Every year, you (along with 600,000 other nurses and midwives) pay a hefty £120 to practise, a fee which has risen by 180% since 2007. But where exactly does your money go?
Around 80% of the Nursing and Midwifery Council’s (NMC) budget is spent on fitness to practise procedures1. The NMC does not shy away from the unsustainably high cost of this process and claims it is being hamstrung by outdated legislation which requires it to take more cases to a full hearing than it believes to be necessary.
‘We know, and accept that it currently takes too long and costs too much to conclude cases,’ says Jackie Smith, chief executive and registrar of the NMC.
The NMC, she says, want ‘changes which will allow us to develop a more proportionate approach to cases, with new powers to resolve some less contentious matters more simply and quickly, taking only the most serious cases to a full hearing.’
Nursing regulation may be expensive and outdated, but a flick through the NMC’s hearing outcomes is a sombre reminder of just why it is so important: failing to administer medicines; continuing to practise while on an interim suspension order; taking drugs on duty. In December 2016, a senior nurse was struck off and a junior nurse suspended for leaving a vulnerable dementia patient alone in a dark storeroom for six hours.
The NMC, along with other health regulators, has a duty to investigate allegations made against health professionals and penalise those who threaten the public’s safety.
But in the last decade scandals at NHS trusts in Mid Staffordshire, where a number of patients are thought to have died as a result of poor care; and Morecambe Bay, where the shortcomings of midwives led to the deaths of 12 babies and mothers, some have claimed that the current system of regulation has failed the public and desperately needs reform.
Creating a super regulator
Last month, The Times reported that the Department of Health is considering a major overhaul of health regulation in the UK2.
One possible plan would see nine current regulators merge to form one body registering more than one million health professionals. However, the second plan under consideration would see the General Medical Council (GMC) and the NMC unify to form a central body, with a separate ‘high-street health’ regulator overseeing pharmacists, dentists and opticians, and another regulator that would oversee osteopaths, physiotherapists and podiatrists (Figure 1).
It is thought that the Department of Health will publish and consult on the options later in 2017.
The proposed regulatory shake-up comes in response to the October 2016 report Regulation rethought3, published by the Professional Standards Authority (PSA), which scrutinised nine regulators in the UK and the decisions they have take on whether the professionals on their registers are fit to practise.
The PSA report’s main recommendations include a set of common standards that should apply to all professions; an inquisitorial approach to fitness to practise and shared investigation, prosecution and adjudication; co-operative working, using data and insight to prevent harm; and a review of quality assurance of undergraduate higher education – all delivered by a single body that holds a shared, public-facing register.
The public often find the regulatory system baffling and hard to navigate, particularly when they have a concern or complaint and want to report it in the right way,’ says the PSA. A merged register of health professionals, it says, would provide a ‘single portal’ through which members of the public could check licenses and make allegations. Establishing a single body would not only address public confusion over who to approach with complaints about poor practice, but avoid duplication of work – cutting the annual cost of regulation by 15-18% – and, through shared intelligence, better inform watchdogs of emerging scandals.
Professional rivalry
The NMC’s referral rate has increased by around 293% over the past decade4 (Figure 2), and after years of pressing for substantial changes to fitness to practise legislation, it has finally won the support of the Department of Health to review its functions. However, these changes fall far short of the significant reform that the health professions and, more importantly, the public, deserve, says Jackie Smith.
‘While the government has not yet published details of its plans for a future model of healthcare regulation,’ says Smith, ‘it is our ambition to work more closely and collaboratively with other regulators including the GMC with who we share common goals’.
The NMC is keen to ally, but it may prove difficult to achieve buy-in from other regulators, such as the GMC, which declined to comment on a possible merger until the government’s plans are published and open to consultation.
Dr Mark Porter, council chair of the British Medical Association told The Guardian that, given the diversity among the professions, ‘we believe that the public interest is best served by continued regulation of doctors through a separate medical regulator’.
Professor Ian Peate, editor in chief of the British Journal of Nursing, who has been critical of NMC performance in the past5, says, ‘the medical profession would resist this and there would, I think, be a great deal of professional rivalry.
‘I would be very surprised if the medical profession would accept being part of a super umbrella regulator.’
Pardeep Sandhu, executive director of professional services at the Medical Protection Society, the membership protection organisation for health professionals around the world, worries that an ‘amalgamation exercise’ could lead to ‘the specific expertise of each profession’s regulator being lost.
‘Any new regulator would need to be able to distinguish between the hugely differing roles within the many professions it would oversee.’
But a new regulator must also adapt to the shift to multi-disciplinary working. In current practice, ‘people in multi-disciplinary teams work to different standards and may be subject to different decisions by different regulators for the same or similar events for which they have individual or shared responsibility,’ says the PSA.
‘They may be subject to different sanctions which patients, employers and registrants find hard to reconcile.’
Under a joint body, improved communication, knowledge-sharing, and a common set of standards could result in health professionals who pose a risk to the public being removed more quickly and efficiently.
Until the Department of Health publishes its plans, we can’t be sure what exactly regulation will look like in the future, and whether a combined regulator can really serve all professions and the public. ‘A ‘super’ regulator may to be unwieldy,’ says Peate. ‘However, the Health and Care Professions Council, which registers and regulates 16 professions, seems to be doing a good job of regulating several occupations. A super-regulator could also do this, but any change would have to benefit the public.’
Finding the right time
Cynics may question the timing of the government’s proposed overhaul when many other problems – such as lack of staff and funding shortfalls – plague the health service. A reboot of the UK’s health watchdogs will be a serious undertaking and will affect over a million health professionals.
The NMC, despite receiving its highest ever annual performance review rating in December 2016 , has trailed behind its counterparts in recent years, and a shake-up could be just what it needs to get back on track.
‘The regulatory and healthcare environment is changing at an unprecedented rate,’ says Jackie Smith. There may never be a right time for this process of transformation, she concludes, but ‘it is important that the government establishes a shared vision for future regulation which will allow us to become the modern
and dynamic regulator we want to be’.
Abigail James is a medical journalist and editor
References
1. The Guardian. 2014. Bill needs push to sweep away ‘inflexible’ healthcare regulation framework. https://www.theguardian.com/healthcare-network/201...
2. The Times. 2017. One watchdog for doctors and nurses would cut red tape and save millions. http://www.thetimes.co.uk/article/one-watchdog-for...
3. Professional Standards Authority. 2016. Regulation rethought. http://www.professionalstandards.org.uk/docs/defau...
4. Nursing and Midwifery Council. 2016. Annual report and accounts 2015–2016 and strategic plan 2016–2017. https://www.nmc.org.uk/globalassets/sitedocuments/...
5. Ian Peate. 2015. The NMC may de doing better, but it’s still failing. http://www.magonlinelibrary.com/doi/10.12968/bjon....
6. Independent Nurse. NMC receives high praise in performance review. http://www.independentnurse.co.uk/news/nmc-receive...