Written evidence submitted by The Nursing and Midwifery Council (RTR0097)

About us

1               Our vision is safe, effective and kind nursing and midwifery that improves everyone’s health and wellbeing. As the professional regulator of almost 745,000 nursing and midwifery professionals, we have an important role to play in making this a reality.

2               Our core role is to regulate. First, we promote high education and professional standards for nurses and midwives across the UK, and nursing associates in England. Second, we maintain the register of professionals eligible to practise. Third, we investigate concerns about nurses, midwives and nursing associates – something that affects less than one percent of professionals each year. We believe in giving professionals the chance to address concerns, but we’ll always take action when needed.

3               To regulate well, we support our professions and the public. We create resources and guidance that are useful throughout people’s careers, helping them to deliver our standards in practice and address new challenges. We also support people involved in our investigations, and we’re increasing our visibility so people feel engaged and empowered to shape our work.

4               Regulating and supporting our professions allows us to influence health and social care. We share intelligence from our regulatory activities and work with our partners to support workforce planning and sector-wide decision making. We use our voice to speak up for a healthy and inclusive working environment for our professions.

Our role in workforce

5               As set out in our strategy, we are responsible for setting the education standards that nurses, midwives and nursing associates must meet to join our register, and the professional standards they must follow in practice. This means that we are not directly involved in training, educating or recruiting the health and care workforce. We maintain the register of professionals eligible to practise and investigate concerns about nurses, midwives or nursing associates and our registration data reports shows the size and breadth of these professions, the diversity of the workforce, and the specialties they work in. 

6               England, Scotland, Wales, and Northern Ireland are each undertaking work to address their specific workforce challenges. As the UK-wide professional regulator, we are committed to doing all we can to help shape and play our part in delivering a sustainable workforce plan that addresses the needs of nursing and midwifery professionals. This includes sharing our data and insight, ensuring that our registration processes are simple and proportionate and making sure that our fitness to practise processes are fair and reflect the importance of just culture.

7               Our regulatory role is enhanced when we support the public, our professions and our partners. We collaborate with employers and educators to provide useful guidance and emotional and practical support to all those involved in our processes, delivering better outcomes for all. This includes our recent communications with the Chief Nursing Officers and directors of nursing across the UK to reassure professionals we recognise the pressures the are under, how the NMC Code is there to support them and that the NMC takes context into account in all Fitness to Practise decision making. It also helps rebalance our focus towards good practice from poor practice, preventing – not just responding to – harm.

8               Employers are able to make use of the NMC’s Employer Link Service and we have also made guidance available for employers on managing concerns. Similarly, we have made guidance available detailing the process that nurses, midwives, nursing associates and pre-registration students can follow to raise concerns. It also sets out where they can access confidential support and advice. This process can be used to raise concerns about issues including, but not limited to, health and safety, staff conduct, concerns about equality and diversity, and staffing and resources. We have also produced animations on key themes about the roles of nursing and midwifery professionals, explaining how the Code can help professionals to feel confident about their decisions and actions.              

9               In addition to this, we undertake a number of different activities to support and contribute to workforce issues and wider discussions around them, including:

9.1             disseminating data on scope of practice and work settings;

9.2             producing joint guidance with the GMC on the duty of candour that applies to all healthcare professionals;

9.3             conducting our annual leavers’ survey to gain insight into why people are leaving the register;

9.4             publishing registration data reports every six months, with details on the changing numbers and composition of the register;

9.5             producing our principles of preceptorship to help those who design and oversee preceptorship programmes; and

9.6             issuing guidance for employers on supporting registrants through revalidation. 

10          Nursing and midwifery professionals across the UK are doing incredible work to respond to the recent increase in Covid-19 cases. With professionals and services facing substantial and growing pressure, we remain committed to doing all we can to help while maintaining our statutory focus to protect the public. For example, in 2020 the UK Government introduced emergency legislation which lets us temporarily register nursing and midwifery professionals who want to support the response to the Covid-19 pandemic.

11          This support all contributes to building and retaining a sustainable and professional workforce and helps us to generate data and insights. Our data and insights directly inform the views we have set out in response to the questions set out in the call for evidence, as set out below.

Our response

12          In this section we have responded to the questions which are the most relevant to our function as UK regulator of the nursing and midwifery professions. These include the questions on flexible models for building the workforce, why people leave health and care roles, international recruitment and the curriculums.

What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?


13          A well supported and appropriately resourced workforce is crucial to the delivery of safe services and care. While our health and care systems have always had to manage significant pressure, this has been exacerbated by the Covid-19 pandemic, leading to concerns about the long-term sustainability of our workforce.

14          While our latest data shows our register is at an all-time high we need a long-term, sustainable workforce plan that addresses the gaps and support required by all nursing and midwifery professionals, particularly those working in the community or in mental health and learning disability services. Both NMC evidence and wider studies illustrate the impact of vacancies and low staffing levels on patient safety and staff resilience. Effective and sustainable workforce planning, making sure we have enough nurses, midwives and nursing associates available to meet demand over the long term, is therefore essential for addressing these problems.

15          In order to achieve the intended benefits, any workforce plan needs to be fully comprehensive in covering the entire health and social care system. Both sectors are crucial and if we fail to account for the future needs of any part of the system, this will inevitably lead to gaps that will severely undermine the success of the whole.

16          For example, we know that retention is an even more significant issue in social care. Over a third of employees leave their roles each year, and social care nursing has a turnover rate that is almost three times higher than that of the NHS. In order to achieve long-term stability for social care staffing, we believe that the needs of this workforce must be treated with parity to that of the NHS, and be considered together in terms of recruitment and retention, pay and reward and education and training.

17          Creating flexible systems is also vital for ensuring that we can adapt to future needs. For instance, in response to the Covid-19 pandemic and after the Government introduced the required legislation, we allowed anyone who left our register between 1 March 2015 and 31 December 2021 to register temporarily to support the response to the pandemic – this cut-off date having been extended several times throughout the pandemic. Our survey of temporary registrants showed that 57.5 percent have worked since, and that a third would consider returning permanently, and this is something we want to facilitate. We are now currently working with the Chief Nursing Officers and employers across the four UK nations to provide the details of temporary registrants to health and care service organisations to encourage them to take up permanent registration.

What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

18          A vital component of creating a sustainable workforce is ensuring that we keep the staff that we already have. We conduct an annual leavers’ survey to explore the reasons people have for leaving our register. The findings from this make it clear that nurses and midwives are at growing risk of work-related stress and burnout, with 22.7 per cent citing too much pressure as one of their top three reasons for leaving and 14 per cent of free text responses citing high workloads. If we do not prioritise recruiting more of the skilled staff we need, and retain and support those we have, then we will continue to lose dedicated professionals due to work-related stress and its effect on their mental health.

19          We have surveyed those leaving our register every year since 2017 to better understand the reasons behind their decision. 5,639 people responded to our most recent survey between December 2020 and January 2021. The three most commonly selected reasons for leaving the register were the same as in previous years: retirement (51.6 percent), personal circumstances (28.5 percent) and too much pressure (22.7 percent). The relatively high numbers citing too much pressure are particularly concerning for workforce retention and the sustainability of the workforce. Workplace culture, a new response we included this year, was the fourth most selected option, with over 600 comments on this theme – around 29 percent of all comments. These all focused on the negative effect on individuals, such as bullying, poor management, and difficulty raising concerns.

20          People who had worked in midwifery or mental health were more likely to cite ‘too much pressure’ and ‘workplace culture’ as their reasons for leaving than those with other job roles. Older age groups most frequently left because they were retiring, there was too much pressure and they felt that the workplace culture had become too negative. Younger age groups most frequently left because they were leaving the UK, Brexit and poor pay and benefits. People who worked in the NHS were more likely to say they were retiring, and appeared to be retiring at an earlier age than those who had worked outside the NHS which may reflect different pension arrangements. NHS workers were also more likely to cite too much pressure, workplace culture, staffing and disillusionment with the quality of care. Our responses to other questions in this call for evidence, particularly on the models of care and the People Plan, go into more details on how we can address some of these key factors and improve recruitment and retention.

What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

21          We know that building and retaining a workforce is tightly linked to a variety of factors, including access to appropriate support and development opportunities, working culture, how employees feel they are treated and respected and all aspects of equality, diversity and inclusion. The People Plan should build on this, and valuing, developing and supporting all staff equally should be central to it.

22          For example, employers should use the principles of preceptorship guidance to provide structured support for newly qualified staff and support them transition their knowledge into the workplace. A positive preceptorship experience is reported to result in newly registered nurses, midwives and nursing associates having increased confidence and sense of belonging, feeling valued by their employer, and effective preceptorship outcomes are linked to improved recruitment and retention. Ensuring new staff get the best possible start in their role is particularly important for any internationally-trained staff, and so it’s vital that they are given comprehensive inductions to help them settle into their new role as smoothly as possible.

23          For existing staff, the People Plan should ensure opportunities for learning and development are readily available for everyone. Employers should support multi-disciplinary team working as well as joint training and development and learning. Everyone should have good access to continuing professional development and the potential for flexible working. Sufficient investment in professional development will help to support and enable all the professionals on our register to develop and meet our standards.

24          In addition, creating inclusive environments and positive workplace cultures should be part of the People Plan. Employers have a key role to play in helping to create the right culture for their workforce, and for making sure that workplaces are the inclusive environments that leave all staff feeling valued. As identified in our leavers’ survey, this is vital to retaining a talented workforce. A central part to creating a productive and supportive work culture is for both employers and employees to raise concerns when appropriate, in line with our guidance. Where possible, employers should try to resolve issues at a local level, engaging with regulation advisers, considering how to manage potential bias in referrals, and using our just culture tool.

What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?

25          Our latest annual report on registration data shows a welcome increase in the number of registered professionals, with growth in both the number of UK-trained and overseas-trained professionals. In the last year alone, the number of professionals on our register who trained in the UK grew from 600,906 to 609,327, increasing further to 613,289 in our mid-year report. While this growth is welcome, demand continues to exceed the supply of UK-trained professionals. It is therefore important that we continue to focus on international recruitment.

26          Between 2020 and 2021, professionals who trained outside the EU grew by 9.4%, from 84,316 to 92,260. This occurred in spite of global travel restrictions resulting from the Covid-19 pandemic, and is a stark contrast to the growth rate for UK-trained registrants (1.4%) and the reduction in EU-trained registrants (-3.4%). This demonstrates that internationally-trained professionals form a vital part of our health and care workforce and are likely to do so for the foreseeable future. It is important, therefore, to continue to focus on international recruitment and to ensure that it is carried out in line with the Department of Health & Social Care’s (DHSC’s) updated Code of Practice for international recruitment.

What can the Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?

27          The NMC is not directly involved in recruitment, including international recruitment, as our role is to set high standards for practice in the UK and to register applicants who meet them. We aim to create a clear and streamlined process for international applicants who are looking to join our register. We do this through our Test of Competence (ToC), which is a fair, fast, and efficient method of assessing all international applicants. We are also expanding the number of locations where applicants can sit the Objective Structured Clinical Examination (OSCE) part of the ToC from three to five from February, making it more accessible.

28          We are confident in the robustness of this assessment approach because it is designed to test the knowledge, skills and attributes needed for nursing and midwifery in the UK specifically. As these skills evolve and change, we can review and adapt the ToC to keep it aligned to reflect our new standards. This was done most recently in August 2021 in order to reflect our new Future Nurse and Future Midwife standards. This ensures that all those delivering care in the UK meet the same high standards, regardless of where they are trained or how long they have been out of practice.

29          In addition, the ToC is applied consistently, transparently, and equally to all applicants. This aligns with the Government’s ambition to see an efficient and fair process for the recruitment of internationally trained health professionals. It also underscores our commitment to fairness and non-discrimination in our processes.

30          Given the importance of the international workforce, it is essential that regulators such as the NMC are free to determine the appropriate routes and criteria for international applicants seeking to join the register. We need to be able to design and carry out all relevant regulatory controls relating to internationally trained applicants in order to uphold our public safety role. It is therefore important that regulatory autonomy is not undermined by the negotiation of any international agreement and that regulators continue to be informed and engaged throughout any negotiation process.

31          We are continuing to engage with the Government over planned reforms to our legislation. These reforms will be an important part of ensuring that we are able to adopt the most efficient and effective approaches by allowing us more flexibility in how we carry out our regulatory functions, including in our assessment of international applicants.  We would welcome a clear, public commitment from the Government to bringing forward these vital reforms to our legislation.

What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

32          We set the proficiencies necessary for registration – the knowledge and skills needed for professional practice – and the education and training standards that enable future professionals to meet these. We also set standards for supervision and assessment that support the student journey and require those supporting, supervising and assessing students to have the necessary knowledge and skills.

33          Some of the skills covered include those that could help professionals to make the changes necessary to improve recruitment and retention. For instance, our Future Nursing standards include understanding the mechanisms that can be used to influence organisational change and public policy, demonstrating the development of political awareness and skills, and exhibiting leadership potential by demonstrating an ability to guide, support and motivate individuals and interact confidently with other members of the care team.

34          We do not believe that the curriculums for our professions need updating as we have only recently updated our education and training standards which underpin the curriculums that education institutions develop. However, there are opportunities to modify programmes if the standards or evidence base changes. Our standards were designed for what people need now and towards 2030 and so are intentionally future-focused and future-proofed. For instance, we have emphasised the increased use and opportunity of digital and new technologies and new areas of science such as genomics. In addition, we expect our professions to work from an evidence base and be person-centred. This means that when the evidence changes then so too should the learning and teaching in curriculums.


Author: Thomas Andrews, Senior Policy Officer

Approved by: Matthew McClelland, Executive Director, Strategy & Insight

Jan 2022


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