Introduction

Why should midwives concern themselves with change and reform in the wider NHS? Working in the health service can sometimes feel like a constant exercise in rearranging deckchairs, as successive waves of restructuring, targets and priorities lap against the heels of professionals working within the NHS. There are many health professionals who do a very good job of taking care of patients whilst paying little attention to the world outside their own practice or their profession. Getting an understanding of the wider picture of midwifery and the context of the health service makes the midwife more effective and able to work as an advocate for women and families. Without that understanding, it is difficult to respond effectively to change and to proactively use the opportunities that change provides. Recognizing where to obtain funding streams and policy initiatives that can transform the maternity services and the wider services that are associated with maternal, child and family healthcare are frequently lost opportunities, as without a realization of the wider picture midwives may not recognize what could be offered to assist in transforming their service. Importantly, an understanding by midwives of the environment and context of their practice allows more control to be exerted, and helps prevent staff alienation and burnout (Sandall 1999).

It is particularly important for midwives to engage with NHS reform (see Midwifery 2020 website). Too often, midwives feel oppressed rather than supported by the system within which they work. Some see midwives’ gradual loss of autonomy – as they came under NHS control, and then into the hospital system over the last few decades – as the loss of a golden age, and believe that the only way to rejuvenate midwifery and improve care for women is to ‘liberate’ midwives from external control – and, in particular, from control by doctors (Kirkham & Stapleton 2004). Much has been written about the historic battle for control between (male) medicine and (female) midwifery (Donnison 1988) (see Ch. 2), and this polarization is still evident in maternity services today (a battle in which midwives usually fare badly and childbearing women fare worse). While gender is an important factor in this dynamic, there are others: the balance of power and resources between primary and secondary healthcare, between the needs of the ill few and the healthy majority, between regulating quality and allowing local flexibility, between the advancement of knowledge and the strengthening of basic healthcare provision. In other words, midwives are facing similar challenges to those experienced by many others in the NHS, and midwives – as much as anyone else in the health service – can work to influence and benefit from NHS reform.

Midwives are proud to be an ‘autonomous’ profession, but the reality is that no health worker is truly autonomous in today’s NHS. The teams of professionals are all as effective as the partnerships they create, the opportunities seized, and the resources identified and used. That means that engaging with wider NHS reform is of crucial interest to all those concerned about the future of maternity services.

At the time of writing, the UK is undergoing a change of government during the deepest economic crisis that has been known for many years (see website). Years of sustained growth in NHS funding, accompanied by ambitious programmes of service transformation, are on the cusp of plunging into an extended period of austerity and efficiency savings (see website chapter 7). In addition, devolution in the UK has increased the diversity of policy and practice across the UK (DH 2002, Ham 2009). These factors make it increasingly difficult to provide accurate and comprehensive detail on how the NHS is changing. Instead, this chapter will focus on the main policy drivers and trends that are consistent across the UK and across UK governments.

A little history

The creation of the National Health Service, 60 years ago, is rightly remembered as among our nation’s finest expressions of collective will. One of the central planks of the post-war reforms that sought to tackle social inequalities, build public health, and create a society that provided its most vulnerable with a safety net ‘from the cradle to the grave’, the health service still commands great loyalty and affection in the public psyche. Yet preoccupation over the accessibility and effectiveness of the NHS’s services is equally a national pastime, and the future of the NHS has become highly contested – between political parties, in the media, and in public discourse.

Before the NHS was established, there was not one single maternity care system: women chose, according to their means, from a plethora of competing providers, including midwives, family doctors, obstetricians and hospitals (private and charitable). The 1946 National Health Service Act, which became operational in 1948, established a comprehensive, if fragmented, model of care, comprising hospital maternity services, community midwifery services (which were under the control of local authorities), and general practitioners. This fragmentation caused duplication and poor continuity, and many midwives were frustrated by what they saw as the encroachment of doctors on the provision of midwifery care. This was exacerbated by the expansion of hospital maternity beds resulting from the 1962 Hospital Plan, and by the Peel Report of 1970 (DHSS 1970), which recommended that all women give birth in hospital, cared for by multidisciplinary teams of midwives, obstetricians, and general practitioners (GPs). In 1973, the National Health Service Reorganisation Act brought all midwives under the responsibility of the NHS.

These reforms, along with the opportunities offered by evolving obstetric expertise, exacerbated the erosion of community-based midwifery. Childbirth became increasingly medicalized, with hospital delivery and many obstetric interventions becoming routine. The development of general management during the early 1980s meant that midwives reported up through general or nursing management, making them feel even more isolated from decision-making power.

Meanwhile, the wider NHS was experiencing repeated restructuring and reform in order to reduce its complex, multi-layered bureaucracy. At the end of the 1980s, it also underwent ideological revolution as the Government aimed to introduce ‘market forces’ to public services. A competitive internal market was established within the NHS, within which the functions of purchasing and providing were separated. Hospitals, community and ambulance services were encouraged to become self-governing trusts. GPs were encouraged to become fundholders, with power over their own resources and responsibility for purchasing care for their patients. The aim of this was to increase choice and efficiency, but both aims were frustrated: efficiency was undermined by the unavoidable management costs of implementing and running the system, while choice was subverted by the system of block contracts and restrictions on extra-contractual referrals.

The new NHS

By the time the Labour Party assumed government in 1997, after 18 years of uninterrupted Conservative administration, it appeared that the NHS was feeling sick and tired itself. Those who worked within it were fatigued and demoralized by continued structural reform and the implicit (often explicit) message that they could not run their own affairs efficiently. Conflict over wages, differentials, professional territories and management influence was widespread. Long waiting lists and poor customer care were alienating NHS users and supporters. There was significant public debate about whether the health service had a future, at least in its current form, or whether it should be dismantled and replaced by a system of private insurance funding. The NHS had become a service that was criticized. Each government attempted to make changes but it was an area of political influence as the public wished to retain its service and would not support privatization. Its future management was one of the key reasons why the country felt ready for change. The highlighted areas of deficiency in quality (see Ch. 7) supported an imperative for change.

Then a government was elected that demonstrated ideological commitment to the NHS and increased funding to enable this (see website chapter 7). This led to a Modernisation Agency and agenda (2002) and the revised structure for the NHS (see Fig. 7.1). The record increases in funding provided were matched with a serious commitment to radical reform. As with the previous administration, it was determined to break up the power cabals and vested interests that dominated the NHS, and to harness market forces to drive up quality and secure efficiency. The central strategy of ‘the new NHS’ was to deliver early performance improvements (in particular, speedier access) and to develop a culture of continuous quality improvement, by:

Thirteen years on, the impact of these reforms is undoubted but contested. Rising demand has been met by increased resource, with NHS funding more than doubled. Waiting lists fell to their lowest level since records began; a new maximum wait of 18 weeks from GP referral to treatment was secured; nearly all A&E patients were seen, treated, admitted or discharged within 4 hours; new hospitals and health facilities were built; significant progress was made in the management of long-term conditions; there was expansion of staff numbers and staff pay. To a very large extent, the NHS has regained public trust.

Nevertheless, the subsequent relationship between the Government and the NHS has not always been easy. Undoubtedly, many NHS staff welcomed the philosophical underpinning of new policy, and few demurred at the impressive investment produced in 2001 (see website chapter 7). But they became wearied by the relentless cycle of structural reform and centralized micro-management that is implemented by successive governments. Many were deeply alarmed by the Government’s commitment to developing a mixed economy of providers, and its efforts to introduce this in a fair and effective way. Many of the professional groups complained about the targets culture, which produced impressive results, and which promoted an inflated sense of its own possibilities, overreached itself and has now been forced into retreat.

At the close of the Labour administration, the NHS was shifting the emphasis of its reform agenda away from speed of access toward quality of care (see Ch. 7), from centrally set targets to local priority setting, from supply-side expansion to demand-side management, and towards the development of a truly primary care-led health service as envisioned by the Darzi Next Stage Review (DH 2008). The scale of change needed in the NHS is clearly evidenced by how much work is still to be done, after a dozen years of full-on modernization (see website).

The challenges of modernization

Stay updated, free articles. Join our Telegram channel

Join