3 Revalidation of nurses
Re-registration of nurses
26. Nurses and midwives pay their retention fee annually,
and once every three years they must re-register with the NMC,
so called "periodic renewal". This requires that a registrant
state on a Notification of Practice form that they have undertaken
450 hours or more of practice in the last three years, and that
they have undertaken 35 hours of continuous professional development
(CPD) activity over the same period.[39]
Collectively, these are known as the Post-registration education
and practice (PREP) standards. The NMC recommends that registrants
keep a portfolio of their CPD activity and states in its handbook
that PREP portfolios will be audited.[40]
However, the CHRE has recently stated that:
The NMC does not audit registrants' continuing professional
development (CPD) portfolios.[41]
27. When asked about this, the NMC told us:
We have, as you know, nearly 700,000 registrants
so we largely have to take that on trust. We now use a riskbased
approach for calling in PREP information but we do not have the
resource to do it systematically across the entire register. The
riskbased approach we would use would be if a nurse or a
midwife comes to our attention for some other reason. For example,
if they have had a caution or a conviction from the police then
we might call in their PREP evidence; in other words, certificates
of attendance, they have to write something to say what they have
learnt from a particular educational initiative, and that sort
of thing. The PREP system, in a way, leads into revalidation.
What we are working on now is revamping that for 2014 when we
start revalidation proper.[42]
28. In supplementary evidence to the Committee the
NMC told us that they have looked in more detail at the registration
renewal evidence of around 115,000 nurses and midwives over the
last five years.[43]
This equates to an average of 23,000 per year or less than
4% of all registrants annually.
29. The Council for Healthcare Regulatory Excellence
has also stated that it supports the NMC's approach in not auditing
CPD as the NMC:
[…] is looking at what evidence would be required
to audit outcome based CPD in terms of professional development
value rather than auditing what professional development has been
undertaken.[44]
30. The NMC also relies on other registrants informing
the NMC when a fraudulent Notification of Practice has been made:
The interesting thing is that, increasingly, colleagues
whistleblow if they feel somebody they know has not done that.
We would then refer those people to fitness to practise because,
in fact, they have submitted a fraudulent entry.[45]
31. The
current standard for re-registration—completing 450 hours
of practice and 35 hours of professional development—is
wholly inadequate, as this tells patients and the public nothing
about the quality of nursing and midwifery practice undertaken
by the registrant. There is also no routine assessment of whether
nurses and midwives have even met this minimal standard. The NMC
instead relies on honesty within the profession and "whistle-blowing"
when registrants are dishonest. For many nurses and midwives this
may well be adequate, but for a significant minority, including
those most at risk of manifesting low professional standards,
it may not be.
32. The Committee
supports the NMC's risk-based approach to the current re-registration
process. However, we are concerned that there are nurses and midwives
who could be failing to meet the already unacceptably low standards
for re-registration but who do not come to the attention of the
NMC and are therefore re-registered unchallenged. Registrants
must feel that their regulator could call in their re-registration
evidence at any time and as such the NMC should undertake an annual
random audit of the registration renewal evidence supplied by
a sample of registrants.
Revalidation
33. The NMC, along with other regulators and the
CHRE were involved in a working group led by the Department of
Health in England on non-medical revalidation i.e. the new process
through which nurses, midwives and other professions would in
future seek re-registration. The NMC has told us that its revalidation
system will be in place by 2014.[46]
The Committee
will monitor progress against the 2014 deadline for the introduction
of revalidation by the NMC at subsequent accountability hearings.
34. The process of revalidation will be constrained
by the number of registrants that the NMC will have to revalidate.
As they told us in oral evidence:
I know one or two other regulators have done a lot
of work with calling in paperbased information. We will
never be able to do that unless we very significantly raise registration
fees, which is not something we wish to do. Therefore, our system
will always have to be risk based and online.[47]
35. Instead, the NMC is proceeding with an online,
risk-based approach to revalidation that will focus on areas of
practice where the consequences of poor practice may not become
evident:
In brief, those are environments that we would regard
as "not managed". By that, I do not mean not managed
at all but that they are not within a large managed system. For
example, I would be less worried—and I think people would
be a lower risk—about those working generally in a wellrun
NHS environment or a military environment than perhaps a very
small, independentlyrun nursing home.[48]
36. In its Command Paper "Enabling Excellence,
Autonomy and Accountability for Healthcare Workers", the
Department of Health has stated:
For those professions where there is evidence to
suggest significant added value in terms of increased safety or
quality of care for users of health care services from additional
central regulatory effort on revalidation, the Government will
agree with the relevant regulators, the Devolved Administrations,
employers and the relevant professions the next steps for implementation.[49]
37. The Committee notes that in addition to re-registration
and eventually, revalidation, every midwife must also have a named
supervisor of midwives (SoM). SoMs are experienced practising
midwives who have undertaken additional education and training
to support, guide and supervise midwives. SoMs develop and maintain
safe practice to ensure protection of women and their babies.
They meet regularly with midwives with the aim of ensuring that
a high standard of care is provided.[50]
38. Local Supervising Authorities are impartial organisations
responsible for ensuring statutory supervision of midwives is
undertaken according to NMC's standards. LSAs are based within
Strategic Health Authorities in England. SHAs are due to be abolished
in 2013 and the arrangements for statutory supervision of midwives
during the transition and beyond 2013 are not yet in place.
39. Revalidation
of nurses and midwives is a significant undertaking that the NMC
is progressing with due caution. The Committee notes that statutory
supervision of midwives is a tried and trusted means of assuring
the quality of midwifery practice. The NMC should consider the
costs and benefits of extending the statutory supervision framework
as a potential means of delivering an effective revalidation process
for all registrants.
40. The NMC
needs to ensure that it monitors the number of nurses and midwives
who retire, leave the profession, have conditions placed on their
practice or fail revalidation. It must develop and share this
evidence with employers to ensure that the future workforce planning
includes the developing outcome of the revalidation process.
41. The Department
of Health must clarify how it will maintain the continuity of
statutory supervision of midwives through Local Supervising Authorities
once Strategic Health Authorities are abolished.
Nurses who qualify overseas
42. The NMC is prohibited by law from systematically
testing the language competence of nurses and midwives who have
trained within the EEA (EU27 plus Iceland, Liechtenstein and Norway)
and Switzerland. Nor can it request training transcripts or test
the knowledge or competence of nurses and midwives from these
places.[51] They told
us that they have made some efforts to pick up language deficiencies
through aptitude tests that can only be administered to some potential
registrants:
For those who have major shortfalls, we have found
a solution within the legislation and we introduced aptitude tests
this year, which started in April. These are tests like the PLAB
test, more or less, that the GMC described earlier on, based on
multiple choice but also OSCE simulation and a reading assessment.
The language competence will be picked up through that because
there will be written and oral communication in English. For those
who meet automatic recognition, we are not allowed to ask any
additional requirements there.[52]
43. In 2010 the European Commission asked the NMC
to lead on a review of the EU directive that has prevented systematic
language and competence testing.[53]
44. The NMC told us that the EU minimum standards
for training were established in the 1970s and that these standards
are not as high as those in the UK at present.[54]
The NMC is working with the other regulators, the Government
and with the EU to address these issues.
Additionally, the NMC has stated that:
We have worked collaboratively with the Department
of Health and the European Commission (EC) and have provided recommendations
to amend the legislation governing the mobility of healthcare
professionals within the EU (EU Directive 2005/36/EC on the recognition
of professional qualifications)[55]
45. Nurses
and midwives from the European Economic Area and Switzerland seeking
to practice in the UK cannot routinely be language and competence
tested by the NMC. The NMC, along with other professional regulators
and the Government is working towards resolution of this with
partner organisations across Europe. The Committee takes the view
that the current legal framework is at odds with good clinical
practice, which is clearly unacceptable.
46. The Government,
the NMC and the other health professions regulators must now grasp
this as a significant risk to patients and dramatically pick up
the pace in resolving or mitigating it.
47. The Committee
is concerned that waiting for regulatory action at a European
level will expose patients to a high risk over an unacceptably
long period of time. We would like to see prompt action on this
matter along the lines taken by the GMC where Responsible Officers
sign off a doctor as competent and fit to practise.
39 "Meeting the PREP standards" NMC website,
7 June 2010, www.nmc-uk.org Back
40
Ibid. Back
41
The Council for Healthcare Regulatory Excellence, Performance
review report 2009-10, HC 7-II, July 2010, p65 Back
42
Q 71 Back
43
Ev 21 Back
44
The Council for Healthcare Regulatory Excellence, Performance
review report 2009-10, HC 7-II, July 2010, p65. Back
45
Q 77 Back
46
Ev 21 Back
47
Q 85 Back
48
Q 85 Back
49
Department of Health, Enabling excellence, autonomy and accountability
for healthcare workers, Cm 8008, 16 February 2011, p 19 Back
50
"The supervision of midwives", NMC website, 9
March 2010, www.nmc-uk.org Back
51
"Nurses and midwives trained abroad", NMC website,
March 2010, www.nmc-uk.org Back
52
Q 143 Back
53
Ev 18 Back
54
Q 135, 136 Back
55
Ibid. Back
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