The NMC isn’t all about striking people off – there’s so much we can do to support care
New chief executive wants registrants going through FtP processes to be shown kindness
New chief executive wants registrants going through FtP processes to be shown kindness
- The nurse regulator has a greater role to play in supporting care improvements, says its new head
- She makes clear distinction between individual culpability and mistakes made under unreasonable work pressures
- The NMC will strive to minimise referrals by empowering employers to handle a greater volume of complaints in-house
For many nurses, the Nursing and Midwifery Council (NMC) is the organisation that takes their registration fee and – should they ever get into serious trouble – removes them from the register. It exists to protect the public. It is a distant and at times punitive presence in the world of nursing.
The NMC’s new chief executive, Andrea Sutcliffe, has a different view. She wants the regulator to be kind – not just to members of the public who have experienced poor care but to the nurses, midwives and nursing associates who go through fitness to practise (FtP) procedures. ‘Kindness is not something people necessarily associate with a regulator but actually it is really important because it is about treating people with dignity and having empathy with them.
‘If you are a member of the public and have had poor care and end up referring a professional to a regulator, you are in a bad space, you have gone through enormous distress and we really should not be making it worse. But the other part of being a regulator that treats people with kindness is we have to think about the impact on our registrants, because when you are under scrutiny that is a difficult place as well.
‘It is right and proper that on rare occasions, when it is necessary, we take people off the register but that does not mean we have to treat people in a bad way. We can treat people decently, we can treat people with kindness and we can ensure we make the best possible decisions.’
‘We don’t want to catch people out’
Ms Sutcliffe doesn’t see any tension between protecting the public and being kind towards nurses and midwives who may be unfit to practise: ‘I don’t think we should make this an either/or equation.’ She argues that a ‘process-driven’ approach that disregards the impact on registrants of FtP procedures only makes it harder to protect patients and their families. ‘It causes professionals to be more defensive, when actually we want them to be open, we want them to share with us the information about what has happened.’ She adds: ‘We want people to be fit to practise – we don’t want to catch them out.’
‘We are sitting on an evidence goldmine that we should be feeding back into the system. It’s not about us fixing the health service but sharing that insight’
Ms Sutcliffe isn’t emphasising the need for kindness and ‘putting people at the centre of what we do’ just to be nice. She believes a kind or ‘humane’ approach is essential if the NMC is to play a bigger, more positive role in improving standards of care. This means working in ‘co-production’ with the public, professionals and other partners, including the Care Quality Commission and, importantly, employers.
Career to date
Ms Sutcliffe started her career in health service management and is a former deputy chief executive of the National Institute for Health and Care Excellence.
She joined the NMC in January after five years at the Care Quality Commission (CQC) where, as chief inspector of adult social care, she was credited with building bridges with care providers and ensuring the CQC listened to people who use care services.
A Guardian article in December 2018 noted she had proved a ‘popular figure’ in the social care sector and predicted she would turn out to be ‘just as strong a cheerleader for good nurses, midwives and nursing associates’ in her new role.
She wants to distinguish between cases where things have gone wrong because a nurse or midwife was at fault and those where the individual was put under unreasonable pressure by failures in the system. Information from the latter is, she suggests, highly valuable. ‘We are sitting on an evidence goldmine that we should be legitimately feeding back into the system. It’s not about us fixing the health service, it’s about us sharing that insight and ensuring that others whose responsibility it is, are aware.’
Ms Sutcliffe emphasises that an adversarial approach to FtP doesn’t make care better, and nor does it satisfy patients and families who have suffered from poor care. ‘When things go wrong people say they never want it to happen to somebody else. Making sure it doesn’t happen again doesn’t necessarily mean you have to strike everybody off. It does mean that people are not in a position to make the same mistake again. If they can demonstrate they understand what went wrong, they have remorse, and they have done training so it is not going to happen again and they are fit to practise, we should enable them to do so.’
The mum test
Having just spent five years at the Care Quality Commission, Ms Sutcliffe wants to transfer the approach she used there to the NMC. This includes the ‘mum test’ (‘Is this a service I would be happy for my mum or someone I love to use?).
It is rare to meet a high-profile leader in the health sector these days who does not talk about the importance of listening and being person-centred, but Ms Sutcliffe does it with a winning sincerity. And she is evidently willing to follow through. One of the first things she did when she moved to the NMC was to meet a young mother who had lost her baby to poor care, and then endured another gruelling experience during the FtP process. She exchanged video messages with the woman’s children and now has some of their drawings pinned up on the wood-panelled walls of her office in the NMC’s elegant London HQ.
Our efficiency has improved, but there’s more to do
To be more person-centred and compassionate, the NMC will have to be more efficient. It holds the largest register of any UK healthcare regulator – 690,000 nurses and midwives, and as of January, nursing associates too – and has too often given the impression of being overwhelmed by the sheer volume of referrals. Ms Sutcliffe says performance improved ‘leaps and bounds’ under her predecessor Jackie Smith, who faced a ‘huge backlog’ of FtP cases, but admits ‘there is more we can do’.
Ms Smith resigned days before a damning report by the Professional Standards Authority, the regulators’ regulator, into the NMC’s handling of concerns about midwives at Furness General Hospital, part of University Hospitals of Morecambe Bay NHS Foundation Trust, where deaths of mothers and babies were linked to poor practice. The Lessons Learned Review identified multiple failures, from poor record-keeping to a lack of transparency and engagement with bereaved families. Arguably the most glaring failure at the NMC was the extraordinary length of time taken to deal with cases. It received its first complaint about midwives at the hospital in 2009, but did not complete its work until July 2017. The delays added to the families’ distress, but the review noted they were also hugely stressful for the midwives under scrutiny.
Ms Sutcliffe says it is difficult to set a time limit on FtP cases because of variables outside the NMC’s control, such as the progress of police investigations. But she agrees no nurse or midwife should ever have to wait the best part of a decade to have their FtP case resolved: ‘That should absolutely not be happening.’
A range of initiatives is under way at the NMC to speed up its handling of cases and improve efficiency, from investment in technology to increased support for staff. But Ms Sutcliffe also wants to reduce the number of referrals by supporting employers to handle cases that come under their remit and do not require NMC involvement. As things stand, more than 50% of cases do not proceed beyond the first stage of the FtP process, which suggests they should never have been referred. An employer link service has been established to build relationships with organisations and enable them to handle more cases themselves: ‘When an employer can manage a case they really should get on with it.’
The Future Nurse Standards
From this September nursing students in the UK will be trained against new standards intended to equip them to meet the complex demands of our ageing population and take on leadership roles in the delivery of care.
But the Future Nurse Standards – the result of a wide-ranging programme led by Dame Jill Macleod Clark and unveiled last year – will also have huge implications for existing nurses and midwives, who will need to support students and ensure their own practice is in line with the standards.
‘At the point of care, nurses do need to know about the standards,’ says Ms Sutcliffe. And this isn’t just about getting the message across that the biggest change in nursing since Project 2000 is on its way: ‘One of the things that is really important is the role of continuing professional development (CPD) in ensuring existing nurses at the point of care are aware of the standards and have the support to develop their practice to meet them.
‘We have had a lot of conversations with [NHS chief executive] Simon Stevens about the importance of CPD. This isn’t esoteric, there are practical implications.’
At the chief nursing officer's summit in Birmingham earlier this year, Professor Macleod Clark suggested that the standards and the NHS Long Term Plan were an opportunity to exercise political muscle and ‘leverage’ to ensure investment in nursing and funding for CPD. Ms Sutcliffe chooses her words carefully but she acknowledges that she has made it clear to the long-term plan’s workforce implementation group that the standards are ‘critical’ to the success of the government’s long-term aims for the health service.
‘You ignore the needs of nurses and midwives at the point of care at your peril,’ she says.
The experience of BME registrants
There is a particular issue with referrals involving black and minority ethnic staff. ‘We have disproportionate referrals of black and minority ethnic nurses from employers, not from the public. That is very interesting. And a high proportion go nowhere – a referral is made and we determine that there is no case to answer.’ Ms Sutcliffe suspects that organisations with high referral rates for BME staff will also score less well against the workforce race equality standards (WRES) that track the career progress and experience of staff. ‘What does the WRES data say [about organisations that make these referrals]? Can we marry it up and feed that back to their organisations and say “You have issues to address”?’.
Even when someone has made a mistake or performed poorly, Ms Sutcliffe wants the regulator to ‘ask about context’ rather than focusing purely on the individual, and risk blaming them for system failures. She emphasises that there are cases where someone working in difficult circumstances has been ‘utterly reckless’ and will need to be held to account. But she does not want an individual to lose their career when ‘in the context in which they are working, anybody could have made this mistake’. A pilot is under way to explore how to take account of these complexities.
A package of support for registrants going through the FtP process is also being developed. An independent helpline should be running by the summer that will direct callers to counselling if appropriate, and there are plans to provide free legal support for the large number of people who have no representation.
With Ms Sutcliffe at the helm, the NMC will attempt to unite kindness with competence and have an influence that goes far beyond FtP. ‘In the coming year we will be developing our strategy for the next five years, 2020-25 (#futureNMC), and one of the things I want us to think about is what is the changing nature of health and social care, what does that mean for nurses, midwives and nursing associates, and how should the NMC respond to that?
‘I want the NMC to be seen as an organisation that adds value in the world of health and social care. What we are about is making sure people get the best, safest care possible and enabling nurses and midwives [to deliver that care].’
If she succeeds then contact with the regulator will no longer be something that makes nurses and midwives anxious. ‘I want the standards we set – and how we use those standards – to enhance professional pride.’
Thelma Agnew is commissioning editor, Nursing Standard