‘A good workplace culture drives performance, it delivers better outcomes, it celebrates success, roots out poor behaviour and embraces continuous learning. Leaders, through their actions or inaction, determine the culture that the organisation accepts.’
[NMC Independent Culture Review, Nazir Afzal OBE and Rise Associates, July 2024, page 5]
The Nursing and Midwifery Council Independent Culture Review, written by Nazir Afzal OBE, was published earlier this month. It concerns a lot of issues very close to my heart, any one of which could form the basis for a separate blog in the future.
The NMC is the independent regulator (by statute) of just over 800,000 nurses and midwives in the UK. It aims to protect the health and wellbeing of the public. Although my own interest is primarily in non-statutory regulation, it is easy to see the relevance of this independent review to professional accountancy bodies, which are also relied upon for the protection of the public.
The Report will be crucial to the wellbeing of NMC staff and those regulated by the NMC; but also to the safeguarding of patients – something in which we all need to be able to trust. The review's methodology included a survey that elicited responses from 1,044 of the NMCs 1,250 staff, more than 200 hours of interviews with current and former staff members, and hundreds of documents received through secure email.
The Report’s findings include damning conclusions in the areas of whistleblowing, racism, discrimination, bullying, competence and public protection. The last of these even includes failure to take regulatory action in cases of serious sexual assault, and ongoing failure to expedite investigations.
I take no pleasure in highlighting some of the contents of the Report. In fact, Nazir Afzal himself, in a letter to NMC Chair Sir David Warren, wrote that the interviewers ‘found it painful to listen to hours of testimony on racism, bullying, safeguarding failures and toxic behaviours that made people feel devalued and degraded. It was frequently hard for people to revisit these experiences and we do not want their testimony to be in vain.’
Whistleblowing
Although very badly handled within the NMC, the review speaks to the value of whistleblowing, as the review itself was commissioned following claims of a ‘toxic culture’ made, to The Independent, by a whistleblower in 2023. But, as the Report reminds us, the NMC is no stranger to criticism (to say the least), and a review in 2020 found that NMC staff often failed to raise concerns for fear of repercussions.
The words of the whistleblower in this case appear in the Report:
‘I am utterly broken by this experience and my physical and mental health has really suffered […] I can’t sleep, am taking antidepressants and worry that it will all be for nothing because they refuse to change.’
Although the whistleblower did not regret exposing the NMC's cultural failings, they claimed that anyone doing the same would be treated harshly, saying that the NMC would ‘turn it against you, just as they have done on me. The NMC will accuse you of taking the wrong tone, of undermining them, anything but confront the substance of what you are saying.’
The Report states how it quickly became apparent, from staff interviews, that senior leaders in the NMC felt anger towards the whistleblower, and were irritated by the issues raised, rather than seeing the information as an opportunity for learning. The Report goes on to state:
‘Everything the whistleblower documented was corroborated and we spoke to many others that had similar experiences. On reflection, given these patterns, it’s remarkable that there have not been more whistleblowers coming forward.’
One reason I have chosen to highlight the Report is that it questions whether the NMC’s apparent commitment to change is genuine, given the large number of criticisms it has faced in the past. I truly hope it is, particularly as the Report concludes:
‘The tragic incidents of registrant suicide, of self-harm and untreated trauma both within NMC and by those they regulate is a call for immediate action, not a five year strategy.’
I would urge you to read the full Report. In the meantime, I have tried to group some important passages from the Report below under headings that are important to me, as they concern ethics, culture, professional standards and mental health:
Leadership and culture
‘We carried out interviews with the executive and senior leadership and it was clear this team was not functioning properly.’
‘Bullying is clearly a problem and the NMC’s response has focused on the movement of complainants either elsewhere in the organisation or to a rapid exit.’
‘… we document many other cases of bullying and bad behaviours that are wholly inconsistent with the NMC’s values.’ [Fairness, Kindness, Ambition, Collaboration]
‘Most people felt confident to talk about issues that concerned them at work with their line manager and peers. However, that figure changed sharply when asked if they were confident to talk about issues that concern them with HR. A majority were not.’
‘Criticism around the leadership centred on its failure to reduce the backlog and maintain a clear purpose, crony culture where talent was side-lined in favour of friends, a lack of diversity at senior levels and the creation of a closed culture with an unwillingness to brook criticism or properly learn from mistakes.’
Regulation
‘Currently, the NMC is trying to get through a huge backlog of Fitness to Practise cases, which is close to 6,000’
‘In one case, a nurse had been accused of sexually assaulting patients and raping a colleague after spiking their drinks. This was closed down in the screening team on the basis that the rape was done outside of work’
‘In the last year there has been multiple Serious Event Reviews relating to the potential failure of the NMC to appropriately handle allegations of physical or sexual abuse against children occurring outside of clinical settings. Some of these cases were closed at screening due to allegations that include accessing category A child pornography.’
‘The absence of a clinical voice in this process was highlighted as a key reason why public protection was not paramount, as was the oft repeated claim that some of the teams did not fully understand safeguarding and were trapped in a dangerous groupthink.’
Racism and discrimination
‘One of the most glaring barriers I’ve encountered is the lack of representation of individuals from diverse backgrounds in senior roles. Despite efforts to promote diversity and inclusion, there remains a significant disparity in the representation of ethnic minorities at the leadership level.’
Mental health
‘delays are having a serious impact on those nursing and midwifery professionals that have been referred. In the worst cases, nurses have taken their lives’
‘we spoke to several people who argued that drawn over investigations were a contributory factor to six nurses taking their lives in the last year. We also saw correspondence from a mother who directly blamed the NMC for her daughter’s death because of an incompetent and biased investigation’
‘Absences related to mental health are of particular concern as 52% of those who reported such absences in 22-23 (107 staff) were classified as long-term absences lasting 10 days or more. This represents approximately 10% of all NMC staff reporting long-term mental health absences, which is a significant number.’
‘There seems to be a concerning gap in how mental health absences are handled at the NMC. A large portion of employees reporting mental health absences do not receive proper follow-up support, as evidenced by a lack of referrals to Occupational Health and a lack of return-to-work interview notes.’
I could go on … but, for now, you might find this report by Channel 4 News interesting ('Toxic culture' found in damning Nursing and Midwifery council review - YouTube). It includes interviews with Nazir Afzal and the NMC Chair, Sir David Warren.
I have no doubt that the vast majority of nursing staff and midwives are competent, conscientious, compassionate and trustworthy. However, public trust must be built on a firm foundation; otherwise it is simply blind trust.
Relating this to a professional accountancy body in the UK, trust in a professional body (and its members) is equally as important. In fact, given the large number of accountancy bodies in the UK (and the large number of unregulated accountants too), it could be argued that transparent, robust and efficient regulation is even more important – ensuring that current and future members of that body will be regarded as trustworthy by clients, employers and the wider public.
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