Compulsory insurance 'could end independent midwifery'.

Independent midwives fear that their livelihoods are under threat following a Department of Health ruling that professional indemnity insurance is to be made compulsory for all healthcare professional(see 'Comment', page 4).

Self-employed midwives have been told that the 1999 Health Act legislation is to be amended and will affect them within 12 to 18 months.

Chief Nursing Officer Christine Beasley has written to some self-employed midwives explaining that the government has been concerned about the impact of a small number of cases where uninsured professionals have beent the subject of a claim for negligence and the plaintiff was left with no means of redress.

Trust-employed midwives are covered by the NHS Litigation Authority via the Clinical Negligence Scheme for Trusts. The problem for independent midwives is that they are unable to source any indemnity insurance. The last insurance company withdrew from the market several years ago because it was not economic for them, even though the premiums were astronomical - often in excess of what the midwife earned in a year.

For this reason, the Royal College of Midwives stopped offering indemnity insurance 12 years ago. A spokeswoman said: "Our insurance company wanted to raise the premiums, which would have been impossible for us to cover as a relatively small union, but more importantly could give us no confidence that they could control the increase in subsequent years. Perinatal care is one of the highest risks in the NHS, and currently the only cover given is to midwives directly employed by a Trust."

When the new legislation is enacted, it will become illegal for independent midwives to practise without insurance. Brenda Van der Kooy, political secretary of the Independent Midwives Association (IMA), described the ruling as "hugely worrying". "This could mean the end of independent midwifery," she said. "Practising without insurance is not ideal and we really want a solution, but there is simply none commercially available. "

This ruling also begs the question about the public's right to make an informed choice. The government is saying: 'We are telling you for your own protection that your midwife needs professional indemnity insurance'. In fact, the people who use our services at the moment are fully aware that we do not have insurance and the implications of that. They weigh up the risks and benefits of their options, then make an informed choice about whether they will book us."

Mrs Van der Kooy said the IMA intended to challenge the ruling if a satisfactory solution could not be found. The Association obtained a comprehensive legal opinion when the issue first raised its head several years ago.

She said one solution would be for ministers to endorse the new NHS Community Midwifery Model designed by the IMA. This is an innovative model of care that would enable a selfemployed midwife to enter into a contract with the NHS and be paid on a set fee-per-case basis. The model builds in full access to NHS facilities and vicarious liability insurance cover, and gives real choice to women and all midwives. The IMA has applied to the Social Enterprise Unit for funds to develop the contract.

Beverley Beech, chair of the Association for improvements in the Maternity Services, which is supportive of the IMAs campaign, said: "What worries me is that if we remove the potential for midwives to practise independently, which is what this ruling will do, there will be more mothers choosing to give birth unattended. We know of a constant trickle of women who say they will not call a midwife because they have been traumatised by a hospital birth."

For further information about the NHS Community Midwifery Model, visit www.independent midwives.org.uk