The recently published Independent Culture Review1 of the Nursing and Midwifery Council sets out the regulator’s failings and recommendations to combat them. but what are the the issues and how do they impact on NMC’s core purpose?
What is the NMC?
The Nursing and Midwifery Council is the statutory, public body accountable to parliament for regulating over 800,000 professionals – nurses and midwives in the UK and nursing associates in England. Its performance is also overseen by:
● the Charity Commission and the Office of the Scottish Charity Regulator
● the Professional Standards Authority (PSA), which reports on its performance each year to Parliament.
Its core purpose is to protect the public. It does this by maintaining the register and investigating concerns about registrants.
What is the issue at the NMC?
The latest series of disclosures, made by a whistleblower in 2023, claimed that ‘a deep seated toxic culture was leading to skewed and failed investigations.’1
Rise Associates and Nazir Afzal were commissioned in January 2024 to review NMC’s culture over the last 5 years. They pursued a thorough methodology (Box 1) to uncover the many facets to this claim.
Of huge significance is that these claims are not new. A litany of similar reports has been undertaken over the last 16 years (Box 2). Despite this, the NMC has failed to learn and implement effective change. These issues have prevailed since the NMC’s early days. The first such report was published in 2008, just six years after it was formed from predecessor organisations.
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Key findings
The report found that the ‘toxic culture’ reaches far and wide into the organisation and is significantly impacting on its ability to function as it should and therefore to protect the public.
Examples include:
● a lack of transparency and dignity in the workplace, characterised by bad management and bullying, where bad behaviours are tolerated, and there is racism and discrimination towards people of colour and people with disabilities
● a lack of compassion. Staff are adversarial and disrespectful towards nurses and midwives.1
● ‘a low trust environment characterised by suspicion, fear, blame, resistance and silos’.1
● a backlog of close to 6000 Fitness to Practise cases. It takes far too long to reach decisions. Many registrants have been waiting four or five years for investigations to conclude, some nearly ten
● safeguarding decisions that put the public at risk.
Process
The way that the NMC has organised itself has built in the difficulties now being experienced. The culture is ‘excessively process-driven’.1
Aspects of this include:
● ‘an incredibly slow screening process’ unable to sufficiently differentiate serious from minor issues
● ‘too few clinical voices in the process’ leading to a lack of understanding by staff of what they are investigating
● a process which has become ‘too legal, combative and procedural’. The impact is that, ‘no matter how much extra resources were pumped in’, this would still lead to difficulties in reducing the backlog.
As one of many, clearly frustrated, staff members said, ‘We are not saving lives, we’re saving PDFs.1
Safeguarding
Of great concern is the report’s finding that the NMC has too few staff in place to fulfil its safeguarding obligations.
The report’s authors heard that decisions had been made by the screening team ‘to close down cases where nurses posed a danger to the public. The reasoning was ‘this is not for us’, they can do what they want outside of work.’
‘Others spoke of safeguarding generally being devalued across the NMC.’ There was a strong sense that any expertise within the organisation, for example on clinical and safeguarding matters, was not valued as highly as legal expertise.
Staffing
Over half of the staff seen by the report authors said they were positively managed. However, the report is clear they found far too many who were struggling and systems which did not support good management.
Managers and HR had little understanding of the conditions faced by people with disabilities. People reported that no reasonable adjustments had been made and they had been put on formal performance improvement plans
‘Bullying is clearly a problem’ but the organisation’s response has been to move complainants to other departments, ‘or to a rapid exit.’1 Performance management has not been taken in any meaningful way, although the appointment of new HR leaders has introduced changes.
Multiple black and ethnic minority workers said they had left because career progression was not meritocratic. They told report authors they had ‘all gone on to get better jobs and argued that their abilities had been overlooked at the NMC.’
There was a lack of diversity noted among panel members. Not only was a lack of courtesy experienced by some ethnic minority staff on panels, they also told report authors that recruitment panel members ‘expressed racist views towards the candidates.’
‘In interview after interview, the experiences of staff stood in stark contrast to the NMC’s declared behaviours of treating everyone fairly and acting with kindness, and the staff knew it.’1
The way forward
The NMC’s Executive Team has fully accepted the report’s 36 wide-ranging recommendations.2 which relate to:
● leadership and management capabilities
● dignity in the workplace
● processes and structures for investigations, and the role of legal expertise in multi-professional teams
● recruitment, retention, development and progression
● equality, diversity and inclusion and effective representation of ethnic diversities in panels
● improved line management, performance management, and trade union recognition
● whistleblowing
● safeguarding
● transparency.
● It has already taken a number of steps, including:
● Expanding safeguarding resources, training and procedures since January
● Strengthening guidance in February on making decisions about abuse by registrants outside their professional practice
● Agreeing an 18 month £30m plan in March to ‘make a step change in fitness to practise’
● Appointing a new independent Empowered to Speak Up Guardian, already in place
● Making listening circles available to staff, facilitated by trained professionals
● Arranging to double the spend on learning and development
● Starting a review by an external partner of NMC’s equality, diversity and inclusion (EDI) training
● Currently working on a behavioural framework to be launched in September.
Conclusion
NMC’s senior leadership has failed to rise to the challenges it faces. This has been the case however for well over a decade. Its incompetence and dysfunction has failed patients, families and staff.
The report’s recommendations are focused and specific. If leaders are able to rise to the task, it should lead to elimination of the backlogs in screening by 2025 and investigations by 2026. It should produce adequate staffing levels and training to ensure the NMC meets its safeguarding obligations. It should result in more transparency and dignity in the workplace and improve the experience and senior representation of ethnic minorities.
The outlook is hopeful. New HR leaders are in place. Safeguarding changes are already partly implemented. Staff have a strong appetite to tackle the issues. It will be interesting to see what the next such report will find.
Amanda Halliwell, Independent care coach
References
1. Rise Associates. NMC – Independent Culture Review. July 2024. https://www.nmc.org.uk/globalassets/sitedocuments/independent-reviews/2024/nmc-independent-culture-review-july-2024.pdf (Accessed 19.07.24)
2. NMC. Reflection, Accountability and Action, Executive Team response. July 2024. https://www.nmc.org.uk/globalassets/sitedocuments/independent-reviews/2024/executive-team-response.pdf (Accessed 19.07.24)