Health, Wellbeing and Local Government
Committee Inquiry: Health and Social Care Workforce Planning
Evidence presented by David Smith
In reviewing evidence presented so far, I have been surprised by the lack of attention to professional healthcare regulation, healthcare support workers, patient safety and person centred service delivery.
I have therefore used extracts from unpublished evidence presented by Public Health Alliance Cymru and WCVA to (i) 'Good Doctors, safer patients - to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients’ (the Donaldson Review) and (ii) the Department of Health’s 'review of the regulation of non-medical healthcare professions’ (the Foster Review) - which I hope the Inquiry will find helpful. Further detail can be found at Appendices A and B.
Question One
* Is workforce planning undertaken by the right agencies and in such a way that takes into account other key factors such as finance, service planning and training capacity? Should it be more or less centralised?
Professional healthcare regulation impacts upon devolved health services and functions. Since this is a reserved matter, it does not receive the attention that it merits, for example, as compared with the Care Council Wales.
In terms of other key factors, attention is drawn to the fact that the current aim of Professional healthcare regulation is to protect the patient through four functions: education, standards, fitness to practice and registration.
Performance combines four areas: skills (a combination of training and experience), knowledge, attitudes, and conditions to reach the performance of standard required.
Attitudes. Despite skill and knowledge, in acceptable conditions, the patient experience may be marred by failure in attitude competency, such as communication or discriminatory behaviour can be an important source of patient dissatisfaction.
The UK Government has published the White paper 'Trust, Assurance and Safety - the Regulation of Health Professionals in the 21st Century’ at the same time as its response to the Fifth Report of the Shipman Inquiry and the Ayling, Neale and Kerr/Haslam Inquiries 'Safeguarding patients’.
White paper:
http://www.dh.gov.uk/assetRoot/04/14/31/43/04143143.pdf
Safeguarding patients
:
http://www.dh.gov.uk/assetRoot/04/14/32/48/04143248.pdf
Question Two
* Is the information available to workforce planners of sufficient quantity and quality to ensure effective planning?
As far as I am aware data on professional healthcare registration is not available on a four-country basis.
Question Five
* To what extent do the current arrangements support or hinder effective joint working between health and social care and across the statutory, voluntary and private sectors?
A uniform basic code of behaviour for all health care professionals, including support personnel would be a welcome development across Welsh public services.
"3.2 Standards
Registered health care professionals subscribe to standards set by their regulator. No basic code of behaviour exists that binds all health care personnel to a common shared sense of professionalism focused on an acceptable patient experience. This lack was identified in the findings of the recent Kerr-Haslam Inquiry. A basic code would represent a first step towards consistency in the regulation of teams and between team members.
Secondly, education and training for each autonomous profession is directed heavily towards the skills and knowledge required. Education and training for all health care personnel needs to address more effectively the behavioural skills that assure an acceptable overall patient experience. This need was identified clearly in the Kennedy Report, which spoke of the need for common learning in this area.
An example of current best practice in health care regulation, such as, the GMC’s Duties of a Doctor, could be used as an interim guide…. All health care personnel could receive instruction on the basic code as part of initial training or continuing professional development. The same basic code would assist the assimilation of non-regulated groups in the future and help to instil a shared sense of professionalism (Public Health Alliance Cymru - see Appendix A below).
Question Six
* What are the arrangements for work force planning in areas with cross border patterns of service use (e.g. health services in North Wales)?
Clearly with a large border with England and the need to attract healthcare staff from across the UK it makes sense to have common four country standards (and beyond) to professional healthcare regulation.
Question Nine
* To what extent is workforce planning anticipating changing patterns of service commissioning and provision and the changing or blurring of professional roles?
Extending the scope of regulation to include healthcare support workers (healthcare assistants) and new roles in healthcare:
The Care Council for Wales …. have recently registered Social Workers, and they now have protected title. They are now moving on to register the thousands of residential, domiciliary and day care workers. The reason for registering these groups (most of whom are called care assistants) is that they are often working with limited supervision, often in peoples own homes, and we know with very variable standards of care. All of these points apply equally well to health care assistants.
It is, in our view, crucial that a commensurate registration is available for Health Care Support Workers. These workers undertake the bulk of the personal and intimate care tasks for patients of all ages and it is a serious public protection issue that there is no mechanism, other than CRB checks for monitoring the work history of these workers. The Soham inquiries cite the need to enable clear, checkable work histories linked to registration for all workers in Health, Social care and Education.
Further we would recommend that the registration standards for social care workers be linked to health care support worker and assistants registration given that they have equivalent access to patients, their information and in most cases their bodies in vulnerable and intimate circumstances. Their pay is closely equivalent and the recommended levels of qualification are similar in that they are pitched at education levels 2 and 3 (eg NVQ 2 and NVQ3).
Regulation is not seen as a panacea, but as part of the response to the need to raise standards and to protect vulnerable people. The issue of vulnerability includes people who know well what is happening, but feel powerless to complain or to change anything” (Response by WCVA - see Appendix B below)
Question Twelve - Identify relevant issues related to patient safety, principles and methods of public and patient engagement in professional healthcare regulation?
In a recent contribution to a special issue of 'Health Matters’ ('Behind the mask of regulation’, Spring 2007, edited by Professor Celia Davies), I make the point that if regulation is to be taken in the public interest, then it must also require public involvement. Below six headings with a brief extract from evidence presented by Public Health Alliance Cymru in November 2006 to the Donaldson and Foster Reviews:
Public concerns
The Consumers Association (2000) (now WHICH?), calling for 'patient - centred’ regulation has strongly questioned the capacity of the system to protect against unsafe practitioners, seeing, for example, no basis for the policy differences between regulatory bodies and no reason for the absence of a shared code of practice.
The Council of Elders: Creating a Culture of Care
'A council of elders: creating a multi-voiced dialogue in a community of care’ Katz, et al (2000) introduces a `Council of Elders' as an educational innovation at Harvard Medical School. Of particular interest this approach is a way to make visible stereotypes and adverse medical and nurse values. Dr Katz states that in an era of `medical care delivery systems', there is an increasing need for the patient's voice to be heard, for it to be invited, listened to, and taken seriously. This has implications for decision-making with the patient, not for the patient and fits very well with Beecham principles and recommendations for Welsh Public Services.
Public and Patient Involvement Principles from the Bristol Inquiry
The public are entitled to be involved at all levels and stages: in both setting and agreeing the systems for assuring competence and in their operation. As regards individual healthcare professionals, assuring competence embraces initial registration, the continuing monitoring of performance through continuing professional development (CPD), appraisal and revalidation, and the application of disciplinary measures when necessary. Historically, the public has only been involved in the last of these. However, we see them all as an interrelated whole in, which the involvement of the public is essential if a truly patient-centred service is to emerge”.
Changes to the governance and accountability of regulators - Strengthening Public Accountability (Question 1)
We wish to emphasise the need to ensure that public appointments to regulatory bodies, …. includes revised criteria, to include the necessary knowledge, abilities, skills and commitment by which successful appointees should demonstrate the ability to network and gather information from a broader perspective.
The importance of defined operationalised standards, against which to regulate (Question 2)
A uniform basic code of behaviour for all health care professionals, including support personnel would be a welcome development across Welsh public services (see your Question 2 above).
Proposals for a 'spectrum of revalidation’ across all healthcare professions: The Use of Patient questionnaires for licensure or certification processes to establish and support fitness to practice (Question 4)
Currently, patient questionnaires are not widely used for licensure or certification processes to establish fitness to practice. The Picker Institute in 'A Review of Questionnaires for gathering patients’ feedback on their doctor’ (2006) propose that routine assessment using valid and reliable instruments could help identify doctors who need training or support. This is one important way in which patients’ views can really count and this model has been tested and provides and excellent illustration of the principles and recommendations set out in the Beecham Review.
As the Chief Medical Officer for England recently stated in his consultation report 'Good Doctors, safer patients’ because their will always be some poorly performing doctors it is vital to "recognise the problems early … and deal with them effectively by rigorous, fair assessment …” (CMO 2006).
David Smith has a particular interest in public and patient engagement in professional healthcare regulation and writes in a strictly personal capacity.
Appendix A
Response by the Public Health Alliance Cymru - November 2006
Preface
We agree the evidence recently presented by WCVA across the three themes and questions answered, except at Question 5, we propose Citizens Council. We now add a further dimension based upon the experience and knowledge of our members across the public service and NGOs in Wales.
1. Public concerns
It is now well evidenced in the Assembly 'Making the Connections’ process that early consultation in public policy development is far preferable in securing acceptable outcomes, culture change and 'good value’ in the sense used by Sir Ian Kennedy, in 'Learning from Bristol: Are We?’ (2006). Sir Jeremy Beecham ('Beyond the Boundaries’, 2006) identifies the need for constructive challenges and this requires involvement of independent stakeholders.
The concerns expressed by consumer bodies are still as relevant today as seven years ago. Regulatory bodies, says the National Consumer Council, provide a patchwork arrangement 'which has not caught up with changes in public demand or with current health practices’ (NCC 1999:1). It calls among other things, for clear measurable standards, a more adequate range of sanctions for failing to comply with them, much more information directed at the consumers, a funding system independent of the professions and systems of local and national representation that clearly balance the different interests that are involved.
The Consumers Association (2000) (now WHICH?), calling for 'patient - centred’ regulation has strongly questioned the capacity of the system to protect against unsafe practitioners, seeing, for example, no basis for the policy differences between regulatory bodies and no reason for the absence of a shared code of practice. In important particulars, then, regulation has become an institution at odds with its time, where public expectations and regulatory practice do not match, not with standing Bristol, Shipman and other recent inquiries. For example, see MORI research on the regulation and revalidation of doctors (Department of Health, 2005).
2. Teams
Increasingly, health care is delivered through a team-based approach. In primary care teams may include members of the social care professions. Neither report addresses this issue. Future workforce flexibility in the NHS will require further integration and team working to ensure positive patient experiences. This will not be facilitated by the development of two different systems of regulation. Further, neither report adequately considers other circumstances in which healthcare practitioners operate, including the private, independent and voluntary sectors.
3. Light Touch Regulation
We need to be careful to avoid a primarily commercial approach. Our impression of discussions of the "burden of regulation" is that the most vocal group are employers. The primary task of regulators and registrants is to protect the patient. and service user. We think with the concept of proportion, we need to think carefully before we go down these paths. Healthcare is a high safety environment.
4. The Council of Elders: Creating a Culture of Care
'A council of elders: creating a multi-voiced dialogue in a community of care’ Katz, et al (2000) introduces a `Council of Elders' as an educational innovation. Of particular interest this approach is a way to make visible stereotypes and adverse medical and nurse values. This has implications for decision-making with the patient, not for the patient and fits very well with Beecham principles and recommendations for Welsh Public Services.
We emphasise that this enterprise is not primarily about patient empowerment, though that is a desirable and an expected outcome. It should not unduly increase the complexity or burden of a higher education teacher’s job, though it may make it more interesting. It is about training for best professional practice, improved health care and public protection and appears to be within the remit of the Assembly Government in the way in which it commissions higher education. It could cost little to implement, and would be easy to organise and provide an opportunity for changing culture - attitudes and behaviour - in a way that will be more engaging for public and patients and produce better health outcomes.
The 'Council of Elders’, was collaboratively developed with professionals and community elders in which medical residents and nurse practitioners met to ask Elders for advice and wisdom about clinical and moral dilemmas they are struggling with. As Dr Katz explains a 'resourceful community' is created. Using the life experience of elders "together - they from their resources and we from ours - create possible ways to engage with each other which were not apparent to either group separately”. They invited community elders to function as a `Senior Faculty', to whom medical residents present their challenging and heartfelt dilemmas in caring for elder patients.
Dr Katz states that in an era of `medical care delivery systems', there is an increasing need for the patient's voice to be heard, for it to be invited, listened to, and taken seriously. This challenge is particularly evident in a domain of clinical training in which educators and clinicians alike must struggle (and did overcome) adverse ageist attitudes.
In this process, the elders come to function not simply as teachers, but as collaborators, where doctors, researchers, and elders together creating a community of resources, capable of identifying novel ways to overcome health-related difficulties which might not have been apparent to either group separately. Katz, et al, describe and discuss the special nature of such meetings and also the special preparations required to build a relationship between participants from very different worlds -- different generations, different cultures (including the professional culture and the world of lived experience).
It is proposed that the Assembly Government actively consider piloting a Welsh model of 'The Council of Elders: Creating a Culture of Care’. Could this be (i) supported by Public Service Management Wales, working in collaboration with HE teachers and an institution committed to this concept and piloted as part of the formal evaluation of the Older Peoples strategy beyond 2008?
Three Overarching Questions
1. Do stakeholders support the principles upon which Good doctors, safer patients is based?
We support evidence presented by WCVA.
Our additional comments are as follows. As the reader will be aware:
(a) issues arise from time to time, which affect the interface between devolved and non-devolved administrations. Healthcare regulation is but one issue.
(b) Currently a Memorandum of Understanding exists between the Department of Health and Wales in terms of the actions and approaches to be adopted in areas of mutual importance.
In the context of (i) Section 26 (7) of the NHS Reform and Healthcare Professionals Act 2002 and (ii) in terms of taking forward UK work to assess, and prepare to implement, changes arising from the two reviews, it would be useful to clarify, which parts have resonance for Wales, and to what extent salience will be given to this in the relevant concordat?
It is noted that, in publishing the two reports, the Department of Health has provided an initial regulatory impact assessment for a number of the recommendations, which include the rationale for Government intervention together with the costs and benefits of the various options considered. However, we believe it is essential that any decisions taken to implement the proposals should be backed by substantive evidence, as well as some experience, that they will enhance public protection.
While it acknowledges that the majority of healthcare is provided through the NHS, we have some concern that both reports are very NHS focussed and generally fail to address issues associated with other models for healthcare provision. There are, for example, already a fair number of practitioners who work outwith the NHS and, as a result of new ways of working, there are an increasing number of practitioners who work within the NHS but are actually employed by a Local Authority or a General Practitioner. Also there are practitioners (support workers) who provide personal intimate care and are advised by a registered nurse at a distance as an NHS community nurse, but who provide this care in a service user’s home and/or a residential home under the description of 'social care’, yet their task is no different from nurses and health care support workers providing this personal part of health care in a nursing home. In our view the public have a right to expect consistency across health and social care.
2. Do stakeholders support the approach advocated in the two reports?
We support evidence presented by WCVA.
3. What are the priorities for stakeholders in terms of implementation
We support evidence presented by WCVA.
3.1 The Council of Elders: Creating a Culture of Care
This important educational innovation resonates extremely well the citizen’s model being developed in respect of public services in Wales. See earlier comments.
3.2 Standards
Registered health care professionals subscribe to standards set by their regulator. No basic code of behaviour exists that binds all health care personnel to a common shared sense of professionalism focused on an acceptable patient experience. This lack was identified in the findings of the recent Kerr-Haslam Inquiry. A basic code would represent a first step towards consistency in the regulation of teams and between team members.
Secondly, education and training for each autonomous profession is directed heavily towards the skills and knowledge required. Education and training for all health care personnel needs to address more effectively the behavioural skills that assure an acceptable overall patient experience. This need was identified clearly in the Kennedy Report, which spoke of the need for common learning in this area.
Through a joint Four Country / CHRE Working Party it is suggested that a uniform basic code of behaviour for all health care professionals, including support personnel. An example of current best practice in health care regulation, such as, the GMC’s Duties of a Doctor, could be used as an interim guide. Individual regulators could add issues specific to a profession but all health care personnel could receive instruction on the basic code as part of initial training or continuing professional development. The same basic code would assist the assimilation of non-regulated groups in the future and help to instil a shared sense of professionalism. Arising from the Minister statement on the Beecham Review, on 14th July 2006, could this be part of the future statement on Regulation and Inspection, in the first part of 2007?
3.3 Public and Patient Involvement
The Assembly Government gave wholehearted support to the Public and Patient Involvement recommendations set out in the Bristol Inquiry Report (2001). Will this position be reflected in the Assembly submission to the UK Health Department on these two reviews? The relevant paragraphs is as follows:
"15 We are concerned here with the network of measures designed to
assure the competence of healthcare professionals. This is the other side of the coin of concern for safety and quality. The public are entitled to be involved at all levels and stages: in both setting and agreeing the systems for assuring competence and in their operation. As regards individual healthcare professionals, assuring competence embraces initial registration, the continuing monitoring of performance through continuing professional development (CPD), appraisal and revalidation, and the application of disciplinary measures when necessary. Historically, the public has only been involved in the last of these. However, we see them all as an interrelated whole in, which the involvement of the public is essential if a truly patient-centred service is to emerge”.
"16 In particular, we would expect the public to have a role in those bodies charged with setting standards for education and training and with controlling access to the professional register. Involvement of the public in these activities serves at least two valuable functions. First, the public can participate in the process of setting and reviewing the criteria for admission to the profession. After all, the professional is going to be caring for the public as patients. Secondly, public participation in this process serves as a warranty that the public's interests are being safeguarded and as a reminder that the profession exists for the public” (Learning from Bristol, July 2001) file://localhost/Volumes/BRI_Inquiry_CD1/web/final_report/report/sec2chap28_10.htm#949077>
Question 1
Changes to the governance and accountability of regulators:
We support evidence presented by WCVA.
Strengthening Public Accountability
We add the following
1.We wish to emphasise the need to ensure that public appointments to regulatory bodies, via the NHS England appointments system, includes revised criteria, to include the necessary knowledge, abilities, skills and commitment by which successful appointees should demonstrate the ability to network and gather information from a broader perspective.
2. Greater attention needs to be given to Learning and Support needs of lay/ public members on regulatory and other public bodies across the public service. Our initial thoughts are that Wales needs to:
(a) Develop arrangements to seek out hard to reach communities and groups to ensure a diversity of representation,
(b) Identify and develop programmes and other resources to orient and support lay members,
(c) Develop reliable mechanisms for lay members to access and share information,
(d) Develop mechanisms for lay members to meet periodically to discuss mutual concerns, and
(e) Establish a support network to which publicly appointed members go, as of right, in terms of accessing and disseminating relevant data and offer a limited research capability.
These issues were submitted in evidence to the two reviews, without response. Could this issue be considered in the context of work to be undertaken by Public Service Management Wales?
3. The GMC 'quadrant model’ requires carefully scrutiny, since it may give insufficient weight to four-country representation on UK wide bodies, or reflect, for example, different four-country academic and employer interests.
4. The Wales Healthcare Regulatory Forum has been developed without consideration to public engagement. This needs to be resolved before the other devolved nations follow this lead. Could Care Council Wales and PPI representatives be invited to this Forum? It is suggested that the Forum Secretariat should be arms length from government and that this could alternate between participants.
4. It is recognised that an election process for Council members of regulatory bodies may not necessarily produce registrant members with the required skills or ensure that a Council has a balance of experience in the fields of practice and education. Neither will it address the issues of equality and diversity. We object to the principle of elected Council members.
5.The NMC, for example, is required to submit an annual report to the Privy Council on the exercise of its functions, and its annual accounts and auditors’ report to the Privy Council and the Comptroller and Auditor General (the National Audit Office). The Privy Council subsequently lays a copy of the annual report and the certified annual accounts before each House of Parliament. In due course, could this practice extended to include the National Assembly for Wales?
6. There should be a consistent fitness to practise (FtP) system for all professions. This requires harmonisation of rules and processes at all stages.
Question 2
The importance of defined operationalised standards, against which to regulate:
We support evidence presented by WCVA.
1. Through a joint Four Country / CHRE Working Party it is suggested that a uniform basic code of behaviour for all health care professionals, including support personnel. An example of current best practice in health care regulation, such as, the GMC’s Duties of a Doctor, could be used as an interim guide. Individual regulators could add issues specific to a profession but all health care personnel could receive instruction on the basic code as part of initial training or continuing professional development. The same basic code would assist the assimilation of non-regulated groups in the future and help to instil a shared sense of professionalism. Arising from the Minister statement on the Beecham Review, on 14th July 2006, could this be part of the future statement on Regulation and Inspection, in the first part of 2007?
2. We support proposals for regulators to be more consistent about the standards required of a person entering the register and note the statement, contained in the report, that indemnity insurance will, over time, become a requirement for all professions. However, while the report refers to employers working with regulators to agree these standards, it does not indicate the nature of the relationship between the employer and the regulator in this respect. However, there are concerns about ensuring that any flow of information between employer and regulator does not impinge on human rights.
Question 3
The appropriate standard of proof:
1.We support the adoption of a common standard of proof across all regulatory bodies.
Question 4
Proposals for a 'spectrum of revalidation’ across all healthcare professions:
The Use of Patient questionnaires for licensure or certification processes to establish and support fitness to practice
Currently, patient questionnaires are not widely used for licensure or certification processes to establish fitness to practice. The Picker Institute in 'A Review of Questionnaires for gathering patients’ feedback on their doctor’ (2006) propose that routine assessment using valid and reliable instruments could help identify doctors who need training or support. This is one important way in which patients’ views can really count and this model has been tested and provides and excellent illustration of the principles and recommendations set out in the Beecham Review.
As the Chief Medical Officer for England recently stated in his consultation report 'Good Doctors, safer patients’ because their will always be some poorly performing doctors it is vital to "recognise the problems early … and deal with them effectively by rigorous, fair assessment …” (CMO 2006).
What use can be made of patient assessments of individual doctors?
Picker Institute state in their report "For assessing healthcare services at a general level (for example within a hospital or local area or for a particular kind of healthcare service) patient feedback surveys are increasingly seen as a key component of quality monitoring (Cleary 1999). In the UK, USA, Canada, Australia, Denmark, Norway, and many other European countries, findings from such surveys are now widely available. Although these surveys were designed to improve organisational performance and quality assessment at organisation level, rather than to assess individual practitioners’ performance, they show how patient feedback can be harnessed on a major scale.
"While systems for gathering feedback from patients at the organisation level are well developed, mechanisms for doing so at physician level are less well established. Yet, the use of a questionnaire, routinely collecting feedback from patients could be a cost effective means to harness patients’ views on the performance and practice of individual doctors. The burden placed by them on patients and doctors is low.
"Such feedback can be used to improve performance. Well-designed questionnaires gather data which allow doctors to identify strengths and weaknesses in their practice and can direct them to areas where improvement is required (Delbanco 1992). Formative assessment using credible sources of feedback is a powerful stimulus to learning (Davies & Howells 2004, Crossley J et al 2002, Ware et al 1978, Ware 1978). Drawing to the attention of doctors issues such as communication skills can be effective in improving the quality of medical practice (Hall et al 1999, Hearnshaw et al 1996).
"Recent UK initiatives have aimed to include such questionnaires as part of routine management: the Quality and Outcomes framework of the New GMS contract encourages GP practices to carry out patient surveys at practice level; and the NHS Appraisal Toolkit also suggests the use of patient questionnaires as one source of evidence for the appraisal of doctors’ relationships with patients. Patient questionnaires are incorporated into the Alberta College of Physicians and Surgeons’ five-year relicensure programme. They are one component of the Physician Achievement Review (sitting alongside feedback from physician colleagues and non-physician co-workers), which provides physicians with formative feedback, which allows them to identify areas of practice where they could improve” (Picker Institute, September 2006).
Given the extensive contact that increasing numbers of older citizens have with doctors, and the above views of the Chief Medical Officer for England, it is suggested that in his advice to the Assembly Governments, the Chief Medical Officer give consideration to the 'Use of Patient questionnaires for licensure or certification processes to establish fitness to practice’. If a positive recommendation is made, could active consideration be given to how that this matter could be supported within the Older Peoples Strategy?
Question 5
Devolution of some regulatory activity to a local level:
We support evidence presented by WCVA - except we propose permanent Citizens Council
We find it difficult to engage in this important public policy issue without further information, guidance and debate. If revalidation is to become the reality, which the public expect (MORI 2005), when will the UK government provide further information, and is the estimated cost and service implications in Wales, if and when this concept is applied to all healthcare registrants?
Our questions include: how many local part-time local GMC affiliates or equivalents will be required in Wales and at what cost? How will the proportion of the initial and continuing costs be shared between the Treasury, the Assembly Government, Local Health Boards, NHS employers and increased professional fees? How 'local’ is local? How will the proposed schemes work in practice and what assurance do we have that stated outcomes will be achieved?
Much money and effort is spent on Clinical Governance by LHBs. How will the respective responsibilities of the local affiliate be reconciled with the local Medical Director or equivalents in other professions? If a local affiliate is based in one organisation, what is the position when a doctor, for example, works for more than one employer? When affiliates are well known in a close knit occupational community, who will wish to undertake this role?
We recommend that our Chief Medical Officer consider establishing a permanent Citizens Council (perhaps based upon the NICE model) to help provide a positive focus and impetus to ensuring adequate investment in public protection.
Aside from the Donaldson review, could the Government have taken further action in respect of the use of 'controlled drugs’ and the future role of the Coroner in addressing the horror visited on patients by Harold Shipman as evidenced by Shipman Inquiry report?
Question 6
The number of regulators:
This should be for independent regulators to determine and not government.
Question 7
The requirement to record post-registration qualifications:
This is sensible.
Question 8
The role of regulation for student healthcare professionals:
The current expectation is that HEIs will work with their service partners to remove those students who prove to be unsuitable for registration. However, in the past, local academic (University) regulations have sometimes made discontinuation on grounds of behaviour difficult and appeals processes can result in the student continually being allowed to return to the programme. HEIs also need to be able to remove students without being penalised by commissioners for the consequent impact on attrition rates.
Question 9
The need for standardised pre-employment English language testing:
We believe that clear communication between professional and client or patient is an important issue of public protection and welcomes the Department’s statement that it expects to deal with the issue of language testing in a consistent way across all the health professions. This is becoming increasingly important with the ongoing programme of enlargement of the European Union. In the meantime, more work needs to be undertaken with employers to clarify responsibilities in this area.
Question 10
Extending the scope of regulation to include healthcare support workers (healthcare assistants) and new roles in healthcare:
We would be concerned if some form of "negative register” were to be used to record those who had been deemed to be unsuitable for employment. The Care Council for Wales must be referred to in this debate.
Question 11
The importance, or otherwise, of a lay majority on the governing bodies of the various regulators:
This will depend upon the future scope and range of regulatory functions.
Appendix B
Below is an extract from evidence presented by WCVA to the Donaldson Review, which makes the case that the registration standards for social care workers be linked to health care support worker and assistants registration given that they have equivalent access to patients, their information, and in most cases their bodies in vulnerable and intimate circumstances.
"Extending the scope of regulation to include healthcare support workers (healthcare assistants) and new roles in healthcare:
The Care Council for Wales must be referred to in this debate. They have recently registered Social Workers, and they now have protected title. They are now moving on to register the thousands of residential, domiciliary and day care workers. It is known that around 70% of these have no qualifications, although achieving one within the first period of registration will be a condition of re-registration. The point of registration for this group will be to: -
1. Bind them to the WCC code of practice.
2. Ensure those shown to be incompetent or engaging in malpractice can be prevented from practicing (and not just changing their employer).
3. Drive up qualifications and therefore the quality of practice.
The reason for registering these groups (most of whom are called care assistants) is that they are often working with limited supervision, often in peoples own homes, and we know with very variable standards of care. All of these points apply equally well to health care assistants.
It is, in our view, crucial that a commensurate registration is available for Health Care Support Workers. These workers undertake the bulk of the personal and intimate care tasks for patients of all ages and it is a serious public protection issue that there is no mechanism, other than CRB checks for monitoring the work history of these workers. The Soham inquiries cite the need to enable clear, checkable work histories linked to registration for all workers in Health, Social care and Education.
Further we would recommend that the registration standards for social care workers be linked to health care support worker and assistants registration given that they have equivalent access to patients, their information and in most cases their bodies in vulnerable and intimate circumstances. Their pay is closely equivalent and the recommended levels of qualification are similar in that they are pitched at education levels 2 and 3 (eg NVQ 2 and NVQ3).
Regulation is not seen as a panacea, but as part of the response to the need to raise standards and to protect vulnerable people. The issue of vulnerability includes people who know well what is happening, but feel powerless to complain or to change anything” (Response by WCVA to Question 10: Extending the scope of regulation to include healthcare support workers (healthcare assistants) and new roles in healthcare)
