Chapter 54 Organization of the health services in the UK
The United Kingdom of Great Britain and Northern Ireland (UK) has different systems of governance to respond to the needs of the UK’s four countries: England, Wales, Scotland and Northern Ireland. The distinct characteristics of the people of each of these countries require the provision of appropriate health services. This chapter aims to explore some aspects of the health services in the UK. Today the primary source of health services is the National Health Service (NHS). A relatively small independent sector also exists but as the NHS is the main provider of UK health services, this chapter will concentrate on the NHS. It is appropriate also to highlight areas where the NHS in its early years, and latterly, affected midwifery and maternity services.
The story of the NHS has a long beginning. In the early twentieth century, the UK contained extremes of circumstances, which affected the population’s health: poverty and deprivation on the one hand; on the other, great wealth. Healthcare varied: some people paid medical expenses by weekly subscription to Friendly Societies; some attended dispensaries, outpatient departments of voluntary hospitals, or, often generous, general practitioners (GPs); some used folk remedies or patent medicines; others went without (Brotherstone 1987a, p 36).
Within the aims of this chapter, it is appropriate to conduct a brief exploration into the recent past. Since the early 1900s, development of the UK health services, while differing depending on the mores of each home country, has shown universal progression. As part of social history, this has had an impact on the health and well-being of all members of society (McLachlan 1987, p xi).
Modern healthcare is a huge complicated web of personal services. Its background lies in the Victorian era’s pressures for social justice, Chadwick’s seminal report (1842) and succeeding wars which highlighted the need for improved health and other services. For instance, the growing acknowledgement of the poor physical stature of children of Britain, highlighted by the rejection of army recruits for the Boer War (1899–1902), further stimulated the growing interest in maternal and infant welfare.
In 1908, Poor Law medical relief represented the biggest public commitment to medical care. However, Labour politicians started pushing for a comprehensive health service for everyone. In 1905, the Conservative government appointed a Commission to investigate the Poor Law and recommend reforms (Brotherstone 1987a, p 43). However, consensus on increased State involvement in the promotion of health was hard to achieve: the Commission’s impact was minimal. Nevertheless, their reports advocated a coming together of concerned individual services to form a health service. This was to be at the heart of much of the subsequent development of public medical care (Brotherstone 1987a, p 47).
Early twentieth century healthcare provided by the Friendly Societies was inadequate, unsatisfactory and unfair. Excluded from membership were: chronic invalids; ‘high-risk’ people; and members’ wives and children. Chancellor of the Exchequer at that time, David Lloyd George, believed that a state-supported health insurance scheme was necessary and in 1911 his National Insurance Act was passed (Brotherstone 1987a, p 48).
The National Insurance Act aimed to relieve poverty among manual workers when off work through illness and to provide a minimum healthcare service. There was a recognized ongoing need to extend the Act. However, in practice, mainly due to costs, little difference in the health services was seen at the time (Pater 1981, p 4–6).
There was a need for a special health service in the Highlands and Islands of Scotland, a wide sparsely populated area. For the self-employed crofters who lived barely above subsistence level, with no money to spare for healthcare, the National Insurance Act was of little relevance. Within 2 years of the Act, Parliament acknowledged the special case of the Crofting Community, allocated funding, and the Highlands and Islands Medical Service (HIMS) was set up. This was ‘Britain’s first comprehensive state medical service’. It ‘provided … necessary pointers towards a full and comprehensive health service in Scotland’ and demonstrated a ‘system of co-operative effort’ (McCrae 2003, p 1–29) which can be seen in some multi-professional team working of today.
In the 1920s and 1930s, the trend towards public policy for the organization of medical services grew (Fox 1986). There was a growing public sense of need. Charitable agencies existed but were not enough to meet the needs of the very deprived; slowly public services became involved (McLachlan 1987, p xii). In addition, voluntary donations attempted to keep hospitals afloat. Anne Bayne recalled:
[When I was four] my mother … took me to visit my aunt in Aberdeen Royal … when it was all voluntary donations (mid 1930s). The nurse … [had] to go round with the plate … and she came and handed me the plate to take round [the visitors].
Change across the UK was required. In 1936, the Department of Health for Scotland (DHS) recognized the need for a national health policy and laid the foundation of a State medical service (DHS 1936; Brotherstone 1987a, p 75). A decade later, an NHS for the UK was about to become a reality.
In the early 1940s, cross-UK debate regarding future health service policy was energized by the publication of a wide-ranging scheme for reconstructing social security; the term ‘welfare state’ was born and ‘a comprehensive health service would be made available to all’ (Brotherstone 1987a, p 88; Department of Health and Social Security [DHSS] 1942). Thus, this was to be a ‘national health service for prevention and comprehensive treatment’ (Webster 1998, p 7). Early in 1943, the National Government committed itself to this ideal; the finer details remained for participating bodies to bring slowly and sometimes acrimoniously to a conclusion.
The long-awaited ‘appointed day’, 5 July 1948, saw the implementation of two separate Acts in Britain: the 1946 NHS Act for England and Wales and the 1947 NHS (Scotland) Act. At this time, since 1922 Northern Ireland had already had considerable legislative autonomy with its own Parliament at Stormont, outside Belfast (Davies 1999, p 917, Levitt et al 1999, p 84). Thus, Northern Ireland’s ‘appointed day’ was heralded by the 1946 Health Services Act (Northern Ireland) (O’Sullivan 2001, p 95–101).
In instigating this huge change in health policy and establishment of political accountability, Aneurin Bevan, the Minister of Health predicted that a ‘dropped bed-pan would resound through the corridors of Whitehall’ (Talbot-Smith & Pollock 2006, p 1). The changes have kept coming: the bedpan has never really come to rest.
Three central values formed the core ideology of the NHS:
Funding for this ‘new institution’ was to be mainly through central taxation (Talbot-Smith & Pollock 2006, p 2). Other sources of funding were local rates and public contributions to a national insurance scheme (Brotherstone 1987b, p 106).
Administratively, the NHS was originally designed to be run on a tripartite scheme: first, Regional Hospital Boards; second Executive Councils which administered general medical services, including dentistry and pharmacy (under the NHS, GPs retained their status as independent contractors); third, there were Local Health Authorities (LHAs) responsible for providing maternity services, child welfare, midwifery (but not including hospitals), health visiting and home nursing (Brotherstone 1987b, p 106).
The Beveridge Report (DHSS 1942) assumed that ‘there was a fixed quantity of illness in the country’. This would gradually grow less with the new NHS. The cost of healthcare would level off, become stable, and perhaps, as people became healthier, it would even decline (Ham 1992, p 17). The cracks in this prediction soon showed as people’s expectations grew along with the spiralling costs of medical care (McCrae 2003, p 242).
No-one in the UK has remained untouched by ‘one of the greatest social constructions of the twentieth century’ (Christie 1998). The general public, hitherto unable to afford treatment, now used the new NHS to the full. One doctor recalled:
There was a colossal amount of unmet need that just poured in … women with prolapsed uteruses literally wobbling down below their legs … [and] hernias … men walking around with trusses holding these colossal hernias in … they couldn’t afford to have it done.
Now they could ‘have it done’. However, expanding waiting-rooms and lengthening queues soon demonstrated that the NHS was a victim of its own success. In addition, along with their consultation, patients expected a free prescription. The rising cost of new drugs and the demand for free false teeth and spectacles added to the total expenditure. In 1949, the government imposed a charge of 1 shilling (5 pence) per prescription and in 1951, further charges on spectacles and false teeth. However, by 1953, costs were prejudicing necessary NHS developments (McCrae 2003, p 244). A subsequent review of NHS finances ‘revealed the potentially unlimited demand for healthcare and the necessity of containing that demand within a finite budget’ (Brotherstone 1987b, p 148).
The new NHS affected midwifery services and midwives’ practice. Although the NHS did not directly alter the Central Midwives Boards (CMBs) or their responsibilities, its tripartite administrative structure fragmented maternity services. This led to the possibility of overlapping, confusion and a diminishing role for the midwife (Johnstone 1953, Robinson 1990, p 73). First, pregnant women could now go to their GP free of charge to ‘book’. Midwives were thus no longer the first point of contact. Second, GPs began to perform an increasing amount of antenatal care. This, exacerbated by the NHS, caused conflict between some GPs and midwives and signalled an ‘unwelcome trend which could wreck the structure of the midwifery services’ (Ministry of Health [MoH] et al 1949, p viii; Robinson 1990, p 72). Extra payment for undertaking maternity care saw GPs’ proportion of antenatal care rising quickly, diminishing the midwife’s role and experience for pupil midwives (Robinson 1990, p 73–74). Third, the NHS brought problems of safety and continuity of care: ‘In some cases, midwives are not seeing patients until they go to deliver them’ (MoH et al 1949, p viii). Fourth, the NHS reinforced the existing trend towards hospital births. The new policy of centralization of obstetric care matched an increasing demand for hospital births with a corresponding increase in medical involvement in normal maternity care (Robinson 1990, p 75, Tait 1987, p 420). From the mother’s point of view hospital births sometimes made economic sense; they also gave many mothers a welcome rest (Williams 1997, p 200). Nevertheless, although the number of hospital maternity beds was rising there were not enough to meet the rising demand (Reid 2003, p 138). Some mothers took for granted the availability of a hospital bed and did not book. Mary McCaskill recalled:
… a relative would phone in … Mrs A was in labour … could she go into hospital? … [If there was no bed] … I had to go out … as a municipal midwife … and … tell them [this] … and the baby was going to be born in the house … [We] often got a hostile reception … because a family was unprepared … for a home confinement.
Nevertheless, hospital births were on the increase and some midwives in the district began to feel very vulnerable. Mary McCaskill continued:
[By 1952] the home deliveries had … started to decline … Older midwives … probably in their fifties … didn’t have so many bookings and they were wondering … what was the future … would they be diversified into some other duties?
Thus the early NHS played a part in diminishing the role of the midwife, and the move towards hospitalization of birth. This also affected midwifery training, the viability of training institutions, and eventual changes in the midwifery curriculum (Reid 2003, p 139).
Successive government reviews of the NHS culminated in a reorganization of the NHS in 1974 following the 1973 NHS Act for England and Wales and the 1972 NHS (Scotland) Act. These Acts abolished the tripartite structure and integrated all health services under a single management structure with a three-tier system through regional, area and district health authorities (Brotherstone 1987b, p 130, NHS 1972). The new structure for England is summarized in Table 54.1 (Ham 1992, p 27).
Table 54.1 NHS: structure in England 1974–1982
| Name | Members appointed by | Function |
|---|---|---|
| Regional Health Authority (RHA) | Secretary of State for Social Services | Planning of health services |
| Area Health Authority (AHA) (parallel to FPCs below) | RHAs; local authorities; Members of non-medical and nursing staff | Planning and management; development of services |
| Family practitioner committees (FPCs) | AHA, local professionals and local authorities | Administered contracts of GPs, dentists, pharmacists, opticians |
| District management team (parallel to CHCs below) | Formed from areas | Administration of health districts (divisions of areas) |
| Community Health Councils (CHCs) | Drawn from public | To represent views of public to HAs |
The new NHS structures in Wales, Scotland and Northern Ireland differed from that in England. In Wales there were no RHAs. The Welsh Office had the dual role of central government department and RHA (Ham 1992, p 28). The 1972 Scottish Act aimed for a fully integrated service. Instead of RHAs, 15 health boards (HB), were to unite the organization and management of Scottish health services with Local Health Councils (LHCs) equating with CHCs (Brotherstone 1987b, p 132–135). In Northern Ireland four health and social services boards, each split into districts, responsible for personal and social services and health, were in direct contact with the DHSS (Northern Ireland). District Committees functioned as CHCs (Ham 1992, p 28).
The 1974 reorganization brought more cohesion between hospital and community but with it, problems associated with integration of midwifery between the community and hospital. This affected midwifery practice. Many midwives were administered by senior hospital nurses often without a midwifery qualification; similar problems arose in midwifery education (Reid 2003, p 149, 151). Administrative change was spurred on by the 1966 Report of the Salmon Committee with concerns over nursing and midwifery structure, status and standards (Davies & Beach 2000, p 3). The timing and thinking behind the implementation of ‘the Salmon Structure’ in the 1970s fitted with Reorganization of the NHS. However, it was the Briggs Committee (DHSS et al 1972) in its review of nursing and midwifery which examined in depth the needs of an integrated health service. Thus, it started changes signaling the end of the existing statutory bodies (Reid 2003, p 166–181).
Integration of the maternity services after 1974 was part of the wider NHS reorganization. By the mid-1960s the service remained disjointed with neither mothers nor midwives achieving continuity. Government attention turned to integration of maternity services but brought with it, without supporting evidence, further hospitalization of birth (Reid 2003, p 159).
Overall, this first major reorganization of the NHS had good intentions. However, integration resulted in the unpopular closure of many small units accompanied by administrative difficulties. To make matters worse the British economy was plunged into a recession following the Middle East Oil crisis and NHS expansion slowed. Staff demonstrated their frustration in unrest and increasing militancy (Brotherstone 1987b, p 146).
In 1979 the Conservative Party was returned under Margaret Thatcher and remained in power for 18 years. The Thatcher administration made NHS spending more ruthless. A change in general management introduced a new breed of hospital managers, business trained and disciplined. Outsourced cleaning and catering services initiated the private sector into the NHS (Talbot-Smith & Pollock 2006, p 7).
This was the beginning of the transition of the NHS to a market. Over the years, wide-ranging disagreement over all aspects of funding undermined the NHS’s initial powerful consensus of public ownership and control (Talbot-Smith & Pollock 2006, p 7). Aware of conflict, the government was reluctant to embark on another total reorganization (Levitt et al 1999). However, in England, for financial efficiency and improved patient care, the government removed one tier of administration and set up District Health Authorities (DHAs). It retained FPCs and CHCs and ordered strict cost limits (DHSS 1979; Ham 1992, p 29).
Change was also evident elsewhere. In Wales, a system of unit management similar to the English one replaced the district level. The Scottish approach created a system of unit management in 1984 (Kinnaird 1987, p 266) and called for increased provision of long-term care (Brotherstone 1987b, p 149, SHHD 1980). In Northern Ireland the basic structure remained. All agreed the importance of delegating power to local level (Ham 1992, p 30).
The new structures were ineffective, lacking in leadership and led to another Report (DHSS 1983): general managers should be appointed throughout the NHS. This would provide leadership and a more dynamic management approach, motivate staff and bring about change and improve costs. The Report did not cover Wales, Scotland nor Northern Ireland; nevertheless, the principles of the Report were adopted there (Ham 1992, p 32, Kinnaird 1987, p 266).
The introduction of NHS general managers reflected governmental preoccupation with analogies of industrial line management. However, to equate the health service with industry was seen as less than satisfactory. It was possible that general managers (sometimes lacking a health service background) could become pre-occupied with the minutiae of management and financial control (Brotherstone 1987a, p 149).
The 1980s saw an overriding concern developing: to maintain financial control. Consumer responsiveness and quality of care took second place. Managers were expected to be actively interested in clinical work; in reality tension remained between professional and managerial values for a long time (Ham 1992, p 35).
In 1991 the government instituted what was imprecisely called an ‘internal market’ within the NHS (Webster 1998, p 202). Hospitals, groups of hospitals and other bodies became Trusts and started behaving like businesses in a market place (DH et al 1989). Health authorities and boards became ‘commissioners’ or ‘purchasers’ of health services and the trusts were ‘sellers’. This changed the way that NHS resources and funding were accounted for and the term ‘purchaser-provider split’ came into use (Talbot-Smith & Pollock 2006, p 6). The change was designed to improve the service by allowing the purchaser to choose and buy care. However, the proposed hasty reorganization, caused the ‘biggest explosion of political anger and professional fury in the history of the NHS’ (Webster 1998, p 194). Nevertheless, regardless of NHS staff feelings of insecurity, alienation and status reduction to an insignificant element in the market mechanism, the reforms went ahead (Webster 1998, p 197). A sense of crisis in the NHS escalated in the 1990s: a ‘decade of turmoil’ which neither tackled nor solved the problems (Webster 1998, p 205).
There were other changes relevant to the internal market. Now all NHS service providers had to pay to the Treasury an annual ‘capital charge’ from what they earned on the value of their land and equipment: paying for their use would make trusts more economical with their assets. An alternative way of drumming up capital for public investments was introduced in 1992: the Private Finance Initiative (PFI). In the PFI a consortium of big businesses join together to ‘design, build and operate NHS premises in return for an annual charge paid by the NHS over the life-time of a contract, usually 25–30 years’. Thus, Trusts lease back their own facilities from the PFI consortium (Talbot-Smith and Pollock 2006, p 7).
There was also unrest in the maternity sector. The background to the need for change was UK-wide and engendered several significant documents including DH 1993a, NIDHSS 1994, SHHD 1993, Welsh Office 1996. Each of these documents called for change, for more informed choice and control for women, for more continuity of care and/or carer and a better way of working for midwives. The much discussed term ‘woman-centred care’ came into vogue (Hillan et al 1997).
While managerial turmoil continued, the thinking behind patient care began to change. There was an acknowledgement that there were priority groups, including maternity care, with wide variations in clinical care and the provision of services. Watchdog bodies voiced concerns. Public health, at the root of the NHS, had a new dynamic importance: the public was invited to be involved with their own care; schemes were afoot to target causes of early death; good health could be for everyone; education of the public was encouraged; partnership between patient and professional was an achievable goal; the NHS should deliver services responsive to user-need including projected improvements in waiting times. In addition there was a universal commitment to improve and maintain standards of all aspects of care across the NHS (DH 1993b, SHHD 1991).
In 1997 the Labour party achieved a landslide electoral victory. Initially, the incoming Labour government introduced a few NHS changes and maintained that clinical services would not be privatized (Levitt et al 1999, p 256, Talbot-Smith & Pollock 2006, p 7). However, the NHS Plan (DH 2000) turned this commitment on its head only to change again as policy-makers acknowledged that a significant volume of private services was not feasible without recourse to NHS staff (Talbot-Smith & Pollock 2006, p 7). The systems which emerged demonstrated a new way of setting and enforcing standards through monitoring, inspections, auditing and legal challenges.
In 1999 devolution of government led to the establishment of a Scottish parliament in Edinburgh, a Welsh assembly in Cardiff and the continuation of Northern Ireland’s assembly in Belfast (although from 2002–2007 suspension of devolution in Northern Ireland caused the responsibility for Northern Ireland departments to be passed to the Northern Ireland Office in London). Differences in the health services across the UK now became more significant. Committees and consultations across the UK led to an NHS plan for each country, commensurate with the needs of its population and demographic spread (DH 2000, DHSSPS 2000, SEHD 2000, WAG 2001).
The Plans in each country agreed with each other in their philosophies for better financial management, greater professional working together, partnership with patients, improved health of each population, better overall statistics on a global scale and improved patient experience. However two main areas where they diverged lay in ideas of structure and finance. Constraints of space preclude a full examination and comparison of the Plans. In addition, plans and minds change as time and thinking move on. Therefore this section will include: a brief description of the current NHS structure in each of the UK countries; comments on differing methods of how the NHS is financed; reference to standards in the NHS and current ways of developing and maintaining them; and, Agenda for Change, a programme that affects every member of staff in the NHS.
The Secretary of State for Health and the DH have ultimate responsibility for the NHS in England. Accountable to the DH are strategic health authorities which along with the DH are classed as organizations with strategic roles. Commissioners of care, accountable to strategic health authorities, are known as primary care trusts (PCT) and (social) care trusts. Below this level in the structure are providers of care:
Thus, we can see that the line of responsibility runs directly through the levels of the structure to the Secretary of State for Health. Even foundation trusts are ultimately accountable to parliament but they are directly accountable only to Monitor (established 2004), the independent regulator of NHS foundation trusts (Talbot-Smith & Pollock 2006, p 112).
NHS Wales is administered by the Welsh Assembly Government. The Welsh Assembly has executive powers and can determine policy through secondary legislation and implementation of primary Westminster legislation. The current structure of NHS Wales goes from the level of the Welsh Assembly Government through the NHS Wales department, to three regional offices. They are the organizations with strategic roles. These lead to the organizations commissioning services: 22 local health boards in partnership working with local authorities. This level leads to organizations providing services: 15 NHS trusts and, for example, GPs, opticians, pharmacists and dentists (Talbot-Smith & Pollock 2006, p 165).
The Minister of State for Health and Community Care at the Scottish government heads the structure of NHS Scotland and the Scottish Executive Health Department (SEHD). These are the organizations with strategic roles. They are followed by organizations planning and delivering services comprising 15 NHS boards, divided into two operating divisions: hospital services and, primary, community and mental health services. The latter division leads on to community health partnerships forming a joint futures body with local authorities and the voluntary sector (Talbot-Smith & Pollock 2006, p 158).
The Minister of Health and Personal Social Services heads the organization of the NHS in Northern Ireland and leads the Department of Health, Social Services and Public Safety (DHSSPS) in its strategic role. Organizations commissioning services follow: four health and social services boards. Then come organizations providing services: 19 health and social services trusts including hospital services and social care services; and, five local health and social care groups encapsulating primary care, other family health services and community care (Talbot-Smith & Pollock 2006, p 171).
Funding for the NHS in the UK is complex and varied, depending on the country. In general, funding for the NHS comes as before from general taxation, national insurance contributions and charges and is allocated to different parts of the service.
In England, recent legislation allowed the formation of Care Trusts. This permitted voluntary partnerships between PCTs and local authorities, thus giving PCTs access to local authority funding. PCTs may also generate additional funds through marketing activities, forming companies either alone or in partnership with the private sector, or selling clinical services. NHS funding can also come from capital allocation to buy and replace, for instance, buildings and equipment. Most assets are now owned by NHS trusts and PCTs. However, PFIs are now a major source of funding for new capital investment in the NHS. In addition some NHS Hospital trusts have become foundation trusts operating under a different framework (Talbot-Smith & Pollock 2006, p 78–103). Thus the Plan allows for different market strategies to take place. In addition there is a new financial framework, ‘payment by results’ which is intended to provide incentives to increase the efficiency and quality of services. There will be competition and contracts, conditions and penalties. The intention/hope is to have efficient, good quality services with choice for the patients (Talbot-Smith & Pollock 2006, p 109).
The Scottish government through the SEHD is responsible for developing health policy, allocating resources and delivering services. The Scottish government’s plan for the NHS (SEHD 2000) has moved forward through legislation and structural reform (SEHD 2005) to do away with the purchaser-provider split and self-governing trusts in Scotland (Talbot-Smith & Pollock 2006, p 157). NHS Scotland is an integrated system with unified health boards funded by annual budgets and responsible for planning and delivering services. Within the health boards local health plans specify how services will be provided; operating divisions take the responsibility for providing services. All primary care services are provided under the title of ‘primary medical services’. Foundation trusts have not been introduced in Scotland. However, being introduced are alternatives to traditional models of secondary healthcare which the SEHD funds. These include ‘special health boards’, for example, NHS 24, NHS Education for Scotland (NES) and the Scottish Ambulance Service (Talbot-Smith & Pollock 2006, p 158).
In Wales, as in England, the ‘purchaser-provider’ split is still employed. Local organizations commission or purchase hospital and community services on behalf of their populations. Yet, Wales has not introduced the policy of foundation status, nor the payment by results financial framework. Neither has it introduced the independent sector as a mainstream provider of NHS services (Talbot-Smith & Pollock 2006, p 166).
In Northern Ireland, health and social services are integrated under a single central ministry. Like England and Wales, Northern Ireland also employs the purchaser-provider split; like Wales, it has not gone down the foundation status, payment by results routes. Although the DHSSPS ‘has no immediate plans’ to use the independent sector as a major provider, it has declared its intention of watching and learning from what happens elsewhere (Talbot-Smith & Pollock 2006, p 174).
Since the 1990s a plethora of related words and terms have come into fashion. Words like: targets; national standards; accountability; clinical performance; performance rating systems; professional regulation; appraisal and revalidation; and, life-long learning. There are many more but these words will do as examples. They are not necessarily new but in the current atmosphere of a rapidly changing NHS, with the added transition in some areas from a public to a market based system of mixed public and private provision it is important to remember that alongside the changes, the patients/users are still coming through the doors and require an ongoing high level of safety and standards of care. So, these terms are on the lips of NHS personnel much more readily than hitherto. They all have something in common and a similar aim: best practice.
Best practice is difficult, perhaps impossible to measure (Reid 2007, p 9–29). In addition, perceptions and opinions of best practice will vary depending upon who is the practitioner, the era under discussion, or, whether or not the best practice is individual or collective. However, it is generally agreed within the NHS that standards which aim towards best practice are better to be discussed, agreed, formalized, written down and disseminated at both local and national levels.
Each government and health department within the UK may decide its process of setting, implementing and monitoring standards. In practice there is some co-working. For instance, the National Institute for Health and Clinical Excellence (NICE) is a mechanism overseen by the DH. Its role is ‘to provide health professionals and the public (in England) with authoritative and reliable information on evidence-based best practice’. NHS organizations are expected to abide by NICE’s recommendations (Talbot-Smith & Pollock 2006, p 113). While NICE applies to England, its remit also extends to NHS Wales. In Scotland, Quality Improvement Scotland (QIS), one of Scotland’s special health boards, ensures quality of services. Within its duties of appraising and advising on treatments and medicines, QIS disseminates NICE guidelines and comments on them regarding their appropriateness for use in Scotland. QIS also funds and supervises the work of the Scottish Inter-Collegiate Guidelines Network (SIGN). This multidisciplinary working group produces evidence-based national clinical guidelines for the management of specific conditions (Talbot-Smith & Pollock 2006, p 161–162). In Northern Ireland, the DHSSPS also uses NICE as a resource and advises health boards and trusts on its appropriateness. In addition there is a multiprofessional advisory committee: the Clinical Resource Efficiency Support Team (CREST) which equates to SIGN in Scotland (Talbot-Smith & Pollock 2006, p 175).
A vital component of the effort towards collective and individual best practice is clinical governance. Clinical governance was introduced for all NHS organizations in April 1999. It is a framework to enable NHS organizations to be accountable for constant improvement of the quality of services and safeguarding of high standards, by making the NHS a service of excellence. So, it is about expanding courses of action that support the continual improvement of standards, services and patient involvement (Proctor 1999, Pulzer 1999, Talbot-Smith & Pollock, 2006, p 114).
Moving to a ‘market mind-set’ called for changes in terms of service of NHS staff. In 2004, under the title Agenda for Change (AfC), pay restructuring arrived and the requirement for most NHS staff to undergo annual development reviews. This involves: discussions with a line manager; a demonstration of staff members’ ability to apply their knowledge and skills against the requirements of their posts; identification of how to maintain current levels of knowledge and skills; and, how to improve where these are lacking (Talbot-Smith & Pollock 2006, p 126). Thus AfC is a key factor of the pay modernization agenda within the NHS. It reinforces the need for articulation between skills frameworks and career pathways and offers opportunities for new ways of collaborative working (NES 2004).
Knowledge and skills for each post are identified through the Knowledge and Skills Framework (KSF). Thus, there is a KSF outline for every post in the NHS (Talbot-Smith & Pollock 2006, p 126) Also, in October 2004 new contracts for hospital consultants and GPs were introduced. The new consultants’ contract enabled foundation trusts in England to vary their conditions of service and the GPs’ contract withdrew GPs’ monopoly over provision of primary care (Talbot-Smith & Pollock 2006, p 10). Regardless of differences in policy across the UK, AfC also applies in Scotland, Wales and Northern Ireland (Talbot-Smith & Pollock 2006, p 163, 169, 176).
As we have seen above, midwives have been involved with, and affected by the NHS since its inception. On one occasion in the 1950s an enterprising midwife was shown where she stood. At the time, mothers in the postnatal ward were kept in bed for five days unless they had an infected episiotomy when they were allowed up for a shower. The midwife thought that it would prevent infection in the first place if all the mothers were allowed up for a shower and suggested this to the senior midwife. She recalled, ‘I was told I wasn’t paid to think’ (Reid 2003, p 281; Reid Archival Collection 1997-2002: 116).
Today midwives who are prepared to think about, embrace and promulgate innovative practice, are the norm rather than the exception. The Nursing and Midwifery Council (NMC) reproduces the globally-recognized definition of a midwife (NMC 2004, p 36), which gives a wide range of skills that a midwife may employ in pursuit of her profession. However it implies a freedom to practise that not all enjoy. Most midwives in the UK practise within the NHS and midwifery practice is therefore conditional upon NHS legislation, restriction, protocol and policy which exist at both governmental and local levels. A strong element of midwifery leadership is needed here, and in the creation of midwifery guidelines. At the same time all midwives, from the most to the least experienced, need to have a part to play in formulating and disseminating best practice. Thus, schemes to improve maternity care across the UK are evolving from a multiprofessional standpoint with professional groups cooperating with others on an equal basis. This brings parity and respect for the opinions and practice of others.
Two examples of multiprofessional cooperation come from Wales and Scotland. In Wales under the auspices of a multiprofessional steering group the All Wales Normal Labour Pathway is flourishing. ‘The intention of the Pathway was to reduce unnecessary intervention in labour and to give midwives the freedom to practise based on evidence and partnership’. It has made an impact on midwifery care all over Wales (Kirkman & Ferguson 2007, p 115).
In Scotland, the Scottish Multiprofessional Maternity Development Group (SMMDG) comprises representatives of all professions with a part to play in the maternity services. The group is working on writing, producing and organizing a continually evolving evidence-based programme of courses (Reid 2007, p 250). Again, the impact has been felt across midwifery care in Scotland.
Yet, all is not well with the challenge of change. In her Zepherina Veitch Lecture, Appleby (2006) highlighted some issues of NHS reforms: foundation trusts; payment by results; modernization and redesign; involvement of patients; the commissioning process; further restructuring. Midwives have not been involved enough with the dialogue and have been asked to do ‘more and more with less and less’ (Appleby 2006). And, financial shortfalls in some NHS Trusts have created further economic restraints in maternity services (Magill-Cuerden 2007).
Some issues, like patient or user involvement, are very commendable. But many midwives feel they cannot provide the service they would like and that families expect because of economic constraints. Yet midwives can make changes: the protest to stop the closure of the maternity unit at Stroud is an example (Magill-Cuerden 2007). Another is the work to prevent the closure of three small maternity units in north-east Scotland and the continuing work to create ‘new’ birth units there (Anonymous 2007a).
The new NHS is not going to go away. Midwives need to accept new ideas and challenges and be a part of the professional team showing the way to reform as succeeding governments struggle to redraw the NHS. As Appleby (2006, p 305) says: ‘Engage with the modernization and redesign agenda … Find out what your services are planning to do … Challenge them … Your service [must] engage with the reforms …You can always ask for pump-priming money or a loan to get your project off the ground’. Even if borrowing is not your style, health professionals in general need to accept change in order to provide safe high-quality care. More specifically, there is a clinical case for change in maternity care with an acceptance that a midwife should be the first point of contact for a pregnant woman leading to earlier entry into the maternity care system (Anonymous 2007b, Shribman 2007). And, the government is committed to developing a high quality, safe and accessible maternity service promising a new national choice guarantee for women (DH 2007).
The NHS is in transition (Talbot-Smith & Pollock 2006, p 1): Bevan’s dropped bedpan (page 1029) is still rolling. There are changes happening within this transition that many find unattractive and unacceptable alongside changes that are necessary and good. This is so across the NHS as well as in the maternity services. But in the maternity services, midwives have the knowledge, the evidence and the will to make change for the better. Stephens (2007, p 159) says ‘there is no place for silence’. Midwives at all levels, for the sake of mothers and babies, the profession of midwifery and the NHS as a whole need to support each other, apply research evidence, talk openly with other professionals in maternity care – and all the while keep looking after our mothers and babies.
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NES NES: www.nes.scot.nhs.uk
NHS NHS: www.nhs.uk
Scotland Scotland: www.show.scot.nhs.uk
Wales Wales: www.wales.nhs.uk
Northern Ireland:www.n-i.nhs.uk
RCM RCM: www.rcm.org.uk
SEHD SEHD: www.scotland.gov.uk
SMMDG SMMDG: www.scottishmaternity.org