News

02.03.16

Midwives among most stressed of NHS staff – RCM

Midwives face higher stress rates than many other types of NHS staff, the Royal College of Midwives (RCM) has found.

Analysis of the recent NHS Staff Survey by the RCM shows that almost 50% of midwives had experienced work related stress in the past year and almost 70% had come to work despite feeling unwell, compared to 37% and 63% of NHS staff in general. The survey also raised concerns about levels of bullying and harassment faced by NHS staff.

In June this year the RCM will launch a health, safety and wellbeing campaign to provide greater advice and better support to midwives and maternity staff on coping with the pressures of their job, and raise awareness amongst employers of the long-term value in promoting wellbeing amongst maternity staff.

Jon Skewes, the RCM’s director for policy, employment relations and communications, said: “These latest NHS staff survey results are shocking but not surprising, midwives day in day out face enormous pressure due to understaffing and an increased birth rate.

“We hear daily from our members of their frustrations and fears about delivering a high quality safe service with inadequate levels of staffing at their units, this is undoubtedly one of the primary causes of work related stress.”

In their October submission to the NHS Pay Review Body 2015, the RCM warned that two-fifths of maternity units are so overworked that they’ve had to temporarily close their doors in the last year.

(Image c. Todd Anderson via Flickr Commons)

Comments

Anon   23/09/2016 at 09:05

I really hope something changes; and soon. I'm five years in and can't face much more. Mentally and physically exhausted. Expectations of women and their partners is so unrealistic..... It's like they think maternity is protected from everything. And when they're tired and disappointed, midwives and msws get told, in no uncertain terms.

Anon   23/09/2016 at 12:27

I have worked for almost 20 years as a midwife and in the last few years have seen brilliant midwives leave the profession due to stress and unsupportive management. We work long hours often staying late and come in on our days off to help out on busy under staffed shifts, working through our unpaid breaks. Our work load has increased as new legislation in brought in. Our pay has stayed the same. It's a wonder more haven't left!!!! Something has to change soon

Anon   23/09/2016 at 14:07

10 years a midwife and desperate to leave the profession. I daily give my sole to a job that wants more and more. I see tears of frustration from colleagues daily, who just want to care. Management are under stresses and often this is disseminated with bullying tactics. The situation is bringing out the worst in us all. We fear litigation as often choices have to be made between care and good documentation. Units are no longer big enough there are not enough staff or equipment. My heart breaks for a job I used to love .

Anon   23/09/2016 at 14:59

I've been a midwife for 30+ years and recently had to go off work with work place stress first time ever! This has been down to lack of managerial support, bullying tactics used by managers to force you into doing things you know are unsafe! Managers refusing to listen to the clinical workers? Everyone that's practised for years will know the work has increased In all maternity units but funny enough the staffing levels have reduced??? I honestly love what I do but now can't wait to retire soon as I don't want to be part of this extremely dangerous environment now!

Colette   23/09/2016 at 15:15

I have left midwifery at 54 (after 30 years). I originally planned to retire at 58 but I could not stand to work another day. I loved the job until about a 2 years ago when all the negative stuff, well documented elsewhere,kicked in all of a sudden. I am lucky as I was in a position to leave(though at a financial loss). Many of my former colleagues have no choice but to carry on. I feel desperately sorry for them and for the women of Britain who are being robbed of a fantastic service and soon it will be gone forever. Midwifery in this country is dying and being replaced by an American model which is outrageous. Everybody in the profession knows this and I do not understand why we cannot stop this treadmill to disaster.

Anon   23/09/2016 at 15:35

I've been a midwife for 16years in that time worked at 2 different hospitals and a stand alone midwife unit, if I hadn't of got to the MLU I would have left the profession 11 years ago, after 10 years of the same bullying tactics and feeling undervalued I left the NHS completely and now working for an alternative provider, it has resorted my faith In the profession for now but still waiting for retirement which I hope I can do at 55, the job will always be very taxing and tiring as we never know when women will birth and can't plan accordingly so long hours are a part of the job.

Anon   23/09/2016 at 15:49

I have been a midwife for 24years and presently working as a labour ward coordinator.I never thought that I would want to leave this beautiful profession,however, after the long shifts with no breaks, staff shortages, increased demands from management, I go home from most shifts feeling demoralised and worried about what I've left behind. This is so so so sad. If I won the lottery I would be gone without even a backward glance, however ,the likelihood of that is silch and I am in no position to take early retirement yet. What is happening to us ? I dread going into work most days, but put on a brave face for the public. Who is there for us ? RCM ? Please help us

Anon   23/09/2016 at 16:12

The striking thing here is that most people are afraid to put their names for fear of intimidation and bullying in their workplace. Nothing will change as long as we have unsupported management , ineffectual representation from RCM and the fact that those who are clinical do not stick together. In the NHS we cannot provide an individually tailored experience for every mother . It is not affordable or practical. I've have been a nurse and midwife for over 30 years and it is only because of goodwill that the service lees going. We are working in dangerous times . Oh and by the way can we please stop saying birthing or birthed. It Should be 'to GIVE birth'.

Anon   23/09/2016 at 17:37

Our unit is so busy that the Birth Centre is either a dumping ground for whatever postnatal women can go there or the midwives are pulled to other areas. They act as receptionist, cleaner, security guard - oh yes, and look after labouring women. The public are so demanding - and yet have to take no responsibility for themselves. We spend hours chasing people who don't come for appointments or blood tests - and we get the blame if they don't access care. Why am I doing this job?

Anon   23/09/2016 at 18:17

I've been a midwife for just one year I work in an inner city hospital and I am seeing very experienced fantastic midwives leave in droves. Yes us new midwives are qualified but we need the experienced staff to guide us as many woman as previously mentioned do not take responsibility for their own health but expect us to pick up the pieces when it doesn't go their way. I feel exhausted already not sure I'll make it to 10 years in a job I thought I'd love. We are constantly over capacity and the equipment is as worn out as the staff, like many others management don't seem to care. I'm looking at moving my family out of the U.K. so I can actually do the job I thought I would and care for women and their families.

Burnt-Out   23/09/2016 at 18:33

As above. Worked a 12 hour day and still called out twice overnight. Took 4 days to recover. Cannot refuse without facing investigation/bullying tactics by hospital staff and management. Fear culture pervades midwifery, everyone's back is against the wall. What hope is there for intelligent, creative approaches to care? Current climate underpins militaristic approach where senior management are selected on basis of being 'yes' people whose idea of safety and quality of care is reduced to a tick-box one-dimensional thinking. Sad.

Anon   23/09/2016 at 18:36

I have just resigned as a very experienced midwife I have worked for the NHS for 35 years . The stress levels are horrendous and the expectations of the midwifes is completely unrealistic . The managers don't seem to see or dare I say it care as long as they make there targets and we making a unworkable situation work . What I mean by that is going without breaks ,leaving work late , even after a 12.5 hr shift , working excess hours . I feel so sorry for the young midwifes who have just started in there career not sure what's ahead for them and the clients .

Annie   23/09/2016 at 18:42

Working in the NHS from 1978 34 years as a midwife both community and hospital Forced to work 13 hour long day shifts On call to cover escalation after working all day. ....and before a day off No meetings or communication between colleagues Equipment fit for 3rd world country Lack of staff facilities Impossible computer systems Lack of clerical support Working alone in high risk areas The list is endless Goodbye midwifery

Sarah   23/09/2016 at 19:08

I have been qualified for 22 years and have spent the last 13 years in labour ward. For 7 years I was a labour ward sister. After 4 episodes of sickness due to anxiety and depression caused by work related stress I made the hard decision to leave labour ward and become a community midwife. It still has its stresses but I feel so much better. We must sit up and listen to midwives who are suffering unbearable levels of stress.

Jackie   23/09/2016 at 19:25

I too worked within the NHS for a number of years and retrained as a midwife in my 40's, a life long ambition. I took early retirement after 12 years as a midwife last year on medical grounds, due to work based stress and I was burnt out. The issue is the same nationally at probably all maternity units and these managing on good will with nothing being given in return other than critiscm. It's all about fire fighting and knee jerk reactions with no real solutions. The NHS has always been really bad at caring for its own staff and it's about time this role was taken seriously especially as they have this responsibility under the Health and Safety Act! I don't think anyone can adequately verbalise how bad it is day after day working in these environments, it can make you very ill and impact on all other areas of your life. Staff constraints obviously impact on all areas of care, resulting in reduced time spent with women during antenatal appointments and having long waiting times, discussing options of care, labour and delivery as you usually get pulled out of the room to assess/ admit someone else. Running from one emergency to another. More on calls as community midwives and being called in to cover staff shortages rather than home births. Long shifts with no breaks or inadequate breaks, late off duty, being pulled from one area of work to cover staff shortages elsewhere, catching up with your record keeping and lack of support; the cattle market scenario and unable to give the care you're desperate to give. Other frustrations include lack of basic equipment as you spend half your time looking for stuff e.g thermometers. Sadly bullying is rife and speaking out is likely to result in intimidation of some sort. As for getting time back, well, you've got more chance of flying to the moon! I appreciate that managers are probably getting pressure from above, but no one appears to care anymore and it's all about bodies being available, numbers and ticking boxes and only care if you turn up for work. There's never any appreciation for what you do and often just empty words, rarely does a manager role up their sleeves and help with the work load, even if it's just covering breaks so collegues can get a break, they're usually mysteriously at 'meetings'. Working as a midwife really is amazing, but nothing is worth getting ill for, however special it is.

Anon   23/09/2016 at 19:48

I've just left midwifery & the NHS to go to work in a private hospital as a nurse. I went into the profession as a nurse wanting to explore such a beautiful profession & help & be a part of something special. The first few years were wonderful, then slowly hospitals were closing or becoming birthing centres, women were becoming more demanding & expecting more & staff levels were reducing. On a shift lucky to get a break often being pulled from one task to another without fully & properly completing anything. Usually finishing late & then spending a sleepless night worrying about what you've missed or haven't done correctly. Fearful of incident forms & reports or complaints against you when you're literally doing your best. Little to no support or understanding from managers, who simply tell line staff to carry on, work harder & prioritise better. Telling senior midwives to prioritise better was just the final straw for me & after 20yrs in the NHS, 10 of which were spent as a midwife. I had to walk away before it crumbled my soul & passion for care.

Anon   23/09/2016 at 20:02

After 14 years I can take no more and have left the job I always loved. I felt stressed, paranoid, unsupported and constantly exhausted. I still work on the bank but sadly leaving midwifery was a hard but necessary decision. I can see my physical and mental health improving daily. Something massive needs to change. This situation is only going to get rapidly worse.

Carol   23/09/2016 at 20:52

I have been a midwife for 26 years, and I am totally burnt out! I find it difficult to go to work now and am wishing my life away til retirement. I work for a trust that does not give a toss about its staff, and seeks to blame us for everything that goes wrong-or more often-when a box isn't ticked which affects their payment. Since qualifying, I have done teaching courses, a degree, supervision, Mres and various qualifications-and where has it got me? Nowhere! Stuck on band 6 with no pay rise for years, and the trust taking payments off us to reduce their wage bill. I HATE IT! If I could do anything else, I would be gone! I recently was diagnosed with a spine problem which means I won't be able to do this job as I age. Another worry!

Anon   23/09/2016 at 21:37

Have been a midwife for nearly 30 years and am off work with work related stress and exhaustion. The unit I work in has been run into the ground with poor leadership and Management. We have bullying consultants who make our lives a misery, bullying band 8s and clinical service manager who doesn't care about anything other than the budget. We get no breaks, no support, no feedback unless it's a bollocking, spoken to like we are children by some managers. Autonomous professionals is what our job used to be. Now we push paper to avoid litigation with no time to care. No one cares for the carers. Women demand the impossible and manages are too scared of complaints to stand up against these unrealistic expectations by supporting their staff. I want out. All of my years of experience list to the NHS despite easily being able to work at least another 10 years. Why stay and be so tired, exhausted, stressed and ill- all because we care. But no one cares about us.... Bye bye NHS and sadly a job I used to love but now detest.

Anon   24/09/2016 at 06:07

Retired due to stress of job after 30 years.No support from management.More and more pressure less trained midwives,HCA doing our job .So glad to out but feel so sad for young keen midwives who will be disillusioned very soon.

Anon   24/09/2016 at 07:47

Left the profession for almost a year and didn't miss it one bit. I've had to return because I can't afford to do anything else. Qualified for six years and work in other units it's still the same stress and getting worse. Units are consistently busy, staffing is a problem. Management are inaccessible and unsupportive and their is a massive obsession with paperwork, computer software and litigation that makes us spend too much time writing and typing instead of looking at and talking to our women.

Anon   24/09/2016 at 10:05

Words cannot explain how sad it is to read all the messages. I absolutely love my job, but after 16 years in the NHS, I left. I was fed up, bullied, underpaid, pissed off with retirement age rising and rising. Work environment wa sshort staffed, dangerous, working 15 hours straight with no break at 35 weeks pregnant, mangers that have no idea how to manage, low staff morale, fear of litigation - the list goes on and on. So now I'm living and working as a midwife in New Zealand and it is amazing. Like the NHS of 20 years ago, but better. It's the little things like free tea and coffee for staff, no more fights over trying to get a slice of bread for a hungry patient from a different ward, Soup made for staff every day, magazines bought by the band 7s for the staff room, the manager being present at handover and wishing everyone a nice day before heading into a room. Being guaranteed that when looking after someone in labour, it is 1-to-1 and you won't be looking after anyone else. I'm starting to love my career again, and I feel so much better, both when at work and when at home. Come out to NZ everyone, and get your love for midwifery back!

Heidi   24/09/2016 at 12:48

Yep have to say moved to nz ten years ago and it's the first time I've loved my job !!!! Yes I'm self emoyed. Choose my caseload ... Never work Xmas ... And I ffwl way more valued !!!

Anon   24/09/2016 at 13:19

Midwifery is reaching breaking point and while it is all very well to offer support in how to handle the pressure, this insinuates that the pressure is reasonable and the individual midwives not resilient enough. The reality is the pressure is unreasonable and the individuals are already extraordinarily strong to have managed so far. I left after only 3 Years, the stress was too great and the impact on my family and my mental health too great. All women deserve more, the women having the babies and those supporting them.

Anon   24/09/2016 at 18:29

I have worked as a midwife for 10 years and many years nursing prior to this but I am exhausted, demoralised and face huge stresses every single day...there really is no break from the awful, perpetual stress. I worked at one hospital where the bullying was endemic, it was known that certain people were bullies but were told that is the way they are!!! I am sick of tick box exercises, what does it prove? Nothing! It certainly doesn't ensure better care and anyone can tick a box but doesn't mean it has actually been done. Thank god I am nearing retirement age, if I could go now I would be gone in the blink of an eye. I truly feel for the newly qualified, younger midwives,if I had 30 years in front of me I would search other employment ! Nothing will change it will only get worse. Management do not care, poor pay, no breaks , only spoken to when an error is perceived etc....

NJ   24/09/2016 at 19:25

I have retired earlier than I would have liked. 40 years in NHS and 25 OnCall on the Community and the last couple of years became unbearable. The micro management combined with a blame culture were the final straw. What other profession thinks its normal for a team to report feeling nauseous and dreading the day. Why is it deemed not worthy of comment when colleagues report sitting in the car crying ? I chose to leave. Most of my team over 55 left earlier than planned. It is so sad. I feel for those newly qualified midwives with the loss of experienced colleagues. I was so lucky to be on a team who had a gold standard before the tarnished bronze was thought by management to be good enough.

Colleen   24/09/2016 at 22:00

I worked as a midwife for 34 years before retrkng last year. Whilst i still loved my job and the caring extremely hard working colleagues, last year finished me off. I had enough of working on an unsafe environment and really feared for patient safety and EVERYONES registration when working under staffed with an ever increasing birth rate. I still miss the heart of the job and my friends and colleagues, but am enjoying my retirement having worked until I was 61yrs old. Good luck to all midwives remaining in practice !!!!

Anon   25/09/2016 at 02:03

Utter despair at how it has become and echoing the sentiments I have read above! COME ON RCM ...,.lets get this sorted and our voices heard at the highest level.

Anon   25/09/2016 at 04:31

I worked for 23 years as a midwife. It was always my life's work. Since the events of Morecambe Bay Midwives have been systematically scapegoated which results in a blame culture.

Scott   25/09/2016 at 09:27

Why is a report about Midwifery depicted with a Cesarean Section? While I appreciate the sentiment of this article this shows a lack of understanding and respect for the profession.

Jayne   25/09/2016 at 12:00

For such 'strong' characters we midwives are bad at getting together and sticking up for ourselves. I believe the way forward is more one to one care, caseloading, or very small teams. Better outcomes, better job satisfaction, better for women, better for midwives. Why are we not seriously pushing for this? How can we give good care when we might only see an individual one or twice in her pregnancy or only meet her when she's in labour? No wonder we are stressed, we can't follow anything through so we don't work in a way that we can give good care. Then we are stupid enough to give up hours and hours and hours of OUR time papering cracks left by staffing which is far beyond inadequate. We seriously need to stand up for our women, our profession and ourselves. We are professionals in our own right, services should be organised to allow us to be just that and get in with our jobs instead of being either micromanaged or at the feet of obstetricians. Midwives are working under so much stress they've forgotten who they are, what they should be doing and what they were taught and should believe in. Please stop blindly following I'll thought out 'guidance' if you want change, challenge things. BE a midwife and let's stop being treated like doormats.

DM   25/09/2016 at 14:12

I have recently retired from midwifery early (55) after 33yrs as a labour ward sister and community midwife.I totally agree with all the above comments. Prisoners would seem to have better conditions and human rights than midwives these days.

Anon   25/09/2016 at 22:57

The reason we do nothing is that we experience bullying and harassment every day of our working lives. I trained to give good care to families for a life changing event in their lives, not to fight with computer systems or to fight for our or women's rights at work. I have given 25 years to the NHS. The government and managers need to be shamed for what they have done. It is appallingly headed by both. If mistakes happen at the point of life it is costly to the NHS yet the best wages are those in management who could not deliver a baby or run a busy delivery suite even if they tried. Working 14 hour shifts with no break is common - how possible is it to give good care for this length of time - we aren't cared about.

RUTH VIRR   26/09/2016 at 20:20

I am a retired midwife...I left midwifery at the earliest possible opportunity. More and more is being asked of midwives, with very little in the way of an increase in resources. I loved midwifery, but my mental health comes first!!!

Vicky Bayley   27/09/2016 at 09:26

I left four years ago after 11yrs. Community staff were working 24hr on calls, covering their caseload AND staffing a birth centre (45 minute ambulance ride away from main unit - we covered the transfers too). We were at huge risk, providing care in a hurried and impersonal way, unable to properly super our women and the students we were trying hard to train well and expected just to swallow it. I LOVED my job. LOVED it. That wasn't enough though, my physical and mental health suffered hugely and leaving was for self-preservation. People ask if I miss it. I miss it HUGELY, but I don't miss what it, and I, had become. Big love and respect to all those still looking after our new families - look after yourselves xx

Anon   18/10/2016 at 22:55

I have read all the comments and they totally match what I am experiencing at work. I have been a nurse and now a midwife for 14 years. It is getting unbearable. I work on a postnatal ward where two Large units have been merged last month and squashed onto one unit. Staffing has decreased and workload increased. No breaks, demanding women and relatives who think they are the only one we care for, regularly 10-11 women to care for each shift on a busy ward (not mentioning their babies). I found myself crying this morning before work. I cried when I got to work at the sheer tiredness of learning g staff was short again and the ward full of complex women and their needs. Knowing I would get no break and nor would I get time back. I cried myself all the way home. I shouted at my beautiful children because they wanted hugs and I felt numb and not wanting to be touched but left alone for some peace. I then self harmed with sheer frustration and upset and inability to cope again. I don't sleep the night before and after a shift. I now binge eat when I get home through hunger and stress. I have it all to do again tomorrow. I cannot go on sick leave to sort my health out as my employer uses the Bradford score for sickness and you are harassed and made to feel you will loose your job. I cannot leave. I am the main wage earner. I work my breaks and then my employer accumulates the break times and slit in an extra 12.5 hour shift to cover the break time. So I work a whole day shift for free for time I didn't take. This is an extra day of stress and inadequacy. This job will ruin my health and my family.

Anon   29/10/2016 at 16:24

When I started, I had such hope, such compassion and so much loving energy to give everyone I looked after. I still have loving energy, I still give it to the women, the babies, the partners I look after. But I no longer have the capacity to give it to myself. Midwifes are cruel to one another, even the good ones. The HCAs, and the newly qualified midwives are the kindest, as are students. They are still TRYING so hard When staff are at their absolute wit's end with exhaustion, then they lash out on one another rather because there is no one else to offload to. You cannot explain to a women that you have just wheeled out of theatre with her new twins, that actually you have been on your feet for 8 hours now and your bloodsugar is in your feet. You have to care for those 3 lives. You might well care for her and the twins, and her husband for another 5-6 hours before someone relieves you for the end of your shift. the idea that YOU are to blame if a 13 hour day tires you out, that that is YOUR, personal weakness, that you need to TRY harder. I know now that this is not how I want my life to be. This is NOT living. I still find birth beautiful, amazing, awe inspiring. But I simply cannot go on. The reason: THERE ARE NOT ENOUGH MIDWIVES FOR THE NUMBER OF WOMEN WE ARE LOOKING AFTER. THERE ARE NOT ENOUGH MIDWIVES TO TRAIN STUDENT MIDWIVES. THERE ARE NOT ENOUGH MIDWIVES TO GO ROUND. the Midwives you meet are trying their absolute best to not let you see the true state the NHS is in, only those working clinically in the NHS are truly aware. And it is a sad fact that we would loose our jobs if we expressed these feelings to those who manage and supervise us. Amongst management there is a culture of; if you can't hack it you are weak and not cut out for the job. But I am not WEAK. I am STRONG. Midwives need to speak out. We must do this now, collectively, to protect British women. To change the culture. Before its too late.

Anon   08/11/2016 at 22:54

Help Our Midwives Please help to make a change, follow the link and sign the petition. https://www.change.org/p/rt-hon-jeremy-hunt-mp-help-our-midwives-join-the-petition-to-increase-staffing-levels?recruiter=615851291&utm_source=share_petition&utm_medium=copylink

Hermit Singh   25/12/2016 at 20:14

My sister is a midwife & educator in Toronto, where she works like there is no tomorrow. She even manages a small (word of mouth) private practice AND micro-manages 2 ailing elderly parents in her off-duty. How she does it I have no idea,myself having left general practice 12 months ago to "perpetually tour the world". Amazingly, she still wants to go and work in Sierra Leone.. Please open your eyes, there is a world of need waiting. Forget the callous bar steward managers destroying the nhs. Move on and upwards !!

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Anonymous   23/03/2017 at 22:47

I left the NHS nearly 2 years ago after being an NHS midwife for 15 years. I was literally broken by the time I handed in my notice. 6 weeks before I finally left, I asked for help twice in 2 weeks because there was literally no one else working in my team that day and I had a massive clinic and visits to organise; on both occasions I was told there was no help and I would just have to 'put women off' on both of these occasions I felt as if I was so close to having a nervous breakdown that I decided to leave the profession I loved dearly. Since then, I've spoken to colleagues and it seems to be just getting worse day by day. The idea of being 'with woman' will be consigned to history books the way things are going, so so sad

Jan   24/03/2017 at 08:51

So sad that a page that is here to support the cause for midwives has a photograph of a caesarean!

Anon   24/03/2017 at 14:48

I've only been qualified 10 years but I can remember when Midwives happily retired because they felt ready, and left on a high after a long and satisfying career, not because they just couldn't carry on any longer and were broken by a profession that just doesn't care for the carers despite us giving our all day in day out, night in night out in what are usually awful circumstances. Can't agree more with all the comments people are leaving, it seems it's the same everywhere not just the Trust I work for. Very sad.

Anon   24/03/2017 at 18:22

I noticed not many have put their name to the comment. Isthis because of repercussions. I have worked for 39 years as a midwife and never before has there been so much pressure. I now work part time but couldnt tolerate the pressure of full time. Stress every minute no time to think things through or discuss the way forward with colleagues. No continuity of carer. It is a worse service that we have ever given and the midwives are at breaking point. I am so glad I am at the end of what was once a fabulous career. I feel so sad for the new midwives coming into the service and fear for the future.

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The Refugee Doctor Initiative

The Refugee Doctor Initiative

Terry John, co-chair of the BMA & BDA Refugee Doctors and Dentists Liaison Group and chair of the union’s international committee, talks about a brilliant initiative that is proving mutual more > more last word articles >

interviews

Cutting through the fake news

22/11/2017Cutting through the fake news

In an era of so-called ‘fake news’ growing alongside a renewed ... more >

the scalpel's daily blog

Ten lessons to support new care models locally

29/11/2017Ten lessons to support new care models locally

Anna Starling, policy fellow at the Health Foundation, offers the top 10 lessons for local leaders seeking to make systematic improvements across services, all based on first-... more >
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