There are many good people working at the Nursing and Midwifery Council (NMC). We can hear their voices in the meticulous report on NMC culture by Nazir Afzal and colleagues https://www.nmc.org.uk/about-us/independent-reviews/
Their voices have led this report to conclude there is a culture of fear around raising concerns on safeguarding, widespread bullying and racism and a toxic culture that is deep-rooted and completely at odds with the values the NMC declares it espouses. The report concludes this culture undermines the work of the many good people working at the NMC, harms staff, endangers public safety and which has been impossible to safely and effectively challenge.
The voices I focus on here are those of impacted by racism, a central feature of the report. A second blog will consider whistleblowing itself.
The racism is deep rooted.
The report notes (P.8) that:
“as far back as 2008, a special report for the Department of Health investigated allegations of racism and bullying” and adds that “Additional reports around race equality, inclusion and the NMC investigations team in the last few years have shone a similarly harsh light on a culture of fear inhibiting honesty and learning, and which also normalises a tolerance of race inequalities. “
The prevalence of racism has not diminished. The report says (P.112) that
“The origins of this review lie in claims of a toxic culture made by a whistleblower last year. The reported claims of racism, people being afraid to speak up and nurses accused of serious sexual, physical and racial abuse being allowed to keep working on wards were all repeated to us on multiple occasions. Everything the whistleblower documented was corroborated and we spoke to many others that had similar experiences.”
Discriminatory behaviours outside work ignored and public not protected.
The Fitness to Practise process refused to address discriminatory behaviours outside work which broke the NMC Code. The report illustrates this (P.9) thus:
“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 after a social event and the sexual assault on a patient was carried out outside of a hospital as the nurse had instigated a meeting” and goes on to add “we heard of similar cases involving racism”
“One NMC lawyer who disagreed with this approach said it was very hard to challenge the safeguarding orthodoxy.
“I have seen mishandling of Fitness to Practise cases relating to racism and sexual assault and we haven’t protected the public,” said one. “Racism cases are dropped in screening because it’s outside of the workplace and the view is, and I’m obviously paraphrasing, that ‘people are free to be racist in their own time’ because they are not involving patients.”
Bullying of staff
“A further humiliation was achieved through bullying and we heard many detailed stories of sadistic managers who seemed to take pleasure in reducing staff to tears. “We should never have hired you,” “you are utterly useless and should not be here” and “why don’t you just leave?” were some of the more polite comments that were relayed to us. Others are unprintable. In one case, an employee described being so traumatised by bullying that he crashed his car while thinking of an abusive conversation he’d had with his manager.” (P.109)
Racism permeated recruitment and promotion.
The report states (P.46)
“There is a culture of promoting people that you like/are friends with. I have seen this myself from being on interview panels where senior team members use coercive methods to pressure you into recruiting individuals that they have earmarked for jobs.”
“Ethnic minority staff recounted sitting on recruitment panels where colleagues expressed racist views towards the candidates. “Look at the rubbish we’ve got today,” one colleague is alleged to have said as they trawled through a list of foreign sounding names. “How are we supposed to appoint anyone from this garbage?”
“We spoke to multiple black and ethnic minority workers who had left, in part, because of this – and, worryingly, they had all gone on to get better jobs and argued that their abilities had been overlooked at the NMC.
Staff told the report that:
“nepotism is rife. There are clear ‘favourites’ among senior managers. Incompetence at a managerial level overlooked. Poor recruitment policies. Too much of a reliance on temporary contracts.”
“Some hiring managers find it difficult to trust someone who doesn’t look or think like them. There is an overriding perception that certain people, particularly from Black and ethnic minority groups are just not good enough for certain positions, so I have found it difficult to get the exposure to be seen to belong in certain spaces.”
Not surprisingly, the report notes that the Executive Team is all white and that:
“There is a noticeable drop in the representation of black minority ethnic staff in higher grades whilst “applicants from black ethnic groups are hired at almost half the rate in comparison to white applicants.”
As the report says:
“As the largest collective professional group within the NHS, 29% are from ethnic minority backgrounds and this rises to much higher levels of up to 40% in some regions such as London. For any regulator to properly represent nursing and midwives, diversity is therefore critical.”
Fitness to Practise processes are impacted.
One panel member told the Review that:
“White men have humiliated me. I am a Black woman… I have never had to complain to other professionals that the way in which they treated me was humiliating and belittling. Within two years at the NMC, I have had to do it twice.”
One witness told the report:
“I have directly experienced racism and detriment in my time with the NMC and it is not a good place to work for people from my background. But I stay because I believe I make a difference to the handling of black minority ethnic registrant cases.”
No confidence in surveys
The report was told (P.46):
“Nothing is confidential - the staff surveys go to the assistant director who identifies who submitted the responses and then basically gaslights people into not raising concerns”
It is perhaps not surprising therefore that the 2023 NMC WRES survey received a 34.3% response rate – very low for a smallish organisation whilst response rates on specific questions are the lowest I have ever seen in the NHS:
Just 9.8% of staff of the 34% who did answer the survey responded to the question asking if they experienced harassment, bullying or abuse from staff in last 12 months i.e. just 39 staff in total
Just 7.5% of the 34% of staff who answered the survey (just 30 in total) responded to the question “In the last 12 months have you personally experienced discrimination at work from a manager / team leader or other colleague?”
The leadership response has been performative
“Things are done for show” was a common refrain from staff, but “nothing changes” is the disheartening conclusion.
Evidence of this came when (P.98):
“the rise of the Black Lives Matter movement following the murder of George Floyd… shone a harsh light on the lack of visible diversity at the top of the NMC ……….”A dozen employees met the CEO to share their powerful testimony. They were asked to pose for a selfie and left the room with promises of action. Within two years half of them had left the NMC entirely and cited inaction and broken promises as the reason why.”
The report continues (P.109):
“for many, what made this even worse, was the external commitments to anti-racism. “There is lots of rhetoric, lots of words, but nothing underneath it,” explained one staff member. “I’ve never known an organisation that talks so much about anti-discrimination and does so little about it. There are lots of words about public protection and anti-racism but nothing underneath it and no delivery.” Others said “the leaders are busy giving speeches quoting Maya Angelou but meanwhile every black minority ethnic candidate pushing for a promotion is rejected.”
“Some had been used in brochures to promote diversity at the NMC, others were asked to go to events at Parliament to promote diversity and then told afterwards they weren’t good enough to progress. For those involved, it felt like they were being deliberately humiliated by the NMC.
“This sense of humiliation even extended to some black minority ethnic employees being told that they were on a list of people that could not be promoted past a further level.”
Systematically breaching the NMC Code
The report notes that:
“the largest criticism came through the cognitive dissonance people felt at not being able to live by the values they expected of nursing and midwifery professionals. “We investigate nurses and midwives but turn a blind eye to bad behaviours in our own workforce,” said one. “We’re looking to set standards around conduct and performance and yet ours are falling all the time. If we can’t properly regulate ourselves, how can we regulate others?”
The NMC EDI Plan states “Tackling discrimination and inequality, celebrating diversity and promoting inclusion, including making sure that our processes are fair for our registered professionals and colleagues, is a priority in our 2022—2025 corporate plan.“ https://www.nmc.org.uk/globalassets/sitedocuments/edi-docs/edi-plan.pdf
The NMC Code of Conduct https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf requires every registrant to:
20.2 act with honesty and integrity at all times, treating people fairly and without discrimination, bullying or harassment
16.1 to 16.6 set out in detail why (and how) registrants are required to raise and, if necessary, escalate any concerns you may have about patient or public safety, or the level of care people are receiving in your workplace
In Too Hot to Handle (2024) Joy Warmington and I explained how our research demonstrated just how difficult it is for Black and Minority Ethnic staff in the NHS to raise concerns - and how even when they did they were frequently not listened to or then subjected to victimisation. What happened at the NMC is an extreme case study from that report. https://27aa994b-a128-4a85-b7e6-634fb830ed15.usrfiles.com/ugd/27aa99_9a9468c5e4da43288da375a17092d685.pdf
Symptomatic of the failure to embed any understanding of racism in the NMC’s everyday work has been:
the hiring, for £54,000, in anticipation of the criticism in the Nazir Afzal report, of the same reputation management company that acted for the Police Federation at the time of the Stephen Lawrence inquiry https://www.contractsfinder.service.gov.uk/notice/70d6a51d-11b3-4469-be62-84f156332e6e?origin=SearchResults&p=1
the decision of the NMC to appoint as its interim CEO the person who was central to the decision to defend a catastrophic NHS race discrimination case – the most expensive case in the last decade cso0ting the NHS over £1 million pounds in which the Tribunal judgement repeatedly criticised the failings of HR at every stage. https://www.linkedin.com/pulse/nmc-you-have-some-serious-explaining-do-roger-kline-krvbc/
Senior internal and external leaders did try to raise concerns
The NHS Chief Nurse Ruth May did raise concerns about this disastrous culture with the NMC leadership. Senior nurses within the NMC did raise protected disclosures, in particular about extremely serious safeguarding concerns. The whistleblower whose concerns prompted the second review (imminent) by Ijeoma Omambala KC was both principled and courageous, and suffered for it. Those who raise concerns systematically became targets of the culture of denial.
The leadership keep promising change
The report notes (P.8)
“A whistleblowing report in 2019 and a review of the culture in specific directorates in 2020 unearthed even more failings, noting that staff often did not raise concerns because they were fearful of repercussions and apathetic about things ever changing. Additional reports around race equality, inclusion and the NMC investigations team in the last few years have shone a similarly harsh light on a culture of fear inhibiting honesty and learning, and which also normalises a tolerance of race inequalities.
“Additional reports around race equality, inclusion and the NMC investigations team in the last few years have shone a similarly harsh light on a culture of fear inhibiting honesty and learning, and which also normalises a tolerance of race inequalities.”
“The substance of these reports weighs heavy on our review. When studying them, we have also noted the repeated response from the NMC is a promise to learn lesson”
“The resistance we saw to the whistleblower encapsulates a wilful deafness to criticism and a culture that is seemingly not open to feedback and opportunities to improve when things go wrong. We heard this mentioned repeatedly – both in our survey and in interviews and focus groups. Many said that the resistance to criticism came from a place of wanting to continually maintain positive mood music. “We call it ‘toxic kindness’ among colleagues,” said one.”
What next?
A second review, by Ijeoma Omambala KC, has been considering alleged botched investigations highlighted by one whistleblower, is due to be published in the near future. It is likely tom come to similar conclusions as this report.
The report highlights the previous scathing reports on culture including racism at the NMC. It notes the absence of change and the repetition of avoidance denial. Learning and improvement should normally be the response to poor culture. In this case the culture has been so systematic, long lasting and leaders actively resistant to change that those responsible must surely move on, or be moved on, so that the NMC had a leadership that can demonstrate they themselves are Fit to Practise
Those who stood by their principles and observed the NMC Code of practice – most notably the NMC chief nurse and the chief nurses of England and Wales, should be congratulated. And thanked. And protected.
A former senior member of staff there told me some months ago told me that “what is happening at the Nursing and Midwifery Council (NMC) may soon be revealed as a having a whiff of the Post Office”.
They may turn out to be right
Roger Kline is Research Fellow at Middlesex University Business School
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