Violence is Never the Answer, But What Is the Answer to It?

 

England has been in the grip of far-right riots, in the previous week, following the horrible murders of three young girls. These riots were stoked by racist lies, mostly online, but fizzled out when confronted by large and peaceful counter protests. So many people were threatened and injured in these riots, so many people have had their businesses and livelihoods destroyed, and many NHS staff were also the victims of these riots.

Two Filipino nurses were attacked in Sunderland. They were sharing a taxi to work. GP Practices and other healthcare clinics closed early, during the riots, to enable staff to get home safely. NHS staff have received threatening messages, clinics have closed early because staff feared being trapped in themby rioters, staff were afraid to use public transport and were not going onhome visits. So many NHS staff were affected by these riots, directly and indirectly. So many NHS staff were feeling very afraid by these riots, and afraid clinicians don’t deliver the best care, and that isn’t their fault.

The new Health Secretary Wes Streeting, in response to this, said: “I will not tolerate, under any circumstances, NHS or social care staff in any health or care setting being subjected to intimidation, harassment or racist abuse.

“We have a zero tolerance policy in the NHS and we'll take a zero tolerance approach in social care too.

“People who are abusing NHS staff can be turned away, and should be turned away, if that is the way that they are treating our staff."

But Wes Streeting wasn’t right, there is no specific NHS zero tolerance policy to violence against staff. Many NHS trusts have zero tolerance policies but NHS England does not have one. In 2018, the then Health Secretary, Matt Hancock, announced the Stronger protection from violence for NHS staff policy. This announced a “violence reduction strategy”, which included:

• NHS to work with the police and Crown Prosecution Service to get prosecutions in the “quickest and most efficient way”.

• the Care Quality Commission (CQC), as part of their inspections, to monitor the level of violence against staff in a trust.
• training for staff to deal with violence.
• prompt support for staff.

What this didn’t contain was a zero tolerance to violence against NHS staff policy.

In 2020, NHS England released Violence prevention and reduction standard, which stated that it was part of an NHS employer’s duty of care to protect staff against violence and abuse at work, but this didn’t contain a zero tolerance policy either.

The Royal College of Nursing (RCN) summarised what NHS staff are allowed to do if they are faced with a violent and/or abusive patient. The nurse (or other NHS clinician) can refuse to treat a patient who is threatening or being violent. But care cannot be automatically withdrawn from the patient, it should be delivered while the patient’s violence is “managed”. Any violent situation must be discussed with the clinician’s manager and assessed. The clinician’s employer has a duty to the clinician but also has a duty to provide care to the patient, even if they are violent to healthcare staff. But an employer cannot dismiss or discipline a clinician for refusing to treat a violent patient. The emphasis is on managing the patient’s violence and ensuring the patient still receives care.

The Nursing and Midwifery Council (NMC), the nursing regulator in Britain (Find a discussion of their duties here), on 9th August, sent an email to all professionals on their register, about the current riots. They first reminded readers that, under the NMC’s Code of Conduct, “that professionals should prioritise people and put the interests of people needing or using health and care services first.” If faced with a violent patient, a nurse “should escalate your concerns as soon as possible. Your health and safety at work is your employer’s responsibility.” The NMC’s language is clumsy but their point is clear, nurses should put the patient first. If they are faced with a violent and/or abusive patient, they should still be treated and later “escalated” for management to decide what to do. There was no mention, nor any discussion, of a zero tolerance policy.

While I worked as a nurse, I was the recipient of violence and abuse from patients and/or their relatives, far too many times, and even more times I supported colleagues who had been the victims of violence and/or abuse at work, especially racist abuse. Only one time was I supported by a manager. As a ward nurse, a patient’s relative had threatened me with a knife. He also threatened a porter. My manager called the police and had the relative arrested for his actions, she also had the patient discharged that day too because he encouraged the attacks. But this was the exception. I have watched managers bend-over backwards to accommodate abusive patients. When I worked as a District Nurse, we had a patient who had physically and racially abused so many nurses that the whole team refused to visit her. Senior management repeatedly put pressure on us to visit her and they went out of their way to arrange a plan so she would get the care she wanted. She suffered no repercussions for her behavior. Senior managers seemed to be far more afraid of violent patients complaining about not getting the care they want, then about the effect of violence and abuse against staff.

I still see that attitude in the current policy about violent patients. NHS staff have to find a way to treat abuse patients. There is still no zero tolerance to violent patients. Would this be tolerated in other professions? If a constituent was violent and abusive towards an MP, would the MP bend over backwards to meet that constituent’s demands?

There are 75,000 physical and verbal attacks on NHS staff each year yet only 2.4% of these assaults ended with the attacker being cautioned or charged bythe police, let alone found guilty by the courts. This 2.4% could be an over estimation because only half of trusts responded to this survey. How is this zero tolerance of anything?

Punch a nurse and you’ll probably get away with it, scot-free.

 

Drew

The Nursing and Midwifery Council (NMC) Fails Again, But Who is Listening?

 

“This place is run like a cult,” NMC employee.

The Nursing and Midwifery Council (NMC) is in trouble again. Their toxic work environment has been exposed but not for the first time.

The NMC is the regulator for the nursing profession in Britain, which is a very important role. They regulate the training/education requirements to become a Registered Nurse, Midwife or a Nursing Associate. They maintain the professional register that all Registered Nurses, Midwifes and Nursing Associates must be a member of to work in their role. It is compulsory for anyone in these professions to be a member of the NMC’s register. They also investigate anyconcerns raised to them about any Registered Nurse, Midwife or a Nursing Associate, and can prosecute them in a Fitness to Practice hearing. They are very powerful and have an important responsibility to protect Registered Nurses, Midwifes and Nursing Associates, but most importantly to protect the public. There is about 826,000 professionals on their register.

The NMC is a statutory body, formed by an act of parliament, but they are independently funded. All their funding comes from the fees they charge Registered Nurses, Midwifes and Nursing Associates to be on their register. It costs £120 a year to be on the NMC register, and all that buys is to be able to work as a Registered Nurse, Midwife or a Nursing Associate. Their yearly revenue, for 2023 to 2024, was £108 million. A lot of money.

In September 2023, The Independent news website ran an exposure of the NMC. A whistleblower blew the lid on the toxic work environment there and how it was directly impacting on their work. The whistleblower said staff were working in a “culture of fear” which was directly impacting on the NMC’s ability to protect the public and the nursing and midwifery profession. This involved:

·         The case of a nurse who admitted sharing indecent images of children but was only struck off three years later.
·         A nurse who groped a patient and was allowed to practice as a nurse, with no restrictions, for eight months after the case was reported.
·         A nurse convicted of racially abusing members of the public but who faced no sanctions.
·         A white nurse was convicted of “racially aggravated intentional harassment” but was not sanctioned.

The whistleblower said the NMC was so desperate to clear the backlog of investigations into complains it had received that it “led to dangerous decisions being made to close cases at all costs”. At the time the NMC had a backlog of 5,339 Fitness to Practice cases.

The whistleblower also told of an internal report, carried out by the NMC in 2022, which was then kept secret. The report found:

·         A “culture of fear” in the NMC, were staff are afraid “of making mistakes” and afraid to be honest when errors occurred.
·         Staff under pressure with “unachievable” targets to clear backlogs of Fitness to Practice investigations.
·         Staff were afraid to raise concerns because they would not be acted on.
·         One member of staff said: “We’re drowning, we’re struggling, we’re telling people: we can’t cope with this pressure.”
·         Serious concerns of racism in the NMC, including bullying of Black staff.
·         Staff claiming sexism and misogyny within the NMC.

Is there any wonder the NMC covered-up this internal report? But that should never be the attitude of a public body.

In January 2023, The Independent news website ran an investigation into NMC’s Fitness to Practicehearings. They reviewed the rulings of NMC’s Fitness to Practice hearings and they found:

·         Male nurses make up for 80% of striking-off orders, yet they only make up 11% of those on the register.
·         More than 700 cases have been left open, without any resolution, for three years.
·         They found multiple cases were nurses were prosecuted, by the police, for domestic violence or sexual assault but faced minimal restrictions by the NMC.
·         A nurse was convicted of and imprisoned for actual bodily harm against their spouse but was allowed to use a “good character statement” during their hearing and was allowed to practice without restrictions.
·         A nurse was placed on the register of sex offenders but was only given a four-month suspension by a Fitness to Practice panel, because they felt it was of the “lower-end” of sexual assaults.

How does this protect the public and the profession?

When the September 2023 article came out in the Independent, the NMC responded by commissioning an independent review of their organisation. It was headed by Nazir Afzal, the Chancellor of Manchester University and the former Chief Crown Prosecutor for North West England. This review was published in July 2024. It is a damning report, at 133 pages long it was very in-depth, but it made for a shocking and sickening read. I have been a critic of the NMC, almost from their founding, but this review showed the NMC has reached the very low depths of incompetency. It found:

·         12% of staff had experienced bullying, in the last year, and 17% had witnessed bullying of colleagues.
·         40% of staff had experienced or witnessed macroaggressions in the last year.
·         Nepotism is rife. People only got promoted if they were one of their manager’s favourites.
·         There have been large fluctuations in staff turn-over. In 2018, 22.8% of staff left, which came down to 9.3% in 2023.
·         There has been a 96% increase in sickness between 2018 and 2023, mostly due to stress, anxiety and depression.
·         The toxic culture at the NMC is a long standing problem, as exposed by previous reports.
·         There is a blame culture where people are afraid to speak up.
·         NMC leadership is defensive and has tolerated bad behaviours.
·         There is a lack of maturity around risk management.

The descriptions of bullying were the hardest to read. I am not naïve, I know that bullying of staff is something that is still tolerated in healthcare, which is not acceptable on any level. How can we say we are in a caring profession, when we tolerate bullying? How can a professional regulator tolerate bullying? Bullying can be the topic in Fitness to Practice hearings, the defendants can be the perpetrators or the victims of bullying. Yet the NMC tolerates it within their own staff.

Since April 2023, six nurses have killed themselves while under investigation by the NMC. This is the most shocking of all, that the NMC failed so completely that six people killed themselves from the stress of being investigated by this organisation. What has gone wrong? Why are we tolerating this?

"Good nurses are finding themselves being investigated for years over minor issues and bad nurses are escaping sanction because of a system that’s not functioning as well as it should," Nazir Afzal.

This review makes eleven recommendations, but will anything come of them? I want to say, “Time will only tell.” But this isn’t the first time the NMC’s failings and toxic culture has been exposed (18) and yet again here we are, exposing the same things.

The NMC quickly released their response to this review. It was high on soft promises, especially promises to make things feel better, but low on measurable interventions. From their statement, I found the following:

·         They are investing £30 million (nearly a third of their yearly income) into a plan to improve the Fitness to Practice process. Their promise is to reach decisions in a “more timely and considerate way.” Though Nazir Afzal’s review recommended that screening of these should not take longer than two months.
·         They have “strengthened” their guidance when sexual misconduct and other abuse is involved in Fitness to Practice hearings.
·         They will appoint an equality, diversity and inclusion (EDI) advisor to the Executive Board.
·         They now have a Freedom to Speak Up Guardian available to their staff. This role was first introduced in 2016, following the Mid-Staffordshire NHS Foundation Trust scandal and Sir Robert Francis's inquiry (13) into it. Is the NMC only now introducing it?
·         They will introduce “listening circles”, “improve psychological safety in teams”, and “extending the offer of decompression support”. But nothing about improving their complaints procedure.
·         They will be “doubling” the amount spent on learning and development, especially with regard to leadership, safeguarding and macroaggressions. But they do not give any figure as to what was originally being spent.
·         They will improve their recruitment and career progression.

But will this improve anything at the NMC? Most of these improvements do not have any measureable outcomes and very few of them have a specific time frame. They also don’t appear to cover all of Nazir Afzal’s review’s eleven recommendations. Will they bring any real change to the NMC? This is not me being overly cynical, this is me looking back on the past scandals of the NMC.

It was founded in 2002 and in its twenty-two year history it has been mired in scandal and failings. The NMC’s toxic culture and failings to manage the Fitness to Practice investigations and hearings is nothing new. In August 2017, I wrote a blog criticising the NMC for awarding their then chief executive, Jackie Smith, an inflation busting 11% pay rise and an eye-watering £11,921 bonus. The blog listed all the reasons I found for why she was not worth this pay rise and bonus because the NMC, under her, was obviously failing. All my reasons were taken from publicly available documents, I didn’t conduct an internal review of the NMC, I just accessed the evidence already available in the public domain. I found the NMC failings were:

·         There was a high turnover of staff, 24.5% of staff left there in 2015-2016. This is a red flag that an organisation has a toxic culture.
·         The NMC had £41 million in reserves but in 2015 they imposed a 20% increase in nurses’ yearly registration fees.
·         They had 120 data breeches in 2016.
·         Their own Head of Internal Audit found the NMC’s own internal control, governance and risk management were failing. “Significant improvements” were needed.
·         The Head of Internal Audit also found, due to the high turnover in staff, deterioration in Finance, Procurement, HR and Technology Business Services.

The Professional Standards Authority (PSA), who oversaw all the UK healthcare regulators, in their yearly review for 2016/2017, found the following failings in with the NMC:

·         The NMC took the longest to resolve complaints against their registrants. The average was 51 weeks (just under a year) and their longest was 401 weeks (just over 7 years).
·         They criticised the NMC for its lack of transparency, especially around how the decisions of their Fitness to Practice hearings were reached.
·         PSA had the power to refer Fitness to Practice decisions to the High Court when they found that these decisions were too lenient. They did that in 62% of the NMC’s Fitness to Practice decisions in the 2016/2017 period.

From the NMC’s own data, I found that BME, male and older nurses were disproportionately referred to Fitness to Practice hearings, in 2017. I found:

·         16% of Fitness to Practice hearings were against BME nurses, though only 7% of Registered Nurses were BME.
·         25% of Fitness to Practice hearings were against male nurses, though only 11% of Registered Nurses were male.
·         76% of Fitness to Practice hearings were against nurses over 40, though only 69% of Registered Nurses were over 40.

Even though the NMC had a legal responsibility to reduce discrimination, apart from collecting this data, the NMC showed no plans to investigate this nor to tackle this discrimination.

I wrote this blog back in 2017, listing all these failings of the NMC, from documents in the public domain, some the NMC’s own regulator had identified, and the NMC has done nothing to change since then. Instead the NMC has allowed its failings to just become worse. Their failings are exposed and the NMC does nothing about them, they certainly do not seem to be trying to improve the service they deliver. This seems to have been their attitude since they were created. There is a scandal and the NMC does nothing about it, certainly nothing to prevent it happening again.

In 2008, Jim Devine MP accused the NMC of bullying and racism, in the House of Commons. The NMC denied it.

In 2009, Margaret Haywood was struck off for exposing the shocking poor standards of care at an NHS trust. She was later reinstated on appeal, and after a very vocal public campaign.

In 2016, Bill Kirkup MP, criticised the NMC for the poor way they handled the failings in thematernity unit, at the University Hospitals of Morecambe Bay NHS Foundation Trust. He said the NMC had "fallen far short of expectations". This led to the NMC being stripped oft heir role of supervising midwives and ultimately was one of the factors that saw their chief executive, Jackie Smith, resign.

Also in 2016, the NMC charged nurse Pauline Cafferkey with misconduct just because she caught Ebola. Fortunately, this case was dismissed.

In July this year, the NMC had to appoint a second new CEO, in a week, after the previous one was exposed to have been involved in a high-profile race discrimination case, in their previous role. They were only in post 24 hours.

The Department of Health and Social Care said it expects the NMC council to respond to the Nazir Afzal’s review's recommendations with “swift and robust action”. But has the NMC ever done this before? Why do they expect the NMC to behave any differently now?

How can we trust an organisation to keep its house in order when it repeatedly fails and fails and not only doesn’t learn from these mistakes, but ignores them and then repeats them? How in any measure, is the NMC fit for propose? They cannot even produce a plan that addresses all the recommendations of their own independent review.

But the NMC isn’t funded with public money, instead its funded by the yearly fee to be on its register, so it isn’t seen as a priority by government, it isn’t seen as “wasting” public money. And so the NMC is left alone to carry on with its toxic culture and disgusting failure to protect the public and the nursing profession.

I want the NMC dissolved, it executives, broad members and senior management publicly sacked for their failings, and their remaining staff transferred to a new regulator who has the active involvement of the nursing profession and rigorous government oversight. But I fear that this is just a wish of mine that will come to nothing. What I am almost certain of, is that the NMC will increase their fees on the back of having to sort out their own mess. Nurses will have to pay for the NMC’s failings, again.

 

Drew.