The NHS has improved in recent years, says a midwife – but there are big risks within the next wave of reforms
“Our maternity suite is typical of a large city hospital: we deliver around 6,000 babies a year, often at a rate of more than one per hour. I’ve been a midwife for 15 years and these days I coordinate the delivery suite, making sure that each mother has a midwife looking after them. It’s a very mixed neighbourhood. Many mothers are very educated and ask lots of questions; others, from lower income areas, tend to have lower expectations and just get on with it.
A lot of the time I’m firefighting. If there’s an emergency – the mother collapses, for example – I have to get the right people into play. I also liaise with doctors and external services, and plan for elective surgeries.
My biggest issue is resources. We rarely have an excess of staff, and demand is unpredictable. If a woman needs an emergency caesarean, that takes two midwives out of the shift team. It’s not uncommon for one midwife to end up looking after two women in full labour.
We’re also using lower-paid maternity care assistants; and while they can help free up midwives, they need a lot of support. They can take blood pressure, for example, but may not know how to interpret the results. Giving untrained staff some extra training is not the answer to keeping wage costs down.
The government says that 3-5,000 midwives are being trained, but a lot of trusts are now slimming down. We’re being made more ‘efficient’, with fewer experienced midwives on the highest pay bands on each shift – though I wouldn’t say we’re badly paid, by any means. Meanwhile our hospital seems to have a million managers well back from the frontline, but we pay cleaners absolutely nothing – despite the importance of the job they do.
We have seen improvements over recent years. The working time directive helped our paediatricians, who now work 12-hour rather than 24-hour shifts. Hospitals have also been encouraged to share good practice: another trust showed us how to get the whole maternity team – midwives, doctors and surgeons – to undertake new training together. That’s created a situation with little or no hierarchy, where the midwifes know the doctors and feel able to challenge them. We don’t just work in our own little silos.
We’re being pushed to be more transparent, which is fine in principle; but while an internet search will reveal our results in terms of the proportions of natural births and caesareans, these things are not put in context and targets always worry me. The ‘too posh to push’ brigade is very small, but there are plenty of legitimate reasons why women have elective surgery.
Because caesareans are expensive, we’re being asked to cut their numbers by one per cent. But meanwhile, we lose funding if we don’t achieve a pre-set number of elective caesareans. Targets like these put a distance between the aims of the mother and the midwife. It’s: ‘Into the theatre, spinal [anaesthetic], baby out, next one please!’ There is less time to support this newly-created family. It’s more like a cattle market.
The Health and Social Care Act could offer some benefits. It should, for example, streamline the way we buy medical goods. We used to have one pre-prepared packet of medical goods for each delivery: gloves, syringes, scissors, clamps and so on. Then it became cheaper to buy these items individually, so now we always seem to be short of something. Right now we can choose between more than 100 brands of surgical gloves and often switch suppliers, which is ridiculous.
In other ways, though, I’m concerned about the Act. In future we’ll be funded retrospectively, with more money for high-risk mothers and less for the low-risk – but someone can be low-risk for 34 weeks and then get pre-eclampsia [high blood pressure] and require intensive attention.
This funding is supposed to even itself out, but I’m not convinced. If you look at the demographic trends, there are more older and fatter women having babies, and more who’ve had serious illnesses or even transplants. They will tend to need greater care and attention. We’re told the Act will help the NHS adjust to such challenges – but I can’t really see it, as we’re being asked to do all this with less money and staff.
Under GP commissioning, local doctors will sign a contract with a particular hospital’s maternity suite; and I’m not clear how that squares with the idea of more choice for patients, who may not be able to choose which hospital they attend. How things change on the ground will depend on local personalities: GPs will decide who they want to work with, and could choose community midwifes or people from outside the area. I’m not comfortable with this: the idea of midwives tendering for business is just too corporate for me.”