Maternity Services

Baroness Watkins of Tavistock Excerpts

Thursday 25th January 2024 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw attention to my registered interests in healthcare. I thank the noble Baroness, Lady Taylor, for bringing this important debate to the Chamber. Her speech was an absolutely laser-focused analysis of the current situation and summarised many of the issues that I will return to—without, I hope, too much repetition.

The current state of maternity services in England is of concern to many stakeholders, but this must be put in context. Most expectant mothers and their significant others receive high-quality care during pregnancy and are delivered of healthy babies. However, the latest CQC report rates 10% of maternity services as inadequate and 39% as requiring improvement. This margin of error in such a vital service is really concerning.

Shockingly, safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for safety and 12% rated as inadequate for being well led. I think we can all agree that this is an unacceptable failure of the women, their partners and babies in this country. Of particular note is the fact that poor provision is disproportionately failing many mothers form minority-ethnic groups, as others have outlined, but also white women who suffer economic deprivation.

Many factors contribute to this situation. Part of it might be that there has been less regard for the profession in the last decade than there was. I remember coming to the end of my general nurse training, just 500 yards down the road, and being asked what I was going to do next. I said I wanted to do mental health nursing, and I still remember the sister tutor saying to me, “But you’re bright enough to be a midwife”. We should hold on to that. I am happy to tell you that I got an obstetrics certificate so that I could work abroad and ended up as a mental health sister with a mother and baby unit in that ward—so I actually used it wisely.

Midwives are now men and women, and we do not seem to have recognised that in some of our structures in multidisciplinary teams. With men, we hoped that it would improve the provision of employment for midwives, as well as double the amount of people from whom we could recruit the pool. That does not actually seem to be working as well as we might have hoped.

Quite frankly, most multidisciplinary teams face large, unmanageable caseloads, and have to work with what—in some areas—are unsafe staffing ratios. To my mind, they often do not receive fair compensation for their important work. As commended by the CQC 2023 report, midwives and staff on maternity wards go above and beyond, when possible, to provide the best care.

However, services are being pushed to breaking point. As has already been acknowledged, it is estimated by the Royal College of Midwives that we have 2,500 full-time vacancies. This obviously leads to overload and understaffing in some areas, and the quality of care provided is put under threat. This is recognised in the 2023 NHS England Three Year Delivery Plan for Maternity and Neonatal Services, which highlights that supporting the workforce to develop skills and extra capacity is vital to providing future high-quality care.

I want to put this in context. When I went off to do mental health nursing as a second qualification, I was paid as a staff nurse. Now, it is almost impossible to get a second qualification without going back on a bursary. I will leave that for people to think about. I therefore support the commitments that have been made to ensure that trusts will meet staffing levels and achieve full rates for midwifery by 2027-28. However, it remains very difficult for a registered nurse to do a shortened course to become a midwife. I therefore suggest that women will continue to face what some do now: hurried care with staff having little time to provide truly person-centred support.

Like many other contributors to today’s debate, I have my own children and know that good health during pregnancy and labour and postnatally is vital. So is good healthcare. If you do not start with good health and then have poor healthcare, that is a pretty difficult situation. Staff need time to listen to mothers and fathers and to act when concerns are identified. As I have told this House before, with my first child, I felt ill. My husband came to visit me in the hospital the day she was born. I do not remember this, but apparently I grabbed his hand and said, “You will look after this baby if I die?” Then he realised he should go and talk to somebody, because this was not the way I normally talked about things. I had fantastic, fast intervention and had my baby within half an hour—who I am pleased to tell you is now a taxpayer. That was a good, cost-effective solution, but too often people do not listen to significant others, who sometimes understand very well what mothers are saying. We therefore cannot rest the whole responsibility on the mother in a time of distress.

It is necessary to think seriously about access to interpreters on a 24-hour rota system, so that women who are unable to speak or understand English because it is not their first language can be assisted in communicating with the staff caring for them. We have situations in some areas in which it is impossible to get an interpreter. That makes the situation really difficult, both for the midwives and for the mother. One cannot always rely ad hoc on a relation interpreting what is really going on. Can the Minister comment on how access to interpreters is monitored within the NHS and, if this is not being undertaken, can he ask the Government to make provision to do so? I have been informed that this is particularly important in genetic counselling in families from cultures that are different from those of the midwives involved.

Staff are often unhappy due to pressure at work, in part associated with low levels of staffing. As other noble Lords have said, it is also because senior midwives are retiring or retiring earlier than planned, for a variety of reasons. Many who are leaving are specialist mid-career midwives, whose skill set cannot be easily replaced, particularly in terms of supervising student midwives. I am really proud that the daughter who is the taxpayer is a teacher. However, teachers get rewarded on top of their salaries for supporting student teachers if they are the lead in it. This is an example of something we could learn from.

In part, retention issues reportedly stem from inflexible working practices. Flexible working is difficult to manage in a 24-hour, seven-day service. I know; I have tried it. However, some trusts have much better retention than others. How can best practice be shared and replicated to retain midwives across the NHS services?

The stress of unmanageable expectations at work is creating burnout, as some others have reported, and encouraging some midwives to leave the profession. Perhaps we should think about a structure for sabbaticals for some midwives. Midwifery is, at the best of times, hard physical and emotional labour. We do not always recognise that. When things go well you get the rewards but, as my noble friend Lord Patel has just spoken about, when things go badly it can be devastating.

Capacity is being undermined by a lack of investment in continual staff development. This is highly worrying because, as others have said, we face an increase in complex births, as more women are giving birth over the age of 35—as I did—maternal diabetes has increased, the use of induction and caesarean has increased, and pre-term births are becoming more common. These cases require specialist skills so that mothers and babies are safe. However, a lack of training and development opportunities for midwives, both men and women, can lead to a deficit of skills that are vitally needed for our specialist services to survive in the future. Midwives need to be skilled at recognising complications in pregnancy, ensuring that they pass those to other members of the multidisciplinary team for assessment, so that, wherever possible, early intervention can be undertaken.

The vast majority of our student midwives in England report having to take on additional debt, over and above the loans available to students, to cover their basic costs. This is undoubtedly putting people off coming into midwifery. The National Union of Students reported a worrying drop in applications to university courses, from 13,500 in 2021 to just over 10,000 in 2023. Can the Minister say whether the Government will consider the NHS undertaking loan repayments for university fees after, say, three or five years of NHS service? It would aid the retention of midwives, nurses and indeed junior doctors, as well as other professions allied to medicine.

Our midwives work tirelessly to provide the best care they can, but they are often unable to do so because of the issues highlighted by other noble Lords and in my own contribution. We must ensure that these issues are tackled, so that every woman is provided with truly person-centred, skilled and compassionate care, and that all babies have the best possible start. The Royal College of Nursing has produced nursing workforce standards that could apply to paediatric intensive care units. Similarly, the Royal College of Midwives has provided evidence on the necessary ratios of midwives to expectant mothers at differing stages of pregnancy. Are this Government prepared to consider legislation on workforce standards in the NHS in future?