Long-awaited changes expected to speed up fitness to practise cases

Reforms that give more powers to case examiners and the option of agreeing ‘undertakings’ with a registrant come into effect on 28 July.

Reforms that give more powers to case examiners and the option of agreeing ‘undertakings’ with a registrant come into effect on 28 July

The NMC reforms include giving more powers to case examiners,
who decide if there is a case to answer. Picture: Daniel Mitchell

Changes to fitness to practise (FtP) referral processes for nurses and midwives, aimed at speeding up the system, come into legal effect on 28 July.

Reforms include giving more powers to case examiners, who decide whether there is a case to answer, to reduce the number of cases that reach full hearings.

The Nursing and Midwifery Council (NMC) has faced fierce criticism in the past over the time and cost taken up by its FtP cases.


new referrals were made to the NMC in 2016-17, a rise of 1% on the 5,415 received in 2015-16.

The regulator says the changes will ensure that steps are taken at the earliest opportunity to protect the public.

NMC chief executive and registrar Jackie Smith said the regulator finally has the same legislation that the doctors’ regulator, the General Medical Council, has had since 2003. She said: ‘These changes will allow us to deal with cases quickly, fairly and proportionately. They will enable us to protect the public at the earliest available opportunity, helping to ensure that we maintain confidence in the nursing and midwifery professions.’

What are the changes?

Where a serious concern is identified, case examiners will now be able to issue a warning to a nurse or midwife if they show insight and action to remedy the problem, and there is deemed to be no risk to patients.

Case examiners will also be able to agree measures or 'undertakings', such as additional training, with a nurse or midwife to address areas of practice that could cause a clinical risk to patients.


cases were closed at the initial assessment stage in 2016-17, an overall closure rate of 60% compared with 51% the previous year.

In cases where there is a minor breach of the Code the NMC will be able to offer advice privately to a nurse or midwife to help them keep their practice safe.

A single FtP committee will replace the existing conduct and competence committee and health committee. It will be able to make recommendations on whether there is any need to review a suspension order or conditions of practice order before it expires.

What are undertakings?

Undertakings are steps the nurse or midwife is required to take if their practice is seen as a risk to patients, but where the risk can be managed and addressed with certain restrictions.

They are different from existing conditions of practice because undertakings are agreed, rather than imposed, and are more flexible because they are not for a set period of time.

When would a warning be given?

Warnings relate to past conduct, such as where a nurse posed a risk to patients in the past but their current practice proves they no longer do so.


The average cost of a hearing fell from £25,000 to £18,000 in 2016-17 due to more efficient processes.

A warning would be issued where there was a finding of no case to answer, and appropriate details of past regulatory concern would be placed on the public register for 12 months. Previous warnings may be considered for up to three years by examiners looking at any new referrals involving the registrant.

When would advice be given?

Written advice may be given by the NMC to a nurse or midwife when concluding proceedings in which it finds there is no case to answer. The person who referred the case would also be told that it had been closed and advice had been given. The advice may also be considered in any future referrals for up to three years.

When do the reforms come into force?

The changes come into effect on 28 July but apply to the current caseload from 31 July.

Case study 1: Assessment of patients

A district nurse at a large trust was referred to the NMC by his clinical director, who had concerns about his practice in assessing patients, giving safe advice and documenting care given.

The nurse began informal capability proceedings with his employer but did not meet the objectives, so it moved to the formal capability stage.

An assessment of his patients identified failings including not contacting GPs when needed, giving patients incorrect advice about medication, and failing to undertake and record assessments.


After this, the nurse was dismissed. He continued to engage with the capability process but showed limited insight.

Under the NMC’s previous processes the nurse, who admitted his fitness to practise was impaired when he was referred to the regulator, would probably have faced a full hearing due to the clinical concerns.

The new powers would enable undertakings to be agreed, such as restrictions on his practice. The undertakings may include retraining to address areas of concern, after which case examiners would review the restrictions on ability to practise.

The nurse began working as a healthcare assistant following his dismissal and there are no concerns about his competency.

Case study 2: Failings in care

An emergency nurse was referred to the NMC by her employer after giving a patient too much morphine and failing to report the error in a timely manner.

The nurse admitted the failings in care, that her practice did not meet the required standards, and that she had not escalated the report on her mistake quickly enough. 

She provided evidence of remediation, including certificates showing attendance at courses on controlled drugs, titration, recording administration of medicines, and safe escalation of clinical issues. The nurse also submitted a statement from her ward manager at her new employer, where she had worked for three months without any concerns.


Under the NMC’s previous framework, this case would probably need to be referred for a hearing.

This is because although the nurse poses no current risk to patients, a finding of impairment may be needed to protect public confidence or promote and maintain professional standards and conduct. 

But under the new powers the case can be dealt with by placing a warning on her record for a period of 12 months.

The reason is that while the case involves a serious incident, the nurse has accepted the concerns, demonstrated insight and shown that her current practice does not present any risk to patients.

Further information

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