Scottish Government

EXECUTIVE SUMMARY

Background and Introduction

1. The pilot aimed to test out arrangements for a model of employer-led regulation of Healthcare Support Workers ( HCSWs). Currently there is no statutory provision for the regulation of HCSWs in Scotland or anywhere else in the UK. The healthcare support worker role has been changing and developing over the last decade and some staff are extending their skills so that they can undertake work previously done by registered professionals. Consultation outcomes in Scotland indicated strong support for regulation (2004), and for the standards developed in the course of this project (2006). Following submission to the Review of Non-medical Regulation (Foster Review 2005) it was agreed that Scotland would test the model on behalf of the UK with strong support from the four countries. The pilot focused on currently unregulated staff employed in the name of NHSScotland.

2. The model consisted of a set of national minimum standards with the addition of a list of HCSWs who met the standards which was maintained as part of the pilot. The standards comprised three elements:

• A set of induction standards for healthcare support workers
• A Code of Conduct for healthcare support workers
• A Code of Practice for NHSScotland Employers

3. This testing of the national standards represents a first step towards helping both employers and employees in NHSScotland fulfil their obligations towards patient safety and public protection as part of a future regulatory framework for HCSWs.

The Evaluation

4. The evaluation aimed to assess the implementation, operation and potential impact of the pilot. The evaluation, extended alongside the pilot to January 2009, comprised both formative and summative aspects and utilised a range of methods including: stakeholder and key informant interviews, individual case studies, surveys of participants, non-participants and supervisors and desk research.

Implementation of the Pilot

5. The Scottish Government Health Directorates' invitation to Health Boards to bid (July 2006) offered three elements of support for the pilot: funding for retrospective Disclosure Scotland checking of existing employees, funding for a Local Pilot Coordinator at each site, and the support of a National Pilot Coordinator based at NHS Quality Improvement Scotland.

6. The two initial pilots NHS Ayrshire and Arran and NHS Lothian commenced January 2007 and the third site NHS Lanarkshire joined later (July 2007). An independent health care site, Ross Hall Hospital also took part but was not part of the evaluation. The pilot was tested with vulnerable client groups in children's, mental health and older people's services. The pilot was extended from one year to two (January 2007-December 2008) following delay in early implementation, largely due to: withdrawal of the original third site ( NHS Glasgow and Clyde, early April 2007), slow recruitment of the National and Local Pilot Coordinators and slowness in establishing pilot steering groups and communication structures. Initial Guidance was well received but limited pre-pilot planning, concerning the level of coordination, information, training requirements and the format of planned individual and Board level assessment processes impacted on the pilot.

7. NHS Quality Improvement Scotland ( NHSQIS) managed the pilot and coordinated both implementation of the standards and the monitoring of compliance. NHSQIS facilitation of the pilot required a difficult balance between 'governance' and 'support' roles and clarification of pilot requirements between SGHD, NHS Boards and NHSQIS was not always straightforward. Boards found some pilot processes more burdensome than anticipated. Pilots suffered from lack of funding for administrative support. There has been strong Partnership input to the pilot at national and local level throughout.

Development of pilot processes

8. Securing the time and motivation of the Workplace Supervisors ( WPS) was key to the pilot's success. WPS experience of formal assessment processes varied. The delivery of training of WPS varied across site and flexible arrangements were required to facilitate weekend and evening staff participation in the pilot. The majority of WPS were willing volunteers, who supported the standards (84%) but thought them more appropriate for new starts. Fitting the task into busy jobs was problematic and only half felt sufficiently supported with this. The low ratio of facilities supervisors to support workers presented serious difficulties.

9. The assessment toolkit for HCSWs, consisted of an oral and observation assessment process supported by HCSW and WPS handbooks. A good degree of overlap between Knowledge and Skills Framework ( KSF) outlines and the standards has been identified, but KSF cannot accommodate the behavioural aspects of some of the standards. The fit remains untested in practice due to the early stages of implementation of KSF at pilot sites but it is anticipated that evidence gathered from the standards can inform the KSF foundation review.

10. The clarification of arrangements with Disclosure Scotland was very time consuming. Two new counter-signatories were put in place at each site to facilitate monitoring of applications. It was found that not all HCSWs were legally eligible for Enhanced Disclosure as originally anticipated. The full potential burden on Disclosure Scotland was not tested as the number of applications was small. All sites had processes in place for dealing with undisclosed material.

11. The technical and practical aspects of setting up a simple local 'occupational list' on the Scottish Workforce Information Standard System ( SWISS) have been tested. There are very mixed stakeholder views on the potential added value of extending arrangements to a national list. The evaluation identified a variety of technical and procedural matters requiring clarification before such a national list could be operationalised.

Numbers and Progress of Healthcare Support Workers

12. More than one in six (470) of identified eligible healthcare support workers (2961) were recruited to the pilot, of whom more than two thirds had an initial meeting with their Workplace Supervisor to plan for learning and assessment, more than half (263) completed all assessment and 193 were formally entered upon the 'occupational list' ( SWISS database) after signing the Code of Conduct declaration.

13. Three quarters (341) of HCSW recruits were Nursing assistants/Clinical Support Workers and one in seven (66) were unqualified allied health assistants. Few (63) non-clinical staff were recruited.

Pilot operation - Views on Recruitment

14. The approach to engaging eligible HCSWs with the voluntary pilot was critical to its success; the two smaller sites Ayrshire and Arran and Lanarkshire were most successful and the latter's approach was most effective; the larger Lothian site faced most challenges. A great deal of Local Pilot Coordinator flexibility was required to engage weekend, night and bank staff. All sites faced difficulties in engaging facilities staff.

15. Participating HCSWs wished to help patients and improve patient safety and to take up a learning, development and potential career opportunity; they confirmed their participation was voluntary; and found face to face marketing most effective. Having enough time to take part was the major concern.

16. Non-participant HCSWs chose not to volunteer because the workplace was perceived to be too busy, they had personal commitments or were about to retire or change job. Some did not see the value of taking part. Returns were biased towards the largest site and the late added older people's service area. An untapped pool of potential volunteers had not been captured.

Pilot Operation - Views on Learning and Assessment

17. The majority of assessments were completed within two to three months as anticipated. However the Local Pilot Coordinator faced multiple logistical challenges in both linking up the Workplace Supervisor and HCSW and in ensuring all elements were in place for final completion, prior to entry on the 'occupational list'.

18. Participating HCSWs felt the standards had potential to affect their job and to improve confidence, knowledge and, most significantly, their ability to take action to keep patients safe. Prior achievements were considered for two-thirds but inclusion was not automatic; further development work was planned for a third. Approximately half the HCSWs undertook some preparation in their own time.

19. Assessment was reported to be a valuable and enjoyable experience, not too excessive a burden though the assessment paperwork required streamlining. It was considered most appropriate for new starts; however, little feedback was received from new employees. HCSWs valued the certificate presentation ceremonies which emphasised appreciation of their role in the healthcare team. Four standards were not easily applicable to non-clinical roles.

20. There was a wide range of experience of both Personal Development Planning and Review and KSF across the three sites; just half the Workplace Supervisors were also KSF reviewers. Three quarters of WPS saw potential for the induction standards to fit with KSF.

21. Multiple reasons were given for the lack of success with facilities staff including: communication issues at national and local level; the pilot not being 'sold' to these groups; the voluntary nature of the pilot and these groups own lack of recognition of the title; the priority of existing commitments such as the Domestic Services Framework Workbook; and the low supervisor high support worker ratio.

NHS Board self-assessment and peer review

22. The Employer Code of Practice was generally supported but there were mixed views about the process ( NHSQIS designed, Board self-assessment framework and peer review) to test compliance. The process was informative but a much more significant burden than anticipated. No serious gaps in human resource or clinical governance arrangements were found but there were challenges in applying a consistent approach to evidence for some criteria and in evidencing 'monitoring' of the standards. The early timing of the exercise meant it could not really address non-clinical workers, the standards fit against KSF, or the impact on HCSWs or patients.

Quality assurance of induction standards and pilot processes

23. There was a large degree of congruity between the NHSQIS additional quality assurance processes and the evaluation findings. External consultants reviewed the implementation of the learning and assessment process and examined completed assessment forms. They found further clarity is required in guidance given to WPS about describing whether and how HCSWs are meeting assessment criteria.

24. NHSQIS coordinated the collation of monitoring data from local sites. This was hampered to some degree by deficits in administrative support at pilot sites and technical support at NHSQIS. Future monitoring would require more resource.

Consultative Workshop

25. Day two of the Scottish Government Health Directorates Regulation event (October 2008) focused on the national healthcare support worker regulation pilot. It was attended by some 200 delegates including a broad range of representatives from healthcare professions and frontline staff. Discussion in facilitated workshop style sessions focused on national and Board level requirements, the standards and the assessment process.

26. Delegates expressed broad support for the Code of Practice for Employers (65%), the Code of Conduct for healthcare support workers (75%), for the standards to be mandatory for all HCSWs (72%), and for the proposal for a positive national level 'occupational list'. Delegates felt that the standards would enhance the patient experience and that there was potential for the model of standards and listing to enhance public safety.

27. There were, however, very mixed views about the piloted assessment toolkit testing achievement of the HCSW induction standards and lack of opinion about the piloted Board accountability framework.

Other policy developments and research

28. The Protection of Vulnerable Groups (Scotland) Act 2007 scheme is likely to encompass all clinical support workers but it is not yet clear which non-clinicalHCSW roles will be included in the scheme, although it is likely that those with a direct contact role will be. It will take at least four years to bring all of the relevant workforce under the scheme, via retrospective checking. The final details of decision making on listing ( i.e. barring decisions) is still being developed. If an 'occupational list' for HCSWs is to be implemented then further work would be required to examine how it might articulate with the PVG scheme.

29. Parallel NHS Education for Scotland ( NES) developments have relevance for the national pilot. A major scoping study has highlighted the ageing workforce, limited availability of accredited learning programmes and the need for more work to support literacy and numeracy needs. Education and Development Frameworks for facilities staff, developed jointly with Health Facilities Scotland, may have potential to incorporate the induction standards. The development of educational support for clinical support workers, beyond induction, has highlighted the need to support supervisor assessment skills.

Summary and recommendations

30. The pilot found that there was some important evidence that implementation of the standards had potential to improve patient safety and public protection. Participating HCSWs were motivated to take part in order to make improvements and felt they knew more about patient safety and felt more able to take action to keep patients safe. Supervisors were made more aware of the importance of the HCSW role. The employer's accountability framework tested made pilot staff more aware of relevant staff governance policies. Disclosure Scotland checks uncovered some (minor) undisclosed material.

31. The evaluation indicates that roll-out of the pilot across all NHS Boards in Scotland might potentially carry substantial resource implications and that this will be to some degree dependent upon future arrangements for integration of the standards with KSF and local Board arrangements for KSF implementation. We suggest NHS Board level resource may be required to cover the following:

• A lead officer/local coordinator role
• WPS training and assessment
• Assessment arrangements for work areas with low ratio of WPS to HCSW
• Flexibility to cover all HCSW and WPS work patterns including bank, weekend, night staff and short shifts
• Administration and materials costs
• Disclosure Scotland applications, new and retrospective (including for some Workplace Supervisors)
• A national coordinator role

32. A clear communications strategy is required to inform healthcare support workers and the public of the proposed way forward, including the proposed timescale and proposals to bring existing employees into the model. Partnership representatives wish to be included in all aspects of future development and implementation and this would also be enhanced by the continued representation of patient and public interests.

33. The induction standards were unanimously supported but the standards and assessment materials required repackaging into a streamlined and more attractive format. There was consensus to implement them with clinical support workers but more exploration on the way forward for non-clinical support workers was required. The following can be recommended:

• The standards should be mandatory
• Implement the standards for clinical support workers
• Review how the induction standards apply to non-clinical support workers
• Explore possibilities for dovetailing the standards requirements with Health Facilities Scotland/ NES Education and Development Frameworks for support staff
• Revise the standards and assessment tool kit, potentially to reflect 'core' and 'role specific criteria'
• Repackage the standards and assessment toolkit to remove duplication, make them a fully accessible, more attractive and more manageable task for both HCSW and WPS
• Clarify the maximum timescale for meeting the standards
• Clarify guidance on practice for HCSWs not meeting the standards within a given timescale
• Clarify the implications of not meeting the standards at Board and individual level
• Consider motivating factors for staff groups where regulation is not part of the existing culture and prepare such groups for undertaking assessment
• Improve guidance to WPS on utilisation of evidence to meet assessment criteria
• Map the standards with common SVQs and induction programmes to clarify applicability of prior evidence
• Support the maintenance of standards through the KSF development review process to minimise the burden on supervisors and Health Boards
• Ensure any recommendations relating to KSF are in line with the 4 UK health departments partnership agreement
• Consider whether behavioural aspects need to be in both the Code of Conduct and the Induction Standards

34. The Code of Conduct was unanimously supported, and the following can be recommended:

• Implementation of the Code of Conduct for Healthcare Support Workers in its current format
• Review how and whether the Code of Conduct might be referenced in HCSW job descriptions for both new and existing staff
• Review mechanisms for monitoring working to the Code

35. The Code of Practice was supported as codifying already existing best practice but there were mixed views as to whether the accountability framework tested was fit for purpose, and we suggest:

• Implementation of the Code of Practice in its current format
• Review options for compliance monitoring
• Explore the potential for the existing NHSScotland Staff Governance Standard and review process to incorporate the Code of Practice.

36. Stakeholders hold mixed views as to whether a national occupational list would be a proportionate response to the perceived level of risk, and we suggest:

• Undertake further work to clarify the potential added value of a national occupational list over the standards and Code of Conduct, taking into account forthcoming outcomes and risk assessment guidance from the UK Extending Professional Regulation Group
• Undertake further work to articulate the links between the proposed HCSW 'occupational list' and the Protection of Vulnerable Groups scheme
• Consider whether a 'positive' means of acknowledging the achievement of the standards / code of conduct is required