Appendix 2: Nursing and Midwifery Council's
22. The Nursing and Midwifery Council (NMC) welcomes
the report of the House of Commons Health Committee and its support
for changes in a number of critical areas that would enable us
to become a more effective regulator. The Committee's support
for legislative changes to improve the speed and effectiveness
of our fitness to practise processes and the mandatory statutory
regulation of healthcare support workers is particularly important.
23. Nursing and midwifery regulation is pivotal
in safeguarding the health and wellbeing of the public. We therefore
fully support the Committee's commitment to hold annual accountability
hearings to scrutinise and help us to improve our work.
24. This memorandum sets out our response to
the Committee's conclusions and recommendations.
Recommendation 1, 11 and 12
25. We welcome the Committee's support for changes
to our legislation that will improve the efficiency and effectiveness
of our procedures, enabling us to take action to protect patients
and the public more quickly.
26. Since our oral evidence session on 14 June
2011, we have held detailed discussions with the Department of
Health about the legislative changes that we require. We have
developed proposals to change our rules relating to the investigation
of fitness to practise allegations, procedures for seeking and
making interim orders in fitness to practise cases and arrangements
for allowing nurses and midwives to voluntarily remove themselves
from the register.
27. We opened a public consultation on these
proposed changes on 1 September 2011 which concluded on 14 October
2011. We anticipate that our Council will approve the proposals
on 24 November 2011. With the cooperation of the Department of
Health we hope to have the new rules laid before Parliament in
December 2011 coming into force by February 2012.
28. The proposals do not address the Committee's
recommendation that voluntary removal must only take place with
the consent of the complainant. However, the rules will require
that the complainant must be given a reasonable opportunity to
comment before the application is considered and for their comments
to be taken into account. This is in line with the approach taken
by other healthcare regulators.
29. Further safeguards have been put in place
to ensure voluntary removal will only apply where specific criteria
are met and not in cases where the public interest demands further
investigation. In addition, the Registrar will take into account
the fitness to practise history of any nurse or midwife who subsequently
applies for readmission to the register.
30. We are also strengthening the competencies
required of the people who chair our fitness to practise panels.
We will be recruiting against these competencies to drive up the
standard of our panels' decision making.
31. Since 2007 the NMC has had, along with the
Health Professions Council (HPC) the lowest fee of the nine health
professions regulators. We have considered arguments for a lower
registration fee for new entrants. However the administrative
costs would be considerable and the costs of regulating new entrants
would remain. We also felt that it would be unfair to give a reduction
to some and not all of those nurses and midwives on our register.
32. Any future fee level will have to be considered
against the dramatic increase in fitness to practise referrals.
We received 4,211 referrals in 2010-11 compared to 2,988 in 2009-2010
- an increase of 41 per cent. Rising public awareness and media
scrutiny of poor standards of care will mean this trend is likely
to continue in the near future. This increased workload is putting
more pressure on our resources. The legislative changes to streamline
our fitness to practise operations will help mitigate these pressures
to a degree.
33. Even disregarding the financial impact of
the increasing pressure on our fitness to practise function, the
Government's proposals to make the Council for Healthcare Regulatory
Excellence (CHRE) a self funding organisation via a levy on the
healthcare professions regulators may have the unintended consequence
of forcing us to increase the registration fee. Under the current
options presented by the CHRE to the Department of Health, we
would be expected to fund 35.5 per cent of their annual operating
costs or £993,000 which is equates to an additional
£1.50 for every nurse and midwife on the register.
34. We do not support the proposed levy options.
We undertook an assessment of the projected running costs of the
CHRE and, based on activities they currently perform for us in
terms of time and seniority of staff undertaking those tasks,
we believe the costs are overestimated. We believe the work of
CHRE could be undertaken - and paid for - on a case-by-case basis.
This approach would be more proportionate, economical and less
likely to impact on the current registration fee.
Recommendation 3 and 4
35. We welcome the Committee's recognition that
the NMC is a much improved organisation. However, we are not complacent
and remain committed to making further improvements to our fitness
to practise function and all other areas of our work. This includes
proactive project work to develop UK regulatory policy where we
believe it will further safeguard the health and wellbeing of
the public. This would include, for example, exploring a mandatory
model for regulation of healthcare support workers.
36. We believe initiating projects in this way
demonstrates to the public our leading role in enhancing patient
safety and standards of professional practice in the public interest.
Recent examples of this include:
15.1. Launching the Meet
the NMC monthly engagement events where directors of nursing,
heads of midwifery and HR directors are invited to our offices
to learn more about fitness to practise and emerging policy initiatives.
15.2. Opening a new office
in Edinburgh to increase our hearings capacity and to provide
a focus for engagement with our stakeholders in Scotland. We are
exploring options for opening an office in Wales.
15.3. Making greater use of
the proactive powers given to us under Article 22(6) of the Nursing
and Midwifery Order 2001 to intervene where we become aware of
poor standards of patient care.
37. CHRE's most recent performance review acknowledges
these achievements, and refers to our project helping to "protect
the safety of some of the most vulnerable patients" (paragraph
"contribute to improvements in patient safety." (paragraph
38. We are committed to demonstrating our leadership
role not just to nurses and midwives but to the public and other
stakeholders. Our new publication NMC Review, launched
in spring 2011, provides policy news, features and comment of
for leaders and managers in the nursing and midwifery professions.
More than 70,000 have subscribed to the publication (October 2011).
39. Other channels of communication include our
Facebook page which communicates our work to over 20,000 people
and our email newsletters which are targeted to specific audiences
such as employers and reaches over 130,000 subscribers. In November
2011 we will commence distribution of a new leaflet: Complaints
against nurses and midwives: Helping you support patients and
the public - which tells patient support organisations what
they can expect from a nurse or a midwife, and what action we
can take if they make a complaint to us.
40. In January 2012 we will launch a new service
for nurses and midwives: the standards and ethics helpline. This
will provide a direct communications channel for nurses and midwives
to seek advice about ethical dilemmas they face in practice.
Fitness to Practise
41. We acknowledged in our written evidence that
we need to understand what is driving the increase in the number
of referrals. We have recently completed a key piece of work funded
by the Department of Health to consolidate fitness to practise
historical data into a single database. This will enable us to
compare our analysis of recent referrals with historical trends
and should add to our understanding of why referrals are increasing
and demonstrate concentrated areas of risk. The findings will
be reported to our Council in January 2012 and will feed into
revalidation and other areas of work.
42. In August 2011 we appointed a new Head of
Equality and Inclusion who is currently analysing the diversity
data contained in our register. A preliminary report will be made
to our Council by the end of the year. Once this work is complete
we will examine how the data can be captured at each of the significant
stages of our fitness to practise process.
Recommendation 7 and 8
43. We share the Committee's concerns about poor
standards of care. There is no excuse for abusive behaviour, neglect
or failure to deliver basic standards of care.
44. It is clearly stated in the code, that nurses
or a midwives have a professional obligation to "make the
care of people your first concern, treating them as individuals
and respecting their dignity". As soon as we become aware
of situations in which nurses or midwives may have fallen short
of the code, we take action. Our response to critical incidents
such as Mid Staffordshire NHS Foundation Trust, the Parliamentary
Health Service Ombudsmen report and Winterbourne View is detailed
in our evidence to the Committee.
45. The majority of these cases involved vulnerable
adults, particularly older people. We are determined to drive
up the standards of care for these groups. The Committee noted
that our Guidance for the care of older people, which outlines
best care practice, provides a good platform on which to build.
Since its launch in March 2009 we have distributed almost 400,000
copies of the guidance, which includes a leaflet for the public.
46. In the autumn of 2010 we launched our safeguarding
hub: an online information and training resource focused on safeguarding
adults. The hub is designed around an award winning suite of films
depicting challenging scenarios relating to the care of vulnerable
people. The hub is designed to facilitate discussion and promote
local solutions to help improve the care of vulnerable people.
47. The importance of providing safe, effective
and fundamental care to older people and other vulnerable groups
is being built into all existing project work and will be embedded
in our review of the code which is currently underway.
48. However, driving up standards of care requires
a multi-track approach that includes ensuring nurses and midwives
report incidents of poor care, keep their professional knowledge
and development up to date and ensuring the fundamentals of nursing
and midwifery care are reflected in all the training programmes
49. Nurses and midwives are required by the code
to report their concerns about poor practice and we encourage
employers to foster a collaborative approach and clinical culture
that welcomes reporting.
50. Our Guidance on raising and escalating
concerns provides a step by step guide on how to raise a concern,
when to escalate it and to whom. It acknowledges local whistle
blowing policies and safeguarding procedures and makes clear that
nurses and midwives have a professional duty to put
the interests of the people in their care first and to act
to protect them if they consider they may be at risk. The
guidance also states that not acting in this way could result
in a nurse or midwife being subject to fitness to practise proceedings.
We recognise how vital it is to patient safety to promote this
message and have in recent months made it a priority to do so.
Our Chief Executive made a clear statement on this point following
the publication of the Committee's report on 26 July 2011 and
again in response to the Care Quality Commission's (CQC) report
into the quality of care in the homes in the Castlebeck Group
on 28 July 2011.
51. However, creating an open reporting culture
will require collaborative working from healthcare regulators,
employers and healthcare professionals. We therefore welcome recommendation
19 in the Committee's report on the Annual Accountability Hearing
with the CQC. The recommendation states "it should be
a key objective of CQC inspections to ensure that the culture
of each provider organisation recognises and respects this professional
obligation, and provides proper security to those professional
staff who discharge it effectively." We will work closely
with the CQC through our memorandum of understanding to ensure
52. We strongly support the Government's proposed
review of the legislative framework to give greater autonomy to
regulators to discharge their statutory duties. We are at the
very early stages of engagement with the Law Commission in its
work to create a single Act of Parliament to cover all existing
health professions by 2014.
Recommendation 13 and 14
53. The NMC is committed to delivering a revalidation
system that will address the concerns raised by the Committee.
It will require nurses and midwives to demonstrate that: they
continue to be fit to practise; their knowledge and skills are
up to date and specific to their current area and scope of practice;
and the learning activities they undertake help them improve their
54. In the meantime we are working to strengthen
the existing post registration education and practice (Prep) system
to increase the safeguards for the public. We have refreshed the
handbook that contains the Prep standards, by removing the examples,
which no longer reflect contemporary practice. The new version
of the handbook has been published and became effective on Wednesday
12 October 2011. We are also increasing the scrutiny of nurses
and midwives who apply to be readmitted to the register within
five years of their registration lapsing. They must now demonstrate
that they meet our post registration practice requirements by
providing a full record of practice undertaken during the period
since their last renewal of registration.
55. To further emphasise the importance of keeping
practice up to date, our registrations department will in the
new year, commence the annual calling in of re-registration information
of a random sample of nurses and midwives on the register.
56. We are confident that we will be able to
deliver a system for revalidation by 2014. We have already engaged
with 1,700 stakeholders to validate our initial proposals, address
key issues and ensure that contributions to the development of
the system are visible. This includes ongoing engagement with
the Department of Health who gave their support for our high-level
principles for revalidation.
57. In early 2012 we will consult on a draft
revalidation standard which clearly sets revalidation against
the revised code, together with a draft revalidation guidance
or advice focused on revalidation processes. We will also define
options, assess their respective costs and benefits (both for
the NMC and for nurses and midwives) and select the preferred
option. We will pilot the system in late 2012 before starting
to roll it out to the whole register in 2014.
58. Revalidation and any legislative changes
needed to implement it will be developed in close cooperation
with the four UK departments of health.
59. We welcome the Committee's recognition of
the effectiveness of the midwifery supervisory model. The model
provides expert advice, clinical leadership and support to midwives
and acts as an independent monitor of safe midwifery practice.
60. However the model is sustainable largely
because of the number of midwives on our register, approximately
40,000 across the UK. The current phase of the revalidation programme
focuses on consolidating the evidence base for revalidation. Part
of this phase will focus on exploring the potential costs and
benefits of extending to nurses a statutory supervision model.
However, with over 630,000 nurses on our register it is unlikely
this would prove economically sustainable.
61. We already record on our register those nurses
and midwives who have conditions imposed on their registration
or who retire, leave the profession and inform us or if their
registration lapses. This will continue to be done when revalidation
62. We are happy to co-operate with workforce
planners to share any data we hold. It should be remembered that
not all nurses and midwives work within the NHS. We therefore
need to explore how any trends emerging for revalidation can be
incorporated into planning both inside and outside the NHS.
63. Since the Government's proposed abolition
of the strategic health authorities in England, we have written
to the Department of Health several times to express our concern
about the impact this would have on the current hosting and functions
of local supervisory authorities and local supervisory authority
midwifery officers (LSAMOs). We would not want to see this valuable
and effective system lost as part of the reorganisation and any
changes may necessitate legislative changes to the Nursing
and Midwifery Order 2001 and the NMC Midwives Rules
2004. We welcome the Committee's continued support
in seeking further information.
Recommendation 19, 20 and 21
64. We welcome the Committee's view that the
current legal framework governing the automatic recognition of
European Economic Area (EEA) trained healthcare professionals,
the EU Directive 2005/36/EC on Mutual Recognition of Professional
Qualifications (the directive), needs to be changed to reflect
modern practice and to better safeguard the public.
65. Since our oral evidence to the Committee
in June we made a submission to the European Commission's Green
Paper consultation making our recommendations for changes to the
directive. The recommendations included: the ability for healthcare
regulators to undertake mandatory checks for language competence;
updating of the minimum training requirements that allow healthcare
professionals to qualify for automatic recognition and introducing
mandatory continuous professional development. The next stage
will be the consideration of draft legislative proposals by the
Commission to the European Parliament and Council of Ministers
later this year.
66. In their Green Paper submission the Government
broadly supports our proposals except those in relation to compulsory
language testing at registration stage. In the meantime, we will
continue to make our case at a European level.
67. We strongly agree with the Committee that
measures must be taken to mitigate the risk under the existing
legislation. We welcome the Government's announcement on 4 October
2011 regarding the introduction of powers for "responsible
officers" to have a mandatory duty to check all non-UK doctors
that apply to work in the UK have sufficient English language
skills. We believe that this is a positive step towards a more
robust approach that includes the regulator as well as the employer,
although we continue to believe that checks should be made before
registration rather than after.
68. The "responsible officer" model
is part of the GMC's revalidation framework and not currently
applicable to the NMC. We are therefore in the process of discussing
with the Department of Health, other possible models that could
69. In the meantime we plan to write to directors
of nursing highlighting their duty under the code to escalate
concerns they may have regarding the communication competencies
of registrants they interview for prospective employment, regardless
of the outcome of the interview. We will also continue to work
with CQC to help enforce the responsibility of employers to ensure
that their staff have sufficient knowledge of English.
Recommendation 22, 23 and 24
70. We welcome the Committee's support for our
proactive approach as we strongly believe this will help to drive
up standards of care within the professions. So far in 2011, we
have opened 241 cases where we have proactively found evidence
of poor care.
71. Since our oral evidence to the Committee
we have appointed a Head of Critical Standards Intervention who
will manage and further develop a knowledge management framework
that responds proactively to the identification of poor practice.
As part of this work they will consider trends in NHS and social
care provider outcome and complaints data and take action accordingly.
72. As part of the Law Commission work to help
create a single Act of Parliament we will explore the scope to
make clearer our existing powers of proactive investigation and
where appropriate extend them.
The future of regulation
Recommendation 25 and 26
73. We welcome the Committee's support for a
mandatory statutory regulatory model for healthcare support workers
working under the direct supervision of nurses and midwives.
74. We agree with the Committee's view that only
a mandatory regulatory model will be sufficiently robust to fully
safeguard against those workers that present the greatest risk
to patient safety and public wellbeing. Any final regulatory response
to this risk should include:
53.1. consistent UK wide standards
of training and practice for healthcare support workers that would
assure the public and employers they have the knowledge and skills
to practise safely
53.2. a mandatory register
to keep track of a nationally mobile workforce and ensure workers
who have been struck off the register maintained by the NMC are
not re-employed in a healthcare support role
53.3. statutory powers to take
action to prevent those support workers that present the highest
risk to the public from practising elsewhere.
75. We have begun a project to fully scope the
cost, standards and training requirements needed for us to establish
such a mandatory model. We would welcome assurance from Government
that clauses 225 and 226 of the Health and Social Care Bill as
submitted to the House of Lords - which legislates for the powers
for regulators to establish voluntary registers - will not bias
against any future considerations of proposals for a mandatory
76. In the absence of regulation of healthcare
support workers, we believe that the only way to ensure public
protection is to provide standards that will give nurses and midwives
real clarity about safe delegation. Inappropriate delegation of
care to healthcare support workers is a serious public protection
issue. Delegation of nursing or midwifery care must be appropriate,
safe and in the best interests of the person in the care of the
nurse or midwife. We are therefore developing standards that will
enable the registered nurse or midwife to be confident in the
tasks they delegate. The standards will also ensure they recognise
that they are accountable for the delegation of the task while
at the same time retaining responsibility for the standards of
care delivered in their areas.
Addendum to the Nursing and Midwifery Council's
(NMC) response to the House of Commons Health Committee's annual
accountability hearing with the NMC
The NMC's response to its annual accountability hearing
with the Health Committee submitted in October 2011 stated that
we would "develop a plan to work towards regulating healthcare
assistants, support workers and assistant practitioners".
Since the submission of our response, over the last few months
there have been a number of developments which have led us to
clarify our policy position.
We believe that any initiative which enhances the
skills, knowledge and competence of healthcare support workers
in enhancing patient and public protection is to be welcomed.
We were clear in our response to the Committee that consistent
national standards of training and practice for healthcare support
workers will help to assure the public they have the knowledge
and skills to practise safely.
We therefore support the government's announcement
that Skills for Health and Skills for Care have been commissioned
to develop common training standards and a code of conduct for
healthcare support workers. We believe that together with the
proposals for assured voluntary registration to be administered
by the Council for Healthcare Regulatory Excellence (CHRE) and
our own development of a delegation standard for nurses and midwives,
this provides an effective framework for public protection.
The NMC has a challenging programme of work that
we are committed to delivering particularly in making operational
improvements to our fitness to practise service and developing
a system of revalidation for nurses and midwives - two key recommendations
of the Committee. The focus of our work and resources has to be
on these priorities and therefore it is neither appropriate nor
feasible for us to develop a mandatory model of regulation of
healthcare support workers.