NHS: Amateur midwives??

NHS trusts could be risking the safety of mothers and babies by using maternity support workers to do the work of trained midwives, according to a report. An independent study for the Department of Health found that a number of trusts across England were converting midwife positions into posts for lesser-qualified maternity support workers.

When challenged by midwives, Patricia Hewitt, the Health Secretary, has always insisted that support workers would not be used as substitutes for professionally qualified midwives. The report found, however, that in some places they were doing tasks deemed to be within the role of midwives and requiring specialist knowledge and training. The report said that a lack of consistency in the training and role of support workers had the potential to leave midwives and hospital managers uncertain about their competence, and placed patients at risk from a low standard of care.

King's College London, which surveyed trust managers in England, noted that there was no statutory requirement for support workers to undergo training, nor any regulation to ensure public protection. Midwives have legal responsibility for the work of their support workers, but systems to enable them to fulfil this task were variable, the report said. It recommends a national framework to set training and standards and said that the tasks that could be delegated needed to be identified urgently.

The NHS collected little data on support workers' cost-effectiveness and the report called for scrutiny where they were being trained to take on complex new roles. It found that they made an important contribution to maternity care and managers were enthusiastic about their role, reporting that they freed midwives to spend more time with women and babies. Their role included breastfeeding advice and support; outreach services to vulnerable women; running antenatal and postnatal groups; assisting midwives at home births and in birth centres; and working in operating theatres.

Ms Hewitt promised last month that support workers would not act as a substitute for qualified midwives, as she outlined plans to guarantee expectant mothers a "full range of birthing choices" by 2009. She described reports to the contrary as completely untrue: "They are there to support the midwife and free up a midwife's time for the work that only she can do. They are not a substitute for a midwife."

Professor Jane Sandall, who led today's research, said: "There is a danger that support workers could cease to become `another pair of hands', freeing the midwife and other members of the maternity team from administrative and routine duties in order to look after women. Instead, they may be called upon to substitute care provided by midwives, without sufficient investment in their training or development."

A Department of Health spokeswoman said: "This study shows that in only a tiny proportion of trusts were inappropriate tasks such as minor examinations being undertaken by maternity support workers. It is completely unacceptable if a hospital is using a maternity support worker as a substitute for a midwife and the Chief Nursing Officer has written out to all trusts to clarify this and asked that they review the working practices of all support workers, ensuring maternity services are provided safely.

"We are very clear about what the role of a maternity support worker is: to support the maternity team in their day-to-day duties, such as clerical work, supporting women with breastfeeding, increasing access for vulnerable women and enhancing the quality of care. In trusts where maternity support workers have been introduced, up to 64 per cent of midwifery time was saved each week and new mothers gained greater choice over where to give birth. This means that midwives have more time to undertake tasks that only they are trained to do. "Every baby must be delivered by a registered midwife or a doctor. This is a legal requirement not an option."

Jon Skewes, director of employment relations at the Royal College of Midwives, welcomed the report, saying: "It identifies some major problems regarding the introduction of support workers in England. "Chief among those is the uncertainty about what support workers can and cannot do, and what a midwife can delegate to them. There is a need for greater control, and the report suggests there needs to be better standardisation of training."

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Americans will die for liberty

Excerpts from a British writer:

We are inclined, in our snobbish way, to dismiss the Americans as a new and vulgar people, whose civilisation has hardly risen above the level of cowboys and Indians. Yet the United States of America is actually the oldest republic in the world, with a constitution that is one of the noblest works of man. When one strips away the distracting symbols of modernity - motor cars, skyscrapers, space rockets, microchips, junk food - one finds an essentially 18th-century country.

The sense of entering an older country, and one with a sterner sense of purpose than is found among the flippant and inconstant Europeans, can be enjoyed even before one gets off the plane. On the immigration forms that one has to fill in, one is asked: "Have you ever been arrested or convicted for an offence or crime involving moral turpitude?" Who now would dare to pose such a question in Europe? The very word "turpitude" brings a smile, almost a sneer, to our lips.

The quiet solicitude that Americans show for the comfort of their visitors, and the tact with which they make one feel at home, can only be described as gentlemanly. These graceful manners, so often overlooked by brash European tourists, whisper the last enchantments of an earlier and more dignified age, when liberty was not confused with licence.

But lest these impressions of the United States seem unduly favourable, it should be added that the Americans have not remained in happy possession of their free constitution without cost. Thomas Jefferson warned that the tree of liberty must be watered from time to time with the blood of tyrants and patriots. To the Americans, the idea that freedom and democracy exact a cost in blood is second nature...

The Americans are prepared to use force in pursuit of what they regard as noble aims. It is yet another respect in which they are rather old-fashioned. They are patriots who venerate their nation and their flag.

The idea has somehow gained currency in Britain that America is an essentially peaceful nation. Quite how this notion took root, I do not know. Perhaps we were unduly impressed by the protesters against the Vietnam war. It is an idea that cannot survive a visit to the National Museum of American History in Washington, where one is informed that the "price of freedom" is over and over again paid in blood.... when the Americans speak of freedom, we should not imagine, in our cynical and worldly-wise way, that they are merely using that word as a cloak for realpolitik. They are not above realpolitik, but they also mean what they say. These formidable people think freedom is so valuable that it is worth dying for.

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