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Maximum midwife-to-supervisor ratios upped under new NHS advocacy model

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The recommended maximum number of midwives that a supervisor should support has increased to 20 under a new model being introduced by NHS England, which also suggests the use of “sessional” staff to provide supervision without extra payment.

The previous system was overseen by the nursing and midwifery regulator, which recommended a maximum ratio of one midwifery supervisor to 15 midwives.

“The 1:15 ratio wasn’t evidence-based, and was just viewed as seeming to work, but this change gives more flexibility”

Carmel Lloyd

But since 1 April, due to legislation changes, the NMC has no longer had responsibility for supervision of midwives, and its standards in this area have now been revoked.

Instead, a new system developed by NHS England, called the Advocating for Education and Quality Improvement (A-EQUIP) model, is being brought in.

Previously, Nursing Times had reported that some organisations trialling new supervision models had scrapped the 1:15 ratio.

Final guidance released this month by NHS England confirms this, stating that under the new model, supervisors – who will now be known as professional midwifery advocates (PMAs) – should be responsible for between five and 20 midwives.

In addition, the guidance suggests PMAs may work on a “sessional basis”. These would be staff who provide supervision but are not employed full-time in that role and receive no extra pay.

When asked by Nursing Times whether these changes could lead to midwives receiving less support, and from staff with less experience, an NHS England spokeswoman highlighted that it would be down to employers to decide their own strategy for implementing the new model.

“Whenever you introduce a new model there is always a risk, particularly moving from a statutory to a non-statutory framework”

Carmel Lloyd

She noted that a range of ratios has been recommended by NHS England to allow organisations to consider the most effective deployment of PMAs within their own workforce.

The Nursing and Midwifery Council’s most recent assessment of the system found half of UK regions were failing to comply with the ratio, exceeding it by up to 1:18.

Meanwhile, the Royal College of Midwives told Nursing Times that the NMC’s ratio of 1:15 was not evidence-based, but it had previously been thought to be effective.

However, under the new model, two time-consuming parts to the job have been removed. Legislation changes meant supervisors would now no longer be responsible for investigating midwives.

In addition, the new model meant they were now not required to give such intensive support to women by being available 24/7, said the RCM’s head of education and learning Carmel Lloyd.

“The 1:15 ratio wasn’t evidence-based, and was just viewed as seeming to work, but this change gives more flexibility,” said Ms Lloyd.

Royal College of Midwives

Carmel Lloyd

Carmel Lloyd

The use of sessional PMAs was very similar to the old system under which midwives who “dipped in and out” of supervision were required to support full-time supervisors with no extra remuneration in order to meet the required ratios, she said.

She noted there was a potential risk that the lack of additional payment would deter some midwives from taking on the role, but said this had not been the case under the old system – or, similarly, with mentors, who also receive no extra money for this part to their role.

In addition, she suggested midwives may prefer to work as a sessional PMA, because it would be a part-time role and under the previous model supervisors had sometimes found it stressful to be in the role full-time.

“Whenever you introduce a new model there is always a risk, particularly moving from a statutory to a non-statutory framework,” said Ms Lloyd.

“That is something the RCM will be monitoring – and we’ve also asked the government to assess the new model in a year’s time,” she added.

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