In earlier sections of the report, mention has been made of how recent and ongoing reforms affecting medical and nursing staff groups, and the healthcare workforce in general, will have a profound impact on the shape of health services. Maternity services are not immune to these trends, and in some cases the special features of the service pose particular challenges. Solutions will require NHS Boards and Trusts, individually and collectively, to take an active lead in identifying and planning workforce requirements for the full range of maternity services in their areas. It is no longer appropriate to address workforce issues in a simplistic, numbers-driven manner: traditional 'manpower planning' approaches are not sustainable in the fast-changing NHS of today. Meeting the needs of the future will involve creative thinking about the best way of ensuring that multi-professional teams have, collectively, the skills identified elsewhere in this report to meet the demands of providing the highest standards of care for every pregnant woman. Options to address the problems caused by workforce issues will need to include alternative working patterns and changes in the composition and use of staff from different professions and disciplines.
Some of the key workforce drivers are concerned with moves to achieve safer working conditions for NHS employees and, thereby, safer treatment of patients. The enforcement of limits on the extent to which care can be provided by trainees, and constraints on medical and nursing hours combine to increase pressure on services. The problem is especially acute for medical positions. Both New Deal for Junior Doctors and the European Working Time Directive requirements are likely to require increases in medical establishment, but this will not be the only solution to a complex problem exacerbated by increasing specialisation and long term staffing shortages in particular fields and specialties. It is vital to plan now a model for the future - those in medical school at present will be consultants in 2020.
Add to these pressures the changing demography of the nursing and medical workforces (midwives are predominantly female and over 60% of the current intake of medical students is female) and it is clear that intrapartum care in existing maternity units cannot be sustained 24 hours per day, 7 days per week. The challenge is not only for obstetricians and midwives: manpower and training issues apply equally to anaesthesia, neonatology and paediatrics.
In this chapter the issues facing some of the key staff groups will be examined and possible solutions presented in the context of the new arrangements in Scotland for dealing with workforce issues in an integrated way.
Pressures
Midwives
Midwives are the key staff group providing care to pregnant women throughout pregnancy, childbirth and the post natal period. Throughout the report, it has been recognised that delivering care in line with the principles set out in the
Framework for Maternity Services will require adequate numbers of appropriately skilled midwives. NHS Boards are moving towards one to one midwifery care during labour and childbirth which has implications for the way in which current working patterns operate and for how midwives discharge their care. There is currently no shortage in the supply of midwives in Scotland and the midwifery workforce is the most static of the whole nursing workforce. The challenge that this staff group faces is in moving towards a different model of service which requires that midwives build on, enhance and refresh skills in order to deliver care within a different framework. This brings with it more autonomy and different working relationships within maternity service delivery teams. Investment in time to enhance existing skills will be required without detracting from the level of service provided currently.
The Scottish Executive has, through its '
Facing the Future' initiative, initiated a wide programme of measures aimed at improving the recruitment and retention of nurses and midwives in Scotland including action on careers, leadership, education and training and new roles. This will benefit midwives and other nursing staff such as health visitors who provide maternity care.
Hospital Doctors
Doctors in training have traditionally provided much direct medical care. The
CalmanReview of medical education and training arrangements for Specialist Registrars in 1993 concluded that medical training took too long and was too reliant on experiential learning, through practice on wards and in the service. The review recommended that training should be programme based, and should meet minimum requirements for components of formal education alongside experiential learning. Calman introduced standards and regulation of medical training for the registrar grade. Medical schools have enforced implementation by removing approval from particular posts for specialist training purposes. Reducing the extent of care by trainees has put aspects of the service under pressure, particularly those, such as labour wards, in which there is a need for regular out of hours cover.
There are proposals to extend application of the Calman recommendations to Senior House Officers. In August 2002, the Scottish Executive began consulting on Sir Liam Donaldson's report '
Unfinished Business' which set out proposals for the reform of the SHO grade. The report agrees that training should be programme based, which will provide a broad base for all trainees. Training should be flexible and provide individually tailored programmes to meet specific needs, allowing movement of doctors into and out of training and between training programmes. It is proposed that, after graduation, all doctors will enter a two-year foundation programme. The first year will comprise of the current pre-registration year. The second year will allow basic specialist training in one of approximately eight broad-based programmes, which would include obstetrics & gynaecology, anaesthetics and general practice.
Continuing tension between training and service delivery in the SHO grade is expected as working and learning cannot always be easily separated. However, there are variations in the amount of service provided by SHOs in different posts and in the quality of training they receive. The reform of training at SHO level will impact on the amount of service delivery made by SHOs and therefore on the working patterns of doctors at other grades and other members of the clinical team.
The expectation that consultants will provide an increasing proportion of direct care is now enshrined in the proposed new consultant contract, which would also revise remuneration for out of hours work. The new contract offers an opportunity to recruit and retain consultant obstetricians for labour room work.
General Practitioners
The importance of the GP role in intrapartum care, particularly in remote and rural areas, has already been acknowledged in this report, but it appears that fewer GPs are willing to be actively involved in intrapartum care. The new GP contract designates maternity care as an 'additional' or 'enhanced' service and this may have an impact on the GPs contribute to intrapartum care in the future.
The General Practitioners Committee (GPC) of the BMA issued interim guidance until the new contract in July 1997 and May 1999. The role of the GP depends on the education and training and the consequent competence they have achieved and the limitations placed on their ability by other commitments. The woman should also understand in advance which skills the GP can or cannot provide.
The present duties of a GP with respect to Maternity Medical Services are:-
The GPs are able at present, to opt out of intrapartum care but others do provide intrapartum care and other maternity medical services e.g at present there are 3 GP led Maternity beds in Victoria hospital, Rothesay in the Isle of Bute. As the new GP contract will be practice based, the contract for maternity services with the practice will depend on the skills available to the practice as a whole and not the GP alone. GPs are being encouraged to develop special interests (GPwSI) as part of their career structure and one of the areas is Women and Child Health. LHCCs through the vehicle of PMS Pilots are using an alternative contractual arrangement to the GMS contract (which the majority of GPs are currently under), to redesign services to the locality using GPs with Special Interests and using the community hospitals and intermediate care in innovative ways
Developing the maternity workforce - a new infrastructure
In 1999, under the Chairmanship of Professor Gillian Needham, Postgraduate Dean for Aberdeen, the Scottish Integrated Workforce Planning Group began a review of workforce issues facing the NHS in Scotland. Their January 2002 report
Planning Together set the direction for further work in this area and established important principles that have guided subsequent developments. Amongst these principles are the important conclusions that workforce development needs to be more clearly linked to service planning in future and that the infrastructure at local, regional and national levels will have to be strengthened to make this happen more effectively.
Also significant is the Review of medical workforce planning conducted by Professor John Temple, President of the Royal College of Surgeons of Edinburgh. The Group's report
Future Practice: A Review of the Scottish Medical Workforce was published in July 2002 and provides the context for future planning of the medical workforce in maternity care, as in other specialities. The review concluded that:
The Scottish Executive published
Working for Health: The Workforce Development Action Plan for NHSScotland on 1 August 2002. The Action Plan acknowledges the clear role that workforce development has in any reform of NHSScotland. Implementation of the Action Plan will be taken forward by a National Workforce Committee supported by a National Workforce Unit in SEHD. NHS Boards will be expected to identify Workforce Officers to participate in workforce planning and development activity. For maternity service planners, these developments offer an opportunity to take a strategic look at workforce issues.
Developing the maternity workforce - investing in skills
The core importance of taking a dynamic approach to workforce issues and of addressing skills shortages has been acknowledged. Earlier sections of this report have identified, in some detail, the particular skills that maternity care professionals need and have identified innovative approaches to meeting the educational and training needs. This analysis will help drive the formulation of integrated workforce plans for maternity service in Scotland, and the involvement of the full range of educational providers in this process will be essential. It has been recognised that multidisciplinary teams are critical to the delivery of maternity care - the opportunities for multidisciplinary training and development need therefore to be maximised.
Developing the maternity workforce - a regional approach
Throughout this report, the need to plan and organise maternity services at a regional level has been emphasised - this is entirely consistent with the general thrust of the new workforce arrangements: integrating workforce planning with service planning at a regional level. Already, with level III maternity specialist sites in the North, East and West there is a sound basis for consolidating models of service provision - and with them the concomitant workforce arrangements - that are necessary to meet the various requirements of the service.
For workforce development in general, three Regional Workforce Co-ordinators are being appointed to liase with Regional Service Planning Groups and Workforce Officers at local level. The Regional Co-ordinators will work closely with the National Workforce Committee, developing national strategies for workforce issues for all staff groups and specialities.
Summary
The maternity services workforce faces similar pressures to the rest of the health workforce and the solutions, for the various professional groups involved, will follow the same pattern. Under the new arrangements for considering workforce development alongside service planning, and overseen by a new Maternity Services Workforce Group, the move to a skills and competency driven team-based approach will be promoted. Multidisciplinary training and development will be a feature and special consideration will be given to the issues in remote and rural areas.