There are “serious issues” in the performance of the Nursing and Midwifery Council (NMC), including delays in handling fitness to practise (FtP) cases and problems in quality assuring education providers and maintaining the integrity of the register, a review by the super-regulator has found.
The Professional Standards Authority (PSA) – which oversees 10 healthcare regulators in England – has today published its severely delayed annual performance review of the NMC for 2023-24.
“The PSA’s latest report reflects a dark period in the NMC’s history”
Paul Rees
In the period analysed, 1 July 2023 to 31 December 2024, the watchdog found that the NMC had met only 11 of the 18 regulatory standards, reflecting the high-profile challenges it faced during that time.
This is a significant drop from previous years, when it consistently met 17 of the standards, apart from the one related to FtP timeliness.
The NMC said the findings reflected “a dark period in the NMC’s history” but that it was “on the road to recovery” and was determined to rebuild trust and improve its culture.
The publication of the PSA report was delayed because the watchdog was awaiting the outcomes of ongoing critical reviews.
An independent culture review, published in July 2024 by former chief crown prosecutor Nazir Afzal and Rise Associates, found a “hotbed of bullying, racism and toxic behaviour” within the regulator, which was putting the public at risk and endangering registrants.
Two outstanding independent reviews into the NMC’s handling of whistleblowing concerns and of certain FtP cases highlighted as part of the whistleblowing disclosures, being led by Ijeoma Omambala KC, are still yet to be published.
The PSA noted that it was in the public interest to report on the NMC’s performance “in a timely way”, which is why it decided to publish the report now.
It said it would consider the findings and any recommendations from Ms Omambala’s reports when they become available.
Overall, the PSA said it found “serious issues” across a number of the NMC’s regulatory functions during the review period.
It highlighted how the NMC was not clear about its purpose as a regulator, nor did it ensure that its policies were applied appropriately across all areas.
This was echoed in the independent culture review, which found that the NMC had “strayed from its central mission”.
The PSA concluded that the issues within the NMC, “both operationally and culturally”, were “sufficiently serious” for it to judge that the standard around its core purpose was not met.
“Whilst the report reflects the past, we are not complacent”
Ron Barclay-Smith
Meanwhile, the super-regulator identified “significant issues” in relation to the NMC’s work to assure the quality of education and training for nurses and midwives.
The NMC, therefore, failed to meet the standard requiring “a proportionate and transparent mechanism” to assure that educational providers and programmes meet requirements for registration.
The PSA spotlighted the decision by the NMC to strip Canterbury Christ Church University’s midwifery course of its accreditation, due to concerns about the practice learning environment.
The regulator later discovered that the programme had been miscalculating students’ practice learning hours.
Subsequent reviews found that other institutions had also allowed students to complete their courses despite failing to meet the standards for practice learning.
“Some significant concerns have been identified about the NMC’s ability to effectively monitor and quality assure [approved education institutions],” the PSA report said.
“By the end of the review period, the NMC was in the process of developing an improvement plan to address these.
“However, this was not finalised and we had concerns about the NMC’s ability to implement it.”
The annual review also identified issues with the NMC meeting its registration standard, which requires it to maintain and publish an accurate register of those who meets its requirements.
It noted that the organisation had seen an increase in the number of incorrect or fraudulent entries to the register during the review period.
In particular, it said there were three separate investigations ongoing into large-scale fraudulent applications for registration, including alleged fraud at a computer-based test (CBT) centre in Nigeria and an occupational English language testing (OET) centre in India.
Fraudulent applications using a forged Pakistan Nursing Council stamp were also being investigated, it said.
The PSA set out that the total number of people added to the register without meeting the NMC’s requirements was more than 350 and could be up to 400 depending on the outcomes of the CBT and OET investigations.
While small in proportion to the NMC’s register – now at 853,000 professionals – the PSA said it was still “a large number of individuals to be registered in error”.
It said: “The NMC has added a large number of people to the register who had not met its requirements, and by the end of our review period it had not been able to fully remedy the situation.
“Whilst it has taken steps to mitigate the risk of widescale fraud in the future and has begun to develop work to improve its controls in education quality assurance, we were not sufficiently assured about the NMC’s ability to ensure the integrity of the register during the period under review.”
Since 2018-19, the PSA has found that the NMC has not met standard 15, which relates to the timeliness of decision making in FtP cases.
While it said there had been some “positive indications” of the tide changing, the overall time taken for FtP cases to conclude “remains concerning”.
It found that, despite a £30m investment and new FtP plan, there continued to be areas of weakness and that cases were taking too long to process.
The regulator therefore failed to meet this standard for the sixth year in a row.
Further, the PSA report found that the NMC did not meet the standard for identifying and prioritising cases in which patients were most at risk.
The PSA has written to the secretary of state for health and social care, Wes Streeting, and the chair of the Health and Social Care Committee, Layla Moran, to make them aware of the concerns in the report.
It said it would closely monitor any actions undertaken this year by the NMC to improve its performance, in its annual review for 2024-25.
The watchdog did not confirm when this would be published.
Responding to the report, the NMC said it was “on the road to recovery” following a challenging two years in the organisation’s history.
Since the period analysed, it noted that the organisation was under new leadership, with Paul Rees and Ron Barclay-Smith taking the helm as interim chief executive and registrar, and chair of council, respectively.
The regulator’s executive board has also undergone a reshuffle, following mass resignations, as reported by Nursing Times.
Meanwhile, the NMC also said it had started to see progress through its refreshed FtP plan, including increasing cases resolved within 15 months, record numbers of decisions at screening and establishing a safeguarding hub and new referral process for raising concerns.
It is also undergoing an overhaul of its toxic culture, as identified in the independent culture review, through a new culture transformation plan.
Paul Rees
Mr Rees said: “The PSA’s latest report reflects a dark period in the NMC’s history, and we expected to fall short on meeting some of the standards of good regulation.
“I recognise that our performance in 2023-2024 was not good enough and since joining the NMC in January, I’ve committed to turning the organisation around – ensuring that we build a positive, empowering and inclusive culture for our people, and improve the regulatory experience for the public and nursing and midwifery professionals.”
Meanwhile, Mr Barclay-Smith said: “It is clear that 2023-24 was a particularly difficult year for the NMC, with significant, high-profile issues during that period, which the organisation has since started to address at pace.
“Whilst the report reflects the past, we are not complacent. We continue to learn and improve so as to be the best we can be.
“As chair of council, I am determined to guide, challenge and support the NMC executive so that the organisation is fit for purpose, and can promote the safe and effective nursing and midwifery care everyone has the right to expect.”
