Conclusions and recommendations
Introduction
1.
The NMC has requested Department of Health support for further
amendments to the legislation that governs its operation. The
Committee broadly supports this request, as improvement to the
performance of the NMC in some key areas is hampered by its current
legal framework. The Government must prioritise this work if it
wishes to see further improvement in the performance of the NMC.
(Paragraph 3)
2. The Committee welcomes
the improved financial performance of the NMC in recent years,
but is concerned about the affordability of the registration fee
for many lower paid registrants. We would urge the NMC to avoid
further fee rises and to consider fee reductions for new entrants
to the register. (Paragraph 4)
3. The NMC is now
leaving behind its previous organisational and financial instability,
and is improving in many areas of its work. There remains however
a significant amount of work to be done in order for it to be
an effective regulator that has public protection as its principal
concern. (Paragraph 9)
4. Although, therefore,
the Committee recognises that the NMC is developing a higher level
of operational competence, it remains concerned that the leadership
function of the NMC remains underdeveloped, particularly in the
areas of fitness to practise, revalidation, education and training
and proactive regulation. The Committee hopes that the NMC will
embrace more ambitious objectives for professional leadership,
some of which are described in this report. (Paragraph 10)
Fitness to practise
5. The
Committee is very concerned about the recent dramatic rise in
the numbers of NMC referrals of nurses and midwives, and that
NMC reports make it difficult to distinguish between referrals
made about nurses or midwives. We are surprised that the NMC has
no clear answer to why referrals are increasing, and recommend
that the NMC undertakes urgent research to establish the reasons
for this increase. This data could and should be used to support
the development of revalidation and a more proactive approach
to regulation. (Paragraph 13)
6. The Committee is
also concerned that an analysis of ethnicity data on the nursing
and midwifery register is still not available despite having made
assurances that this would take place in 2010. Of more concern
is the fact that, according to its own records, the NMC is still
not recording ethnicity or other diversity monitoring in fitness
to practise cases. Without this, neither the professions nor the
public can have confidence that the NMC discharges its functions
in a manner that is fair and equitable to minorities. (Paragraph
14)
7. Following our earlier
report into complaints and litigation, the Committee remains very
concerned about the existence of low standards of basic nursing
care in our acute hospitals and care homes, which appear to be
in breach of the code of conduct for nurses and midwives. We are
particularly concerned about this in light of the ongoing inquiry
into Mid Staffordshire NHS Foundation Trust, the Winterbourne
View scandal and the recent Health Service Ombudsman report into
care of the elderly in hospital. (Paragraph 17)
8. This evidence presents
a challenge to the NMC which is responsible for professional standards
in the nursing and midwifery professions. Based on its existing
guidance on care of the elderly, we propose that the NMC should
develop a programme of action to deliver a demonstrable improvement
in outcomes for this vulnerable group. (Paragraph 18)
9. Furthermore, the
NMC needs to send a clear signal to nurses and midwives that they
are at as much risk of being investigated by their regulator for
failing to report concerns about a fellow registrant as they are
from poor practice on their own part. (Paragraph 19)
10. The Government
is proposing to have one Act of Parliament that establishes the
core functions of professional regulators, leaving them to decide
how they discharge these. The Committee welcome the Governments
plans for simplification of the legislation that underpins professional
regulation in the UK. (Paragraph 22)
11. However, in the
light of criticisms by the CHRE about "significant weaknesses"
with the process, the Committee urges the Government to bring
forward amendments as soon as possible to the Nursing and Midwifery
Order 2001 so that the NMC can streamline its fitness to practise
procedures. (Paragraph 23)
12. The Committee
supports the proposal that nurses and midwives be able to voluntarily
remove themselves from the register. However, where concerns have
been raised about a nurse or midwife seeking erasure, or where
an investigation is taking place into fitness to practise, erasure
must only take place with the consent of the complainant and on
publication of the full details of the case against the registrant.
(Paragraph 25)
Revalidation of nurses
13. 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. (Paragraph 31)
14. 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. (Paragraph 32)
15. The Committee
will monitor progress against the 2014 deadline for the introduction
of revalidation by the NMC at subsequent accountability hearings.
(Paragraph 33)
16. 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. (Paragraph 39)
17. 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.
(Paragraph 40)
18. 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. (Paragraph 41)
19. 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. (Paragraph 45)
20. 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. (Paragraph 46)
21. 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. (Paragraph
47)
Proactive regulation
22. We
welcome the NMC's initiative in opening proactive investigations
into registrants without a formal referral from an employer, a
member of the public or another professional. (Paragraph 50)
23. The NMC's plans
for investigation of and intervention in a healthcare organisation
where concerns are being raised is a creative and interesting
approach to regulating what is a large group of professionals
working across a variety of settings. It offers the NMC another
tool to strengthen public protection. (Paragraph 55)
24. We do feel however
that whilst the power to look at the quality of educational environments
gives the NMC "a foot in the door", clear power must
be established in law for further expansion of this role, and
we encourage the Government and the NMC to work together to develop
this approach. The Committee would particularly like to see the
NMC responding to trends in outcome and complaints data from NHS
and social care providers. (Paragraph 56)
The future of regulation
25. As
previously mentioned, the Committee has ongoing concerns about
the care and treatment of older people both in hospitals and care
homes. Of particular concern to the Committee is the lack of regulation
of a range of groups who undertake many basic nursing care tasks.
(Paragraph 63)
26. The Committee
endorses mandatory statutory regulation of healthcare assistants
and support workers and we believe that this is the only approach
which maximises public protection. The Committee notes that the
Government intends to give powers to the relevant regulators to
establish voluntary registers for non-regulated professionals
and workers, but would urge it to see healthcare assistants, support
workers and assistant practitioners as exceptions to this approach
who should be subject to mandatory statutory regulation. However,
the NMC needs to make significant improvements in the conduct
of its existing core functions (such as in how it manages fitness
to practise cases) before powers to register these groups are
handed to it. (Paragraph 64)
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