The role of the midwife will not be protected’‘Women will lose support; expertise for providing advocacy for women will go’‘Remuneration will stop and be used as a cost saving’‘Numbers of supervisors of midwives will reduce and current ratio will be ignored’‘Who will support self-employed and agency midwives?’‘How will we benchmark if there are no audits?’‘Who's going to provide professional midwifery advice across England?’
The impetus for change is mainly a result of two key reports from the Parliamentary and Health Service Ombudsman (PHSO, 2013) and The King's Fund (2015). These reports highlight a structural flaw in the deployment of statutory midwifery supervision that relates to an inability to effectively and appropriately escalate poor care and incidents within maternity provider governance processes. Equally, the relationship between the regulatory function of the Nursing and Midwifery Council (NMC) and statutory supervision of midwifery was found to be unclear.
As a result, it was proposed that the system of midwifery regulation should change so that midwifery supervision and regulation are separated, enabling the NMC to have direct control of regulatory activity (PHSO, 2013; The King's Fund, 2015). These proposals were accepted by the NMC and agreed by the Secretary of State. To implement these principles, the NMC requires legislative change. It is estimated that this process may not be complete until 2017. Until then, it is important to emphasise that statutory supervision of midwives must continue. In preparation for the law change, the development of a new model of midwifery supervision is required. This process will be overseen by the Chief Nursing Officer for each UK country.
Developing a new model of supervision will create an opportunity to harness the strengths of the statutory current model and improve areas that require development. With regard to the concerns expressed, it is important to note that there will be no change to the scope of midwifery practice. Equally, the protected title of ‘midwife’ and the protected function of ‘attendance on a woman in childbirth’ will not change, and are preserved under the proposed legislative change. Other concerns can be mitigated by the development and implementation of a model of supervision where the woman and her family are supported by resilient, compassionate, competent midwives who practise within a framework of supervision that has a restorative function. The latter involves interventions aimed at enhancing personal confidence, self-efficacy and stress management (Hunter and Warren, 2014), in addition to supporting clinical competence. Other considerations when developing a new model of supervision should include:
- The function and role of supervision within an employer-led model
- The significance of a supervisor-to-midwife ratio
- Supervision for midwives and the integration with the revalidation process for NMC registrants
- Educational requirements for the new model of supervisor: 4-country approach
- Levers and incentives for the deployment of supervision in the absence of statute: a focus for maternity providers, commissioners and midwives
- Local, regional and national intelligence about midwifery: the benefits of Local Supervising Authority audits
- Leadership and professional support
- Transitioning from a statutory model to an employer-led, professional model
- Process, impact and outcome evaluation.
The benefits of carefully planning and undertaking evaluation are well known and should be prioritised when developing a new model of supervision. The potential for research should also be considered to build on the repository of evidence about this subject. Learning from the current situation is key. At present, incidents involving midwives that are investigated locally may have sanctions applied locally, without referral to the NMC. There is, however, a dearth of evidence that this extra layer of regulation is safer for women and their families than other regulatory approaches.
We have an opportunity to reflect on the past, improve on the present and transform supervision for the future. Midwifery supervision really is here to stay!