Response
Response to the
Scottish Government
discussion document:
National Health and Social
Care Workforce Planning
March 2017
15 Mansfield Street
London
W1G 9NH
Tele: 0300 303 0444
Fax: 020 7312 3536
Email: [email protected]
The Royal College of Midwives
March 2017
The Royal College of Midwives
15 Mansfield Street, London, W1G 9NH
The Royal College of Midwives’ response to the Scottish Government discussion
document on NHS and Social Care workforce planning.
The Royal College of Midwives (RCM) is the trade union and professional organisation
that represents the vast majority of practising midwives, maternity support workers
and student midwives in the UK. It is the only such organisation run by midwives for
midwives. The RCM is the voice of midwifery, providing excellence in representation,
professional leadership, education and influence for and on behalf of midwives. We
actively support and campaign for improvements to maternity services and provide
professional leadership for one of the most established clinical disciplines.
The RCM welcomes the opportunity to make a submission in response to this
document. Our submission focusses on workforce planning for the midwifery
workforce in Scotland and addresses the following issues:



How factors affecting the demand for maternity services and the supply of
midwives impact on workforce planning.
The implications for planning the midwifery workforce of The Best Start, the
five year forward plan for maternity and neonatal care in Scotland.
Current workforce planning processes and how these can be better
coordinated.
Factors affecting the demand for maternity services in Scotland
The RCM believes that planning for the right number of midwives in Scotland has to
be based on an assessment of what is needed to meet the needs of women and
babies. Understanding the various factors that affect the demand for maternity care
is therefore essential to assessing whether Scotland’s services have sufficient
capacity to meet demand. In this section we outline some of the main trends that are
driving demand for maternity services in Scotland.
The major driver of demand for midwives is the number of babies being born. There
were 54,488 live births in Scotland in 2016, a reduction of 610 on 2015 and 5,500
-2-
The Royal College of Midwives
March 2017
births fewer than in the recent peak year of 2008 when the number of births topped
60,0001. Looking further back, the number of births now is at about the level of a
decade ago and slightly higher than the rate at the start of the century.
The overall trend of a steady fall in births does however mask a more mixed local
picture. Analysis of live births for 2003-15 reveals big rises in the birth rate in
Grampian (up by 23%) and Lothian (11%) and more modest increases in 10 other
health boards2. Whilst some areas did see falls in the number of births, these were all
fairly small, with none exceeding the 4% reduction in Dumfries and Galloway.
Whilst the falling birth rate has lessened some of the pressure on maternity services,
this has largely been offset by the growing complexity of many births. For example,
births to older women has increased significantly so that the profile of women using
NHS maternity care in Scotland is ageing. Between 2000 and 2015, births to women
aged under 20 have more than halved and there has also been a fall in births to
women in their early 20s. For every other age group the birth rate has increased and
this has been particularly marked for women aged 40 and older (up by 80%) and in
their late 30s (a 28% increase in this period)3. In the last 40 years, the number of
women giving birth who are aged 30 or older has more than doubled. This matters
because, taken as a whole, women who give birth later in life will require more care
from the NHS than younger mothers.
Women with greater health needs, including those who are obese or who smoke, will
also require more care and support. Last year 22% of pregnant women were classed
as obese at the time of booking (compared to 18% in 2011), with a further 27% of
women classed as overweight (up from 22% in 2011)4. Rates of smoking amongst
pregnant women are falling, with the proportion of women who are smokers at
booking down from 21% in 2006/07 to 16% in 2015/165. This reduction may in part
reflect the increased focus on providing smoking cessation support by midwives
across Scotland as part of a number of programmes. This work has included the
introduction of routine CO2 monitoring for all pregnant women by midwives and the
offer of nicotine replacement therapy and smoking cessation support. Nevertheless,
rates of smoking in pregnancy are still higher in Scotland than in most other
European countries.
1
National Records Scotland (NRS) (2017) 2016 Births, Deaths and Other Vital Events
https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/generalpublications/births-deaths-and-other-vital-events-preliminary-annual-figures/2016
2
RCM (2017) State of Maternity Services Report 2016 p9 https://www.rcm.org.uk/state-of-maternityservices-2016
3
NRS (2016) Live births, numbers and percentages, by age of mother and marital status of parents,
Scotland, 2000 to 2015 https://www.nrscotland.gov.uk/files//statistics/vital-events-reftables/2015/section3/15-vital-events-ref-tab-3-1b.pdf
4
ISD Scotland (2016) Births in Scottish Hospitals: Year ending 31 March 2016 p20
https://www.isdscotland.org/Health-Topics/Maternity-and-Births/Publications/2016-11-29/2016-1129-Births-Report.pdf
5
ISD Scotland (2016) p14 https://www.isdscotland.org/Health-Topics/Maternity-andBirths/Publications/2016-11-29/2016-11-29-Births-Report.pdf
-3-
The Royal College of Midwives
March 2017
The midwifery workforce in Scotland
The number of midwives working in the NHS in Scotland has remained relatively
stable in recent years. As at 31st December 2016, there were 2,385 whole-time
equivalent (wte) midwives working in Scotland’s maternity services, almost exactly
the same number as five years previously6. During this period the number of wte
midwives has never exceeded 2,450 and always remained above 2,350.
While Scotland has enjoyed the benefits of a stable workforce, the RCM would
caution against complacency. This is because of changes to the age profile of the
workforce: between 2011 and 2016 the number of midwives and maternity care
assistants or support workers (MCAs) aged under 50 fell by 217; in the same period
the number of staff aged 50 and older increased by 2857. Midwives and MCAs aged
50 and older now constitute 41% of the workforce. Older midwives can bring
considerable experience to their roles and are great assets to the NHS in Scotland.
But it is a concern if such a large proportion of the midwifery workforce is close to
retirement. Vigilance is needed therefore in order to ensure that the NHS in Scotland
in not storing up problems due to the increasing proportion of the workforce that will
be eligible for retirement in the five to ten years. A failure to get to grips with this
challenge could wipe out the success that Scotland has had in recent years, especially
compared to England, in maintaining an appropriately sized midwifery workforce.
One way of avoiding problems associated with a retirement bulge is to train up
enough students and bring them into the service so that they can gain experience
and confidence before their more senior and experienced colleagues retire.
Midwifery training numbers in Scotland have fluctuated in recent years. For example,
between 2010/11 and 2011/12 the number of student midwife training places was
halved from 203 to 101. The number has since recovered to stand at 178 in 2015/168,
the highest level for five years. Places for 2016/17 will stand at 191 across Scotland.
There has also been a recovery in the total number of midwifery students in training,
up from 396 in 2013 to 518 in 2015. These increases are very welcome and should
help to tackle the approaching challenges in the age profile of the midwifery
workforce. The RCM welcomes the Scottish Government’s decision to protect the
bursary for healthcare students for 2017/18 as this can only help to maintain student
midwife numbers and we hope that this decision will be extended beyond the next
academic year.
In addition to reducing the number of student midwives in 2010, the number of
universities providing pre-registration midwifery education was reduced from six
(RGU, Dundee, Stirling, Edinburgh Napier, UWS, Glasgow Caledonian) to three (RGU,
Edinburgh Napier and UWS). Lead midwives for Education at the three HEIs have
6
ISD Scotland (2016) Nursing and midwifery staff in post as at 30th September 2016
http://www.isdscotland.org/Health-Topics/Workforce/Publications/data-tables.asp?Co=Y
7
ISD Scotland (2016) Nursing and midwifery staff by specialty and age group
http://www.isdscotland.org/Health-Topics/Workforce/Publications/data-tables.asp?Co=Y
8
ISD Scotland (2016) Nursing and midwifery student intakes and students in training
http://www.isdscotland.org/Health-Topics/Workforce/Publications/data-tables.asp?Co=Y
-4-
The Royal College of Midwives
March 2017
indicated that this change appears to have led to changes in the demography of
applicants to courses, with a reduction in the number of mature applicants and a rise
in the number of school leavers. This appears to be due to the requirement for
students to undertake placements over a much wider geographical area, which
presents more problems to those with caring responsibilities. Concern has also been
expressed to the RCM by Senior managers from NHS Highland that there are fewer
students from the Highlands as a result of the Stirling university campus in inverness
no longer offering midwifery and students from Highland having to travel to
Aberdeen for study. This has significant implications for the ongoing ability of the
Highlands and Islands to recruit and retain midwives. The RCM would recommend
that consideration is given to not only the number of student midwives but the
location of their educational institution and placements in order to maximise the
opportunities for maintaining an adequate workforce in remote and rural areas such
as the Highlands and Islands.
A related issue that Heads of Midwifery in Scotland have raised with the RCM is
whether there is scope for moving back to the system of having two intakes per year
of newly qualified staff from which to recruit from? One of the reasons given for
moving to the one intake each autumn was that students emerging from the second
cohort fared less well as securing work, but the RCM is sceptical as to whether this
argument still stands. With just one intake a year, all midwifery services are
effectively ‘fishing in the same pool’; this can be particularly difficult for services
which, having filled their posts in the autumn, fine themselves with vacancies early in
the new year that cannot then be filled until the next autumn. Whilst we have no
doubt that universities may not be enthusiastic about a return to two annual intakes,
we believe such a move would command support across the healthcare professions
in Scotland.
One other way of mitigating supply challenges is to recruit more overseas staff and in
recent years a number of midwifery services have recruited midwives from the
European Union. Around 4% of nurses and midwives in Scotland are from the EU9.
Leaving the EU will therefore present a significant challenge for planning Scotland’s
NHS and social care workforce. With uncertainty about when the UK will leave the
European Union and what this means for freedom of movement, the RCM has called
on the Westminster Government to give a commitment to EU nationals working in
the NHS that they can remain living and working in the UK.
Maternity policy and the impact on workforce planning
On 20th January 2017, the Scottish Government published The Best Start, a five-year
forward plan for maternity and neonatal care in Scotland10. The report, which makes
76 recommendations, sets out a vision and proposals that have the potential for
transforming the planning, design and delivery of maternity and neonatal care.
9
Scottish Government Press Release 8 November 2016 https://news.gov.scot/news/brexit-risk-tonhs-recruitment
10
Scottish Government (2017) The Best Start: A Five-Year Forward Plan for Maternity and Neonatal
Care in Scotland http://www.gov.scot/Resource/0051/00513175.pdf
-5-
The Royal College of Midwives
March 2017
Radical recommendations include: providing pregnant women with continuity of
carer from a primary midwife; delivering integrated team care from community hubs
and improving the care received by women living in deprived communities and those
who experience mental health problems.
Such fundamental changes to the way that maternity care is delivered and
experienced will inevitably have implications for the midwifery workforce and,
therefore, for workforce planning. Successful implementation of The Best Start will
require a robust assessment of the workforce implications of the report’s
recommendations, particularly in relation to:
 Organising midwifery services in a way that enables more women to receive
continuity of carer from a primary midwife, aligns midwifery teams with a
caseload of women and which will require most midwives to work in the
community.
 Relocating midwifery services in community hubs, where women will receive
the majority of their antenatal care and where some women may also birth.
 Ensuring that women are offered a full range of choices, particularly in
relation to place of birth and of pain relief.
 Supporting and educating staff to adapt to new ways of working, with an
increased emphasis on working in teams and multi-professional working.
 Better utilisation of MCAs and other non-registered staff, especially in relation
to the public health agenda.
 Reviewing staffing models for postnatal care.
 Providing staff with incentives to work in remote and rural areas, or other
areas with significant recruitment and retention challenges.
There are also specific recommendations for the transformation for the midwifery
workforce, which reflect the emphasis on normality, working in the community, and
the need to improve postnatal care. These recommendations relate to:
 Giving midwives refresher education and training in core skills, including
supporting normal birth processes and providing care across the whole care
continuum, and in examination of the newborn (recommendation 25).
 Developing clinical midwifery roles across the career framework as part of
national work to transform nursing, midwifery and allied health professional
roles (recommendation 26).
 Developing revised staffing profiles for inpatient postnatal maternal and
neonatal care, underpinned by education and training in postnatal and
neonatal care (recommendation 27).
Given these recommendations it is perhaps not surprising that the report recognises
how important it will be for NHS Boards to plan for, and incrementally build,
workforce capacity across maternity and neonatal pathways. This is reflected in a
number of recommendations that are aimed specifically at improving workforce
planning and which will require:
 Boards to undertake comprehensive workforce planning, including an
assessment of future supply and demand, and new roles, and to feed the
results into national level work (recommendation 64).
-6-
The Royal College of Midwives


March 2017
NHS Education for Scotland, universities, colleges and other training providers
to plan for education and training capacity in parallel with the workforce
planning undertaken by NHS Boards (recommendation 65).
Consideration to be given to the provision of protected training time for all
staff, in order to ensure that training is given the appropriate priority
(recommendation 66).
The RCM welcomes these recommendations and is ready to help shape these
reviews into the midwifery workforce requirements for the new models of care.
Workforce planning arrangements
The main tool that is used for planning the midwifery workforce in Scotland is the
Scottish maternity workload tool developed through the Nursing and Midwifery
workload and workforce planning programme, led by the Scottish Government.
In England, Wales and Northern Ireland the main midwifery workforce planning tool
is Birthrate Plus®. The RCM continues to support Birthrate Plus® as a robust and
credible workforce planning tool for midwives11. It has a long track record in enabling
managers to measure the work and time involved in providing high quality maternity
services and translating this into staffing numbers.
The RCM is currently working with Birthrate Plus® on the development of a
methodology for assessing the midwifery workforce requirements associated with
the development of continuity of carer teams. While this work is being carried out in
conjunction with the maternity transformation implementation programme in
England, the methodology may also be helpful when it comes to implementing
continuity of carer in Scotland.
In Scotland the Birthrate plus tool was trialled during 2010, but concerns were raised
about the accuracy of the tool’s calculations in the Scottish context. The decision was
then made to develop a Scottish maternity workload tool.
The tool was developed, based on observational studies carried out across maternity
inpatient facilities in Scotland in 2011-13. In 2013 the new tool was tested nationally
for two weeks and retested again for three months in 2014. In 2015 the new
maternity tool was signed off by the Heads of Midwifery.
Since 2015 the tool has been run nationally three times a year for four week periods.
In January 2017 the RCM was present at the Maternity workload tool national
working group meeting to discuss the functionality of the tool. At this meeting, views
of the adequacy of the tool were variable among the Heads of Midwifery. Some
health boards felt that the tool was working very well, particularly where significant
resource had been assigned to support staff to use the tool correctly.
11
RCM, Ball J, Washbrook M (2012) Birthrate Plus®: What it is and why you should be using it
https://www.rcm.org.uk/sites/default/files/Birthrate%20Plus%20Report%2012pp%20Feb%202014_3.
pdf
-7-
The Royal College of Midwives
March 2017
Other Heads of Midwifery raised concerns that the tool was not yet fully functioning
to capture workload in services that are not described as 24 hour services in the tool
(such as some freestanding midwife led units and community midwives), so that
activity that had actually taken place at night was having to be recorded as daytime
activity.
Some Heads of Midwifery raised concerns that the tool had been devised to reflect
inpatient maternity activity – no observations were undertaken in the community in
the original development phase of the tool. Much of the work of midwives is
undertaken in the community setting in clinics, community maternity units and
women’s’ homes. The proportion of midwives working in the community setting will
increase very significantly to fulfil the recommendations of the ‘Best Start’ review.
The RCM is of the view that there is still considerable uncertainty as to whether the
Scottish maternity workload tool in its current form is fully fit for purpose to reflect
midwifery care in the community and as maternity services develop. The RCM will
continue to support the continued testing and development of the Scottish maternity
workload tool nationally through ongoing Scottish Government work. The RCM
would recommend that the Scottish Government team liaise with the Birthrate plus
developers to explore approaches to measuring workload and workforce needs when
providing continuity of carer models of midwifery care.
Coordinating workforce planning
In terms of the proposals outlined in the discussion document, the RCM is in general
agreement with the roles outlined for workforce planning at national, regional and
local level. We suggest that at the regional strategic level, an additional role should
be to consider the need for incentives to stimulate labour markets for regions that
have particularly difficulties in recruiting and retaining staff.
The RCM also concurs with the broad thrust of the argument that the paper makes in
support of more effective coordination of workforce planning. We agree that a silo
approach to workforce planning can make it harder to deliver integrated services.
Better coordination of workforce planning would also help to avoid the unintended
consequences that can arise when workforce planning for a particular group of staff
is carried out in isolation. In this respect an issue of particular concern for the RCM is
when recruitment drives are planned for professional groups like health visitors or
family partnership nurses. In the absence of a coordinated approach to workforce
planning across healthcare groups, there is a risk that recruitment targets groups like
midwives, resulting in an increase in the number of midwife leavers.
The RCM agrees in principle that an overarching process for workforce planning
across health and social care would be helpful, although of limited relevance to
midwifery which is largely funded and managed within the healthcare sector.
The Royal College of Midwives
March 2017
-8-