Cab drivers and care workers

The recent King’s Fund conference on the Francis Report has generated considerable debate and discussion, not least because Robert Francis was present to make some powerful observations on the challenges that lie ahead.

One of the areas that was addressed by many of the speakers was around future plans for healthcare support workers. During one of the sessions, we heard about a new approach to recruitment and retention of these staff. Lucy Connolly, Assistant Chief Nurse at York NHS Trust, described how the Trust had moved from a competency based approach in the recruitment of support workers to a values based approach. This includes a person specification with a primary emphasis on values, mandatory open events, which include talks from support workers and a DVD of interviews with support workers talking candidly about the role, and interviews with an emphasis on values and compassion. Once appointed, all support workers undergo a two-week induction, again with an emphasis on values and personal responsibilities. There is a year-long period of preceptorship with a competency assessment, and a buddy scheme to provide more informal support and mentoring. The new approach has had a measurable impact on sickness levels and staff turnover. There has been less reliance on temporary staff and a reduction in recruitment costs. Perhaps most importantly, there has been improvement in care indicators from patients.

This approach reinforced messages from other speakers at the conference about the need to make radical changes in the culture of the NHS. Some of this starts with the recruitment of staff. Francis himself placed great emphasis on the need to change values and behaviour and to reward good practice. However, he also very strongly supported the need for sanctions against those who do not deliver, be they boards, managers or staff. There are a minority of workers in every health and care setting who do not comply. The emphasis on values and behaviour, and employer-led initiatives like the one described by Lucy Connolly, are absolutely vital if we are to see change. But this will not stop those who fail patients, are asked to leave, and move on to another care setting.

One of the challenges of delivering high quality care is finding, training and retaining high quality staff, be they doctors, nurses, or support workers. Currently, there is no registration process in England for adult social care workers or for healthcare support workers. We have been exploring the options for how adult social care workers in England might best be regulated. Our favoured option is a statutory code of conduct that is enforceable. This is an alternative to statutory regulation but is nevertheless one that can hold to account the small minority of care workers who provide unacceptable care. We introduced a similar system for social work students last year, which is working well. It is already used in the UK to regulate estate agents. In New South Wales, Australia, it is used to regulate all those health workers who are currently not on a statutory register.

Last week, Robert Francis said: "It's extraordinary that the cab driver that takes you to the hospital has more regulation that the healthcare assistant who wipes the bottom of your grandmother. This is not acceptable. We need to disqualify people who fail our patients." I can only agree.

Anna van der Gaag
Chair, Health and Care Professions Council

Accountability and the adult social care workforce

When Polly Toynbee referred to Jeremy Hunt’s in-tray as "a pyramid of hand grenades with loose pins,"(1) she may not have had the regulation of support workers in mind. However, for those of us involved in professional regulation, we have been debating the issue for some time. Winterbourne View brought home the toxic consequences of mismanagement, lack of training and a "hospital run by support workers" (2). We know from different sources that the ratio of professional staff to support staff is changing throughout the country and that many are employed directly by people with disabilities in their own homes. Estimates on the numbers in the adult home care workforce are around about 400,000 in England.

It is likely that the vast majority of these individuals are committed, compassionate individuals who have been involved in caring work for many years. Without them, society would not be able to function. However, we also know that there are a minority who fall short of the high standards we expect of someone caring for our mothers or grandmothers. These are the individuals we want to ensure are made accountable and are not able to move from place to place when concerns begin to be raised about their behavior or conduct.

The government has asked the HCPC to look at the options for regulating this workforce. At our Council meeting last week, we agreed that, as a statutory regulator, we were not minded to set up a voluntary register because it would not provide the public reassurance and protection that is needed here. Statutory regulation for this workforce would not be a proportionate response and is one that the coalition government would probably not support. A third option would be to introduce a negative registration process, in effect, a register of individuals who cannot work in the sector, rather than one for those who can. Any individual who is found to fall below statutory national standards of behavior and conduct could be placed on an HCPC ‘negative’ register. The system could impose a range of sanctions on individuals, for example, require specific training or supervision to be put in place. One key question is: how much would it cost? The answer is: much less than any of the alternatives. The evidence from other countries that have a similar model shows that few people are stopped from working in the sector permanently. However, the statutory nature of the negative registration scheme means that there is a clear deterrent, an enforceable means of holding individuals to account. This is what is missing at the moment.

As a Council, we are clear that our responsibility is to explore all the options and reach an informed decision before making any recommendations to government. We will be looking at this alongside the regulation of care home managers. As in all our endeavors, we will be seeking the views of stakeholders from across the sector to assist us.

Anna van der Gaag
Chair
HCPC

(1) The Guardian, 6 September 2012.

(2) Flynn M (2012) Winterbourne View Hospital: A Serious Case Review. South Gloucestershire Safeguarding Adults Board.