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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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The Royal College of Midwives – in Conference at Manchester

Filed Under (Reform of the NHS) by Paul on 16-11-2010

The trouble with blogging is that you can end up thinking (as with its more precocious cousin twitter) that the things you do are important just because you are doing them. The reading public will be as interested in them as you are. The little voice at the back of my head often gets me editing posts that seem to simply be what I have done that day. Sometime these things are interesting – most often I am just advertising something that has just happened to me – and, because I did it, I think  it matters to you.

But today I think something interesting was happening and the truth is I just happened to be there trying to make sense of it. I was a member of a panel of speakers at the Royal College of Midwives. We spent an hour compèred by the excellent Jenni Murray from Radio 4.

The panel were asked to talk for five minutes answering the question, for midwives, “Who do you really work for?”.On the way up to Manchester I tore up the rather twee answer of being the only part of the NHS that actually has two customers – the mother and the baby – whereas the rest of the NHS usually has one patient. And I spent some time thinking about other professions. Who do lawyers work for? Not just the defendant – ultimately they also work for the law. Accountants don’t just work for a firm but follow rules that have been around since double entry bookkeeping. So I talked a bit about how complex this was and how the point of professional associations was not to simplify such complex things but to help individuals work their way through them.

Polite applause. Just about what you might expect from professionals who really didn’t need telling what I had to say.

The last person on the panel was the President of the Danish Association of Midwives. She talked about how they had developed a form of strike action two years ago because the Government weren’t listening to them. The strike did not involve walking away from labouring women but was very selective and involved not taking part in some ante natal care. After 2 weeks they stopped the action because they were aware that journalists were phoning round trying to find a dead baby or some angry, and let down, mother. It was thoughtful and difficult. But she thought they got it wrong.

They have spent the last 2 years working out in much more detail the moral and ethical case for very specific action. It was a moving tale of how professionals felt they had to act in order to defend both the safety of their work but at the same time refusing to harm the people that need them the most.

I wrongly thought this was just a tale from Scandinavia, but as it turned out this was the question that had been being discussed across the whole of the Conference so far. When is it right to take action in defence of your professional standards and what should that action morally be? The unacceptable answer appeared to be doing nothing.

So Jenni Murray then says “Dear panel member what is the professional way to take action?”  And suddenly I am in a discussion with an audience that is interested in how they can make themselves heard without hurting women and children in any way.

It’s at this stage that even someone like me – who can be quite slow – recognises that something a bit odd has happened. The policy they were angry about was the U turn by the Government since the White Paper concerning the commissioning of maternity care. The White Paper made it clear that maternity care would be commissioned not by GP commissioning consortia but by the National Commissioning Board. At the time this looked odd and there was much speculation as to why GPs would not be allowed to commission maternity but would be allowed to commission cancer care?

It looked odd and over the last few weeks word has come out of the DH that maternity commissioning will be transferred to GP commissioning consortia.

The RCM were very unhappy at this change of policy. I was really surprised at the vehemence with which they did not want to be commissioned by GPs and the extent to which they thought this was a dangerous idea. They believe that in making this change the Government is demonstrating that it does not care about maternity. And they were angry about this.

Over the last few months I have come across a wide range of emotions about GP Commissioning but angry professional staff is a new one for me. They seemed to think that being ‘commissioned by a GP’ – in fact ‘working for a GP’  -was a really bad thing for their profession.

But their anger goes beyond what they see as being treated badly by Government policy. Many of the midwives in the room felt that they were often being expected to cross the line of safe practice. One of their number said that they should fill in an incident form, and this was backed up from the platform. Many of the audience did not see that as helpful.

So what did I say about how a professional in a heath profession take action? I said that all industrial action in the public sector was lost and won with the public. I thought women liked midwives and that they needed to make sure that their thoughts and fears were made as public as possible. That this was not best done individual to individual but must be done collectively. The issue under discussion was what to do if you felt in a large hospital that the care was unsafe. For a lot of the audience this seemed to be a real, and not a hypothetical situation.

The depth of the anxiety was surprising. And unless I was reading this group of staff wrongly, very real…

The Minister  – Ann Milton – is going there tomorrow to talk to them. The last question from the floor to the panel was how should they make their feelings known to the Minister?

Every now and then history throws you a very odd ball to hit. Here was I being asked by a few hundred angry midwives what advice I would have for them on how to embarrass a tory Health Minister. So what did I say? I am afraid – forgetting the great days of student radicalism a mere 42 years ago  – I advised them not to be overtaken by the moment, to play the long game rather than the joy of two minutes on the 10 clock news and make sure that what they did would be interpreted as professional by the mums to be that are their real long term allies.

Sometimes I hate the boring person I have become!


6 Responses to “The Royal College of Midwives – in Conference at Manchester”

  1. Paul
    Never boring. Maternity and ante-natal commissioning should be done by the pregnant mother/family by way of individual budgets and hold the professional midwife to account, regulation possibly through CQC
    Patent the solution to “Conflict resolution between Professional Groups”….or ‘How to be a professional Professional’

    Caroline Mitchell

  2. Completely agree with Caroline. The NZ model of “voucherizing” maternity care, providing women with independent information on choice, allowing women to choose their lead maternity carer is a good example. There are plenty of others examples like this that have worked through the network relationships and payment arrangement with additional services for high risk/specialist care. GP consortia would never do this on their own. National Board would have to develop the package and payment arrangement. Not sure who could be trusted to provide reliable independent information to women for choice in this future world of GP led commissioning – they are not independent or neutral in this instance. But maternity care is perhaps just the first example to highlight this type of problem – other forms of inter-professional competition, conflict and mistrust will play out over time.

  3. @Caroline Mitchell

    “commissioning should be done by the pregnant mother/family”

    It happens already. My brother-in-law (and I use that term deliberately) decided that the NHS was not for them and him and his wife paid for a private midwife for their first child. What a complete faff that was! “interviewing” candidates, trying to get a reassurance that she would be able to get to their house on time and if she was attending another birth having to make sure that there was a back up. They didn’t have any budget issues, so there was no negotiation of the fee, but most people are not blessed with such financial circumstances.

    With our children we used the local NHS: there was a community midwife-lead unit at the local hospital so the same midwife who cared for my partner at home also delivered our son in hospital. We did not have to hunt around for this service because the NHS provided it. And we didn’t see any money passing hands either.

    Perhaps you may think it odd, but I do not think about the delivering our child with the same mindset that I have when deciding who should service our central heating boiler.

  4. Your advice was sound, Paul. You may or may not be surprised to know that the midwives took your advice and put the minister on the spot with some passionate but well aimed questioning.

  5. Dear Sean
    I am pleased (and a bit surprised given the emotion in the hall on Tuesday). The truth is the RCM need a relationship with Ministers very badly and burning bridges this soon in a new Government is bad politics. I think your members were very professional and mature in how they wanted to move forward.

  6. Paul,

    I remained quiet during your presentation because my own feelings about the arrogance of this newly and marginally elected Government, was on a fast boil and close to erupting.

    However, as I pointed out to the Minster, midwives have been in this position before with a previous Conservative Government. GP Fund Holding in respect of midwifery was nothing short of a disaster. So why should GP commissioning improve on this? Previously some GPs used their Fund Holding status to blackmail the rest of the NHS for what they wanted rather than what their patients needed. They threatened to move maternity services to another NHS Trust if the primary service was not prepared to meet what was seen as unacceptable demands. They wanted midwives to work for them rather than for women. They wanted to retain medical dominance rather than encourage a social model of midwifery care and above all, they wanted to continue the practice of receiving payment for the work done by midwives. Is it any wonder that midwives are furious and what reassurances have we had that GPs or those that serve them, will take a more egalitarian and inclusive approach to commissioning.

    At at previous RCM conference, Andrew Lansley was asked the question “why based on your past performance as a Government, should we trust the Conservative party once it returns to power”. His answer was as you might expect from a party in opposition. However, even the most cynical are surprised at the rapid rejection of pre-elections promises and the u-turn which David Cameron is prepared to make in order to keep GPs on side.

    As a midwife with over 30 years experience, I truly despair at times. I have little faith in what the Government continues to say about their commitment to maternity services, mothers and midwives; for it is not the same reality as that experienced by mothers and midwives in the UK on a daily basis.

    Unlike the Danish Midwives, I don’t believe we can ever strike as it would harm those who we are committed to serve; it would also harm our reputation and professional standing. What I would advocate, is that we withdraw our services from the NHS but continue to service the needs of the women in our care. We will strive to use the premises that our taxes have paid for, but if prevented from doing so, then it is the NHS employer and Government which are depriving women and families of the facilities they need. As midwives we may have breached our contract of employment, but not our professional contract with women, whose safety and wellbeing is currently undermined by the diminishing facility of the NHS under
    Tory Government policies of cut back, cut out and couldn’t care less.

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