Introduction

Why should midwives concern themselves with change and reform in the wider NHS? Working in the health service can sometimes feel like a constant exercise in rearranging deckchairs, as successive waves of restructuring, targets and priorities lap against the heels of professionals working within the NHS. There are many health professionals who do a very good job of taking care of patients whilst paying little attention to the world outside their own practice or their profession. Getting an understanding of the wider picture of midwifery and the context of the health service makes the midwife more effective and able to work as an advocate for women and families. Without that understanding, it is difficult to respond effectively to change and to proactively use the opportunities that change provides. Recognizing where to obtain funding streams and policy initiatives that can transform the maternity services and the wider services that are associated with maternal, child and family healthcare are frequently lost opportunities, as without a realization of the wider picture midwives may not recognize what could be offered to assist in transforming their service. Importantly, an understanding by midwives of the environment and context of their practice allows more control to be exerted, and helps prevent staff alienation and burnout (Sandall 1999).

It is particularly important for midwives to engage with NHS reform (see Midwifery 2020 website). Too often, midwives feel oppressed rather than supported by the system within which they work. Some see midwives’ gradual loss of autonomy – as they came under NHS control, and then into the hospital system over the last few decades – as the loss of a golden age, and believe that the only way to rejuvenate midwifery and improve care for women is to ‘liberate’ midwives from external control – and, in particular, from control by doctors (Kirkham & Stapleton 2004). Much has been written about the historic battle for control between (male) medicine and (female) midwifery (Donnison 1988) (see Ch. 2), and this polarization is still evident in maternity services today (a battle in which midwives usually fare badly and childbearing women fare worse). While gender is an important factor in this dynamic, there are others: the balance of power and resources between primary and secondary healthcare, between the needs of the ill few and the healthy majority, between regulating quality and allowing local flexibility, between the advancement of knowledge and the strengthening of basic healthcare provision. In other words, midwives are facing similar challenges to those experienced by many others in the NHS, and midwives – as much as anyone else in the health service – can work to influence and benefit from NHS reform.

Midwives are proud to be an ‘autonomous’ profession, but the reality is that no health worker is truly autonomous in today’s NHS. The teams of professionals are all as effective as the partnerships they create, the opportunities seized, and the resources identified and used. That means that engaging with wider NHS reform is of crucial interest to all those concerned about the future of maternity services.

At the time of writing, the UK is undergoing a change of government during the deepest economic crisis that has been known for many years (see website). Years of sustained growth in NHS funding, accompanied by ambitious programmes of service transformation, are on the cusp of plunging into an extended period of austerity and efficiency savings (see website chapter 7). In addition, devolution in the UK has increased the diversity of policy and practice across the UK (DH 2002, Ham 2009). These factors make it increasingly difficult to provide accurate and comprehensive detail on how the NHS is changing. Instead, this chapter will focus on the main policy drivers and trends that are consistent across the UK and across UK governments.

A little history

The creation of the National Health Service, 60 years ago, is rightly remembered as among our nation’s finest expressions of collective will. One of the central planks of the post-war reforms that sought to tackle social inequalities, build public health, and create a society that provided its most vulnerable with a safety net ‘from the cradle to the grave’, the health service still commands great loyalty and affection in the public psyche. Yet preoccupation over the accessibility and effectiveness of the NHS’s services is equally a national pastime, and the future of the NHS has become highly contested – between political parties, in the media, and in public discourse.

Before the NHS was established, there was not one single maternity care system: women chose, according to their means, from a plethora of competing providers, including midwives, family doctors, obstetricians and hospitals (private and charitable). The 1946 National Health Service Act, which became operational in 1948, established a comprehensive, if fragmented, model of care, comprising hospital maternity services, community midwifery services (which were under the control of local authorities), and general practitioners. This fragmentation caused duplication and poor continuity, and many midwives were frustrated by what they saw as the encroachment of doctors on the provision of midwifery care. This was exacerbated by the expansion of hospital maternity beds resulting from the 1962 Hospital Plan, and by the Peel Report of 1970 (DHSS 1970), which recommended that all women give birth in hospital, cared for by multidisciplinary teams of midwives, obstetricians, and general practitioners (GPs). In 1973, the National Health Service Reorganisation Act brought all midwives under the responsibility of the NHS.

These reforms, along with the opportunities offered by evolving obstetric expertise, exacerbated the erosion of community-based midwifery. Childbirth became increasingly medicalized, with hospital delivery and many obstetric interventions becoming routine. The development of general management during the early 1980s meant that midwives reported up through general or nursing management, making them feel even more isolated from decision-making power.

Meanwhile, the wider NHS was experiencing repeated restructuring and reform in order to reduce its complex, multi-layered bureaucracy. At the end of the 1980s, it also underwent ideological revolution as the Government aimed to introduce ‘market forces’ to public services. A competitive internal market was established within the NHS, within which the functions of purchasing and providing were separated. Hospitals, community and ambulance services were encouraged to become self-governing trusts. GPs were encouraged to become fundholders, with power over their own resources and responsibility for purchasing care for their patients. The aim of this was to increase choice and efficiency, but both aims were frustrated: efficiency was undermined by the unavoidable management costs of implementing and running the system, while choice was subverted by the system of block contracts and restrictions on extra-contractual referrals.

The new NHS

By the time the Labour Party assumed government in 1997, after 18 years of uninterrupted Conservative administration, it appeared that the NHS was feeling sick and tired itself. Those who worked within it were fatigued and demoralized by continued structural reform and the implicit (often explicit) message that they could not run their own affairs efficiently. Conflict over wages, differentials, professional territories and management influence was widespread. Long waiting lists and poor customer care were alienating NHS users and supporters. There was significant public debate about whether the health service had a future, at least in its current form, or whether it should be dismantled and replaced by a system of private insurance funding. The NHS had become a service that was criticized. Each government attempted to make changes but it was an area of political influence as the public wished to retain its service and would not support privatization. Its future management was one of the key reasons why the country felt ready for change. The highlighted areas of deficiency in quality (see Ch. 7) supported an imperative for change.

Then a government was elected that demonstrated ideological commitment to the NHS and increased funding to enable this (see website chapter 7). This led to a Modernisation Agency and agenda (2002) and the revised structure for the NHS (see Fig. 7.1). The record increases in funding provided were matched with a serious commitment to radical reform. As with the previous administration, it was determined to break up the power cabals and vested interests that dominated the NHS, and to harness market forces to drive up quality and secure efficiency. The central strategy of ‘the new NHS’ was to deliver early performance improvements (in particular, speedier access) and to develop a culture of continuous quality improvement, by:

Thirteen years on, the impact of these reforms is undoubted but contested. Rising demand has been met by increased resource, with NHS funding more than doubled. Waiting lists fell to their lowest level since records began; a new maximum wait of 18 weeks from GP referral to treatment was secured; nearly all A&E patients were seen, treated, admitted or discharged within 4 hours; new hospitals and health facilities were built; significant progress was made in the management of long-term conditions; there was expansion of staff numbers and staff pay. To a very large extent, the NHS has regained public trust.

Nevertheless, the subsequent relationship between the Government and the NHS has not always been easy. Undoubtedly, many NHS staff welcomed the philosophical underpinning of new policy, and few demurred at the impressive investment produced in 2001 (see website chapter 7). But they became wearied by the relentless cycle of structural reform and centralized micro-management that is implemented by successive governments. Many were deeply alarmed by the Government’s commitment to developing a mixed economy of providers, and its efforts to introduce this in a fair and effective way. Many of the professional groups complained about the targets culture, which produced impressive results, and which promoted an inflated sense of its own possibilities, overreached itself and has now been forced into retreat.

At the close of the Labour administration, the NHS was shifting the emphasis of its reform agenda away from speed of access toward quality of care (see Ch. 7), from centrally set targets to local priority setting, from supply-side expansion to demand-side management, and towards the development of a truly primary care-led health service as envisioned by the Darzi Next Stage Review (DH 2008). The scale of change needed in the NHS is clearly evidenced by how much work is still to be done, after a dozen years of full-on modernization (see website).

The challenges of modernization

If there is any unanimity in discussion of the NHS, it is on the necessity of modernization. Calls to abolish or partially dismantle the NHS have quietened down in the face of public hostility, and the focus now is on how the health service can meet the challenges of the future. The concept of ‘modernization’ has been taken up by all political parties, who have moved away from ideology-driven politics into a focus on effective management – ‘what counts is what works’. This helpfully allows all parties to portray their health service plans as common sense and working for and on behalf of ‘the people’ – and to portray any opposition to new developments and to the increased use of technology to support the health service care and reforms.

There are, undoubtedly, significant and persistent problems in the NHS. Its inflexibility, lack of responsiveness and perceived indifference to patients’ wishes, have shown it to be out of step with our modern consumer society. As a monopoly provider of healthcare and thus maternity services, it has been too quick to prioritize its own interests over patients’ needs. The services that are provided are not always of high quality: too often, users face excessive delays, fragmentation, poor coordination, and conflicting advice. Maternity care services are not immune to these criticisms. Quality is variable, and clinicians are sometimes slow to adopt best practice or apply research evidence to their practice. Above all, patients often feel that services are not geared to their needs; rather, they are expected to fit into the service’s requirements, and sometimes treated with less than full respect.

The causes of these problems are multifactorial. Some are structural; the sheer size of the NHS, and many of its constituent institutions, leads to impersonality and inflexibility. The complexity of the system defies attempts to reform and throws up unexpected effects of the most carefully planned change programme. Persistent over-centralization deadens local initiative and ownership. The barriers between services confuse and alienate patients and disrupt effective, seamless treatment. Hospital and community services are not sufficiently integrated; the gaps between health and social care are even more marked. Links between social care and maternity care are essential as the understanding of birth within its social and environmental context becomes relevant where there is increasing diversity and population movement. Women require a seamless approach in the services offered to them, but increasingly their care is fragmented; for example, a woman and family who require mental health care, maternity services and social support may not have an integrated team to follow her care through.

From the midwifery perspective and the team of care professionals, the volume and pressure of work never seem to allow for adequate communication or relationship-building across these barriers, and the development of information technology and communications systems to help bridge the gap has not been given sufficient priority. Paradoxically, given the problems arising from NHS structures, it is also clear that successive governments’ addition to structural change has caused, and is causing, real damage – lowering morale, diverting priorities, consuming resources, and inhibiting the development of expertise and partnerships.

The general public and some clinicians are fond of blaming managers for all the health service’s woes, and certainly poor management has played its part in the slow pace of service improvement. Performance management – while necessary and important – has often been badly executed: lack of incentives, targets that are seen as meaningless or perverse, and a culture of blame have all been evident. The very definition of quality is contested between different professions, organizations and sectors.

However, important though it undoubtedly is to ensure that structure serves purpose, and that leadership and management are of the highest quality, culture is the trump card that so often defeats attempts to create change. Ham and Alberti (2002) have written convincingly of the breakdown of the contract between the NHS and its doctors. They point out that the implicit contract, agreed at the founding of the NHS, was based on the government providing resources and the medical profession taking care of clinical standards. Prior to 1948, British doctors were private practitioners and their freedom to practise as they wished was curtailed less by the State than by the strong moral and ethical context in which they worked. Although many were not enthusiastic about the establishment of the NHS, they ceded to government the right to determine the budget and the national policy framework for their work, in return for continued medical control over regulation and clinical decision-making. In these early years of the NHS, managers were administrators and saw their job as facilitating doctors rather than managing them. Patients, too, accepted that ‘doctor knows best’, and were generally happy to acquiesce to medical authority.

This implicit contract was undermined by the growing consumer movement in the 1960s, the increased publicity given to poor standards, and the medical profession itself becoming more vocal and lobbying for higher budgets to keep pace with growing technological opportunities (see website). Over the next 30 years the implicit contract was further undermined by growing regulation, clinical audit and patient involvement. Public-spending constraints led governments to seek efficiency improvements in the NHS, and increased management power led to strained relationships between managers and doctors. The rise in litigation and challenges to self-regulation further undermined doctors’ sense of professionalism (see website chapter 7). Doctors, along with other health professionals and managers, have become increasingly frustrated by their workloads and by the growing gap between what it is possible to do for patients and what can be done with available resources.

Midwives, meanwhile, have experienced the breaching of their own implicit contract. In the first half of the last century, midwives worked very hard and their pay was poor. Compared with other working women, however, their lot was not so bad. Although their social status never rivalled that of doctors, they worked with a significant degree of autonomy and often enjoyed high status in the communities where they worked. The level of continuity of care they were able to offer provided them with job satisfaction that was some compensation for their long hours. It should also be remembered that they were often unmarried and childless, wedded to the job in a way that today’s midwives – many of whom have children, and most of whom believe in a life outside work – could not countenance.

Sixty years of NHS reform have not been altogether negative for midwifery, but they have altered this original agreement out of recognition. NHS midwives generally work shorter hours with lighter caseloads than their predecessors. They have the support of medical back-up, technological and other resources, and employment benefits. Yet the highly risk-averse nature of modern healthcare does not allow for the full flourishing of essential midwifery skills, and as midwives have been drawn into the traditional doctor–nurse dyad that characterizes our system of healthcare, they have lost status and pride. Many midwives would go so far as to argue that the modern hospital environment – fast-moving, technological, strongly directive – is intrinsically oppositional to birthing and to a midwifery philosophy of care.

In addition, the historic drive to professionalize midwifery has had ambivalent results. While it may have saved midwifery from near-extinction, as happened in other countries, it did so at the cost of autonomy from medical direction (and of the livelihoods of many working class midwives). Over 100 years on from the establishment of legal regulation of midwifery in all countries of the UK, midwifery is not fully a profession, and midwives continue to feel devalued by their role and status within the health service. Critically, the status of the midwife – relative to other health professions, and to other working women – has fallen, while consumer expectations have risen.

With the expansion of alternative – and more lucrative – occupations for educated women, this lack of consensus on the relationship between midwifery and its paymaster is finding expression in chronic staff shortages and a growing sense of crisis. The future for midwifery is uncertain, and it is in this area, as much as any other, that the necessity for effective NHS reform is most marked.

Looking to the future

The challenges facing the NHS for its next 60 years are not new; they are, rather, persistent and evolving. Our ageing and diversifying society, the growth of long-term health conditions, rising patient and public expectations, the costs and opportunities offered by new technologies, all in the context of a global recession, together demand truly creative solutions, delivering significantly better outcomes for significantly lower costs.

Even without the benefit of a crystal ball, there are some near-certainties about the future:

The future of the NHS is crucially dependent on its ability to tackle these challenges (see website). The health service is a complex adaptive system – an interconnection of parts sharing an environment, with each part having some freedom to act independently (NHS Confederation 2001). This means that change cannot be delivered by simply issuing instructions and expecting that implementation will just happen; policy pronouncements may have completely unexpected effects when put into practice, and anything that discourages creativity and innovation will slow down the whole system. As the national economy has changed and there will be a period of unprecedented austerity, it will be tempting for the Government to micro-manage the health service towards inflexible, politically driven targets. This will not help to create an environment that encourages innovation, experimentation, partnership and inspirational leadership. Whatever the risks, the government that will truly save the NHS will be the one that can understand and embrace the real drivers of sustainable change, and encourage a more mature public discourse on what can be expected from the nation’s health service and how those working within it can achieve it.

Midwifery in the future nhs

There has probably never been a time that combined the large number of patient satisfaction audits and surveys which express the value of the contribution of midwives with such widespread dissatisfaction within the midwifery workforce. Despite great efforts over the last decade to boost the midwifery workforce, there are still chronic shortages. Despite a national guarantee that women can choose where to give birth, this freedom seems more rhetorical than real. Despite the policy objective of creating a more humane, family-friendly maternity service, there is a trend and a danger that hospital centralization will lead to the creation of huge, impersonal units – what Cathy Warwick, RCM General Secretary, has called ‘baby factories’ (Campbell 2010).

For the busy midwife in an overstretched maternity unit, national debates about health service policy may seem remote and irrelevant, like the distant buzzing of an irritating fly. But the coming half decade will be tough on everyone in public services; midwives, too, will experience the sharp impact of job losses, centralization and service ‘efficiencies’, and beyond those immediate challenges, they will need to influence the persisting and critical questions facing the profession.