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The group agreed that the prime purpose of regulation is to protect service users,
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All regulators should adopt a single definition of “good character”, one of the legal requirements for getting registration. This should be based on objective tests. (chapter 2)
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Any investigation needs to determine what actually happened.
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All regulators have the same role of protecting the public.
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Some or all of the elected professional members of Councils should be replaced by appointed professional members. A clear person specification s required, identifying desirable qualities. Professional majorities on each regulatory body could remain, but they should in future be made up differently, with most or all professionals appointed rather than elected.
A regulator like the Health Professions Council, dealing with a range of disparate professional groups, can deliver the functions which public protection requires.
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The goal of professional regulation is patient safety.
2. This means professional regulation needs to:
• set and promote those standards which, for reasons of safety, everyone in a profession (or branch of a profession) has to meet
• publish a register of those who meet these standards, and
• ensure that everyone on the register continue to meet the standards, both by periodic checks for all and by procedures for resolving concerns which a complaint or incident might create.
this does not make regulation a mere process of weeding out people who fall short of a standard. A balance needs to be struck between doing this and promoting higher standards for all. For regulation to motivate and engage with the majority who always aim to practise safely, it must aim for improvement, not mere compliance.
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Most health professionals are now employees, a fact which is insufficiently recognised by the existing approach to professional regulation. (An important minority are of course self-employed.)
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Research we commissioned from MORI showed that there is a high level of satisfaction with medical and non-medical professionals, but little public understanding of how they are regulated.
There is strong public support for regular checks being carried out on non-medical healthcare professionals, as there is with doctors, and many thought, incorrectly, that this already happened. Most wanted to see assessments take place every couple of years. There was strong support for the idea of using patient feedback as a component of assessment.
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The 2005 Review therefore looked at how much of the existing system should be retained and at what needed to be changed. Its recommendations amount to a vote of confidence in the fundamentals: statutory regulation of professionals by bodies which are independent of government and with a leading role for members of the professions.
the main themes are that regulation of the professions should: be co-ordinated with the regulation of health services;
build on systems used by employers (and NHS commissioners) where possible;
form one integrated and consistent framework of regulation across the different professions, in which departures from the standard approach need objective justification in terms of public protection, and
adopt a risk-based approach, in which any new regulatory activities (revalidation in particular) must be as simple and light touch as is consistent with their patient safety goals.
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All regulators should adopt a single definition of “good character”, one of the legal requirements for getting registration. This should bebased on objective tests
Demonstrating fitness to practise begins, obviously enough, with securing an educational qualification recognised by the regulatory body. The setting of educational standards was outside the remit of the review and in any case did not appear to give cause for concern. It is worth noting just how important this process is, nonetheless. It is largely from their pre-registration education that members of professions derive the professional standards, attitudes and behaviours which normally protect patients effectively. Setting the necessary standards and verifying that education providers and students meet them is the heart of professional regulation, though it normally attracts little public attention.
different regulatory bodies require evidence that a new registrant is fit to practise, mostly in terms of health, “character” and training.
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What is needed most now is a further effort to identify a common approach to the issue of “character”.
It has not always been very clear what the requirement for a professional to be “of good character” meant. It was put to the review that the whole concept was unhelpful and that the emphasis should be placed instead on conduct – the outward expression of a person’s attitudes.
Checking on a person’s character should be based on objective tests such as the absence of criminal convictions, adverse decisions by regulatory bodies, the information about likely criminal activity contained in an enhanced CRB disclosure and so on. While it is clearly a good thing that standards for preregistration education should include the promotion of suitable attitudes, finding objective (and fair) ways to test these is much harder and we may need to satisfy ourselves with only testing what can be objectively measured.
CHRE is developing work on the definition of good character. This should continue and should receive regulators’ full support with a view to early adoption of a single standard.
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Professionals will fall into one of three groups for revalidation:
i. employees of an approved body – revalidation carried out as part of the routine staff management or clinical governance system.
ii. self-employed staff providing services commissioned by NHS primary care organisations – revalidation processes built into the relevant NHS arrangements and carried out under the supervision of the commissioning organisation
iii. all others – regulatory bodies develop direct revalidation arrangements.
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The K(knowledge)S(kills)F(ramework) is a broad generic framework that focuses on the application of knowledge and skills – it does not describe the exact knowledge and skills that people need to develop. Linked to the KSF, the National Occupational Standards (NOS) produced by Skills for Health have been praised for producing a consistent basis across the UK for describing particular competences. NOS are a useful currency in which to talk about competences and should be used in regulation where they are available.
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Professionals will fall into one of three groups for revalidation:
• employees of an approved body – revalidation carried out as part of the routine staff management or clinical governance system.
• self-employed staff providing services commissioned by NHS primary care organisations – revalidation processes built into the relevant NHS arrangements and carried out under the supervision of the commissioning organisation
• all others – regulatory bodies develop direct revalidation arrangements.
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The different F(itness)t(o)P(ractice) systems are inconsistent with each other. A doctor and a nurse involved in the same incident may find their cases being handled in different ways, which is confusing to the patient who has referred the matter to the regulator.
It can also be reasonably claimed that there is too much law in this field. When nine regulators have separate FtP systems which each require Rules made under different Acts of Parliament, and these need amendment from time to time to close loopholes or reflect new policy, the result is a small cottage industry which is inefficient at producing good quality, consistent law. This increases costs, as solicitors and barristers who work for a number of regulators (as prosecutors, defenders, or legal assessors) in FtP cases have to be familiar with a range of different FtP law. This all adds to overall FtP costs. Problems have arisen in developing the law because of changing goalposts and there is a need to ensure consistency in drafting.
the notification or raising of a matter of concern or a complaint, complainants would benefit from having a single source of advice (perhaps a portal on a website and/or telephone service) which would help them decide whether they wanted to make an NHS complaint, a complaint to a private resolution procedure such as the General Dental Council (GDC) and General Optical Council (GOC) are setting up, take civil legal action, institute criminal proceedings, or refer a professional to a regulator.
DH is considering the idea of a “single portal” separately as part of its work on the complaints system, in response to the recommendation made in the Fifth Report of the Shipman Inquiry.
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Suggestions for regulating new groups included a wide range of support workers at different levels on the career framework and very different stages of readiness in terms of nationally-recognised competences and training:
• assistant practitioners;
• HCAs/care assistants;
• therapy assistants;
• scientific support staff;
• ambulance technicians.
• Some suggested that porters, administrative and clerical staff and educational assistants should also be regulated.
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The new roles using the working titles1 of Anaesthesia Practitioner, Emergency Care Practitioner, Endoscopy Practitioner, Medical Care Practitioner and Surgical Care Practitioner need statutory regulation, if healthcare providers agree they are fit for purpose.
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All regulators have the same role of protecting the public.
Some or all of the elected professional members of Councils should be replaced by appointed professional members.
Any new profession coming into statutory regulation should be regulated by one of the existing regulatory bodies, most likely the HPC.
The role of the regulatory system, and of regulatory bodies within it, should be to ensure patient safety, although there are other important if subsidiary objectives such as to maintain public confidence and trust.
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Four regulators currently have a role outside the scope of regulation. The RPSGB, the PSNI, the General Chiropractic Council and the General Osteopathic Council are each charged in law or in a Charter with promoting their profession, in subtly different ways. While there is no suggestion that they are expected to put the good of the profession before that of the public, these words have caused uncertainty and dispute at times. Although the roles of professional leadership and promoting the profession, which have to be exercised for the public benefit, do indeed benefit the public, there is a tension between their focus inwards on the professions’ interests and the need for the regulator to be seen to be free from such influences. The implementation of changes following this review will provide opportunities to bring the regulation of these professions into line with the majority.
The main functions of a regulatory body are:
• setting and promoting standards for admission to the register and retention on the register;
• keeping a register of those who meet those standards (including in future checking that registrants continue to meet the standards), and
• administering procedures (including making rules) for dealing with cases where a registrant’s right to remain on the register is called into question.
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Another important note of caution is the need to maintain professional buy-in for the system of regulation. There could be a risk that the merger of existing regulators could alienate members of the affected professions. This is not automatically so and could be guarded against, in particular in the important area of standard-setting, where professional bodies would need to continue to feel that they were key players.
A regulator like the Health Professions Council, dealing with a range of disparate professional groups, can deliver the functions which public protection requires. Professional bodies dedicated to providing leadership and developing the future scope of practice as the professions develop, which can then inform the regulators’standards-setting function, are also needed: the two work together.
It follows that any new profession coming into statutory regulation should be regulated by one of the existing regulatory bodies, probably the HPC.
Some aspirant groups have argued that new bodies should be set up to regulate their professions. The preceding discussion has led to the rejection of that approach.
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This report and Good doctors, safer patients establish the direction of travel. Following consultation and further work on the practicalities of implementation, more operational details will be made available, following discussion with those most affected.
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The people responsible for the report:
Andrew Foster Director of Workforce
Chris Beasley Chief Nursing Officer
Kay East Chief Health Professions Officer
Sue Hill Chief Scientific Officer
Raman Bedi Chief Dental Officer
Jeannette Howe Acting Chief Pharmaceutical Officer
Jane Wesson Chairman, CHRE
Sandy Forrest Director, CHRE
Steve Barnett Director, NHS Employers
Alastair Henderson Deputy Director, NHS Employers
Sarah Thewlis Chief Executive, NMC
Marc Seale Chief Executive, HPC
Hew Mathewson President, GDC
Ann Lewis Registrar, RPSGB
Nic Greenfield Deputy Director – Workforce, DH
Steve Catling Head of Professional Standards, DH
Harry Cayton National Director for Patients and the Public, DH
Norman Morrow DHSSPS, Northern Ireland
Paul Martin Chief Nursing Officer, Scottish Executive
Stephen Redmond HR Director, Wales
John Wilkinson Principal Research Officer, DH
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Competence
Competence is built up from knowledge (for example facts about physiology) and skills (for example inserting an intravenous line safely and effectively). Modern HR practice breaks the requirements for any job down into several individual competences. An example of one would be history taking and consultation skills. In a wider sense, “competence” to carry out an entire role consists of having all the individual competences required, plus the ability to use judgement at a higher level (for example by knowing when to use which competence and when it is clinically right to depart from a standard clinical approach). The agreed working definition of “competence” from the Scottish OPRS Committee is the “consistent integration of skills, knowledge, attitudes, values and abilities that underpin safe and effective performance in a professional or occupational role.”
There is an important difference between knowing what to do (competence) and actually doing it (performance). A competent radiographer knows how to use Xrays safely, but might sometimes fail to do so: one who performs adequately is a radiographer who always works in a safe way. Revalidation should be much more relevant to patient safety if it can test performance rather than competence.
Character and Conduct
Character is an elusive concept and our focus would better be directed towards conduct and, where possible, to the attitudes which direct it. The ‘moral strength’ to know what is right is what is important and is a feature of self-regulation. Irrespective of professional status this ‘quality’ should be expected/articulated.
Competence
Competence is built up from knowledge (for example facts about physiology) and skills (for example inserting an intravenous line safely and effectively). Modern HR practice breaks the requirements for any job down into several individual competences. An example of one would be history taking and consultation skills. In a wider sense, “competence” to carry out an entire role consists of having all the individual competences required, plus the ability to use judgement at a higher level (for example by knowing when to use which competence and when it is clinically right to depart from a standard clinical approach). The agreed working definition of “competence” from the Scottish OPRS Committee is the “consistent integration of skills, knowledge, attitudes, values and abilities that underpin safe and effective performance in a professional or occupational role.”
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Purpose and intended effect
Objective:
2.1 A safer NHS through safer healthcare professionals such as nurses and pharmacists:
• Promoting and assuring good professional practice and protecting patients from bad practice.
• Rebuilding of public confidence in the regulatory institutions.
• Closing the gap between the regulatory responsibilities of the professions and healthcare organisations.
We aim to do this in a way which:
i assures patients and carers that their complaints are listened to and taken seriously
ii recognises and celebrates the high standards of service delivered by the vast majority of healthcare professionals
iii supports learning and continuous improvement in all services provided to NHS patients.
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Background:
2.3 The vast majority of health professionals practise to a high quality but there is a small minority whose standard is not acceptable whether through inadequate training, insufficient support, ill health, lack of motivation or malice. Publication of Supporting doctors, protecting patients [1999] and the NHS Plan set in motion the reform process, but there is unfinished business.
Rationale for government intervention:
2.4 The vast majority of healthcare interventions are completed through the NHS. Unsatisfactory practice compromises patient safety. The professions have a duty to identify such practice and to remedy it. However, they cannot do this on their own.
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A degree of professional ‘ownership’ of regulation can be regarded as a defining feature of professionalism and is essential to engagement.
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At present, in addition to the GMC for doctors, health professionals are regulated by one of the following seven bodies: General Dental Council, General Optical Council, General Chiropractic Council, General Osteopathic Council, Health Professions Council, Nursing and Midwifery Council, Royal Pharmaceutical Society of Great Britain.
