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

Leadership, responsibility and professionalism – personal reflections

Finding an agreed definition of ‘leadership’ has never been straightforward. Constructs of leadership in health and social care are probably even more complex than they are in business or politics, and prone to narrow definitions based on hierarchies and responsibilities. Peter Senge famously observed that genuine leadership is deeply personal and inherently collective. Ron Paterson, in his new book: ‘The Good Doctor – What Patients Want’ observes that health (and social) care are increasingly diversified across a range of specialists and professions. Health and social care is changing, consumers are changing, and the professions need to respond to this in ways which open up possibilities for leadership, rather than closing them down.

In recent years, the NHS has been at the forefront of developing the concept of shared leadership across these professions through various initiatives, notably – the recent publication of the NHS Clinical Leadership Competency Framework (CLCF). This is a helpful and important resource which aims to provide a common language and approach to leadership for all clinicians in the NHS, describing the leadership behaviours that all staff should demonstrate as they develop throughout their careers. The CLCF is based on the idea of ‘shared leadership’. Instead of being confined to those who are in senior roles or who have line management responsibilities, leadership is something that should be demonstrated by all clinicians. All this isn’t intended to take away from the responsibility and accountability of those in managerial positions but, in line with our standards, this emphasises appropriately both individual and collective responsibility for the care and services an organisation provides.

Failures in leadership are often diagnosed to be part of the problem when failures in health and care services are identified but leadership is also seen as integral to the solution. The public inquiry into the failings of Mid Staffordshire NHS Foundation Trust led by Robert Francis is due to report early next year, and the King’s Fund amongst others has predicted that the report will make far reaching recommendations about how quality assurance systems should help to create an environment in which effective leadership can flourish. The King’s Fund has also linked leadership to the challenges facing the NHS, arguing that these challenges require a concept of leadership that is ‘shared, distributed and adaptive’, with clinicians and managers working in partnership.

We have recently published a position statement for education providers which sets-out our position on the CLCF. This sets-out how the framework relates to our role as a regulator, and in particular and responsibility for setting standards for entry to the Register and quality assuring education and training programmes across the UK.

Although they are often talked about separately, I believe that leadership and professionalism are intimately linked. Research we commissioned from the University of Durham found that professionalism, like leadership, could not be defined in exact terms. Professionalism was found to be best thought of as consisting of situational judgements about what to do, and what not to do, in a given situation. The idea of ‘shared leadership’ emphasises our common responsibility in addressing and ensuring professional behaviour – through ‘leading by example’ regardless of our role; taking responsibility for our actions; and reporting concerns where we have them. Karen Middleton, Chief Health Professions Officer at the Department of Health, has recently encouraged Allied Health Professionals (AHP) to engage in a ‘big conversation’ about what is and is not professional behaviour. The aim is to create an environment in which talking about behaviour is commonplace, and unprofessional behaviour is challenged immediately and constructively. Regulators like the HCPC have an important role to play by setting standards and dealing with instances of poor behaviour but this initiative very importantly emphasises our collective ownership of these issues.

Although the focus on the CLCF is developing leadership capabilities within the NHS, we consider that the majority of the content is generic and applicable across the range of different professions we regulate. We are confident that leadership knowledge, skills, attitudes and behaviours as outlined in the CLCF are already well embedded within our standards. Practitioners from the wide range of HCPC regulated professions will develop and augment these competencies as they develop within their careers. However, like professionalism, regulators play only one part in the development of leadership capabilities; this is very much a shared endeavour.

Anna van der Gaag
Chair, Health and Care Professions Council


References
Paterson, R (2012) the Good Doctor – What Patients Want. Auckland University Press

Senge, P In Greenleaf, B. (2002) Servant Leadership. New Jersey, Paulist Press.
King’s Fund Commission on Leadership and Management in the NHS (2011). The future of leadership and management in the NHS: No more heroes. London: King’s Fund.

Dixon, A., Foot, C., Harrison, T. (2012). Preparing for the Francis report: how to assure quality in the NHS. London: King’s Fund.

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.

The end and the beginning: Social workers in England have a new independent regulator

Yesterday marked the beginning of a new chapter in the regulation of social workers in England. From 1 August, all practising social workers in England have to be registered by the re-named Health and Care Professions Council (HCPC). This follows many months of preparation by HCPC in collaboration with the outgoing regulator, the General Social Care Council (GSCC), to ensure a smooth transfer.

What this change means for all social workers in England is that they are required to sign up to a new set of standards. These describe not only the ethics and conduct of their work, also the knowledge and skills expected of them. The HCPC will also require social workers to sign up to new standards on CPD, which are focused on the outcomes of learning, rather than the hours or points system which social workers have been used to. There will be more of a focus on personal responsibility for undertaking learning activities, and a requirement to undertake a wider range of activities, both formal and informal, which contribute to the process of keeping up to date and fit to practise.

The benefits of this new system of regulation are in part to do with HCPC's legislation. We have a wider range of standards, describing social worker competencies as well as conduct. We have stronger powers for dealing with concerns and complaints, which will make the process of investigation more efficient. We have a broader range of sanctions when dealing with concerns about a social worker’s fitness to practise, for example we can impose conditions on a social workers practise, ensuring that they receive supervision or re-training if their practise falls below our standards.

Taken together, these new standards, powers and sanctions will allow us to protect the public from poor practitioners and affirm the high standards in the profession. However, regulators do not operate in isolation. We will be building on the achievements of GSCC, working with the profession, with professional bodies, service users, advocacy groups and unions, as well as with educators to ensure that registered social workers in England are practising safely and effectively.

Over the last two years I have learned much about social work practise from listening to social workers and service users. Society has high expectations of those who practise as social workers. The work of a social worker is frequently challenging, often complex, and rarely acknowledged. For every one social worker who falls below national standards, there are many hundreds whose commitment and service to children and adults bring lifelong benefits and significant improvements. A huge amount has rightly been invested in the profession in recent years and the work of the Munro team, the Social Work Reform Board, and most recently, the new guidance on safeguarding children and the Social Care White Paper, are all promoting the vision of a stronger, more confident profession for the 21st century. HCPC, as the newly appointed independent statutory regulator of social workers in England, is looking forward to contributing to this vision. We will be working closely with our colleagues in the Care Councils in Scotland, Wales and Northern Ireland, whose experience and insights have already proved invaluable to us.

Yesterday also marked the end of an important chapter in the regulation of social workers. The outgoing regulator, the GSCC, has made a significant contribution to the profession. It established the first statutory register of social workers in England 11 years ago, developed the first standards and redefined the entry requirements for education. Perhaps most significantly, GSCC was far sighted in its approach to involving service users in decision making. Their legacy work on ensuring that the lessons learned during this important period will be disseminated and carried forward have been very well received, and will continue to influence social work practise into the next decade and beyond.

On behalf of HCPC, I would like to thank the Council and Executive at GSCC for working with us over many months, and pay tribute to their professionalism and commitment.

Anna van der Gaag

Chair