The price of nursing

In one of the most divisive decisions this year, nurses and midwives will now have to pay £120 a year to register with the NMC. On 1 October the NMC decided to raise the annual fee from £100 to £120. This was despite an overwhelming reaction against the decision from both registrants and other nursing unions and organisations that a rise in fee would hit nurses hard. Of the 680,000 nurses registered with the NMC only 4532 responded to the 12-week consultation on whether they supported the rise or not. Of those, 96 per cent disagreed with the increase, two per cent agreed and the final two per cent were unsure. When there was such obvious negativity towards an increase in fee, why did the NMC decide to go ahead and increase it anyway? Legislative restrictions When the NMC began the consultation in May 2014, it attached a business case to the consultation form. This outlined that when the fee went up to £100 back in 2012, they had actually intended an increase to £120. This was based on figures which showed that in order to be able to keep up with the increasing number of fitness to practice referrals more money was needed. However, the government stepped in and provided the NMC with a one-off grant of £20m, which came with several conditions, but meant that the fee rose to £100 only. The conditions set up by the government for receiving this grant included clearing the historic caseload by autumn 2014, which it has managed to achieve. The NMC also had to meet a key performance indicator (KPI) relating to the percentage of cases that have progressed through the adjudication stage to the first day of a hearing or meeting within six months by 31 December 2014. It is also on target to meet this. The regulator also has to meet its bank reserves target by 2016. However, this government grant has now been spent and as the NMC is an independent body funded solely by the registration fees of the nurses and midwives, the DH will not to intervene this time. A DH spokesperson said: 'The NMC is an independent body and decisions on its fees are a matter for its Council. We know they will not have taken this decision lightly, and will have considered the impact on hardworking nurses and midwives.' Jackie Smith, the chief executive of the NMC, says that the number of fitness to practice cases are continuing to increase, which was why the Council decided to implement the fee rise. 'In the last financial year we held over 2300 final fitness to practice hearings. The average cost of each hearing is £13,000 and we hold around 30 a day. If we had the same framework that the General Medical Council (GMC) has in place then we wouldn't need to hold as many hearings. In a financial year, the GMC receives 10,000 complaints on average and holds just over 200 hearings. We get half of those [complaints] and we held over 2000 hearings.' The difference in the number of hearings held by the GMC and the NMC hinges on the different legislation governing the organisations' operation. If the NMC had the same framework that the GMC has in place, Ms Smith says, there would be no need for it to hold so many hearings a year. 'It is this kind of change that we desperately need and why we have been pushing so hard for the amendment of the Law Commission Bill. We have been very clear that there is a direct link between the cost of fitness to practice [cases] and the cost of registration fee, and unless we have those changes to the legislation to our fitness to practice, there is a risk that the fee will continue to go up.' Patchy communication Should this happen the NMC are required to consult with their members over any further fee rise. However, many Independent Nurse readers have expressed the communication of the fees consultation was 'inadequate', with some even saying that they didn't know it was happening. Louise Silverton, the RCM's director for midwifery, said that the NMC had conducted so many consultations recently that this one might have been lost. 'There have been two big ones on revalidation, the first one had around 10,000 respondents. The second one had fewer but then it was focusing down on more specific issues,' she said. A spokesperson from the NMC said that the fees consultation was widely advertised on the website, on Twitter and in the media. Figures obtained from the NMC show that they sent out newsletters to 106,416 nurses and midwives on 1, 20 and 27 June, to 22,023 students and educators on 23 May and 8 August, 14,257 employers and managers on 13 June, 5 July and 15 August, and to 12,553 patients and members of the public on 8 June. 'Our members expressed very strongly that they didn't feel it was a consultation,' says Jane Beach, professional officer for Unite. 'A consultation means that you are meant to take into account what people say and make changes. [The NMC] received an overwhelmingly negative response and yet they still went ahead. Our members have said that that wasn't a consultation which is why they didn't respond directly to the NMC, they responded to us.' Ms Smith cites the vast number of registrants as one of the reasons why some may have missed it. 'I have spoken about it at various nursing events across the year and have been in contact with over 3000 nurses in this way. Employers have a responsibility and so do individuals to keep up with what's going on. I absolutely understand the significance of it, but there isn't any way that we can reach out to all 680,000 individuals without adding a significant cost to our operating model.' Out of touch The small percentage of respondents to the consultation combined with the overwhelmingly negative response has left the NMC open to allegations of being 'out of touch with working nurses'. In the previous issue of Independent Nurse (6 October 2014, p14), it was revealed that more and more working nurses are relying on food banks and some are one pay cheque away from the breadline. Unions predict that the increase in the fee rise, though it is fairly small, will hit those nurses who are already struggling. Ms Beach says, 'Nurses haven't had pay rises and we are hearing that some organisations are giving food bank vouchers to our members because they are finding it difficult to manage. This is just another increase in what it costs to work.' 'It is out of touch with midwives [and nurses], and this point was made very clearly, that their pay hasn't kept up with inflation,' adds Ms Silverton. 'My concern is for those who work minimum hours, particularly those midwives with caring responsibilities. We've worked out that [with the fee increase] midwives will be paying £9.50 a 12-hour shift [to pay off their registration fee], which is ridiculous.' The NMC has said that it will introduce staged payments from December 2016 to ease the pressures of having to pay £120 in one go, but even this arrangement could raise alarm bells for some working nurses and midwives. 'If NHS workers are short of money, there could be a fear that the monthly direct debit will fail because they don't have enough money to pay for the monthly or quarterly payments,' says Ms Silverton. 'This could see them fall foul as they will then be taken off the register and will be disciplined.' Ms Smith said that the council members were very aware of the financial difficulties being faced by working nurses. 'Every single council member recognised that it is an incredibly difficult climate for every nurse and midwife at the moment, they recognise the pressure they are under and the demands made of them and the fact that they are working with challenging pay constraints.' However, nurses are eligible, she says, to claim for tax relief on their registration fee. At the increased fee of £120 nurses will be able to claim back £24 in tax relief, according to the NMC, which would reduce the fee to £96. Seventy per cent of nurses are currently not doing this, the regulator says. Effect on workforce Nursing unions and organisations are concerned that financial difficulties faced by nurses may have a detrimental impact on the workforce. 'I was struck by the negative comments that we have received because a lot of our members are an older workforce. They feel really hard done by and now that the fee may go up every year some of them are saying that this is the last straw and they cant wait to finish. We are concerned by the impact of that,' says Ms Beach. Ms Silverton says that it isn't that simple. 'It's more the fact that many of our members feel undervalued as the work is getting increasingly harder. There has been an increase in birth rate of up to 30 per cent, and then the next problem is the fee increase and then coming up at the end of next year is revalidation. We think that those at the end of their career or who are working minimum hours will just give up.' The NMC says that it will monitor the workforce to note if there is a significant increase in the number of nurses and midwives leaving the profession. 'We would consider a five per cent decrease in the workforce a significant reduction,' says Ms Smith. 'However, it is difficult to say what kind of action we will take, should this happen.' Whether the number of nurses diminishes or not, the increase in fees has heightened the negative feelings that many nurses and midwives have towards the NMC. With rising numbers of nurses facing financial difficulty this is seen as just another added increase in the cost of work. However, unless the government dedicates time to changing the legislation to allow the NMC to reduce its fitness to practice burden there is a possibility that this fee rise may not be the last.

'I have thought about leaving the profession'
'I think that the NMC fee rise is just unfair. We've had a 58 per cent rise in fees in two years as well as the cost of living going up by six per cent in the same period and nurses have not had a pay increase.
I didn't even know that the consultation was going on. I do read nursing magazines but I don't have time to read them cover to cover as I'm run ragged at work. As I say, I would've thought that they would publish something that could be accessed by everyone.
I have definitely thought about leaving the profession, even though I have been a nurse for 17 years. But because nurses are caring and value the role they play, they keep going and putting up with it.'.

Anonymous practice nurse, Midlands