Understanding Public Protection

Because the fitness to practise is such an important part of the work we do to protect the public, it is an area we are constantly trying to increase our understanding of and a process we are always reviewing.

Research

One important way we do this is through research. Today, we have released the data from our latest study, which shows that a fifth of UK adults have encountered behaviour from a health or care professional that made them doubt their fitness to practise.

The research also found:

• More than a quarter said the health or care professional in question seriously or persistently failed to meet standards.
• 16 per cent said they felt the professional failed to respect the rights of a patient to make their own choices. 
• 13 per cent felt they were ‘hiding mistakes’.
• 9 per cent felt they were exploiting vulnerable patients. 
• One in twenty said they had experienced or witnessed reckless or deliberately harmful acts.

Despite these figures, just three out of ten reported their concerns and a further 73 per cent said they would not know where to go to report concerning behaviour.

 

This data supports our research published earlier this year exploring public perceptions of the concept of public protection and how this might inform the fitness to practise of health and care professionals. That research showed that the public was most concerned about dishonesty, both on and off duty, and had an expectation that, at a minimum, professionals would be competent and qualified.  Importantly, the public also thought that judgements should always consider the context of a situation and be made on a case-by-case basis.

 

The findings of both research reports are reassuring because we are dealing with the areas the public feel they need protecting from the most – skills and behaviour – and support the case-by-case approach we already take fitness to practise. See our latest annual report and key information for a look at what we have been doing over the past year to protect the public.

 

Improving the FTP process

 

In addition to making interesting reading for professionals and regulators alike, the findings of the research are helping us in a broader piece of work to improve the FTP process for all concerned, for example reviewing the information we provide about the process.

 

Earlier this year, we held an event with representatives from stakeholder organisations, including professional bodies, to discuss the research on public protection and explore how we can continue to do this. Some key themes emerged from the discussions. These included:

• More and clearer information for employers and registrants explaining the difference between the FTP and other disciplinary or criminal proceedings.
• Case studies indicative of FTP cases that could be used as learning and discussion points.
• Clearer information for service users about what an FTP case looks like to help manage expectations on what we can and cannot deal with, as well as support and clear signposting for service users when they have a concern that is not a FTP issue.
• Better integrated and more interactive information, including cross-referencing exiting documents and more video and multimedia content.

We will be looking at both the research and the feedback we have received so far as we continue our review of the FTP experience.

Brian James

Head of Assurance and Development, Fitness to Practise

Notes:
- Today's research release
- Understanding public protection research, 2013

- Fitness to practise annual report
- Our How to raise a concern booklet

A look back at the first year of social work programme approvals

When the Register for social workers in England opened on 1 August 2012, we became responsible for the 249 pre-registration social work programmes that had previously been approved by the General Social Care Council (GSCC). To ensure these programmes meet our standards of education and training (SETs), we will visit each of these programmes to confirm their approval.

We held the first year of these approval visits during the 2012–13 academic  year and will continue with the visits for another two years As with all professions new to the HCPC, we have completed a review of this first year of approval visits to social work programmes.

Considering the other recent, non-regulatory changes in the social work education sector, we expected there would be significant changes to education providers’ social work provision.

One thing we saw was a twelve per cent reduction in the number of approved and transitionally approved programmes a year after the transfer. Of the 82 education providers running transitionally approved programmes at the point of transfer, 79 continued to deliver social work programmes, with three closing their social work provision entirely. The graph below shows how these closures have affected the split between approved undergraduate and postgraduate programmes over the last year. You can read more about these changes in the full paper, which you can view on our website here.

Comparison of programme numbers at the point of transfer and at the end of the 2012–13 – by qualification level

We also noted that there were significant changes to some programmes in areas such as curriculum design and delivery, and practice placements standards as they adapted to meet our standards, but also due to the recommendations of the Social Work Task Force, including The College of Social Work’s (TCSW) Professional Capabilities Framework.

Our review shows that the approval process was implemented effectively and that we have learned from the recent onboarding of other professions, such as hearing aid dispensers and practitioner psychologists. Specifically, as part of the preparation for the onboarding of the profession, we ensured that we worked closely with TCSW, holding regular meetings and developing a suggested agenda for joint approval / endorsement events.

In the full paper, we have provided detailed analysis about which standards had a higher number of conditions set, and have discussed reasoning for why we needed to set more conditions for these standards. Education providers, in particular those who have yet to have their visit, may find the full report useful in preparing for their own visits.

In particular, we have noted that many conditions were set in several of our broad SET areas, specifically those related to curriculum and assessment (SET 4 and 6), practice placements (SET 5), and programme management (SET 3). However, it is important to note that these are not issues that are specific to social worker programmes in meeting our standards. We expect to see conditions in these areas when onboarding any new profession or visiting new programmes from existing professions.

Number of conditions for social work programmes in 2012–13 – by broad areas of the standards of education and training

Where necessary, programmes have implemented changes to ensure our regulatory requirements are met. This shows that our standards, which are designed to be broad and flexible, can be applied across different professions and education programmes.

All social work programmes that we visited in the 2012-13 academic year have now successfully completed the approval process. The programmes now have ongoing approval confirmed, subject to satisfactory monitoring. We will continue to review the outcomes from our approval visits to social work programmes on a regular basis throughout the next two academic years.

Jamie Hunt
Education Manager
HCPC

Notes:

View the full review paper at www.hcpc-uk.org/assets/documents/100042FESWapprovalreview12-13.pdf

Find out more about our education processes at www.hcpc-uk.org/education/

Putting public protection in the spotlight

We are on the road in Gloucestershire today to officially re-launch our ‘Older, wiser …be sure’ campaign with an exclusive screening of our new film at the National Care Forum’s managers’ conference.

The ‘Be Sure’ campaign is aimed at care home managers, carers and older service users, urging them to check that their health and care professional is registered and to raise any concerns about their conduct or competence. The campaign draws on research we have done that shows most older people do not check whether the person treating them or the person they are caring for is registered.

Checking that a health and care professional is registered with us is vital because it is the only way you will know if the professional meets our national standards for training, skills and behaviour. It is also important because it offers you protection if the professional fails to meet these standards, as we can take action against registered professionals.

In order to convey this message to a wide audience in an engaging and thought-provoking way, we chose to refresh the campaign with a dramatic film that shows what can happen when things go wrong.

The film depicts three older service users, ‘Doris’, ‘Rasheed’ and ‘Rose’, who receive inadequate treatment from both registered professionals and unregistered practitioners. Meanwhile ‘David’, a stretched care home manager, learns how quick and easy it is to check the register when a professional comes to see one of his residents.

Making the film was a great learning experience for our team. We carefully researched the chosen scenarios, which are partly based on actual fitness to practise cases. To make the film as accurate and realistic as possible, we shot on location at a care home, in a hospital and at a house. We also had HCPC registrant partners involved to coach the actors on good and bad practise for their respective professions. This was a wonderful opportunity for us to interact with our partners and learn more about their roles on a day-to-day basis.

It was also a good opportunity to see professional filmmakers at work and to appreciate how much time and effort goes into getting that perfect scene. There were some great acting and make-up artist skills – keep an eye out in the film for a very realistic-looking foot sore!

I hope the work that everyone put into making the film as realistic as possible will really get people thinking about the importance of checking that their health and care professional is registered and remind them that they have recourse if things go wrong.

If you are not joining us in Gloucestershire today, you can watch the film below. We will also be showing a shorter version of the film at the Care Show in Birmingham next month, so do stop by and say hello if you will be attending.




Ebony Gayle
Media & Public Relations Manager, HCPC

Notes:

Check the register online at www.checkthregister.org

Study amongst Older People aged 70+, Ipsos MORI Research Institute for the Health Professions Council, 2008.

A short version of the film is available at: youtu.be/PO8MuHeVaYY

To find out about other regulated professions see : www.hcpc-uk.org/aboutregistration/regulators

Review of the process of HCPC approval of practitioner psychologist pre-registration education and training programmes

On 1 July 2009, the British Psychological Society (BPS) transferred its regulatory responsibilities to the HCPC and practitioner psychologists became the fourteenth profession to join the HCPC Register.

In addition to agreeing new standards for the profession, the HCPC became responsible for all the pre-registration programmes which transferred from the Society.  Over the following three years, we visited each of these programmes to confirm their approval against our standards.

As with all new professions, we have undertaken a review of these visits to look at what, if any, key trends emerge.

From the review, we have identified that the approval process was implemented effectively and there were no outstanding issues specific to this profession. Importantly, this shows how our standards, which are designed to be broad and flexible, can be applied across different professions and education programmes.

The review also enabled us to identify where work was greatest over the past three years, if it was what we expected and what we can learn from the process. Specifically, we have used the findings of the review to develop the process of opening the Register to other new professions.

In particular, it has helped us to identify the most efficient way to transfer and utilise information about education and training programmes from previous regulatory or professional bodies. We have also been able to develop our communication with new professions and education professionals to make sure we effectively communicate who we are and what we do to ease the transition for those directly involved.

These developments have been put to good use as we have since welcomed hearing aid dispensers and then social workers in England onto the Register.

The findings in detail

It is clear from our review that no trends emerged that are specific to practitioner psychologist programmes when compared to programmes from the other professions we regulate. All 98 practitioner psychologist programmes we visited were granted approval or had approval reconfirmed.

Although the number of conditions set against each of the practitioner psychologist programmes  varied, the overall average when compared with all other programmes visited over the same period was exactly the same. The particular standards against which conditions were set also mirrored those most commonly set on programmes from other professions.

 

Number of conditions set on programmes between 2009 and 2012
  

 

 

Percentage of conditions set on programmes between 2009 and 2012

 

 

This is a very positive outcome as the results do not suggest that a profession-specific risk profile has emerged or that there are any difficulties in meeting our regulatory standards.

We will now monitor and review how practitioner psychologist  programmes interact with the established monitoring and major change processes to see if any specific trends emerge and, if so, what lessons can be learned from this.

Ben Potter
Education Manager, HCPC

Notes:
Download a copy of the full  report
www.hcpc-uk.org/aboutus/committees/archive/index.asp?id=652

Detailed information on the HCPC’s approval and monitoring processes can be found here: www.hcpc-uk.org/education/processes

All HCPC- approved programmes, including practitioner psychologist programmes, appear on our register of approved programmes: www.hcpc-uk.org/education/programmes/register   

Independent prescribing for chiropodists / podiatrists and physiotherapists

Today, legislation to allow independent prescribing by appropriately trained chiropodists / podiatrists and physiotherapists came into effect. This is the result of several years of work by the Department of Health, professional bodies, education providers and regulators, including the HCPC.

Chiropodists / podiatrists and physiotherapists will need to complete appropriate training and be marked or ‘annotated’ on our Register as independent prescribers before they can act as an independent prescriber. As independent prescribers, chiropodists / podiatrists and physiotherapists will be able to prescribe an appropriate medicine for their patient based on the patient’s clinical needs and within the legal framework.

In line with the new legislation, we have published new standards for prescribing today. The standards set out a robust framework for education providers delivering training in prescribing and also for the prescribers themselves. We will now start the process to approve education programmes delivering training in independent prescribing against these standards.

We asked a physiotherapist and a chiropodist / podiatrist what the change in legislation means for their service users and their practice.

Julie Read, physiotherapist working in a community specialist respiratory care team 

“I can currently only prescribe medicines within a clinical management plan that is agreed and signed off by my designated medical practitioner and the patient’s GP practice. So being able to independently prescribe will mean I can now prescribe antibiotics, cortico-steroids and inhalers when needed by patents in a more timely and efficient way. Patients benefit from getting exacerbation medicines or new inhalers faster.

“Physiotherapy-led community respiratory services are a great step forward as it means the GP and consultants can be less involved in routine cases, which frees up their time for patients with more complex needs. Previously, the lack of independent prescribing was the barrier stopping this happening more frequently.”

Matthew Fitzpatrick, musculoskeletal specialist podiatrist

"As a podiatrist in the acute setting, I sometimes need to have the flexibility to respond to the clinical needs of patients, which was not always supported as well with previous medicines management options. Heavy reliance on medical staff, both locally and regionally, meant that there were delays in care that then affected the patient pathway.

“The benefit of independent prescribing for podiatrists working as part of the overall health care team is that we can provide the right care at the right time, delivered in the right place.

"Having this option as part of the patient's pathway will mean I am able, where necessary, to positively impact the patient’s outcome as well as relieve pressure on other health care providers. Being able to implement this within the appropriate settings and with appropriate support will certainly revolutionise the way in which my colleagues and I will deliver care to our patients."

Will you be taking advantage of the opportunity to train as an independent prescriber once the programmes have been approved? How will the ability to train as an independent prescriber affect your own practice? Leave us a comment below.

If you have any questions about the new independent prescribing standards, contact us at policy@hcpc-uk.org

Charlotte Urwin
Policy Manager, HCPC

Striving for good governance

On 29 July, the Health and Care Professions Council (HCPC) launched its campaign to recruit a new Council. This rose from a government directive that all UK professional regulatory bodies for health and care create smaller, ‘more board like’ governance structures. The General Medical Council, the Nursing and Midwifery Council and the General Dental Council have already made this change. Over the last 7 years, HCPC has moved from a Council of 26 appointed and elected members and 13 alternate members (39 in total), to 20 appointed members. It is now moving to an appointed Council of 12 members.

HCPC has enjoyed a period of substantial growth under the direction of a strong and cohesive Council. We must maintain our UK wide focus and ensure that we recruit individuals who provide the strategic and financial oversight required. I have no doubt that we will continue to attract individuals with a wide range of skills and expertise from different arenas including service user advocacy, social care, health and psychological services, education, commerce and finance.

We also need individuals who can engage with the big, difficult issues facing public services. Recent events have revealed serious breaches of public trust and confidence in the governance of health and social care providers. Mid Staffordshire, Winterbourne, Ash Grove, Gwent, Vale of Leven and Rochdale all point towards serious failures of governance as well as failures of care. There will continue to be conversations around the HCPC table about these failures and how and why they occurred and what can be done to mitigate the risk of such failures occurring in other contexts. No-one in health and social care regulation can be complacent and HCPC has a shared responsibility with other regulators to make improvements.

The move to a smaller Council also creates the space to think about the underpinnings of good governance. We need people with a range of skills and expertise and big picture thinking, but we also need to create a governing body with shared values. One of the themes across a range of guidance documents on governance (1-4)  is fidelity to values. This means not simply being able to articulate the seven principle of public life, (4) but to have an appetite to re-visit what they mean on a day to day basis, how they impact on relationships, decision making, outcomes. How they can challenge and create conflict. How they influence the culture of the organisation at every level.

It is the combination of skills, expertise and the values of public service that are critical to this new Council. We need individuals who can hold the purpose of professional regulation at the centre of corporate decision making. That purpose is to provide public protection for those who use the services of professionals on the HCPC Register. Clarity of purpose, fidelity to core values are key.


Anna van der Gaag
Chair
The HCPC

References

1. Carver, J. (2006) Boards that make a Difference. Jossey-Bass, California

2. Independent Commission on Good Governance in Public Services (2004)
http://www.jrf.org.uk/publications/good-governance-standard-public-services

3. PSA (2013) Fit and Proper? Governance in the public interest.
www.professionalstandards.org.uk

4. Committee on Standards in Public Life (2013) Standards matter: a review of best practice in promoting good behaviour in public life.

What is the opposite of competence?

One of the key responsibilities of a professional regulator is to ensure that professionals are competent when they join the register and remain competent throughout their working lives. HCPC sets standards of competence (called proficiency) to do just this, and at the moment we are in a phased review of these for 15 out of 16 of the professions we regulate. This involves extensive review, consultation and further revisions in order to ensure that the standards remain fit for purpose and up to date. Good regulation depends first and foremost on having robust and credible standards which reflect professional practice in meaningful ways.  

 However, there is much more to maintaining competence than good standard setting. More than twenty years ago, I worked on a research project looking at the nature of professional competence in my own profession. Phil Davies and I published a series of papers describing in some detail the methodology and results of this work (1). We observed that competence is always more than the sum of its parts, and it is often if not always context sensitive – that is, influenced by the context in which practice plays out. It is also as much about the underlying values of the practitioner as it is about the ‘technical’ knowledge and skills.

 I was therefore particuarly pleased to attend a lecture  in Edinburgh last month which reinforced some of these points, taking a fresh look at competence from the perspective of the onlooker (2). Professor Zubin Austin from the University of Toronto described how a patient or service user’s perspective on competence will differ from an educational or a legal or a  professional perspective. Patients and service users want accessibiity, affability and acknowledgement. They want kindness as well as knowledge. There has been much to reinforce this in the recent debates about the training and supervision of care assistants (3).

 Perhaps the most potent point Zubin made was that, in his view, the opposite of competence is not incompetence, but disengagement. Professionals become disengaged, not deliberately or suddenly, but incrementally and often in ways that go unnoticed for months or even years. The events in Mid-Staffordshire would seem to support this, too. 

 The challenge for us all is how do  we address this engagement issue? How do employers, educators, peers and regulators work together to help individuals to stay connected? Zubin’s assertion is that systems and relationships need to reinforce good behaviours not just focus on bad behaviours. Think of competency in a different way.

 

Anna van der Gaag

Chair
HCPC

 

NOTES

(1) van der Gaag, A. Davies, P. (1992).The professional competence of speech therapists: IV: Attitude and attribute base. Clinical Rehabilitation 6,4, 325-332.

 (2) Austin Z. (2013) How competent are we at assessing competency?

Keynote, CLEAR Congress on Professional and Occupational Regulation, Edinburgh, June 27-28,  2013 www.clearhq.org

(3) Cavendish C. (2013) What the NHS needs is a degree of kindness.The rest can be taught. Sunday Times, 14.7.13.

Education annual report 2012

Our Education Department approves and monitors education and training programmes throughout the UK. This relates predominantly to pre-registration programmes for the 16 professions we regulate, although we do also approve a small number of programmes linked to post-registration areas of practice. Our standards of education and training (SETs) ensure that a programme that maintains its approval with us produces individuals who are fit to practice and are therefore eligible to apply to our Register.

We published the Education annual report 2012 on Tuesday 7 May 2013. Here, we look at some of the key themes from our review of our approval and monitoring activities across the UK during the 2011-12 academic year.

In numbers
During this period we:

• conducted 67 approval visits assessing 110 programmes;
• reviewed 256 annual monitoring declarations and 221 annual monitoring audit submissions;
• considered 316 major change notifications;
• investigated four concerns raised about approved programmes that were within our remit; and 
• transferred 269 social work pre-registration programmes and 27 approved mental health professional (AMHP) programmes to our register of approved education and training programmes following the transfer of social workers in England from the General Social Care Council on 1 August 2012.

The video below provides a brief overview of key facts and figures from this year's report:



Conditions for new programmes
A key area of growth over the last three years related to new programmes for practitioner psychologists and hearing aid dispensers following the opening of these Registers in July 2009 and April 2010 respectively. We concluded the schedule of approval visits to these programmes in summer 2012.

A common theme across these programmes was the number of conditions we applied on approval that related to practice placements. Our SETs require an education provider to hold overall responsibility for placement provision. Conditions in this area are therefore often focused on the quality assurance arrangements the education provider has in place to manage these important areas of teaching and learning.

This is a trend we often see with new profession programmes that transfer over to us and with new programmes from our existing professions. Our Visitors normally ask for further evidence that education providers are well placed to manage practice placements and that placement educators are equipped to provide appropriate learning experiences. This often means education providers must demonstrate that there are formal, documented arrangements underpinning the relationships they have with their placement providers. When considered in this context, these results do not suggest any profession-specific risk profile for either new profession.

To help address this across all professions, we have been delivering seminars for the past two academic years that are focused on supporting education providers in their management of placements. For these seminars, we invited both education providers and placement educators to attend as we recognise the important role they each play in ensuring the education experience meets our standards. These seminars were well attended by representatives from the majority of our professions and facilitated useful discussions about different approaches to the management of placement provision.

The MSC initiative
The Modernising Scientific Careers (MSC) initiative – a workforce strategy from the Department of Health – has also had an impact on education programme numbers, with the creation of 16 new biomedical scientist programmes in 2011-12, which we approved. We also approved a new route to registration for clinical scientists modeled against the new MSC scientific training pathway. It is possible that we may see the creation of more new biomedical scientist and clinical scientist programmes in future years as a result of the MSC initiative.

These developments suggest that our standards remain fit for purpose and can be appropriately applied to a range of professions and models of education and training for the professions we regulate.

Monitoring
When compared over the last five years, it is clear that our monitoring workload is growing. For annual monitoring, we have seen an increase of 85 per cent between 2007-08 and 2011-12. Major change notifications also increased by 32 per cent in the 2010-11 academic year. These increases are expected each year, because as we approve more programmes, more programmes are subject to meeting our monitoring processes. We anticipate further growth as practitioner psychologist and hearing aid dispenser programmes move into our monitoring cycle.

We required additional documentation for 41 per cent of annual monitoring audit submissions. This is comparable with the results from last year, which reflects the requirement for education providers to show how they meet the revised SETs implemented in September 2009. All programmes in the annual monitoring cycle have now provided this evidence and we expect the number of requests for additional documentation to fall again next year accordingly.

No programmes required a further approval visit as a result of an audit submission and only 2 programmes required a further approval visit as a result of a major change submission.  We only decide to conduct an onsite approval visit when the changes submitted by an education provider have significantly changed the way their programme meets our standards. Pleasingly, these results mean our model of open-ended approval is achieving the task it was set out to do: preventing the need for cyclical re-approval visits where possible.

Looking ahead
We anticipate the majority of our approval and monitoring work over the next three academic years to be focused on the schedule of visits to social work and approved mental health professional (AMHPs) programmes in England.

As with all new professions, we will undertake a review of these visits each year to inform our own approval and monitoring approach for these professions and the application of our standards. This review will also feed into future seminar topics and stakeholder liaison that we conduct with the social work profession.

Brendon Edmonds
Acting Director of Education, HCPC

Notes:

You can download a copy of the full Education annual report 2012 here: www.hcpc-uk.org/publications/reports

Further information on the HCPC’s approval and monitoring activities can be found here: www.hpc-uk.org/education

All programmes approved by the Education and Training Committee for meeting our SETs appear on our register of approved programmes: www.hcpc-uk.org/education/programmes/register

Don Berwick: a challenging voice from the US

The government has published its initial response to the Francis Report, with a wide range of proposals to take the recommendations forward (1).  

Amongst the many initiatives, Professor Don Berwick, a veteran of the healthcare quality movement in the US and former adviser to President Obama, has been invited to report on ‘a whole system approach to make zero harm a reality in the NHS’ (1).  

For over twenty years, Berwick has been a leader in the field of health improvement, looking at how services can improve to make care better, safer and more efficient. His work at the Institute of Health Improvement has made a major contribution to understanding quality and safety in health care.

At a recent lecture at the Kings Fund in London (2), Berwick suggested that the UK health and social care system, like the US system, needed radical solutions if we are to achieve ‘better care, better health and lower cost’. Besides the economic pressures, which are considerable, he talked about the public and the professions being ‘confused’ about what the future of health care delivery would look like. Patients and their carers worry that changes will mean a loss of services, and the professions are unsure about what kind of practice they will have in the future. At a political level, in the US at least, Berwick spoke of a loss of authentic dialogue about exactly what changes will deliver better outcomes.

A quietly spoken man with a powerful combination of conviction and experience, Berwick’s vision had a moral dimension – with a challenge to professionals to focus on the needs of the vulnerable in society. He suggested that, in the future, care must be less centred on hospitals, and be much more community based. He saw the future of care delivered in teams made up of individuals with ‘an expanding scope of practice’, able to meet the needs of local populations, using new technologies and advocating a new approach to involving service users in the decisions about their own care.

Berwick illustratated his vision with examples of innovative care in the US,  many of these based on integrated teams, with little or no heirarchy, and much less doctor-focused than our current systems advocate. He said the first rule of change is to cooperate. The training of health care professionals  must include ‘process improvement, courage, transparency and openess and above all cooperation’.

These are huge ideas, and huge challenges, but arguably they articulate what many people in the UK already recognise.  When HCPC was established over 12 years ago, there was resistance to the idea of an integrated system of professional regulation – where all professions were subject to the same regulatory processes, one register, one fitness to practise process, shared standards and one Board with oversight of all.

Today, the HCPC is seen as an effective and efficient regulator of 16 health, psychological and social work professions. It may well be a model for the future which Berwick describes.

 

Anna van der Gaag

Chair

HCPC

Notes

1)    Department of Health (2013) Patients first and foremost: the intial government response to the Report of the mid Staffordshire NHS Foundation Trust Public Inquiry

2)    Don Berwick (2013) The role of clinical leaders. Kings Fund lecture, 16 April 2013. www.kingsfund.org.uk

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

The role of professional regulation after the Francis inquiry

Last week I attended the King’s Fund conference looking at the outcomes of the public inquiry into the failures in care at the Mid Staffordshire NHS Foundation Trust.

The conference was an opportunity for all those with responsibility for health and social care (from funding, to delivery, to regulation and oversight), to come together to continue the process of exploring the fundamental question after any public inquiry – what now?

What will endure with me most in Robert Francis’ opening presentation were the patient stories – the first-hand accounts of truly appalling care. As Robert Francis emphasised, on the whole these were not examples of deviation from good practice, but ‘obvious’ failures in the fundamental standards of care which we should all expect.

Culture and culture change was a consistent theme throughout the day. Robert Francis spoke about the development of a culture at Mid Staffordshire where patients and staff were either not listened to or felt discouraged or disempowered to speak up. A number of the participants in the audience were former NHS staff with a poor experience of reporting and escalating instances of poor patient care. They were keen to ensure that the inquiry led to real change in how whistleblowers were treated and supported, from the actions of the Board in setting the tone for how reports of poor standards were handled, to how whistleblowers were treated by their peers. At times there was a hint of weariness from some in the audience – a fear that reducing the problem and solution to intangible references to culture would be a blueprint for inaction. We were reminded by Robert Francis at the beginning of the day that many of his recommendations could be implemented now and without the need for legislation, there was no need for delay.

So, what role do professional regulators have to play in a ‘post Francis world’? The challenge from Robert Francis was for all organisations to reflect on the report; to evidence their acceptance of the report’s recommendations; and to take effective steps to translate that acceptance into real action. Our Council will begin that process with a paper at its next meeting in a few weeks’ time.

Some of the changes we might need to make are immediately apparent. For example, we have begun the process of reviewing our standards of conduct, performance and ethics and we know as part of that we will want to strengthen our existing requirements about the responsibility of our registrants to report and escalate concerns about poor care. This will build on our existing commitments as part of the NHS Employers Speaking Up Charter. We will also want to continue encouraging and engaging in debates with health and care professionals about professionalism. Francis spoke of a conversation with one professional who described the process of becoming ‘immune to the sound of pain’ in an atmosphere of intense pressure, low staffing levels and even lower morale. How do health and care professionals and their leaders address this kind of pattern?

We need to think about both the role we play as a regulator in setting standards for a range of health and care professionals, and the role this plays in helping to shape the culture. But we also need to think about the wider lessons we can learn from the Francis report for us as an organisation.

We were reminded last week that professional regulation is only one part of a wider jigsaw puzzle that collectively ensures quality and safety, but that certainly shouldn’t exempt us from thinking about the part we can play in taking the ‘post-Francis’ agenda forward. And in doing so, the personal stories of pain and suffering should be uppermost in all of our minds.

Michael Guthrie
Director of Policy and Standards

Personal reflections post Francis

Yesterday, I attended a one-day conference on the Mid Staffordshire Report at the King's Fund. Listening to Robert Francis, I was reminded of an incident that took place many years ago when I worked as a speech and language therapist in a hospital unit providing care for the elderly. The incident concerned a lady who had a stroke, resulting in some weakness on her left side. She had severe difficulties expressing herself, although her understanding of language was unaffected. She knew exactly what was going on and what was said to her. She did not appear to have many visitors, but was always pleased to see me and was very motivated to work to regain her speech.

The enduring and disturbing memory triggered by Francis was of coming to her bedside, to find her distressed, agitated and unable to speak, gesturing frantically to me, pointing to her bed. Her sheets were wet and soiled. I got her out of bed and helped her to sit on the chair. I told her I would go and find help. I went to the nursing station; there was no one there. There appeared to be no one around. I eventually found a nurse and told her what had happened. She looked blankly at me. She said: “I'm the only one here. Everyone else is on a tea break.” I said: “Where are the sheets? Can I change Mrs W?” “No,” she said. “It's not your job.” “But she is very distressed,” I persisted. “She will have to wait until the others come back.” “No,” I said. “She needs help now.” I went back to Mrs W and explained that there were very few nurses about. “I know!” she cried.

For several days afterwards, she was subdued, tired easily and was less motivated to work on her speech. I spoke to colleagues about the incident. I felt there was something wrong with a system that could not respond to distress, still less find it acceptable that a speech and language therapist was interfering in the care of a patient. I don't know how typical this was at the time, of course. Nevertheless, in my view, this should not have happened.

Since those days in the early 1980s, the NHS has gone through at least a dozen re-organisations, as well as witnessing a few major inquiries. Sadly, the same themes recur. From patients, those themes are poor care, not enough staff, not knowing what is happening to them, and lack of involvement in decision making. At worst, they are about neglect, rudeness, and lack of respect from staff. What do staff say? Staff shortages, lack of management support, poor supervision, feelings of disempowerment and disconnection. I have often heard front-line nursing staff say they are too overworked and understaffed to be able to afford the luxury of talking with their patients. Too many demands lead to emotional shut down and apparent lack of compassion.

Francis highlighted for all of us involved in delivering health care that a positive culture and clear lines of accountability are not optional extras. They are fundamental to good care. One element necessary to create and sustain both of these is for professionals to have and maintain a clear sense of purpose and a shared set of values that drive everything they do. Some would call this the heart of professionalism. HCPC has been working over the last few years on a programme of research looking specifically at professionalism. We have known for some time that the majority of complaints are about conduct not technical competence. We wanted to address this, initially through research, and later through dissemination and debate with clinicians, educators and students, as well as within the regulatory community. We published the first report in 2011 and the second will come out in 2015. The wider questions we have posed for those on our Register are: What does being professional mean to you? What do you do if you see unprofessional behaviour in others? Can you have a conversation about difficult things, like being a witness to poor care? How is professionalism learned? How do you cope with the stress of being a professional caregiver, working daily with vulnerable people, dealing with unforeseen illness, disability, distress and uncertainty?

Nothing in the Francis report or in today's discussions leads me to think we need to do less. In fact, stepping up our call to registrants to deal constructively with these difficult issues seems all the more relevant in light of this report. We will be looking closely at our responsibilities as a professional regulator, what more we can contribute, and what needs to change in our standards and our engagement with other agencies. Whatever re-organisation the health service undergoes in the coming months and years, it must not lose sight of the need to address the fundamental commitment to care, which we know is not universally delivered, still less universally understood. In the words of Francis: "Every single person serving patients must contribute to a safer, committed and compassionate and caring service."

This is not just about doctors and nurses. If we do not act collectively, we are all undone.

Anna van der Gaag
28 February 2013