On Tuesday 19 November, NMCWatch released data on the number of Fitness to Practice (FtP) referrals by NHS employers to the Nursing and Midwifery Council (NMC). In the run-up to this release, we had some healthy internal discussion about what the data represents and how it might be interpreted. Our finance director, Peter Bates, is a retired statistician. These are his thoughts.

At first sight, there appear to be big differences in the numbers between similar NHS Trusts. 

Though, surprisingly, not all Trusts have provided this important information so we can’t be definite yet. Some of the employers who are currently at the top of our list for referring nurses and midwives to the NMC may not really deserve that place at the top. Perhaps the Trusts who are really at the top have failed to reply because they are embarrassed at the high number of referrals they’re making? (They certainly should be embarrassed if they simply do not know that number). 

Failures of clinical care are, thankfully, not everyday occurrences. And as the overall numbers of referrals are small, those differences between employers could be just down to chance. Again, we can’t really analyse these differences with the statistical rigour we want to until we get information from all the employers.

But we can start to consider how that variation could exist. How is it that – at least at first sight – some employers seem to refer practitioners to the NMC at double the rate of others? 

One simple answer is that the nurses and midwives employed at some Trusts are inherently less conscientious or skilled than those in others. Frankly, that seems unlikely.

A more plausible answer is that management styles differ between employers. 

In some places managers and supervisors are perhaps able to be more vigilant and to identify more failures in care. Elsewhere, what may be different is the management reaction to those apparent failures. 

What we have learned from the many individual practitioners who we have supported, is that some employers will often deal with failures in care internally. For example, managers make corrections or give further training, or if the failure is more serious or systematic, internal staff disciplinary processes will be used.

With other employers, these care failures will, in addition, be referred to the NMC – the statutory body for regulation. In very serious cases that is exactly what is needed, and this is what the regulatory system was designed to do. The referral means that the failure of care is looked at independently of the local management structure. If professional sanctions are found necessary to protect the public (for example limiting what a nurse or midwife can do, or even taking them off the professional register altogether) then those additional powers are available.

But it is apparent that employers’ judgement of what is a “serious case” can vary. Sometimes that variation can be between different types of error. But it can also be between different levels of evidence seen as necessary. From the registrants we support we know that some managers dealing with, say, a failure to make a proper written record see it as a matter for internal discipline, while others make a referral to the professional regulator. 

Are those managers that do refer simply more conscientious in protecting public safety? Or do they want to cover their own failures to supervise? Or – and again we have anecdotal evidence of this – are they using the referral to carry on their own personal agendas?

There are a number of cases we have seen – after enquiries and hearings that can take years – in which all the “charges” against a nurse or midwife brought to the NMC are dismissed. 

There are then no sanctions against that practitioner. Apart, of course, from four or five years of mental stress and financial worries in which a highly trained nurse or midwife often can’t use their much-needed skills. 

Significantly, there seem to be no follow-ups to employers when the “case is dismissed”. As part of the referral process, nurses and midwives are often asked to write a “reflection” – a narrative about what happened, their own thoughts and ideas about how things could have been different. But even this reflection process is not something that is required of the manager who made the referral which turns out to be pointless.  

Or the HR department that endorsed it.

NMC has a serious backlog of cases – they are detailed in our work and in NMC’s own publications. The variations which our data is starting to suggest might identify places where the NMC’s own guidelines about referral are being misunderstood or ignored because of local management culture.

Wouldn’t it be a good idea for everybody if NMC was able to spot those places and do something about it?