1. PROTECTING THE PUBLIC: THE CURRENT REGULATION OF MIDWIFERY JACQUELINE WIER DOCTORAL STUDENT/ SENIOR MIDWIFERY LECTURER INTRODUCTION AND BACKGROUND OVER THE PAST 35 YEARS AS A RESULT OF GOVERNMENT POLICY AND REFORM THE AMOUNT AND LEVEL OF REGULATORY CONTROL OF HEALTHCARE HAS CONTINUALLY INCREASED. MUCH OF THESE STRATEGIES HAVE BEEN INFLUENCED BY NEOLIBERAL IDEOLOGY IN ITS VARIOUS GUISES. WHILST IT IS TRUE THAT MATERNAL MORTALITY AND STILLBIRTH RATES HAVE NEVER BEEN LOWER (KNIGHT EL AL, 2014), PATIENT SAFETY INCIDENTS (NHS ENGLAND, 2014), AND CLAIMS OF CLINICAL NEGLIGENCE IN OBSTETRICS HAVE CONTINUED TO CLIMB (NHSLA, 2012). ADDED TO THIS BRENNAN (1998) NOTES THAT THERE IS A PAUCITY OF EMPIRICAL DATA ON HEALTHCARE REGULATION (PARTICULARLY WITH REGARDS TO MIDWIFERY). TAKEN TOGETHER THIS RAISES THE QUESTION OF WHETHER THE REGULATORY MECHANISMS WHICH ARE DESIGNED TO ENSURE THE HEALTH AND WELLBEING OF THE PREGNANT WOMAN UNDERMINE OR PROMOTE QUALITY CARE AND, WHETHER THE CURRENT STATUTORY AIM OF ‘PROTECTING THE PUBLIC’ IS BEING REALISED. THE RESEARCH QUESTION IS THEREFORE: ‘DO MIDWIVES BELIEVE THAT THE CURRENT REGULATORY FRAMEWORKS THAT GOVERN MIDWIFERY PRACTICE FACILITATE OR UNDERMINE THE ‘PROTECTION OF THE PUBLIC’? Empirical Research Methods  Online Survey – distributed to 192 midwives – 70% response rate (n=132)  20 Semi-Structured interviews  Participants included NHS and Independent Midwives Emergent Themes Risk, Society and Service User Expectations “My worry with having a big industry called “risk management” is that society feels that we can get rid of risks and we can make everything lovely and nice and that babies never die….. And so I think there is a societal expectation that things never go wrong, and if they do someone is to blame and I think it can become a bit of a witch hunt and I think that can affect midwifery practice because then you are petrified of the adverse outcome.” (June: NHS Midwife >20 yrs.) Clinical Governance and its Relationship to Litigation “Clinical governance is there to look at how we can reduce risk and so reduce litigation…. It’s about bringing the insurance policies down, isn’t it? Everybody knows that it’s all about the money. It’s not about the care as such. I don’t think people would spend that much money sorting out different ways of managing risk if it wasn’t about money…it’s not about the women’s care. It’s how to reduce litigation.” (Lilly : NHS Midwife 0-5 yrs.) Clinical Governance and Decision Making “ People are thinking that they’ve got to follow the guidelines, because that’s going to protect the public and keep them safe and they’re not thinking intelligently about the individual in front of them and the clinical situation in front of them.” (Laura: Independent Midwife, >20yrs ) Clinical Governance and Individualised Care “It seems that we practice with 'one size fits all' policies and procedures which could result in providing women centred as opposed to woman centred care” (On- Line Survey NHS Midwife, 0-5 yrs.). Discussion  There are inconsistencies between regulatory systems designed to ensure safe care and the broader system of maternity service provision.  Some participants were sceptical about clinical governance strategies, believing that their primary function was to reduce the cost of litigation to NHS Trusts.  A heavy emphasis on risk management, for what is sometimes seen as the wrong reason of reducing costs and meeting government targets has the potential to produce ineffective outcomes for women seeking care.  Limited funding impacts on the provision of care, particularly for women who are high risk. These women are less likely to receive quality care as a result of staffing issues and the lack of resources in a finically restricted service.  The clinical guidelines may reduce decision-making based on professional judgement. Midwifery compliance with clinical guidelines is complex and may include: creative compliance to avoid unnecessary intervention in childbirth, and conversely rigid adherence to clinical guidelines as a defensive practice mechanism to avoid poor outcomes which might lead to practitioner culpability.  The clinical governance policy is often in tension with the woman centred care agenda such that the service user voice is only heard when it is consistent with clinical governance strategies. Recommendations  A clinical governance policy that takes into account the individual woman and her needs. This might help to reduce litigation costs by facilitating safe effective care whilst meeting the expectations of the woman.  Stronger more coherent regulation that would provide solutions that respond better to the many arrangements of support and opposition that occur within the NHS.  Increased participation from service user groups who could represent the pregnant woman and so address questions of performance and quality in a pragmatic and efficient manner.  The development of midwifery skills, particularly in relation to the production of individualised guidelines for pregnant women, which would enhance confidence in clinical decision making and possibly reduce defensive practice.  Resolution of the question of resources and the provision of adequate midwife numbers so that the quality of care that pregnant women have access to can ultimately be improved. Key Literature Cited : Ayres I and Braithwaite J Responsive Regulation: Transcending the Deregulation Debate (Oxford University Press; Oxford, 1992) Brennan T.A. The Role of Regulation in Quality improvement Milbank Quarterly 76(1998):709-31 at 725 Harvey D., A Brief History of Neoliberalism (Oxford University Press; Oxford, 2007) National Reporting and Learning System (NRLS) Six Monthly data on patient safety incidents Report (NHS England; London, 24 th September 2014) National Health Service Litigation Authority (NHSLA) Ten Years of Maternity Claims: An analysis of NHS Litigation Authority Data (NHSLA; London, 2012) Peck J., Tickell A., Neoliberalizing Space Antipode 34(2)(16 TH December 2002):380-404