The recently published independent culture review of the Nursing and Midwifery Council (NMC) made shocking reading with its revelations of cultural shortcomings (Rise Associates, 2024). The NMC, as the regulator of the nursing and midwifery professions, is hugely important to public safety, the professions and the 800 000 professionals themselves. In the latest inquiry, while it seems some of the NMC staff reported being well led and content with their working lives, a significant proportion of staff and stakeholders reported experiencing inappropriate behaviours from the NMC leaders and staff (Rise Associates, 2024). These inappropriate behaviours have remained unaddressed despite these same issues being raised repeatedly from 2008 onwards, with the NMC promising to ‘learn the lessons’ on each occasion but seemingly not doing so. Most worrying is the huge backlog of fitness to practise cases, which stands at nearly 6000, comprising minor and serious concerns as far back as five years. Worse is the claim that the screening team is closing down cases, which endangers the public and warrants further inquiry. The Queen's Nursing Institute (2024) has reminded the Secretary of State that the NMC was given a £20 million grant by the Department of Health and Social Care in 2012 to clear its fitness to practise case backlog; however the backlog has built up again with more than 400 cases awaiting initial screening and over 5000 cases awaiting hearings.
No doubt people will be asking how a whistleblower's claim of ‘a deep-seated toxic culture’ in 2023 and the growing fitness to practice case backlog had gone unnoticed by the Council, the governing body for the NMC. The NMC website states that the Council sets the NMC's strategic direction, takes key decisions and makes sure the NMC fulfils its duty to protect the public. In other words, the Council is the oversight body of the NMC and has no executive functions, and as such will be dependent on what the executive shares, including data relating to the fitness to practise backlog, staff satisfaction and turnover. Similarly, the Boards of NHS Trusts, including the NHS Foundation Trusts, provide oversight of their respective NHS Trust executives and operations and have, on occasion, been unaware of care and organisational shortcomings in NHS Trusts. This is evidenced by the Mid-Staffordshire NHS Foundation Trust inquiry (Francis, 2013), University Hospitals Birmingham NHS Foundation Trust (Parliamentary and Health Service Ombudsman, 2023) and various NHS Trusts, where maternity services (Ockenden, 2022) and mental health services have been subpar. The Post Office Horizon IT inquiry (2024) has also revealed how the Boards of Directors (Royal Mail and Post Office) were not fully aware of key details relating to the Horizon IT system and sub-postmaster prosecutions. While not seeking to excuse the lack of curiosity of some governing bodies (Boards), it must be remembered that most people put themselves forward to serve on governing bodies with the best of intentions and do of their best to read reams of documents before meetings, listen attentively to the narrative offered by the executive and ask questions about the materials presented. In hindsight, it is clear that some Boards including the NMC Council may not have asked the correct questions or sufficiently probed the executive.
‘Most worrying is the huge backlog of fitness to practise cases, which stands at nearly 6000, comprising minor and serious concerns as far back as five years. Worse is the claim that the screening team is closing down cases, which warrants further inquiry.’
The NHS rightly emphasises the importance of organisational and personal values because a poor organisational culture is associated with work-related stress and compromised patient safety (NHS Resolution, 2023). NHS Resolution has revealed that work-related claims have cost more than £14 million over the decade from 2010 to 2020. The NMC data indicated that ethnic minority practitioners had 1.7 times the rate of cases per 1000 with the Practitioner Performance Advice service, compared to White practitioners. It is difficult to understand the disproportionate rates of disciplinary action between White and ethnic minority staff; however, it is important that the healthcare system must be fair and just, and to be perceived as such, if all staff are to feel valued, learn from incidents and remain in a workforce facing growing retention challenges.
The NMC Register annual report (NMC, 2024) indicates that the retention of nurses and midwives in the NHS workforce is an increasing challenge, with one-fifth leaving the Register within 10 years of joining because of poor mental and physical health, and burnout. This echoes the latest NHS Staff Survey in England (NHS England [NHSE], 2024) where two in five survey participants reported feeling unwell because of work-related stress during the last 12 months, with those aged 21–30 years more likely to report work-related stress (King's Fund, 2024. On a positive note, the survey data suggested that there had been a general improvement in the workforce's experience of working in the NHS in England, with fewer participants indicating that they were thinking about leaving and more recommending the NHS in England as a place to work, despite the ongoing industrial action and winter pressures. While there has been progress in improving staff experiences related to compassionate leadership, team working and involvement in workplace decisions, the survey data recorded lower scores for workload and adequate resources, which was echoed in terms of morale scores. The scores for equality and diversity also did not improve as compared to previous years, which is worrying if the NHS plans to recruit and retain nurses from all communities that make up the population.
‘The changing demographics of the UK population, characterised by a below-replacement fertility rate and an ageing population, have major consequences.’
The changing demographics of the UK population, characterised by a below-replacement fertility rate and an ageing population, have major consequences. This is not only in terms of the reduced numbers entering the working age population and thus impacting the size of the caring workforce, including the NHS workforce. It will also impact the availability of funding, as it is the working population who fund public services through taxation (Watt et al, 2023) at a time when healthcare demand is increasing. The imperative of attracting and retaining a diverse nursing workforce is clear (Hemmings et al, 2021).
Using the latest course application data from the University and Colleges Admissions Service, The Times has reported that there has been a 12% decline in the number of teenagers applying to study medicine in the last two years (13 850 in 2022, compared to 12 100 in 2024) (Times. 2024). The decline in applications to study nursing is even greater (58 550 in 2020, compared to 41 250 in 2024) (Times. 2024). According to the National Health Executive (Morris, 2024), the total number of students accepted for nursing degrees in England is 13 870 for 2024-25 entry, a reduction of one-fifth (20%) in three years. As community nurses are recruited from the wider NHS nursing pool, a decline in applications to study nursing will impact the future size of the district nursing workforce.
Nurturing the current district nursing workforce must be a priority for the current Government to achieve the ambitions of providing support and care, including nursing care in the home. Providing high quality nursing care in the home is key to minimising healthcare costs as well as meeting the preferences of clients to remain in their own homes as long as possible, rather than receiving care in hospitals or other institutions. Without a competent and adequately resourced district nursing workforce, it will not be possible to transfer more care out of hospitals. Most nurses are proud to deliver care to patients in whatever clinical setting and district nurses acknowledge the privilege of delivering care to clients in their homes. However, all nurses need ongoing training and support to develop their practice alongside an acknowledgement of their well-being needs. The 2023 NHS Staff Survey (NHSE, 2024) results indicated areas where NHS staff felt that their experience at work fell short of the ideal.
The NHS cannot afford to be complacent if it wants to attract teenagers to nursing as a career and for the long term retention of a diverse NHS nursing workforce. Without a strong and diverse hospital nursing workforce, there will be no district nursing workforce in the future—hopefully developing and building the district nursing workforce will be a priority for the current Government.