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