The workforce plan is wrong to focus on recruitment over retention

In our recent Saving Babies’ Lives progress report, we highlighted how NHS England is not on track to achieve its target of halving rates of stillbirths and neonatal deaths by 2025; that inequalities in pregnancy loss and baby deaths are persistent and have shown little change over time; that parents’ experiences of care are deteriorating; and that Care Quality Commission ratings of maternity services are declining.

Numerous reports have made clear the impact of workforce shortages on maternity and neonatal services. With NHSE describing their Long Term Workforce Plan as a “once-in-a-generation opportunity to put staffing on a sustainable footing and improve patient care”, what will it mean for these services?

Growing the workforce

The Plan’s modelling suggests a growth in the number of midwives to between 31,000 and 33,000 by 2036-37, an increase of up to 43 per cent. Based on Office for National Statistics population forecasts, this would amount to one midwife for every 19 births or fewer. A marked improvement from the 2021-22 ratio of one midwife for every 26 births. This change is welcome given the changing profile of the birthing population and the increased support required during the antenatal and postnatal period.

Workforce planning is complex for maternity and neonatal services and requires coordination across multidisciplinary teams. Despite well-described shortages in other professional groups, midwives are the only relevant group included in the modelling.

The broad approach taken by the plan risks ignoring some of the areas and specialisms where staffing issues are most acute. The shortage of perinatal pathologists is affecting the ability of services to learn from deaths, and impacts the care provided to bereaved families. Perinatal pathologists are not included in the modelling, nor are other maternity and neonatal-related specialisms, such as obstetricians, anaesthetists and sonographers. While the Plan recognises the importance of complementary professional groups, such as health visitors and maternity support workers and nurses, limited details are provided. Future work alongside Royal Colleges and patient groups will be critical to identify specific shortages and create tailored solutions.

Keeping staff in the NHS

The Plan’s ambition to increase the number of students on midwifery courses by 13 per cent to more than 4,000 each year is far in excess of the number of new midwives it forecasts. This suggests low rates of student retention, high rates of leavers from elsewhere in the midwifery workforce, or both. It raises questions about increasing student numbers before improving retention, as well as the effect on the skill and experience mix of the midwifery workforce.

The 2022 NHS staff survey highlighted several key issues for midwives including stress and burnout, lack of work-life balance, and dissatisfaction with pay. One in five people who left the Nursing and Midwifery Council register in 2021 cited pressure and its impact on their mental health as reasons for leaving. For those remaining, monthly sickness absence rates are higher among midwives, nurses and health visitors compared to all professionally qualified staff.

Staff are concerned about the proportion of posts being filled by newly qualified midwives which is skewing the skill mix towards relatively inexperienced staff. Poor staff retention may also affect the provision of clinical placements and training for student midwives. Already, midwives joining the NMC register describe feeling pressured to undertake tasks they felt unprepared or inadequately supervised for because of staffing shortages.

The “retain” component of the Workforce Plan includes only generic principles and aspirations, with few tailored measures for individual services. The Plan assumes improved retention will increase the midwifery workforce by between 1,500 and 2,600 by 2036-37, but with no targets or projections for individual retention policies. Without improving retention, any gains from increasing new joiners are under threat and the NHS risks losing valuable experience and skills.

Scaling up alternative training routes

The Workforce Plan supports the expansion of alternative education routes, including shortened midwifery courses and apprenticeships, as well as harnessing technology to provide blended learning programmes.

Initial indications suggest that student attrition rates are lower among apprentices compared to traditional routes. Qualitative research led by the NMC found mixed perspectives on the quality of simulation learning – some felt it helps students to practice skills in a less pressured environment, while others felt it delivered limited impact compared to real clinical experience. Real-world communication and soft skills need to be embedded in training to help maternity and neonatal professionals provide the best care to parents and families.

The introduction of alternative training routes must be underpinned by robust evaluation to ensure that growth in the workforce does not come at the expense of quality of training and safety of services.

Workforce is one component of maternity safety

It is important to acknowledge that improving staffing levels, while necessary for improving safety of maternity and neonatal services, is insufficient on its own. In his report into maternity services in East Kent, Bill Kirkup made clear that staffing and resource shortages were not the primary cause of the failings identified. Instead, the origins of harm lay in failures of teamworking, professionalism, compassion and listening.

To ensure safe and personalised care, expansion of the workforce must go hand in hand with culture change which embeds these values, and crucially puts women and their families at the centre of their care.

Find out more about how the Sands and Tommy’s Joint Policy Unit is working to save babies’ lives.