Written evidence submitted by The Royal College of Midwives (RTR0126)


The Royal College of Midwives (RCM) is the trade union and professional organization that represents the vast majority of practising midwives in the UK. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and provide professional leadership for one of the most established clinical disciplines.

The RCM welcomes the opportunity to contribute to this Inquiry, particularly as issues relating to workforce recruitment, training and retention are of such importance to the provision of safe and high quality maternity services in England.


The midwifery workforce

The role of the midwife is to ensure that women receive the care they need throughout pregnancy, childbirth and the postnatal period. Much of this care will be provided directly by the midwife, whose expertise lies in the care of women and babies during normal birth and pregnancy. Where obstetric or other intervention is necessary, the midwife continues to be responsible for providing holistic support, maximising continuity of carer and promoting a positive birth experience for the woman.

Midwifery staffing has been a cause of concern for many years. The Government has assessed that at least 2,000 WTE more midwives are needed in England to deliver the current maternity transformation programme. We therefore welcomed the Government’s announcement, in March 2018, of an additional 3,650 training places over the next four years.

However, historically high vacancy rates have been exacerbated over the last 12 months due to the Covid pandemic and resulting staff absence. An RCM survey of Heads of Midwifery in 2021 found that 87% of respondents reported midwife vacancies (up from 71% in 2020). Almost two thirds (64%) of these vacancies were over three months old, and 77% of the respondents said it was ‘difficult’ or ‘very difficult’ to recruit Band 6 midwives.

The most recent figures from NHS Digital paint a worrying picture. October 2021’s figures show an annual fall of 278 in the number of full time equivalent (FTE) midwives in the NHS in England. This is the first year-on-year fall since monthly workforce numbers started being published in 2009.

For women this means that they have a 20% chance of being left alone in labour or shortly after the birth, antenatal care is often disjointed and postnatal care poor. It also means that there are insufficient specialist midwives for women with particular needs and conditions (such as recently highlighted shortages in maternal mental health care) and it means that units close or services are withdrawn because of staffing shortages.

For midwives, it means working long hours without a break or even food and drink. It means working through stress and fatigue, aware of the implications that has for safe practice. It means not being able to access colleagues’ support and advice when needed. It means not being able to spend time with women, building trusting relationships and practising higher midwifery skills.

This is not just a recruitment issue. It is also evident that many of our hospitals just do not employ sufficient midwives, leading to excessive workloads/caseloads, long hours worked beyond shift, reductions in training and development, high use of agency staff to cover shortages and failure to properly manage peaks of activity. Our ability to retain experienced and expensively-trained midwives is in crisis along with staff morale.


  1. What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long term?

What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

The RCM recommends three key priorities:

-          A national workforce strategy

-          A fairer pay settlement

-          A focus on retention. Without retention, recruitment efforts can at best generate marginal improvements in midwife numbers.


Additionally, we recommend the following short-term actions:

-          Use recruitment and retention premia to target posts and areas with the greatest shortages. This is permitted under Agenda for Change where “market pressures would otherwise prevent the employer from being able to recruit and retain staff in sufficient numbers for the posts concerned;

-          Facilitate the speedy introduction of newly qualified midwives into the workforce, for example through quicker issuing of PIN numbers, and effective support through preceptorship programmes;

-          Prioritise the health and wellbeing of maternity staff, including for example by retaining some of the measures brought in during the pandemic, such as safe rooms, access to psychological support, free car parking and the availability of hot meals;

-          Slow the pace of implementing change programmes, such as continuity of carer schemes, until services can ensure that safe staffing levels are in place;

-          Ensure the improved Agenda for Change flexible working provisions become a reality for midwives and MSWs;

-          Tackle the discrimination and harassment that lead to toxic workplace cultures.

In the medium term, we should:

-          Develop pay and reward packages that incentivise retention and that make staff feel their contribution is valued;

-          Restore bursary or other funding for preregistration nursing and midwifery programmes;

-          Diversify entry routes, including overseas recruitment, return to practice and nurses converting to midwifery via shortened programmes.


In the longer term, we need to:

-          Widen access to midwifery through apprenticeships, access courses for maternity support workers, and shortened conversion programmes for existing health professionals.

-          Strengthen professional development pathways into clinical academic careers, teaching and professional leadership, with supportive resources and pay structures in teaching and researching reflecting those of clinical roles.



  1. What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term? 

What can Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?

Midwifery, like other health professions, has traditionally recruited from overseas – most commonly from the European Union. Brexit has clearly diminished this resource and the RCM is working with the NHSEI to support international recruitment of midwives. Until the end of this year, European candidates do not need to undertake competency testing as they meet EU standards. Most of these midwives are looking for professional development and do not seek to settle in the UK long term.


However, it is important to be clear that overseas recruitment will only ever have a marginal impact on UK midwifery numbers. In non-EU countries, the role, qualifications and skill of a midwife are not comparable to that expected in the UK. So we have never been able to rely on international recruitment to the extent that the nursing profession has. Our focus should remain on sustainable, home-grown, UK-trained staffing supply.


Where we do use international recruitment, we should:

-          Avoid recruiting from countries with poor maternal outcomes and significant workforce issues of their own;

-          Continue alignment with EU standards in order to ensure the highest standard of safe quality care;

-          Provide adequate support for overseas midwives on arrival, with training, supervision and housing.


A more stable workforce is likely to be created by drawing student midwives and returners from local communities, and indeed from the refugee, migrant and asylum-seeking population already in the UK. The last years have seen large numbers of Syrian and Afghanistan migrants, including women who were in professional roles (male midwives are not known in those countries).



  1. What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors?


-          In the midwifery workforce there is a significant disconnect between planning student numbers and funding workforce establishment, leading to a double whammy of vacancies (without sufficient people to fill them) but also not enough actual jobs. So the RCM recommends routine and realistic assessment of workforce needs, rather than vacancy rates. We support the proposed amendment to the Health and Care Bill to require the Secretary of State to publish independently verified assessments of current and future workforce numbers and then act on the findings.


-          Birthrate Plus is the only credible and national workforce planning tool for midwifery. It is endorsed by NICE and is consistent with the NICE safe staffing guideline for midwives working in maternity settings. NHSEI also now recommends that NHS Trusts undertake Birthrate Plus to satisfy themselves that they have safe staffing levels.


-          The midwifery curriculum has recently been updated by the Nursing and Midwifery Council. During the consultation phase there was particular debate about whether the degree programme should last four years, rather than the current three. There is widespread acknowledgement that three years does not sufficiently equip midwives with the confidence and competence they need to embark as autonomous practitioners, and hence the preceptorship year which provides a structured start for newly registered midwives. But there are concerns about the quality of preceptorship, as there is no standardized programme or route for progression.


  1. What are the principal factors driving staff to leave midwifery and what can be done to address these?


A recent RCM member survey found over half (57%) of respondents reporting that they are considering leaving the NHS, and the same percentage saying they would do so in the next year. This is not just true for those nearing retirement: of those respondents who had worked in the NHS five years or less, 50% were considering leaving and 46% said they would do so in the next year. If we cannot retain our current staff we cannot hope to solve the staffing crisis faced by the NHS.


The RCM in our evidence to the Pay Review Body last year that midwives may vote with their feet, and workforce data shows that this has started to happen. In July 2021 we saw for the first time – in monthly figures going back to 2009 – a year-on-year fall in the number of midwives working for the NHS in England.


The top three reasons that RCM members told us they were considering leaving the NHS were: staffing levels, unhappiness with the quality of care they were able to deliver, and pay.


NHS workforce morale could scarcely be lower than it is today. If the NHS is to address the challenges it faces, it must pay its staff fairly and address the real terms losses of the last decade. Years of pay restraint, rising prices and inflation are a poor reward for the dedication of a highly skilled workforce, particularly over the last two years.


Following the announcement by the Government of a 3% pay rise for NHS staff in England, RCM members overwhelmingly told us that it was not enough. Fair pay is integral to recruitment and retention; currently we see a vicious cycle of midwives unhappy with staffing levels and leaving, further exacerbating shortages. Our evidence suggests that many of those considering leaving could be persuaded to stay with increased pay leading to improved staffing levels and in turn to improved working conditions.


Our evidence demonstrates a workforce under extreme pressure, that feels undervalued, with low morale and motivation, and the impact this has on ability to provide quality care.


Excess working hours and lack of breaks is a common for midwives – 85% of Heads of Midwifery told us it is difficult to ensure that all staff take their breaks and leave on time. This was a notable deterioration from previous years (54% in 2020 and 52% in 2019). Almost all the Heads of Midwifery (97%) said they rely on staff goodwill, and that morale and motivation were just ok or poor (90%).


Workforce pressures impact on midwives in many ways: in reduced opportunities to work flexibly and to accommodate caring responsibilities; in reduced time for professional development; in reduced time for quality interactions with patients; in pressurised, high stress working environments; in negative workplace cultures and feeling undervalued; in limited opportunities for advancement.


  1. Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this? 

Traditionally, and unsurprisingly, London and the South East have had the biggest problems with recruitment and retention. The cost of housing, and of childcare, are significant obstacles and more could be done to support midwives with these in order to attract them to areas with a high cost of living.


More remote and rural maternity units can also struggle to recruit and retain staff. Local initiatives to market NHS careers into schools and colleges can help here, along with placement opportunities during pre-registration education.


More creative thinking is needed to unlock the potential of particular populations and access points into midwifery in hard-to-staff areas. For example:


-          Maternity Support Workers (MSWs) are non-regulated, non-professional staff members who are able to provide support to midwives, take on some routine tasks and work under delegated authority. Over the last 20 years MSWs have proved their value to the wider maternity team and to women, providing capacity and skills, allowing for a more flexible workforce deployment, and allowing midwives to spend more time with the women who need them most. It is inevitable that the future workforce will include more unregulated staff, but this must be done safely with appropriate training, development, oversight and career progression.


-          Since the end of the bursary the age profile of those joining midwifery has dropped, as older entrants are less likely to be able to afford to train unwaged. One of the consequences of this is that younger people are not so settled on their career choices and do not see themselves having just one career for their entire lives, hence a higher attrition rate through early careers. In both the South East and rural areas, it would make sense to market midwifery careers to slightly older people because they are more likely to stay – and the bursary would significantly improve our chances of attracting those applicants.


  1. What should be in the next iteration of the NHS People Plan to address the recruitment, training and retention of staff?

The NHS People Plan should champion and resource the improved Agenda for Change flexible working provisions so they become a reality for midwives. RCM research shows that only 35% of our members do NOT have some form of caring responsibility: either for children, or for sick, disabled or elderly relatives.

Over one quarter of our members (26.7%) are in their 50s, approaching retirement, and may be retained in the NHS through better access to flexible retirement options or ‘retire and return’.  Flexible working, then, is good for our members and good for retention. RCM research in 2121 found that 67% of midwives and MSWs who had left or were considering leaving the NHS could be encouraged to return if there were greater opportunities to work flexibly.

Currently, these opportunities are not always available. One third (36%) of those respondents who had made a request to work flexibly had their request rejected. In practice, maternity units are very inflexible in the variety of shift patterns and shift lengths they offer to staff. Several RCM surveys have shown that many units only offer 12 hour shifts and ask their staff to go on a rota system so their days and hours of work vary from week to week. While some staff are happy to work this way, others find it very disruptive to their work-life balance (for example, it can make childcare planning very difficult).

We believe that organisations should grant midwives’ and MSWs flexible working requests, and offer a variety of shift patterns and lengths, to encourage staff to stay in the service. Without holding on to existing midwives, we cannot hope to end staff shortages.


  1. To what extent are the contractors and employment models used in the health and social care sectors fit for the purpose of attracting, training and retaining the right number of staff with the right skills?

The midwifery workforce benefits from the use of Birthrate Plus, which is the only credible and national workforce planning tool for midwives. It is endorsed by NICE, recommended by NHSEI and has also been positively discussed in your own report on maternity safety. It is also used as the basis for the Government’s own midwifery workforce needs assessment.


Unfortunately, as your maternity safety report sets out, there is not an equivalent for other health professionals involved with maternity care. All health professions need to be using evidence-based workforce planning tools, and this is particularly important as increased flexibility sees, for example, midwives extending their duties into those historically undertaken by junior doctors.


As the inquiry into maternity safety also reports, even though NHSEI now recommends that NHS Trusts use Birthrate Plus to ensure safe staffing levels, Trusts can do and do refuse to be bound by the findings. Nationally and locally, workforce planning should work to targets underpinned by a robust evidence base, not a tradition of underinvestment.



  1. What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?


Integrated care systems (ICSs) will play an increasingly important role in the planning and provision of NHS services, including workforce planning and development. Indeed, the devolution of workforce responsibilities from the centre is critical to the ability of ICSs to achieve their policy aims. This will be challenging for local partners, and also for those national organisations which will need to focus on local system collaborations.

Greater local ownership of workforce development may deliver a number of benefits, including early identification of developing local issues and needs, closer knowledge of and working with all parts of the community to provide greater access to local NHS jobs, and meaningful staff engagement. They could be nimbler, faster-responding and better informed than national organisations.

However, there are some functions that clearly sit better at national level, including leadership for funding strategy, planning support and evaluations of good practice that can be spread elsewhere.  The challenge lies in finding the right balance, and developing effective . Given that ICS development has been a locally led process with significant differences in the size of systems and the arrangements they have put in place, it is particularly important that national workforce strategy blah

The RCM has some concerns about how the development of responsibilities and accountabilities at ICS level will be achieved in practice. In particular, we hope that the recent merger of Health Education England with NHEIS will not mean the loss of expertise and focus on workforce planning in national strategy.  This is not the time to dilute our national systems for workforce planning. We continue to believe that assessing the demand for services and determining the supply of NHS staff to meet that demand should have national oversight.

The need for a strong national overview is all the more important because maternity services in England are currently working to meet national targets arising from a national review of maternity services. It is vital that local and national processes should complement and inform each other.

ICSs could play a significant role in in better utilizing the existing health and social care workforce, developing new roles and default flexible working across traditional clinical boundaries. The RCM agrees that the provision of safe, effective and high quality care requires a reasonable degree of flexibility on the part of staff groups and care consideration of an appropriate skill mix for different settings. We welcome the fact that midwives and MSWs are developing areas of interest and specialist skills and recognize that this is an important part of providing a service response to the increasingly diverse needs of all communities.

However, while NHS organisations may wish to maximise the flexibility of their workforce, it should not be acceptable to permanently alter roles to compensate for staffing shortages or changes in the roles of other staff groups. Service needs will vary in different localities and with different populations, which is why it is reasonable to expect ICSs to have a role to play in developing new roles of particular skill mixes. Our expectation would be that ICSs adopt a rationale for role development that is about demonstrable improvements to service delivery and outcomes rather than plugging gaps or other short-term fixes.


Jan 2022