1 BACKGROUND AND INTRODUCTION
Introduction
1.1 This chapter sets out the policy background to the national pilot testing the employer-led model of regulation of Healthcare Support Workers ( HCSWs) within three NHS Health Boards in Scotland. It outlines the previous consultations on proposed regulation and national minimum standards for HCSWs and current developments in UK regulation policy and sets out the background and format of the Scottish pilot.
Background
1.2 Healthcare support workers ( HCSWs), defined for the purpose of the pilot as those who provide a direct service (that is, having a direct - although not necessarily a direct 'hands on' role - on patient care/treatment/relationships) to patients and members of the public in the name of NHSScotland, play a vital role in the National Health Service in supporting healthcare professions and provide a wide range of ancillary services. 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. 1 Currently there is no statutory provision for the regulation 2 of HCSWs either in Scotland or anywhere else in the UK. The Regulation of Healthcare Support Workers in Scotland is not a matter reserved to Westminster.
1.3 In 2007-2008 Scotland tested a model of employer-led regulation, in three NHS Boards and one independent hospital. The other three UK health departments are awaiting the outcomes of the pilot.
1.4 The elements of the employer-led model tested are:
- a set of induction standards that focus on concepts considered to be important for public protection
- a Code of Conduct for Healthcare Support Workers
- a Code of Practice for Employers
- a centrally held list of names of those who meet the standards required
1.5 The model focuses on currently unregulated groups of staff, collectively known as Healthcare Support Workers ( HCSWs). This includes those in support roles to the healthcare professions (such as care assistants) and those who provide ancillary services (such as porters, domestics, unqualified laboratory workers and mortuary attendants).
1.6 Any support worker who 'provides a direct service to a patient in the name of NHSScotland' and who is not already statutorily regulated, or due to be ( e.g. psychologists; healthcare scientists, pharmacy technicians), has the potential to be included. Annexe B provides the list of healthcare support workers who were to be involved in the pilot (any other group was not to be included).
Consultation on the regulation of healthcare support staff
1.7 Some form of regulation for support workers was considered by stakeholders 3 as key to promoting the safety of the public. In 2004 two parallel consultations were undertaken in the UK to explore opinion on proposals for widening regulation to support workers, the need for regulation, and what form regulation should take.
1.8 The devolved Scottish administration issued the Consultation on the Regulation of Health Care Support Staff and Social Care Support Staff in Scotland (open May to August 2004). The purposes given for extending regulation were: to protect the public; to capture the changing roles of unregulated support staff; to close existing loopholes (whereby suspended or dismissed staff might apply for alternative posts); and to meet the needs of the Joint Future agenda with increasing numbers of joint health and social care teams and changes in worker roles.
1.9 The Scottish consultation paper sought opinion on the groups to be included in formal regulation. It suggested arrangements might be extended to specified assistant and support staff 4 who provide direct care to patients and service users. It also suggested that other support staff (working in areas such as domestic, portering, administration and clerical work which do not involve direct patient or service user care provision) might be less well served by formal regulatory arrangements and that the performance of these groups might be more appropriately managed locally by the employer.
1.10 The consultation also sought opinion on the format of regulation, who should regulate these groups, and the appropriateness of statutory or alternative forms of regulation (statutory self-regulation; statutory shared regulation; voluntary regulation led by staff organisations; employer-led regulation linked to employment contracts).
1.11 Consultation responses 5 were received from professional bodies, employers and employees of the health and social care sector. A summary of consultation outputs can be found in Annexe C. The responses indicated very strong (93%) support for the extension of regulatory arrangements to cover health and social care assistants and support staff. The majority of respondents felt that support workers should be accountable for their own practice, but that this should be dependent upon their level of training and/or scope of practice. However, it was felt that setting standards should remain the responsibility of the manager/employer. There was also some call ( UNISON Scotland) to consider further extending regulation to ancillary staff groups like porters and domestic/house-keeping staff who came into direct contact with patients and who could impact directly on the health and welfare of patients.
1.12 The majority (90%) were content that statutory regulation was the most appropriate way to ensure public protection but there was no general consensus over which of the regulatory bodies should regulate these staff. The Council for Healthcare Regulatory Excellence remained to be convinced that statutory regulation was appropriate and encouraged the consideration of employer-led regulation.
1.13 There was also significant awareness among respondents to the consultation of the need to avoid multiple registrations and to facilitate transferability of staff between the four UK countries; and that it would make sense for regulators to work together to develop core/common standards.
1.14 In parallel to the Scottish consultation the Department of Health issued Regulation of health care staff in England and Wales: a consultation document. This consultation had focused on clinical support staff 6 but excluded consideration of other non-clinical support staff (domestic, portering, administration and clerical work). Again, the consultation responses expressed broad support for statutory regulation of some, but not necessarily all, support staff. Respondents wanted more debate upon who might be included, what body might regulate them and the form any regulation might take.
UK developments in regulation policy
1.15 Most health care professional staff are already regulated 7. The work of the Council for Healthcare Regulatory Excellence ( CHRE) 8, set up in 2003 and working across the UK, focuses upon the importance of patient safety and public protection. Other, currently unregulated healthcare professions (some healthcare scientists, psychologists and psychotherapists) are in the process of, or considering, statutory regulation for their professions. Social care professionals are in the process of being regulated by the four separate social care councils 9.
1.16 The function of these health and social care regulatory bodies is to ensure that professionals have the skills and knowledge needed for practice, that they meet appropriate standards, are registered and act ethically. The bodies also take action to protect the public by investigating complaints and by taking action should there be issues about a professional's fitness to practise because of poor health, misconduct or poor performance 10. They can remove people from the register and prevent them from practising.
1.17 Over the past few years, a number of high profile cases have focused attention upon the scope and format of regulation of individuals working within the National Health Service 11.
1.18 Two key reviews of regulation by the UK Department of Health, published in 2006, have influenced the development of the Scottish pilot. Good doctors, safer patients12 was a broad review of medical regulation . It aimed to create an improved approach to promoting and assuring good medical practice, and protecting patients from bad practice . The review of The regulation of the non-medical healthcare professions (2006) was chaired by Andrew Foster (former Director of Workforce at the Department of Health .13 One of the six key themes explored through the review was the need for the regulation of healthcare staff with lower levels of qualification. The review decided that the Scottish pilot on healthcare support workers would provide important evidence and could lead to the adoption of a UK-wide approach.
1.19 In February 2007, the UK Government White Paper - Trust, Assurance and Safety - The Regulation of Health Professionals in the 21st Century, (2007) 14 was published. This set out Government proposals for improving public safety by strengthening the system of professional regulation for healthcare professionals. The proposals were based on consultation, in 2006, on the above two reviews. The White Paper was complemented by the Government's response to the recommendations of the Fifth Report of the Shipman Inquiry and to the recommendations of the Ayling, Neale and Kerr/Haslam Inquiries, Safeguarding Patients, which set out a range of measures to improve and enhance clinical governance in the NHS.
1.20 Chapter 7 of the White Paper considers plans for extending regulation to 'New roles and emerging professions'. In particular, it drew attention to the role of support workers and said that the Government in England would:
- Evaluate the results of the Scottish pilot and consider the way forward with stakeholders
- Consider whether there is sufficient demand for the introduction of statutory regulation for levels 3 & 4 on the Skills for Health Career Framework - against criteria
1.21 In 2008, the UK Extending Professional Regulation Working Group took this work forward in close liaison with the devolved administrations 15. The Group aims for a common approach across the UK for determining which healthcare and professional groups should be subject to regulation now and in future. Its task is to set out criteria against which the appropriateness of potential regulation for un-regulated groups might be judged. It has commissioned further work to identify the range of potential methods for safeguarding the public (including models of regulation and methods used internationally, voluntary registers, and employer-led models). The Group's work indicates that a proportionate and risk-based approach should underpin any future decisions about regulation (final report anticipated early 2009).
Background to the Scottish pilot
National (Scotland Group) - the 'regulation of healthcare support workers project'
1.22 In order to progress discussions on how the 2004 consultation outcomes should be addressed, the Scottish Executive set up a short-life, National (Scotland) Group for the Regulation of Healthcare Support Workers which met twice (May and June 2005). The group, whose membership consisted of a wide range of key stakeholders 16 ( Annexe D), considered a number of options for the regulation of HCSWs including: doing nothing, non-statutory approaches ( e.g. the employer-led model) and statutory options ( i.e. similar to those in place for the regulated healthcare professions). The group considered both the consultation results and the practicalities of what might be possible to achieve on a Scotland-only basis. Statutory regulation was not considered achievable on a UK wide basis within a timeframe acceptable to the group, given that the other three government health departments were not in a position to progress at that point. The National (Scotland) Group was keen to see public protection measures implemented for the people of Scotland sooner 17 rather than later and expressed a preference to progress on a Scotland-only basis until the other three home countries were in a position to consider their own approaches. The group agreed to progress with the implementation of a model of service-led regulation with the addition of a centralised, mandatory, occupational register18.
1.23 As a result of the work of the National (Scotland) Group, the 'Regulation of Healthcare Support Workers' project was born. The National (Scotland) Group expressed interest in testing the viability of the preferred option on behalf of the four UK countries. Following a request by the secretariat to the Department of Health ( DH) Review of Non-medical Regulation, a position paper was presented by SGHD to the Advisory Group (July 2005) setting out details of the proposed Scottish model. As a result, it was agreed that Scotland would introduce a set of arrangements and lead the way for the rest of the UK, with input and support from each home nation. The aim 19 was to develop and test, a model of 'employer-led' regulation for HCSWs (with national consistency) built on the premises of patient safety and public protection, and underpinned by nationally agreed standards for safe recruitment and induction, a code of conduct for HCSWs and a code of practice for employers. Compliance with these standards by HCSWs and Employers would underpin regulation.
1.24 This work was to be guided by the core principles (transparency, accountability, targeting, consistency, proportionality) set out by the UK Government's Better Regulation Commission 20 and additional principles identified by the National (Scotland) Group ( Annexe G).
1.25 In late 2005, a four-country Steering Group 21 ( Annexe E) was established to steer the pilot project. This had representation that included the Nursing & Midwifery Council, Health Professions Council, Royal College of Nursing, UNISON, Council for Healthcare Regulatory Excellence, Scottish Social Services Council, independent sector and lay reviewers. A Working Group, consisting of stakeholders from a broad range of backgrounds and a wide range of interest in both public protection and the development of healthcare support workers ( Annex J) was also established. Its remit was to develop the standards and codes and to prepare for public consultation.
Consultation on standards for healthcare support workers
1.26 The Scottish consultation National Standards relating to Healthcare Support Workers in Scotland (May-August 2006) sought views in order to further refine the draft standards for HCSWs employed in NHSScotland. The developed codes and standards focus on public protection. The Induction Standards consist of fourteen public protection statements with associated performance criteria ( Annexe K).
1.27 Prior to consultation, the Working Group had taken into account a number of systems and processes already in place across Scotland. The Group was mindful of the need for compatibility with existing systems and hoped to reduce potential duplication of effort and processes for NHSScotland Boards. Scottish Health Boards were in the process of implementing Agenda for Change, under the UK wide NHS pay modernisation agenda 22 along with its development arm The Knowledge and Skills Framework ( KSF) 23 (and e- KSF, the supporting on-line tool). The draft induction standards had drawn on applicable and already tested competences 24 from the Skills for Health database (the Sector Skills Council ( SSC) for the UK health sector). Although not planned as part of the pilot, there was potential over time, for mapping across to the Scottish Credit and Qualifications Framework (using induction standards performance criteria as evidence for achievement). From 2003, the PIN (Partnership Information Network) Guidelines on people management had been mandatory in NHSScotland; in particular, Personal Development Planning and Review, which cross referenced with KSF25. The PIN guidelines are also used voluntarily by independent and voluntary sector services which aspire to provide services for the NHS to the same standards. It was anticipated the pilot would also take into account the NHSScotland core induction programme and local induction schemes.
1.28 The consultation response indicated strong support for the principle of public protection and a positive response to the standards. There was some call for the standards to be mandatory. There was some concern expressed regarding 'tone', 'language' in relation to the Code of Conduct and induction standards.
1.29 During September and October 2006 responses 26 to the consultation were used to refine the standards before they were reviewed by the Plain English Society. During the late summer and autumn of 2006, SGHD held a series of communication events with NHS Chief Executives and other senior representatives 27 in healthcare. SGHD found that the principles of the pilot were unanimously signed up to. There was a Scottish Ministerial launch of the final revised standards 28 and the pilot in November 2006. The standards have been available for voluntary implementation across NHSScotland since then.
The Pilot
1.30 The purpose of the pilot was to explore the effectiveness of regulatory arrangements for healthcare support workers with a view to informing further debate. The proposed employer-led model comprised the set of national minimum standards (Induction standards; Code of Conduct for HCSWs; Code of Practice for employers) and a list of HCSWs who met the standards which would be maintained as part of the pilot. As noted above, the definition of healthcare support worker is particularly important in the Scottish pilot and it includes both clinical and non-clinical support workers.
1.31 The national standards were piloted in three NHS Boards and one independent sector hospital. At the outset, the pilot was to be limited to HCSWs working in mental health and children's services; older people's services were added later. The pilot, initially planned to run for one year (January 2007 to January 2008), was extended to two years. HCSW participation in the pilot was to be on a voluntary basis. Frontline managers and workplace supervisors were expected to assess HCSWs against the standards using existing Human Resources practices and supporting guidance from SGHD. Participating HCSWs would also be required to undertake a Disclosure Scotland criminal record check. HCSWs who achieved the standards would have their name entered on the occupational list (to be held on SWISS29). The pilot was supported by a national coordinator and local coordinator in each participating site. It was expected that there would be consistency of approach of operation across all pilot sites. A key objective of the pilot was to develop systems for monitoring compliance with standards in line with existing governance arrangements (such as staff governance and clinical governance frameworks).
Related policy and research developments
1.32 Two key areas of policy development have potential to impact upon future arrangements for the pilot. (Further detail is provided in Annexe J). At the outset of the pilot it was envisaged that the 'vetting and barring scheme' for the protection of vulnerable groups and children would have been introduced 30 and that the evaluation would have opportunity to explore links between its provisions and the proposed HCSW 'occupational list'. However, progress on implementation of the Protection of Vulnerable Groups Act has been slower than anticipated.
1.33 Currently it appears that if an 'occupational list' of HCSWs were to be put in place then this would be complementary to the PVG scheme. The HCSW list would signify safe recruitment of the HCSW and that a basic induction level competence was reached. Further work would need to be done to clarify what communication links would need to be established between a proposed HCSW 'occupational list' and the PVG scheme. A flow chart showing communication lines between the NHS employer, PVG scheme and individual HCSW would need to be drawn up, illustrating decision points and potential actions concerning the 'occupational list'.
1.34 Two NHS Education Scotland ( NES) lead projects have been developed in parallel with the first year of the HCSW pilot. Firstly NES was in the process of conducting a scoping study of the administrative and support services in Scotland and their support needs 31. This study has high relevance to the HCSW pilot in terms of understanding the range of literacy levels across support workers and implications for mechanisms to support learning.
1.35 Secondly, key staff involved with the HCSW pilot have contributed to NES work on developing educational support for clinical HCSWs, going beyond the induction stage. The three potential parallel assessment practices ( HCSW induction standards, KSF, vocational qualifications) all require supervisor assessment skills and the person taking on the role of the pilot Workplace Supervisor (anticipated to be the KSF reviewer) may potentially need to cover all three practices.
Report structure
1.36 Chapter two sets out the original SGHD aims and objectives for this evaluation study and the methodology followed by the evaluation team. Chapter three highlights key findings from the early implementation of the pilot and issues arising during the subsequent operational phase. Chapter four describes the development of key pilot processes including the training of workplace supervisors, the learning and assessment toolkit, the Disclosure Scotland application processes and arrangements for the 'occupational list'. Chapter five sets out the numbers and characteristics of healthcare support workers taking part in the pilot. The following two chapters present stakeholder, supervisor and support worker views on recruitment ( Chapter six) and learning and assessment processes ( Chapter seven). Chapter eight outlines the NHSQIS devised processes for NHS Board self-assessment and review and the perceptions of those taking part in these activities. Chapter nine outlines the additional NHSQIS quality assurance measures for the pilot. The process and outcome of the final consultative workshop is highlighted in Chapter ten with a final summary and recommendations in Chapter eleven.
1.37 The Annexes provide further detail on pilot steering group membership, pilot processes and pilot and evaluation documents. Abbreviations and acronyms common to the pilot are listed in Annexe A.