NMC urged to review midwife training standards
A damning report into maternity care in England has led to calls for a review of midwife regulation and investment in the workforce, amid reports that staff are acting outside of their scope of practice and are being stretched beyond their limits.
The report, published by the Care Quality Commission (CQC) this week, found significant concerns relating to the safety of women looked after by maternity services, “variation” in response to adverse incidents and “normalisation” of poor care.
“Well publicised staffing pressures can affect the quality of care that midwives are able to provide”
Tracey MacCormack
The CQC found “pockets of excellent practice” in its review of maternity services across the UK. However, only 4% of the 131 maternity services the regulator inspected between August 2022 and December 2023 were given the top rating of ‘outstanding’ overall.
Meanwhile, 36% of the settings were rated as ‘requires improvement’ overall, 12% as ‘inadequate’ and 48% as ‘good’.
The report concluded that many of the issues identified at individual trusts through high-profile investigations, reviews and inquiries in recent years were “widespread” across England’s maternity services.
In particular, the CQC aired concern about findings of sub-standard safety at many trusts; not a single trust inspected as part of the report were rated as ‘outstanding’ for safety, while 18% were rated as ‘inadequate’ in this domain, and 47% as ‘requires improvement’.
Inspectors noted “significant variation” in the quality of maternity triage care and examples where understaffing and under-resourcing had caused women to have delayed or even missed care.
“We found instances where the triage phone went unanswered and when people arrived at hospital, issues with staffing and the triage environment meant some women were not assessed in a timely way,” the report read.
“In some cases, delays in triage were so severe that women discharged themselves before being seen by a midwife or doctor.”
Staffing issues were leading to staff having to “perform tasks or cover for roles that are outside of their training and not in line with national guidance”, warned the report.
It found examples of unregistered staff taking on the roles of registered staff during surgey for caesarean sections.
In other cases, services had used registered nurses to perform tasks reserved for midwives and doctors, such as attending to a woman in childbirth outside of an emergency or training.
The watchdog also noted that some services were not providing their midwives with the training to keep up with the rising complexity of care.
“The complexity of maternity care has increased in recent years, with higher numbers of women needing higher levels of care, including high dependency care,” the report said.
“As highlighted by the Royal College of Midwives, this demands more of the maternity workforce.
“Services need staff with the skills and expertise to look after people at each part of the pathway – from antenatal to triage, labour, and postnatally… modern day maternity services have not always kept up with this change.”
The regulator aired concern about the absence of a national training requirement for midwives providing high dependency maternity care.
More widely, the CQC’s report found instances where problems with leadership, culture and a failure to report issues in settings affected patient outcomes.
Elsewhere in the report, the CQC criticised the poor quality of the NHS estate.
The regulator noted: “Some maternity units assessed as part of the programme were not fit for purpose, as they lacked space and facilities and, in a small number of cases, appropriate levels of potentially life-saving equipment.
“Women should receive safe, timely care in an environment that protects their dignity and promotes recovery.”
As well as this, the CQC said it remained “concerned” about racial health inequalities in access and experience of maternity services.
One mother told the report: “The problems started when I was moved to the postnatal ward. Staff were racist, rude and couldn’t care less.
“They didn’t listen to my concerns as a new mum and were desperate to discharge me even when I told them that my baby had only fed once in 36 hours since birth.”
The CQC heard that staff could see a “lack of respect” for women from ethnic minority backgrounds, with the report emphasising the “safety implications” this had, including inequity in access to pain relief during labour and to interpreter services.
It issued a list of recommendations to the health service, professional regulators and policymakers in response to the issues it found.
Among these were two relating to the regulation of midwives.
First, the CQC asked that NHS England, the Royal College of Obstetricians and Gynaecologists and the Nursing and Midwifery Council (NMC) set a “minimum national standard” for midwives delivering high dependency care.
Secondly, the NMC was asked to “review” its proficiency standards for midwives in general.
“We cannot allow an acceptance of shortfalls that are not tolerated in other services”
Nicola Wise
Tracey MacCormack, assistant director for midwifery at the NMC, said in response to the report: “We keep our standards under review to reflect new evidence and its impact on people, and we’ll carefully consider the findings of this report.”
She welcomed the CQC’s findings, and called for midwives to receive the “right resources” and continuing professional development (CPD) training to help maintain standards.
“As the report highlights, well publicised staffing pressures can affect the quality of care that midwives are able to provide,” said Ms MacCormack.
The CQC also asked the Department of Health and Social Care (DHSC) to provide “additional capital investment” for maternity, to combat the impact old or otherwise unsuitable hospital buildings had on maternity care.
DHSC, the regulator said, must work with NHS England to make sure any money remains ringfenced for maternity specifically.
Further recommendations were made for NHS trusts and integrated care boards. These included improving demographic data collection, particularly for ethnicity, and ensuring this data is used to reduce health inequalities.
NHS Providers chief executive Sir Julian Hartley said the report “confirms what trust leaders have long known” regarding the issues in maternity.
“Trusts are committed to improving both outcomes and experiences for women but to deliver meaningful and system-wide improvement, they need sufficient and sustained investment, including in staffing and in maternity facilities,” said Sir Julian.
“Trusts are tackling inequalities head-on too, ensuring they understand the diverse needs of those they are caring for, as well as supporting staff and women to feel able to speak up and be confident they will be listened to.”
Nicola Wise, CQC director of secondary and specialist care, said: “Sadly, our latest maternity inspection programme has further evidenced the need for urgent action with continued problems indicating that the failings uncovered in recent high-profile investigations are not isolated to just a handful of individual trusts.
“We cannot allow an acceptance of shortfalls that are not tolerated in other services. Collectively, we must do more as a healthcare system.
“This starts with a robust focus on safety to ensure that poor care and preventable harm do not become normalised, and that staff are supported to deliver the high-quality care they want to provide for mothers and babies today and in the future.”
