There will be surprise and shock among UK midwives following the Nursing and Midwifery Council's decision that statutory supervision of midwives should no longer be part of its legal framework (NMC, 2015). This decision by the NMC comes as a result of an independent review of statutory supervision by the King's Fund. The review was initiated as a result of a report by the Public Health Service Ombudsman (PHSO) for England into the maternity services at the University Hospitals of Morecombe Bay. Her report stated that she believed that there was a major flaw in midwifery regulation due to the delegated model of regulation. This referred to the investigatory powers held by supervisors of midwives and the local supervising authorities (LSA). During this whole process the Royal College of Midwives (RCM) has lobbied on behalf of its members and provided papers and letters to the King's Fund, the Public Administration Select Committee, the Chief Nursing Officer (CNO) England and the NMC Midwifery Committee, outlining the critical role supervision plays in protecting the public through the support it provides to midwives and women in their care.
During the last year, the RCM has often found it has been up against a lack of evidence for the regulatory aspects of supervision and an overwhelming opposition from a number of key stakeholders. If you have seen the NMC press release or the cover paper for the NMC discussion of the King's Fund report, you will note that there was little or no support for the continuance of statutory supervision from other stakeholders including the Department of Health for England, the PHSO (England), the Public Administration Select Committee, the Professional Standards Authority and the NMC itself. The reality is that challenges faced by regulatory systems as a result of significant failures in health care—Shipman, Mid-Staffordshire, Winterbourne View and Morecombe Bay—have brought the era of self-regulation to an end in the UK. From the point of view of the regulator, the investigatory aspect of supervision must be under their control. The RCM was never going to win this argument.
At the Council meeting, held on 28 January, there was a large midwifery attendance and the RCM was at least able to make representation from the floor which was well received. The points raised included:
What next?
This is very much in the hands of the NMC and, to date, it has not identified in detail what the next steps will be. At the NMC Council meeting it was announced that the Midwifery Committee will be looking at the Midwives' Rules and Standards to see if any changes can be made ahead of legislative change. What form this review will take is uncertain. Any proposed changes will need a full consultation and ratification by the Council and for the Rules, Privy Council. The NMC will also be planning for legislative change to the Nursing and Midwifery Order.
A major concern to the RCM is the risk of confusion during this transition period. Many of those outside midwifery do not fully understand how the supervision of midwives is integral to midwives' daily lives. The elements within the clinical supervision support for midwives are key to a high-quality woman-centred service. We know from nursing that although clinical supervision was seen to be a good idea, it was never resourced and has therefore, in most cases, disappeared from sight.
In clinical governance terms, the RCM thinks it is vital that midwives have access to someone 24 hours a day with the skills and capacity to support them on the ground in clinical decision-making. Increasingly, midwives are working outside acute hospital settings, in freestanding midwife-led units, case-loading antenatal and postnatal care or supporting women having a homebirth. Who will provide support for midwives and women in these circumstances? Who will be there for midwives to work through ethical issues and balance allocation of scarce resources to ensure that women are kept safe?
Well-run services will probably see this clinical supervision for midwives as a vital and central component of good clinical governance arrangements and risk management. But what about the others? Will axing clinical supervision for midwives be seen as a cost-saving measure? As midwives we need to make our case locally to ensure that this doesn't happen. The fact that nursing doesn't have clinical supervision is irrelevant, those nurses who make clinical decisions in the same way as midwives should make their own case. However, for midwifery with up to 113 years experience of supervision, practising without it will feel for some like jumping out of a plane without a parachute. We need to ensure that this support remains consistently available across maternity services in the UK.