Select Committee on Health Written Evidence

Memorandum by the Nursing & Midwifery Council (PS 58)


  The Nursing & Midwifery Council (NMC) is the UK regulator for two professions, nursing and midwifery. The primary purpose of the NMC is protection of the public. It does this through maintaining a register of all nurses, midwives and specialist community public health nurses eligible to practise within the UK and by setting standards for their education, training and conduct. Nurses and midwives, of which there are currently around 674,000 registered with the NMC, renew their registration every three years.

  It may be helpful to set out the regulation that the NMC, the largest regulator on the delivery of healthcare in the UK works to in the role of safeguarding the public. The responsibilities of the NMC are set out in the Nursing and Midwifery Order (2001) and include:

    —  Maintaining a register of nurses and midwives

    —  Consulting on and setting standards for education, ethics and conduct

    —  Giving advice to registrants, employers and the public

    —  Dealing with allegations of unfitness to practise, lack of competence and ill health

    —  Setting the standard for the function of the Local Supervising authorities and the supervision of midwives

    —  Quality assurance of the Local Supervising Authorities.

  The NMC has also worked and continues to work closely with other health regulators on matters such as the recommendations arising from the Shipman Inquiry and the programme of regulatory reform set out within the White Paper Trust, Assurance and Safety—the Regulation of Health Professionals in the 21st Century (2007).

  As our response is related to the regulatory responsibilities that we are charged with we would like to offer the following comments:


The Code:

  1.  All nurses & midwives are benchmarked to the standards set out within the Code. If registrants fail to comply with the standards, their registration may be at risk in order to safeguard the public. The NMC recognises that patient safety is everybody's business and by clearly stating within the Code that nurses and midwives "make the care of people your first concern" we are ensuring that this places patients at the centre of healthcare being delivered across all environments of care. The Code serves to increase individual's mindfulness of the professional requirements placed upon them to make patient care safer. It aims to demonstrate patient & public safety by highlighting the contributory factors for reducing risk and increasing safety, for example, good communication, team working, education and training and working conditions.

  2.  The Code clarifies the responsibility of nurses and midwives to alert someone in authority regarding any concerns about their working environment. There are shared responsibilities in providing care which do not always fall on individual professionals. In these circumstances, nurses and midwives have a duty to ensure that those in positions of authority are aware of any issues which have an impact on the ability of a nurse or midwife to provide safe and effective care and/or in which patient safety could be compromised.

  3.  The NMC considers seriously all complaints made about registrants and all allegations are investigated thoroughly and fairly. Most complaints about nurses and midwives can and should be resolved locally, where the care was given or the incident happened. However, if the problem is so serious that the nurse or midwife may not be safe to care for patients, the NMC needs to know about it. NMC guidance for both the public and employers sets out the process to progress this.

  4.  The aim of all the NMC's standards, including the Code, is to improve how care is provided in all environments whether directly or indirectly. The Code sets out the core principles and values that nurses and midwives must work with to ensure safe and effective practise is carried out within their level of competency. The use of the phrase "you must" within the Code makes this responsibility clear, reminding nurses and midwives that the care of patients is their first concern. However, the Code by itself cannot prevent poor practise from ever occurring. For professional self-regulation to work effectively requires nurses, midwives, employers and the NMC to work together in partnership.

  All the NMC Standards can be accessed via our website at:


  5.  The NMC reviews and maintains standards of nursing and midwifery education for practice and post-qualifying programmes ensuring that students can demonstrate their fitness for practice prior to entry to the register.

  6.  In 2005/6 the NMC worked with key stakeholders to produce Good Health and Good Character Guidance (The Guidance) accessible to students and registered nurses and midwives but in particular for use by programme providers, (Universities and placement providers). The public can raise fitness to practise issues regarding students but with the universities and placement providers and not the NMC as we have no fitness to practise regulatory function with students. This was published on the NMC website and updated in 2008 and refers in particular to nursing and midwifery programmes leading to NMC registration. Whilst the Guidance refers to both good health and good character, consideration is being given to removing the health requirement, along with other health regulators. This follows concerns raised following the 2007 DRC inquiry which looked at how equality duties were being addressed in nursing, teaching and social work.

  7.  Nursing and midwifery are self-regulating professions. A significant aspect of self-regulation is the moral understanding of knowing what is right or what is important (DH 2006)[359]. All registrants are required to abide by the NMC rules, standards and The Code (NMC 2008). Pre-registration students are expected to work towards being able to apply the Code at the point of registration. An important determinant of good character is the individual's commitment to, and compliance with, the Code.

  8.  Good character is important as nurses and midwives must be honest and trustworthy (NMC, 2004). Good character is based on a person's conduct, behaviour and attitude, as well as any conviction and cautions that are not considered compatible with professional registration and that might bring the profession into disrepute. A person's character must be sufficiently good for them to be capable of safe and effective practice without supervision. As an outcome of the White Paper Trust Assurance and Safety the NMC is also taking forward this year work on student engagement which draws on previous work on student values and people skills. It aims to increase professional identity and awareness of the role of regulation and public protection at an early stage of their career.

  9.  NMC guidance requires that all applicants must be considered as individuals and programme providers should assess each of them to decide what the effect a conviction or cautions might have on the person's ability to meet the NMC requirements for entry to a programme leading to registration. If an applicant has a conviction or caution, the relevance, seriousness and circumstances in which the offence was committed must be taken into account.

  10.  The Universities Central Admission Service (UCAS) or CATCH (Scotland) will request references as part of the application process. A Criminal Records Bureau (CRB) or Disclosure Scotland check will also be done because students may be working unsupervised with vulnerable client groups. Programme providers should check that all selected applicants are not named on any lists of those barred from working with children (POCA) or vulnerable adults (POVA) and List 99. They should also check applicants' identity and any change of name by checking passports or other relevant formal documents that include photographic identify.

  11.  Applicants should be reminded that if they are offered a place it is their responsibility to notify the university if their character status changes in the time between the offer being made and beginning the programme. As a student progresses on the programme they are required to inform the programme provider of any pending charges, and resulting cautions or convictions. The NMC requires education providers to have in place local Fitness to practise panels to consider such cases and determine whether the student should continue on their programme. The panel should have representation from education and service partners. Depending on the programme under consideration, there should be a nurse, midwife or specialist community public health nurse representative. The midwife representative should be a supervisor of midwives. Additional nurse representatives should be co-opted to make sure that there is representation from the same field of practice as the student, such as from adult, children's, mental health or learning disability nursing

  12.  Essential Skills Clusters (ESCs) There are profession specific ESCs for nursing and midwifery as their roles, responsibilities and client group needs are different. In nursing there are UK-wide generic skills statements set out under broad headings that identify skills to support the achievement of the existing NMC outcomes for entry to the branch, and the proficiencies for entry to the register. They aim to provide clarity of expectation for the public and profession alike and seek to address concerns about potential skill deficits. ESCs must be incorporated into pre-registration nursing programmes for all new students commencing from September 2008.

  13.  Review of pre-registration nursing education- A new framework for pre-registration nursing education is to be developed with a view to ensuring that the new nurse of tomorrow is able to work safely and effectively to meet the needs of the people in their care as the delivery of healthcare services continues to change.

  14.  At the Nursing and Midwifery Council (NMC) meeting on 4th September 2008, Council members agreed to a set of principles that will form a new framework for pre-registration nursing education. The principles were developed following a three-month consultation in which over 3000 nurses, members of the public and stakeholder organisations took part. The consultation asked what nursing education should look like in the future, explored whether nurses should be generalists or specialists, if they should be graduates, and how much of their training should be conducted in the community. It also looked at how new nurses should be supported after they first qualify. Feedback from major stakeholders, including professional bodies and unions, as well as recent developments in UK health policy and other inter-related work within the NMC was also considered when developing the principles that will shape the new framework.

  15.  Council also agreed that the project is now ready to move to the next phase which is to use the principles to develop new Standards of proficiency for pre-registration nursing education and new Standards for preceptorship¹, aimed to be in place for academic year 2010/11. This will involve further consultation so we will be seeking the views of our stakeholders once again as this work continues to progress. This also links to the work undertaken by our government colleagues via the Modernising Nursing Careers workstream.

  16.  A review of pre-registration midwifery education was completed in 2007 and new standards are being implemented at this time.

  17.  Health Care Support Workers- Due to the unique relationship that registered nurses and midwives have with Health Care Support Workers (HCSWs), Council determined that there was a need to explore issues around regulation of this group. The NMC hosted the UK Summit meeting in February 2008 with key stakeholders from across the UK "Health Care Support Workers: exploring developments—a UK debate" to explore and debate aspects around the regulation of HCSWs. While there was general agreement that HCSWs should be regulated, there was great debate on options, advantages and disadvantages on any possible regulation. Outcomes from this debate were presented at Council in June and were shared with key stakeholder organisations. The NMC will continue to engage with stakeholders from across the UK and keep abreast of relevant workstream and policy developments.


  18.  The NMC's UK Wide QA Framework provides assurance of the quality of professional education for nurses and midwives. The Framework addresses risks to public safeguarding that are part of preparing practitioners who are fit for practice. Detailed information including a good practice bulletin is available via the NMC website.


  19.  The content of this response is informed by some of the information described in the reports received from Local Supervising Authorities for the supervisory year 2006/7. In addition, issues identified to the midwifery unit during conversations with midwives who contact the midwifery advisers for guidance in relation to practice or supervisory issues.

  20.  There is a level of concern about the safety of maternity care in England—a review by the Healthcare Commission (2008) underlined the variability in the quality of care in different maternity units around the country and the recent independent inquiry undertaken by the Kings' Fund (2008) found there to be shortcomings in the way care is organised and there were issues around clinical leadership, staffing levels and deployment, training, information and guidance as well as the role of hospital boards. The findings and recommendations of the Healthcare Commission and Kings Fund inquiry may assist in providing a steer for this inquiry. Other recent reports that have had a significant impact of the provision of maternity care include the National Service Framework (NSF) for Children, Young People and Maternity Services (DH2004), Maternity Matters (DH 2007), the NICE antenatal, intrapartum and postnatal guidance (2006-2007), the CEMACH report Saving Mothers' Lives (2007) and the recently published RCOG Standards for Maternity Care (2008).


  21.  Supervision of Midwives is a statutory requirement for the profession and the NMC sets Standards for the preparation and practice of supervisors of midwives (2007). The supervisory framework aims to monitor and improve the standards of midwifery practice and care and lead to better outcomes for women. Supervision applies to every midwife in the UK regardless of where they are employed.

  22.  Although a statutory requirement the supervisory mechanism is not formally funded but supported usually through employers, either in the NHS or the independent sector. There is an expected minimum standard ratio of 1 supervisor of midwives to a caseload of 15 midwives. However, there is inconsistent application to this standard across the UK with some services demonstrated to have a ratio of 1 supervisor of midwives with up to 30 midwives to support. Those units with low supervisor/midwife ratios are able to support more proactive supervision and through this function, enhance the safety of women and babies. Examples of such activity include support for newly qualified midwives, targeting particular practices where greater expertise is required such as the interpretation of CTGs (electronic foetal heart monitoring), record keeping and supporting the provision of normal birth.


  23.  A key role of a supervisor of midwives is to monitor and support the practice of midwives to ensure protection of the public. A frequent duty of the supervisor of midwives is to investigate adverse events surrounding the care of a woman during childbirth regardless of where the event took place. The outcome of this investigation is reported to the Local Supervising Authority. This function often sits within the clinical governance framework in NHS bodies but is separate to the investigation undertaken by the employer. This may be seen as duplicative if the role of supervision of midwives is not understood.

  24.  The collaborative interrelation of good governance mechanisms in maternity care must include the statutory role of supervision. Opportunities to assist and develop the midwife following complex events whereby the care has been sub-optimal may therefore be lost if the supervisory mechanism is not supported by the employing authorities. The NMC sets Standards for the supervised practice of midwives (2007), this is a formal process with academic and practice learning outcomes that seeks to assist the midwife to improve her knowledge and skills so that she can demonstrate that she is competent to practice and my be assessed as fit to remain on the NMC Register.

  25.  Supervision of Midwives also enables risk assessment and risk management, particularly if individual women or groups of women are considered to be at risk. The most common challenges in this area relate to supporting women's choice around place of birth particularly home birth and access to maternity services in labour. With the increasing birth rate nationally women have reported that the maternity services are unable to support home births and the lack of beds and staff within maternity units results in frequent closure of maternity units in some areas. This has a consequent effect on the safety of the women and unborn babies and promotes potentially dangerous alternative choices such as "freebirthing" (NMC A-Z advice 2008).


  26.  Supervision is a means of ensuring safety for women and babies by maintaining the safety of midwifery care and by supporting midwives to practise with confidence. The Government's NHS modernisation programme aims to deliver consistent and high quality care to all service users, with an increasing focus on client choice and also on user involvement. Midwives have a head start in this process with an established, effective system of statutory supervision and a framework for the regulation of midwifery practice.

  27.  Each Local Supervising Authority is responsible for ensuring that statutory supervision of all midwives, as required in the Nursing and Midwifery Order (2001) and the NMC's Midwives rules and standards (2004) is exercised to a satisfactory standard within its geographical boundary. Each Local Supervising Authority has an appointed Local Supervising Authority Midwifery Officer to carry out the Local Supervising Authority function. Local Supervising Authority Midwifery Officer's are all practising midwives with experience in statutory supervision and provide a focus for issues relating to midwifery practice within each area. They also contribute to the wider NHS agenda by supporting public health and interprofessional activities at a Strategic level.

  28.  The role of the Local Supervising Authority Midwifery Officer is unique: it does not represent the interests of either the commissioners or providers of NHS maternity services. Regular contact with all supervisors of midwives and with the UK forum of Local Supervising Authority Midwifery Officers ensures that they have detailed knowledge of contemporary issues.

  29.  Each Local Supervising Authority Midwifery Officer is supported in their role by supervisors of midwives, who are practising midwives and have undertaken further education and training. Supervisors of Midwives develop and maintain safe practice to ensure protection of women and babies. They meet regularly with midwives and ensure a high standard of care is provided.

  30.  A supervisor of midwives function is independent of the employer and they often work in a team. Their role is different to the midwifery manager who is responsible to the employer to make sure that maternity services run effectively. The Supervisor of Midwives is accountable to the Local Supervising Authority and is responsible for ensuring the safety of women and babies receiving midwifery care.


  31.  The Department of Health document, Maternity Matters (2007) recommends that maternity care must be comprehensive and flexible to respond to the clinical and social needs of women and their families. However, the sustainability of such provision is costly and will require appropriate funding for maternity services to be effective in supporting the implementation of government policy and national body guidelines. There is considerable disquiet around the centralisation of services and the closure of smaller services that appear to have less activity, or are midwifery managed birthing units. Additionally, there has been significant reconfiguration of neonatal services. As a consequence, women have to travel further in order to access maternity and neonatal services thus compromising their safety and the safety of their babies.


  32.  The NMC Midwives rules and standards describe the responsibilities and sphere of practice of a midwife. A midwife may not arrange for anyone to act as a substitute, other than another midwife or registered medical practitioner.

  33.  The supporting role of maternity care assistants and the role of the learner in the clinical environment is often one of conjecture, particularly when a midwife in her own assessment considers such a colleague to have particular competencies and skills that can be delegated confidently to them. In all circumstance however the midwife is accountable for the decision to delegate and remains responsible for the whole or total care of the woman and baby.

  34.  As maternity services are becoming increasingly congested and busy, there is evidence that midwives are delegating inappropriately to non-regulated health care personnel who are not trained and therefore not competent to provide midwifery care (Kings College, London 2007). However, it is recognised that there are many duties that a trained maternity support worker can provide without direct supervision by a midwife. These duties will include both direct care to mothers and newborns that is not midwifery, in the acute hospital environment as well as in the community clinics and women's homes. It is important therefore that the current debate on the scope of practice of a midwife and the role and duties of the maternity support workers are clarified. This will enable maternity services to workforce plan with the appropriate skill mix in order to deliver the spectrum of care to women and their families safely without contravening regulatory standards and guidance.


  35.  The NMC does not stipulate the management provision for the leadership of maternity services. The NMC Midwives rules and standards do not for instance, identify that maternity services must be led by a midwife. However, both the Healthcare Commission review and King's Fund inquiry supports the view that maternity services require a strong midwifery leader and that advocacy for maternity safety must be strengthened on the boards of NHS bodies. Failure to adequately fund and develop maternity services in response to government policy and national guidelines compromises the care that women and babies receive (NMC The Code 2008). In addition, the mechanisms of support to midwives, such as the facilitation of the supervisory function and their continuing personal and professional development, which are regulatory requirements, are critical to ensuring midwives are fit to practice.


  36.  Recent Local Supervising Authority reports to the NMC identify the fitness to practice referrals to the regulatory body. The typical examples of poor midwifery practice usually involve issues such as:

    —  Misinterpretation of the CTG (electronic foetal heart monitoring)

    —  Non-recognition of abnormal developments in ante-natal care or in labour

    —  Poor management in an emergency

    —  Non-referral to an obstetrician for either advice or to take over the direction of care

    —  Poor record keeping of care provided by the midwife and the reasons for decision-making.

    —  Maladministration of drugs

  37.  It is imperative therefore that midwives have the continued protection of mandatory training supported by their employer, access to continued professional development and the opportunity for supported or supervised practice in the event of identified learning needs following periods of absence from the profession or following incidents. To this end the NMC sets minimum standards that must be achieved by nurses and midwives related to their post-registration education and practice (NMC The PREP handbook 2004).

  38.  Generally over this last year there have been increased referrals to the NMC by Local Supervisory Midwifery Officers to the Fitness to Practice department. Of significance however, is the increased number of programmes for supported or supervised practice and referrals to the NMC, of midwives still quite junior in the profession. The mechanisms of effective mentorship for students undertaking midwifery training and the onward support of preceptorship on qualification in their first year of practice cannot be under-estimated.

  39.  Much as it is not clear as to why this is occurring, the context of how maternity services are provided at present with increased activity on labour ward when the risks to mothers and babies are at their highest, also contribute to midwives making mistakes due to the pressure of the clinical environment. This will be a significant contributor to this problem.

  Analysis of the LSA reports to the NMC 2006/7-The full analysis of these reports can be found on the NMC website.


  CEMACH Saving Mothers' Lives (2007)

  Department of Health (2004) National Service Framework (NSF) for Children, Young People and Maternity Services

  Department of Health (2007) Maternity Matters

  Healthcare Commission (2008) Towards better births—a review of maternity services in England

  Kings College London (2007) Support Workers in Maternity Services

  Kings' Fund (2008), Safe Births: Everybody's business

  Nursing and Midwifery Order (SI 2002/253)

  NICE (2006-2007) antenatal, intrapartum and postnatal guidance

  NMC (2004) Midwives rules and standards for midwifery

  NMC (2004) The PREP handbook 2004

  NMC (2007) Standards for the preparation and practice of supervisors of midwives

  NMC (2007) Standards for the supervised practice of midwives

  NMC (2008) The Code

  NMC (2008) A-Z Advice—Freebirthing

  RCOG (2008) Standards for Maternity Care, Report of a Working Party

September 2008

359   The regulation of the non-medical healthcare professions: a review by the Department of Health (2006). Back

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