The NMC has 'long-standing problems at every level', according to the final report of the Council for Healthcare Regulatory Excellence (CHRE), which published the findings of its strategic review of the nursing regulator earlier this month.
This stark summary follows a turbulent eight months for the beleaguered organisation, which has seen the resignation of both its chair Professor Tony Hazell, and chief executive Professor Dickon Weir-Hughes. The CHRE review, launched in January, concludes the NMC is confused about its regulatory purpose, suffers weak management and poor planning, and uses out-dated, ineffective information technology. It highlights failures in 'leadership, strategy, decision making...and culture'.
Financial failings
In addition, the organisation 'lacks proactivity in pursuing cost savings', and has struggled to manage its finances, the review states. It has shown poor control of project spend, and failed to instill financial leadership at the top of the organisation. Last year alone, the NMC spent more than £4.5 million on temporary staff, consultants and contractors. This at a time when it is consulting on a proposed 58 per cent hike in the cost of registration.
Some CHRE recommendations advocate simple common sense. 'We recommend that there is a member with financial expertise on Council', the report concludes. 'The NMC should introduce a process by which Council members can raise concerns and be sure they are being heard.'
'The NMC must finally leave its troubled past behind and apply itself to protecting the public and rebuilding confidence in regulation,' says Harry Cayton, chief executive at CHRE.'New leaders must be appointed who are competent, credible and capable of addressing the NMC's very serious organisational problems and transforming the NMC into the regulator that the public, nurses and midwives deserve.'
But many question how the regulator, responsible for protecting the public by ensuring nurses and midwives provide high standards of care, came to be in such disarray. The CHRE acknowledges the failings are not new.
Indeed, a 2008 report by the CHRE identified 'significant weaknesses in the NMC's governance and culture, in the conduct of its council, its ability to protect the interest of the public through the operation of fitness to practise processes and its ability to retain the confidence of key stakeholders'.
Speaking then, Mr Cayton said: 'We have serious concerns about the inadequate operation of the NMC's fitness to practise processes, governance framework and lack of strategic leadership.' So why have lessons not been learned?
Back to basics
The current report begins with a critique of the NMC's core regulatory function. It states previous leadership wrongly saw the NMC's role as supporting the development of nurses and midwives beyond fitness to practice. It says frequent calls for the regulator to take a lead on specific professional matters or specialist guidance, had 'blurred the boundaries between regulation and professional development'.
It concludes: 'Fitness to practise is a baseline, a set of fundamental standards that must be met by all registered professionals in order to practice safely and effectively. The same basic rules of conduct, ethics and competence apply to all nurses and midwives.'
But Jenny Aston, chair of the RCN's Advanced Nurse Practitioner (ANP) Forum, has long campaigned for the register to take account of the different responsibilities of nurses practising at advanced level.
'I fail to see how improvements in quality of care will be achieved with such a narrow focus,' she says. 'It is a bit like the police only concentrating on arresting people and taking no part in setting any standards to guide nurses to help prevent the crime happening in the first place.
'If the NMC spent a good proportion of its time setting enforceable standards for nurses and ANPs, that would be more likely to protect the public. Licensing and revalidation would be much more useful, and nurses would really have to demonstrate their on-going competence.'
The CHRE insists it is the role of the Royal Colleges, both of nursing and midwifery, to lead, support, develop and encourage professional practice, and that the NMC should 're-focus its thinking and its work solely on regulation'.
However, with the NMC consulting on plans to increase its annual registration fee from £76 to £120, critics say this could mean nurses paying more for fewer services.
'Nurses will see the fee increase as being asked to pay more for a regulator that will be doing less than it has been up until now,' says RCN director of policy Howard Catton.
'It is not easy to draw a line between what is a core NMC function and what is peripheral. Identifying what constitutes advanced practice and annotating the register to identify nurses at that level could be considered a core function of a regulator that is responding to changes in the profession.'
The CHRE's findings paint a confused picture of an organisation that showed 'a collective lack of competence' when costing its planned activity. At the heart of the problems was a failure by the council to appoint a financially qualified member into an influential management-level position.
'Monitoring of expected efficiency savings has also been weak,' it continues. 'The March Council papers ... state that £5.6 million of efficiency savings are to be factored into the budget, but there is no detail as to what savings relate to and how they will be realised.'
In fact, the CHRE found many of the papers produced by the NMC lack clear information on financial consequences, making it difficult for the management team to make effective decisions.
'There is little financial awareness and understanding across the NMC,' the report concludes, and the organisation has failed to recognise potential cost savings on a timely basis.
'It is perverse to demand registrants should bail out organisations who are in trouble as a result of their own financial mismanagement,' says Gail Adams, head of nursing at health union Unison.
'The NMC has clearly been mismanaged in finance, governance and leadership in the past, but registrants do not have a say in the management of the organisation, so it is wrong that they should be expected to pay for its mistakes.'
Mr Catton is seeking assurances that the NMC's assessment of its financial needs is accurate. 'If the NMC wants to introduce a 58 per cent fee increase, we must be completely sure the rise is absolutely necessary and required. If there have been poor financial processes in the past, we need assurance that the amount of money they say they need is actually required.'
He questions the 'automatic assumption' that nurses should pick up the cost of NMC improvements through increased contributions.
'The government could pick up some of the cost, or offer support in some form, or the NMC could be given some sort of loan,' he suggests.
As part of its report, the CHRE gathered feedback from 24 'external stakeholders', including the RCN, the four UK chief nursing officers and the Care Quality Commission.
They expressed concern that the NMC was unaware of how its poor performance was damaging public perception of the professions it regulates. They believed the council was 'confused over the role and function of the section of the register for specialist community public health nurses (SCPHNs)', which includes health visitors and school nurses.
'Many questioned the value this added to protecting the public and feel the NMC should give serious consideration to its future,' the CHRE says.
Third part of the register
Independent health visiting adviser Cheryll Adams says the report 'fails to understand the specific issues' relating to the health visitor and school nursing professions; she is concerned the CHRE report appears to put the future of the third part of the register in doubt.
'Health visiting, in particular, is very different to nursing and midwifery and tends only to be really understood by those who have undertaken training - that is why it had its own separate statutory regulation for a century; previous administrations understood this,' she says.
'The CHRE itself seems to have consistently misrepresented the public protection issues related to health visiting. The suggestion of closing down the third part of the register is another reflection of this.'
Sharon White, professional officer at the School and Public Health Nurses Association, adds: 'The ethos behind the third part of the register was to recognise and emphasise the public health role of nurses. This had been recognised in a small way for health visitors, but not for others such as school nurses. Sadly, the report highlights very poor governance of this by the NMC that has resulted in it being devalued by many.'
Meanwhile, a recurring criticism in the report relates to the NMC's poor communication with the public.
'Members of the public ... described an organisation that is reluctant to listen, does not follow its own published policies or adhere to its own set timescales, that frequently misplaces documentation, that fails to respond to communications in a timely manner or present accurate responses and information that is written in plain English,' the CHRE says.
As for the NMC's staff, the report makes clear they have 'kept going' despite enduring 'years criticism and frustration'. This, it says, is to their credit. However, employees have cultivated a culture of 'resigned resilience', meaning they have come to accept and tolerate poor standards because they feel powerless to change them.
There was a 31 per cent turnover of staff during 2011/12, meaning the HR department 'focused much of its work on recruitment rather than on other strategic human resource activities'.The NMC must therefore focus on 'reducing hierarchy, encouraging openness, listening to staff, enabling management to take responsibility and make decisions by consistently valuing quality and customer service'.
Catalyst for change
NMC acting chief executive Jackie Smith, said the report made for 'difficult reading', and would act as 'a catalyst for change'.
'We recognise the failings the CHRE sets out in their reports and we are sorry,' she said. 'The CHRE draws attention to the hard work and commitment of the NMC's staff. I would like to add my personal thanks to all those who have responded so positively to the strategic review of the NMC and are working hard to ensure the protection of the public.'