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Q&A The NMC's Jackie Smith

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The NMC's Jackie Smith The NMC's Jackie Smith

Q) What is the most important issue, aside from revalidation, facing the NMC this year?

It is difficult to pick one issue. As a regulator charged with protecting the public, the NMC has a number of important initiatives to address. But let me pick one if I may. The NMC has a key function in Fitness to Practice (FTP). We have a key performance indicator around adjudication that we are committed to achieving. We have to achieve a six-month waiting time for each FTP hearing by the end of this year.

Costs are driven by FTP and it is where we spend 77 per cent of our budget. The expensive bit is running hearings. We hold 22 hearings everyday. To put that in context, it is equivalent to the size of Birmingham and Southwark crown courts. If you put all the regulators together and added up their FTP hearings it wouldn't come anywhere near the number the NMC deals with.

Q) Why are there so many?

ATwo reasons. The massive increase in referrals in 2010/2011 (40 per cent increase) and FTP didn't have the investment to keep pace. We had to play catch up and the only way to do that was by holding more hearings.

The other reason we hold so many hearings is that our legal framework is out of date. Six out of every ten complaints that come in end up in hearings, because the legal framework requires it. The General Medical Council (GMC) can agree on the outcome of a case at the end of an investigation. The NMC doesn't have that facility, so a panel must decide what the outcome should be.

The GMC can decide at the end of an investigation that conditions will be imposed on a doctor's practice. The NMC has to take all cases to a hearing.The doctors are still agreeing to restrict practice but without having the expense of hearings. And that is primarily driving our costs. The NMC's only source of income is registrants fees, and it must protect the public. We don't have a choice.

So the most important issue aside from revalidation is achieving the six-month waiting time for FTP hearings, because it is absolutely critical.

Q) The revalidation consultation closed on 31 March. How many submissions were received and what has been the initial feedback?

We received 6700 responses, but we have submissions from organisations, individuals and members of the public. If these are added up it is probably around 10,000.

The sorts of things that emerged were around the need for another registered nurse or midwife to confirm fitness to practice, that feedback must include positive and negative feedback and that appraisal, if it is the method for delivering revalidation, will need to be consistently adhered to and applied.

Q) Does the NMC acknowledge that there will be difficulties in practice and community nurses meeting the requirements of revalidation?

The fact that the appraisal process is not consistent is not a reason not to introduce revalidation. In fact, it is a reason to introduce it, because a by product of revalidation will be that appraisals improve. There is a public expectation that members of the profession will have an appraisal. I would expect someone caring for me to have had an appraisal.

Q) What do you say to practice and community nurses concerned that their appraisals are not conducted by nurses?

It might not be, and we haven't made any decisions yet. We will have to analyse what emerges from the consultation. That's the essential part of the consultation. You should have an appraisal, you should reflect on learning and your practice, and you should reflect on the Code. I quite accept that there will be variations. In the acute sector, I am sure the process is much more consistently applied than it is in practice and community settings, because there are different clinical governances in place.

I can see that there are challenges there but, equally, it is important to test that to see where the gaps are and for the NMC to be clear about its expectations. All the NMC is saying is that as a professional you should have an appraisal. And this is what we think your appraisal ought to consist of in terms of practice.

I recognise that some people that haven't had an appraisal might not want to have one, but that is not the NMC's problem. That is for clinical governance.

There is a public expectation that nurses have an appraisal. Where they don't, that needs to be sorted out, and the NMC will set out how it is going to revalidate nurses.

Q) How can nurses have useful appraisals when a nurse is not appraising?

It is important not to confuse revalidation and appraisals with performance management. Appraisals and performance management are for individuals and their employers to resolve. What the NMC is talking about here is a reflection on the Code, which is not about performance management. There are Standards set out in the Code that individuals should reflect on in terms of their practice, not how they do their job on an individual basis. That is a different thing. The two things are getting mixed up. We are not talking about ordinary performance management here, which is about how a nurse does as an employee. We are talking about the Code, which sets out the Standards, and how one's practice relates to the Standards. That is very different.

Q) What leads the NMC to believe that nurses having to seek third-party practice-related feedback will improve standards of care?

Over the last 18 months every single review, particularly in England - Francis, Clwyd, Berwick - has talked about the need to get feedback. It is a way of ensuring that individuals take account professionally and personally for their practice. If nurses are not seeking feedback on how they deliver care, it is an opportunity missed. You have the friends and family test, all sorts of things in everyday care, to inform individuals about how they are doing. I can't imagine that in a clinical caring environment you wouldn't want feedback on how you were doing.

I think there is an assumption that feedback is always going to be negative. But in most cases I don't believe it is. It is actually positive. It is a reflection. I don't think it is new or anything to be feared.

Q) What forms of feedback will be accepted?

I couldn't say. This will need to be teased out through the early adopters of revalidation.

Q) How would the NMC ensure practice and district nurses are complying with revalidation, should the proposed model be accepted by Council?

Revalidation is about reflecting on standards set out in the Code, which applies regardless of setting or the work you do. The need to be honest and open, the need to put the patient first. Those are things that nurses will be able to deliver.

Q) How will revalidation be checked?

ARevalidation will be linked to the renewal proess every three years. Appraisal will be annual, renewal will be three-yearly, and revalidation will be tied to renewal. We will do an audit of revalidation records. The sample size will need to be significant, based on the size of the register, but I don't know yet how many. We need to take advice from our experts on what would be a statistically significant sample and then audit those records. The sample size wouldn't have to be 10 per cent of registrants. It would be a much smaller number. The value added is that the NMC would look at whether that individual has had an appraisal, whether they have reflected on the Code, and whether or not they have got the feedback.

Q) What will the NMC do with the increased fees, should Council implement the rise?

The increased fee will enable the NMC to continue make much needed improvements. It will allow us to invest in IT equipment, so that we can provide registrants with online registration services. It will enable us to continue to hold the necessary number of FTP hearings currently needed, and will allow us to ensure the financial stability of the organisation.

It is important to note that since 2012 with the combination of registrant fees and the government grant the NMC has had a fee of £120 per registrant. As the government grant comes to end the NMC continues to need a fee of £120 per registrant to ensure the protection the public.

Q) What is required to change the legal framework?

The Law Commission Bill gives us and the other regulators the prospect of a single legal framework so that we can be much more flexible and agile when setting the rules and regulations. It will enable the NMC to make changes to FTP, to dispose of cases more quickly in ways other than through hearings. That's why we are desperate to see the Law Commission Bill find its way into the Queen's speech on the 4 June and into the last session of parliament beore the general election.

If we get the changes we need then FTP will be quicker and cheaper. If we don't there is a real risk that fees will continue to rise.

We want to reduce from 22 hearings a day. We want registrants to agree conditions but at the end of an investigation.

From our perspective, when the Francis report was published on 6 February last year, David Cameron stood up in the House of Commons and said, 'I want to sweep aside the NMC's outdated and inflexible legal framework'. Unfortunately we are still waiting. It's vital for the NMC to get the changes it needs.

Q) What one thing are you most proud of since you have been leading the NMC?

I took over when the NMC was at its lowest point and it was in absolute crisis. I am proud of stabilising it and putting it on the path of improvement.

Q) What do you believe is the biggest challenge facing primary care nursing workforce and how might it be addressed?

The demands on primary care and the squeeze, and the constant dilemma between acute and primary care. The focus is always on the acute sector and we can lose sight of primary care, but we mustn't. We do so at our peril.

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