Health Service Focus

Healthcare support workers - registration and regulation

The Francis Report has called for a mandatory register of healthcare assistants (HCAs), alongside common training standards and a code of conduct. But the Government has up to now only been willing to consider a voluntary scheme, and the Cavendish review will not consider regulation. NHE discusses the issues with Royal College of Nursing HCA adviser Tanis Hand.

The arguments for and against a mandatory register of healthcare assistants (HCAs) have been well-rehearsed, but the Francis report comes down on the side of organisations like the RCN, the Nursing & Midwifery Council, Action against Medical Accidents and the Health Select Committee, saying: “The evidence is strongly in favour of at least a compulsory registration scheme, and the imposition of common standards of training and a code of conduct.”

It says a voluntary system – the Government’s preferred solution – “has little or no advantage for the public”, and RCN HCA advisor Tanis Hand told us: “It’s the people who don’t sign up and don’t care who are far more likely to put their patients and the public at risk.”

She added: “It’s worrying to think that there are employers who happily take people on and just throw them into the workplace without any true support.”

The Francis report adds: “There is almost no protection available to patients or the public. There are no minimum standards of training or competence. Should a [HCA] be dismissed by an employer for being unfi t to undertake this form of work, there is no system which prevents the worker being re-engaged by another employer, or even to ensure that a prospective employer is aware of any adverse past history.”

Regulation vs accreditation

The RCN has welcomed Francis’s recommendations on HCAs, and the Government’s decision to bring in Camilla Cavendish to review the role of healthcare support workers over the coming months.

The DH already got back the report it commissioned from Skills for Health and Skills for Care last year to develop a code of conduct and national minimum training standards, but had not yet replied as NHE went to press.

Scotland and Wales both have a code of conduct for healthcare support workers and a code of practice for employers, which requires them to ensure their healthcare support workers meet induction standards. In England, the DH has been keen to stipulate standards for behaviour and education, but not mandatory regulation.

In his evidence to Francis, for example, NHS chief executive Sir David Nicholson “felt that focusing on training was likely to be a more benefi cial use of available resources”, while Dame Christine Beasley, the former Chief Nursing Offi cer said mandatory registration and regulation “was disproportionate in terms of patient safety and cost”. The report explains: “She thought definitions would be difficult, and that regulation would not be capable of coping with the mobility of this part of the workforce.

She considered that a ‘clear licensing policy’ and ‘accreditation’ of organisations and individuals would be sufficient.”

But Francis calls it “strange” that many lowskilled jobs that give rise to a risk to the public are thought suitable for regulation through registration and licensing, such as security guards and taxi drivers, while HCAs are not.

Complex clinical tasks

There are certainly large numbers of HCAs, but no defi nitive estimate. The best recent research suggests 300,000-plus NHS HCAs, and a similar number or more in the independent sector, including care homes.

In the past the Government has said it hasn’t found evidence to demonstrate that healthcare support workers put patients at risk, Hand said. But in fact there are obvious non-NHS examples, she said, such as Winterbourne View – whose owner Castlebeck went into administration in early March.

There is also the fact that many HCAs are performing roles “very similar to that performed by registered nurses”, meaning there is certainly a risk to the public.

She said she hoped the Cavendish review should give the DH “a better understanding of quite how extended some of the roles that healthcare support workers perform are”. She said: “They do some quite complex clinical tasks, and they should be under the supervision of the registered nurses and should be appropriately trained and assessed as competent.

“My concern [with the Cavendish review] is – is it putting the whole discussion around regulation onto the back burner? Training is massively important, as is conduct. But it should be implemented as part of a system, which should be mandatory.

“I’d find it difficult to divorce looking at education and support from the wider system in which it’s implemented.”

Talking about the more complex tasks that some HCAs do, and the patient safety implications of these, Francis says: “Even if it is accepted that only a small proportion of this workforce is unfit to provide this form of care, that will amount to a very large number of individuals and an exponentially greater number of patients who are exposed to the risk of unacceptable care as a result.”

Confusion with registered nurses

There is no doubt that patients are often confused as to the difference between nurses and HCAs, and this is often not an accident, Hand said. “There are some places where healthcare support workers are almost deliberately being put into uniforms which are very similar to the registered nurses, which is misleading the public.”

Francis says: “Many HCSWs are mistaken for nurses. A national uniform description of such workers should be established. The Inquiry suggests that the relationship with (currently) registered nurses should be made clear by the title. The Inquiry suggests ‘nursing assistant’, ‘community nursing assistant’ and ‘midwifery assistant’.”

It adds: “Nursing is an activity partly performed by staff who are not registered nurses and no longer carry ‘nurse’ in their title. This leads to a great deal of confusion among patients and the public who often attribute the incidents of poor care of which they complain to ‘nurses’ when in fact what they have experienced are the actions, or inactions, of a category of staff variously named ‘healthcare support workers’ or ‘nursing assistants’ or some other similar title.”

Hand said: “You know with a registered nurse that that person has been trained – nowadays, to degree level. You know what you can expect of them in terms of performance and behaviour.

“But a HCA can be anybody; someone who has just been put into the workplace and told to get on with it, or equally somebody very welltrained and competent. It’s unfair on those who are well-trained and competent to be tarred with the same brush. It’s often not their fault: it’s down to the employers, who have a duty to ensure their staff are competent.

“There should be a recognised standard; that would be easier for the employer, and for the registered nurse who has to delegate tasks to the HCSWs, knowing they had at least had an induction to a certain standard.”

What details could a HCA register contain?

The essential ingredients of a minimal system designed to offer protection to the public would be a register kept and managed by a healthcare professional regulator, which in respect of each person working in a regulated activity would record:

• A unique identifi er;
• A registered address;
• Current and past employers;
• The reasons for termination of previous employments as reported by the employer;
• Any observations on those reasons recorded by the registrant.

(Source: The Mid Staffordshire NHS FT Public Inquiry, Vol 3, 23.138)

Francis on the RCN

The role of the Royal College of Nursing itself at Mid Staffs came in for criticism in the Francis report, which raised questions about its dual role as trade union and professional body. What is in the best interests of its members is not necessarily the same as what is in the best interests of patients and the public, leading to potential conflicts of interest.

The report says: “At Stafford, the RCN was sadly ineffective both as a professional representative organisation and as a trade union. The concerns of, and problems faced by, members either were not addressed effectively (although it must be noted that some attempts were made to represent members’ interests, for example by [RCN regional representative Adrian] Legan) or were simply not addressed, due largely to weakness of representation within the organisation and problems in communication with members. Furthermore, no action seems to have been taken to promote excellence in nursing.”

RCN chief executive & general secretary, Dr Peter Carter, welcomed the “powerful and monumental” Francis report and said the RCN “will work closely with the Government, regulators and NHS managers to ensure Robert Francis’ vision for a patient centred NHS becomes a reality”.

On the criticism of his own organisation, he said: “The RCN is acutely aware that it has real lessons to learn from how it supported members locally at Mid Staffs. Although we have already put in place numerous measures, we will look at the report in depth to see what other steps we can take to improve our effectiveness.”

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