The Nursing and Midwifery Council Independent Culture Review July 2024.

Our statement on the Rise Associates report.  In response to the report released today we have made several observations and pulled out 10 themes that need urgent attention.

Theme  1:

“At virtually every level of the organisation, across all directorates, we witnessed a dysfunctionality that was causing emotional distress to staff and preventing the organisation from properly functioning. This is perhaps best illustrated through comments from a senior leader who referred to a “low trust environment characterised by suspicion, fear, blame, resistance and silos”.  NMCW response: we see this all the time with our members reporting that one department does not communicate with another, having to repeat key information when cases move from screening to investigation and key evidence from the registrant lost between those handling the case. For example Nurse A described at screening key contextual information and assumed this would be put infront of the case examiners. The case examiners did not view it and when going to hearing, the NMC objected to it being included as evidence because it supported Nurse A’s testimony. Questions: 1.1  Who is responsible for ensuring continuity during case management?

Theme 2:

Training and Job satisfaction of teams: We would expect our regulator to be demonstrating the best workplace culture and part of this is ensuring people are in the right jobs, can develop in those roles and use their experience to train others to their high standards. All of this seems lacking. This isn’t a surprise but extremely concerning. We have for a number of years been asking for transparency around how staff are trained, supervised and spot checked to ensure working as they should be. The report shows us that internal staff have equally been asking the same questions for years too. We have also asked for this in regards to training of panels and case management teams – the NMC have been very guarded in supplying this and have only given brief summary with no specifics Questions: 

1. Why have council not picked up on this to date? 
2. Why are council not setting standards for training of staff and ensuring they assess competence and continuity across teams?

Theme 3:

More diversity in panels / experience of panels: We have noticed recently that panels are being slightly more inquisitorial particularly around challenging the NMC when evidence is missing. However, this is still not consistent and needs to be paramount to their role to ensure fairness to all parties. It is difficult when the panel are recruited, trained and paid by NMC though to assure independence. With the nearly 70 cases we have been involved with we are yet to see any panel member that has a current role within the NHS at ward level. The background of panel members is not disclosed and should be as sometimes there can be unrealised bias if they are employed by the trust for which is at the centre of the dispute, for example.  Questions : 3.1 Why can panels not be managed externally so they are truly independent?

Theme 4: 

Poor case management and pre hearing preparation We completely agree with this – cases that have gone on many months or even years, still at hearing with missing evidence and key evidence not sought. Documents only entered in part eg prescriptions sheets, that could give better oversight of the problem if the whole document was included – is this deliberate? Questions: 4.1 What is the consequence for those not being transparent with evidence?

Theme 5:

“Demystyfying the process” We spend a huge amount of time explaining the process to registrants, what each stage means and the impact it has. We ensure they understand what is needed from them and what the areas of concern are and what they need to do to address them. The NMC sends out +++ written information but much of it is repetitive and much of it not relevant eg same information sent out more than once. This causes the registrant to be overwhelmed and potentially miss key information  We are attempting to design a training program for registrants – however should this be left to a voluntary organisation with no funding?! Questions: 

1. Why can the NMC not send out short leaflets explaining each stage?
2. Why does case management not include ensuring the registrant understands what is expected of them?
3. Why does the NMC not develop a training program around insight and remediation that panels would recognise as part of their portfolio of evidenceto support improvement?

Theme 6:

“willful deafness to criticism and a culture that is seemingly not open to feedback and opportunities to improve when things go wrong. “ We have raised numerous complaints to the NMC and escalated to the PSA, many of which have common themes. Eventually they are responded to but rarely are responded to in full. Responses tend to explain what the NMC are doing rather than what they are not and do not address the evidence provided that it has not occurred in practice.  Question: 6.1 Who’s responsibility is it to track common themes between complaints 6.2 Why do council not review and track?

Theme 7:

Investment to clear backlog – no acknowledgement that there have been continued investments dating back to 2016 band yet we still have a backlog

1. What will be done differently this time?

Theme 8:

“duty of candour responsibility for healthcare professionals to be honest when things go wrong has become anathema at the NMC. “  A large proportion of our group are whistleblowers – raised concerns at their workplace and then found themselves referred to the NMC. This information is passed on to the NMC as context but little is done with it, sometimes used as a way of the registrant seeking to blame others rather than taking responsibility for their own actions. The suggestion of an independent oversight board is a good one but will this include looking at how whistleblowers referred to NMC are treated and ensure that FtP process does not play into m is treatment of whistleblowers?

Theme 9:

“Data driven organisation” since NMCWatch’s outset 7 years ago we have been asking for accurate data on suicide, self harm and retention in profession following FtP. This is still either none existent or poor and needs to change

Theme 10:

Safeguarding people involved in our processes:  The report highlights that since April last year, six people have died by suicide or suspected suicide while under, or having concluded, fitness to practise investigation. Condolences to their relatives is not enough. One lady has contacted us, following the suicide of her close friend last year whilst under FtP investigation. She tells us: “I don’t want David Warren’s condolences. His worthless apology is far too little, far too late. The NMC’s Fitness to Practice procedure ate away at a wonderful nurse for years over a totally invalid accusation. It took her confidence, her joy, and ultimately her life. No apology can atone for their cruel and thoughtless treatment. Radical change is needed immediately before we lose any more lives.” Since 2016 there have been 27 registrants die by suicide prior to the conclusion of their case: 2016 – 18 11 2018 – 19 4 2019 – 2020.   1 2020 – 2021 0 2021 – 2022 3 2022 – 2023 2 2023 – 2024 6 We have escalated a number of nurses to the NMC to try to get agreed removal on health grounds due to their mental health. We have provided extremely clear medical evidence that the process is exacerbating their suicide risk and to continue would put them at severe harm. One lady had a suicide attempt on receipt of NMC correspondence, we tried to ensure all comms would come to us moving forward and yet they still send to the registrant – luckily her family intervened. Despite efforts of some well minded people at NMC ultimately the lawyers make the decisions and the decision was always “NO”. The cases continued with hearings. If the nurses did not have NMC Watch supporting them they would no doubt have been one of the 6 who died by suicide last year and similiar numbers on previous years. Registrants are made out to feel like they are playing the mental health card to get out of process. This has to stop. When you have a nurse that has made the painful decision that they are no longer well enough to work, the NMC must respect this and ensure they do not make things worse – safeguarding must not be sidelined “ Question: 10.1 How many more registrants have experienced worsening self harm during FtP investigation 10.2 Why when medical evidence is provided to show FtP is increasing suicide risk is this ignored or not given weight.    

Next steps needed:

1. The report failed to examine the poor integrity around information governance and the multiple amount of GDPR breaches during FtP
2. The report failed to dig down into the aspects concerning the nurses who died by suicide and causation during process
3. There was no analysis of the impact on nurse retention in profession following investigation.