The need to take action relating to the known issue of disproportionate referrals to the Nursing and Midwifery Council (NMC) of certain groups of registrants has been one of the live areas of discussion identified to me since my induction. In 2017 the NMC published research by the University of Greenwich that found that certain groups of registrants are more likely to be referred to NMC fitness-to-practise processes (West et al, 2017). The research also found that the NMC receives more referrals from employers of some groups – including professionals who are male and/or black – compared with the proportions on our register.
In 2020, Ambitious for Change examined the impact of NMC regulatory processes on professionals with different protected characteristics. It found that sometimes people receive different outcomes from the processes based on who they are. This includes differences in our education, overseas registration, revalidation, and fitness-to-practise processes (NMC, 2020). Following this work, the NMC committed to working with employers and partners across the health and care sector to progress solutions that target these inequalities.
The NMC initially looked at the referrals received between 1 April 2016 and 31 March 2019. Most referrals we received during this period came from employers rather than other sources. Nearly half of the professionals referred by employers were Black, male, or Black men. In comparison, 11% of the NMC register were men and 10% were Black in 2021/22. It was also found that, in contrast to male professionals, although Black professionals are referred in higher proportions by employers than the proportions on our register, they are no more likely to be removed from our register than White nurses and midwives. Male professionals are both referred in higher proportions by employers and are more likely to be removed from our register than females.
The NMC (2022a) has published phase two of the Ambitious for Change work, where fitness-to-practise referral rates were compared with workforce diversity data. This was limited to the available data from NHS trusts in England, however, findings included that some employers refer more black and/or male professionals compared with both the register and their own workforce. Employers referred between 10% and 99% more Black and/or male professionals compared with the proportion of the Black and global majority staff they employ. In addition, it was identified that more of employers' cases involving male and/or Black professionals are closed at earlier stages of the NMC process compared with other employer referrals, due to not meeting the threshold for a fitness-to-practise referral.
The NMC analysis suggested that employers refer Black and/or male professionals for different reasons from professionals in other groups. Overall, most employers' referrals relate to allegations about patient care, prescribing medicines and record keeping. In contrast, allegations about Black and/or male professionals relate to the inappropriate or delayed response to negative signs, deterioration or incidents, concerns with diagnosis, observations and assessments or concerns with patient and/or clinical records. This may suggest that employers deal with concerns about male and/or Black professionals differently compared with those involving other groups of professionals. Since I started at the NMC there has been a clear aim to work with employers to share insight in a meaningful way – and there is a real need to get the right information at the right level (NMC, 2022b). This includes updating NMC data about the number of referrals received from employers and breaking this down further to the context of an organisational level to enable the sharing of this information for wider consideration and understanding.
Where it is identified that employers have made a disproportionate number of referrals of Black and/or male professionals compared with the size and profile of their workforce, we will aim to share this information with the relevant employers, and importantly the detail relating to the referrals – eg, whether these referrals are in line with NMC fitness-to-practise principles. There is also an opportunity to triangulate wider data sources such as Workforce Race Equality Standard (WRES) scores or average staff survey ratings to support the right conversations with employers.
A key aim of this work is for the NMC to work in partnership with employers to share insight and identify what can be progressed, to address the issue of over-referrals of groups of professionals. One other key area of engagement that is currently being scoped is to work with the membership organisations that represent and support a wide range of professionals. With at least 40 international nursing and midwifery associations, identified, these key stakeholders have significant potential to advise the NMC on how to progress reducing inequalities.