The NMC and insight

Context

The Kirkup report into the life and death of Elizabeth Dixon recommended that regulatory bodies should have an inbuilt stopping mechanism for investigations when evidence of systematic or organisational failures are revealed, and that finding such evidence should trigger an investigation into the wider systemic failures. Kirkup recommended that this mechanism is embedded in legislation.

Insight

We know, from feedback in our research, that being involved in our fitness to practise processes can be stressful and impact people’s mental and physical health and wellbeing. That’s why we want to resolve our cases as soon as we can.

Our approach to taking account of context enables us to identify system issues and, where appropriate, we will refer issues to other organisations to investigate and place cases ‘on hold’ pending the outcomes of those investigations (for example, a criminal investigation). In our view, introducing a legislative ‘stop’ mechanism was therefore unnecessary and, indeed, could cause undue stress to those involved in fitness to practise cases by inadvertently introducing delays into our processes.

Action

Instead we proposed amending our fitness to practise guidance to add an additional circumstance under which we might decide to place a case on hold. This addition was to allow us to understand and account for the impact of systemic concerns on the actions of an individual.

Outcome

Our guidance was updated in July 2022 and is now being used as part of our approach.

Context

When we receive a concern about a nurse, midwife or nursing associate, we check if anyone else has background information that could be useful to us or, where there has been an incident, saw what happened.

In more serious cases, where we consider there is a need to impose a sanction to protect the public or where the nurse, midwife or nursing associate does not accept there are concerns about their practice, we will hold a hearing before an independent panel. We may ask witnesses to participate if we believe their involvement is necessary to the case.

Insight

We sought the views of people who have experienced a hearing and they suggested we could improve how our panels assess witnesses’ evidence. At the same time, there were developments in case law relating to the weight placed on people’s demeanour when assessing the credibility of their evidence.

Action

In July 2022, we updated our guidance to our fitness to practise panel members and legal assessors on how they assess witness credibility. The guidance aims to improve the way we interact with, and support, people going through the hearings process. It makes clear that panels should not rely on the appearance or behaviour of a person giving oral evidence when assessing credibility. Rather, panels should focus on the content of a person’s evidence – whether it is plausible and consistent with other objectively verifiable evidence (including what the witness may have said on other occasions) and with known or probable facts. (A person may speak with confidence in his or her recollection and be honest, but that does not mean that their confident expression should in itself/isolation be taken as a reliable guide to the truth.)

Outcome

This should support panels to focus on the right things in their decision-making. help avoid panels being influenced by any personal biases and prejudices in their decision-making.

Context

Our public support team engages with people involved in fitness to practise cases, including those who have raised a concern with us and others involved, such as witnesses. It aims to improve their understanding and expectation of our role and function, and the fitness to practise process, and ensures that we have fully understood the concerns that have been raised.

Insight

Our oversight body, the Professional Standards Authority, recommended in its 2018 Lessons Learned Review: The Nursing and Midwifery Council’s handling of concerns about midwives’ fitness to practise at the Furness General Hospital report, that we could make improvements in how we support and communicate with people involved with our fitness to practice investigations. It reflected feedback we received from people involved in fitness to practise cases about mismanaged expectations: not feeling listened to, not understanding process or not being engaged in the process.

Action

The public support team was set up in 2018.

Outcome

To date, the team has supported more than 500 people with 1,000 people accessing our independent, 24-hour emotional support telephone line. Five people have accessed our independent advocacy service since we launched it in December 2021. The service was highly commended in the Patient Safety Team of the Year category at the annual Health Service Journal (HSJ) Patient Safety Awards in 2020, with judges noting that it was “vital work which is truly patient centred, a valuable initiative which enables patients to share their experiences.” They also commented:

“The real strength of this project is that the NMC are demonstrating learning and are now listening to and engaging with those who were previously treated like evidence rather than people with feelings.”

Context

NHS continuing healthcare (CHC) is a package of ongoing care, for adults aged 18 and over, provided outside hospital. It is arranged and funded solely by the NHS, where it has been assessed that someone’s need for care is primarily due to their health needs (a ‘primary health need’). It is designed to meet physical and/or mental health needs that have arisen because of disability, accident or illness. CHC exists in England and Wales and there is equivalent provision in Scotland and Northern Ireland.

Assessment for CHC is in two stages: an initial assessment to decide if an individual needs to be referred for a full assessment. Then, if referred, a full assessment, undertaken by a multi-disciplinary team made up of a minimum of two health or care professionals who are already involved in the patient’s care. Registered nurses can be involved in both stages of assessment.

Insight

We received complaints from people who had had their applications for NHS continuing healthcare rejected or amended. They had raised concerns with us about the registered nurse’s role in that process. Typically, their cases were closed by us:

• after initial assessment, either because we concluded the concerns did not require regulatory action, or because we were unable to identify the nurse on our register
• after investigation, because we felt that, based on the available evidence, there was not a realistic possibility that a panel would find a registrant’s fitness to practise impaired.

Using insights from the referrals we had received, we found that many people had raised concerns with several organisations prior to coming to us and felt ignored and frustrated by their experience.

Action

We shared our findings with NHS England and NHS Improvement, as well as national and regional continuing healthcare leads and nurse assessors, to make them aware of people’s experiences.

We also updated our website and guidance to clarify our role with continuing healthcare assessments and to assist our decision makers on how to deal with these cases. We have introduced a referral helpline for people who are considering making a referral to us to provide them with advice and guidance about what we can investigate and the information we require.

Outcome

This should benefit people such as those who referred continuing healthcare matters to us, because we may be able to steer them towards more appropriate channels for the resolution of their concerns.

Context

When Covid-19 lockdown measures were first introduced in the UK, we received an increase in referrals related to the use of social media. Most of these referrals were made by members of the public.

Insight

We analysed these referrals and found that most involved allegations that professionals had inappropriately posted content, such as insensitive or poor choice of phrasing, behaviour or attitude.

Action

At the start of 2022, we were contacted by someone writing a textbook for students and newly qualified professionals for information about the referrals we had received relating to social media use.

Insight

In response, we looked at trends over a longer period (April 2017–November 2021) to isolate any impact resulting from the Covid-19 pandemic. This found many of the same themes as our previous analysis, with most referrals alleging that professionals were sharing inappropriate content.

Outcome

The textbook helps promote good practice and raise awareness of our Code and guidance with a wider audience.

Context

Everyone applying to join our register must share evidence of a qualification from an approved programme completed within five years of their application. Under our previous overseas registration process, qualifications were evidenced by certified verifications from the regulator of the applicant’s registration in their home country.

Insight

We received an anonymous referral alleging that some professionals on our register had used a counterfeit verification certificate from an international regulatory body as part of their registration application. We contacted the relevant international regulatory body, and they confirmed that the individuals had not been registered with them and stamps on their certificates were counterfeit.

Action

We used the insight from these enquiries to create an image-recognition model, to identify other instances where fraudulent stamps may have been used to gain entry onto our register. The model identified stamps that matched an image of a genuine stamp, those that matched an image of a bogus stamp and categorised stamps by how similar or dissimilar they were to the genuine and bogus stamps.

Outcome

We identified a small number of other potentially fraudulent certificates, which we investigated. To date, we have removed 14 professionals from our register.

Context

In 2021, the UK Government introduced the Professional Qualifications Bill. This proposed setting up a new system for the recognition of international professional qualifications following the UK’s withdrawal from the European Union. It also sought to allow regulators in the UK to mutually recognise qualifications either unilaterally or as part of trade deals.

Insight

We provided briefings for parliamentarians scrutinising the Bill, drawing upon insights from our overseas registration process and data about the number of internationally educated professionals on our register.

Action

Our brieings raised concerns about the draft provisions in the Bill including:

• maintaining our well-established and robust process for assessing an applicant’s fitness to practise via our test of competence
• ensuring that health and care regulators are involved in discussions on international trade deals to maintain standards for public safety and appropriate registration processes for international applicants.

Outcome

The legislation was amended in line with our advice, meaning that the Government must now consult with regulators before seeking to introduce any changes that might affect our registration processes.

Context

In 2021, the UK Government consulted on making Covid-19 and flu vaccinations a condition of deployment for those working in health and care settings.

Insights

Our response used insights from our involvement with third party research into attitudes towards Covid-19 vaccination and the ethnicity profile of professionals on our register. Most respondents to the consultation (65%) did not support the proposal.

Action

In our response to the Government, we highlighted several risks:

• Negative impacts on workforce numbers and availability of placements for unvaccinated students across the UK.
• Disproportionate impact on people with different diversity characteristics having lower vaccination levels and higher hesitancy towards vaccinations.
• Increases in unnecessary fitness to practise referrals related to employment issues around vaccination.

Outcome

The Government’s response to the consultation highlighted that many other respondents were concerned about the potential for a disproportionate impact on those with protected characteristics, such as people from particular ethnic minority backgrounds.

They revoked vaccination as a condition of deployment for health and care workers in 2022.