As HCAs take on more responsibilities and carry out more procedures, the pressure to regulate them is increasing. Views on how this should be done differ, explains Adrian O’Dowd
More from: HCAs: The Heart of Healthcare
Regulation of HCAs is a long-standing and still unresolved issue that may finally reach a conclusion this year.
Debate and discussion about whether to and, if so, how best to regulate this huge section of the NHS workforce has been ongoing for several years. As time passes and public expectations of a safe and capable workforce rise in the wake of the recently published NHS Constitution’s promise of high standards, pressure to agree on a way forward is mounting.
The arguments in favour of regulation are compelling. Just as the roles and responsibilities nurses take on have been increasing steadily over recent years, so too have those of HCAs.
Many HCAs are now carrying out procedures such as venepunctures, catheterising patients, undertaking cervical smear screening, ECGs and phlebotomy, and running smoking cessation clinics.
Gail Adams, head of nursing at UNISON, says that regulation of HCAs is important for many reasons.
‘Their role and responsibilities have changed beyond recognition in the last 15 years,’ she says. ‘Historically, HCAs undertook supportive roles, but now they have extended roles in areas such as cervical smear screening and phlebotomy.
‘Because of the reduction of hours for junior doctors due to the working time directive, nurses have the opportunity to take on additional roles and for their roles to become more extended. This is already happening with HCAs.’
Ms Adams believes that greater numbers of HCAs will be recruited in the future, underlining the need for regulation.
‘From a public protection point of view, most members of the public genuinely don’t appreciate who is caring for them,’ she says. ‘What they care about is that they receive good-quality care, given sensitively - but they don’t necessarily ask whether the person is a nurse, a HCA or a support worker.
‘The public also has an expectation that there are standards in place and that anyone who lays a hand on them has had a minimum level of training. That is not the case with HCAs as there are no national standards established.’
UNISON’s near 100,000 HCA members seem to want regulation, as shown by a survey carried out by the trade union last year. A total of 1,351 HCAs responded and the vast majority (79%) were in support of regulation, while most (77%) also thought it should be UK wide.
The survey also revealed that 43% of HCAs felt that any regulatory system should be run by healthcare regulatory bodies such as the NMC or the Health Professions Council; 36% favoured it being led by employers.
UNISON says its HCA activists confirm that the majority of staff are more in support of regulators taking the lead.
‘HCAs themselves want regulation and, when we talk to them, they always mention public protection,’ says Ms Adams. ‘They see the fact that their roles have changed and that they work alongside different healthcare professionals who are regulated while they are not.
‘They feel regulation will enable or would help to facilitate consistency across the standards that they are supposed to perform at.
‘They are acutely aware that they give highly personal care to some of the most vulnerable in society and that not everybody upholds the same standards as they feel they should do.’
Following the Department of Health’s review of non-medical regulation in 2006, the government’s 2007 white paper Trust, Assurance and Safety - The Regulation of Health Professionals in the 21st Century, said that there was a need to continually review the scope of professional regulation to cater for new forms of health care and developments in the scale and nature of unregulated health workers’ interactions with patients.
Since then, the DH’s working group on extending professional regulation, which is due to report soon, could change the goalposts again on regulation of HCAs, something that Unison is prepared for.
Ms Adams says: ‘What we would want to see is a system that works effectively across health and social care.
‘There are lots of trains of thought at the moment. One view - which I don’t agree with - is that you should start regulation at band 4. There are very few HCAs at band 4 currently - probably fewer than 1%. Most are on bands 2 and 3.
‘Regulation based on band is not a public protection system. You don’t regulate based on earnings. First, we need a regulatory system that looks at the type of activities that they are undertaking, such as extended roles, and second, looks at where they are working.
‘I think there is a greater public protection issue for staff working in community services than those who work under direct supervision or who have access to supervision within an acute sector provider.
‘Then we want to develop a regulatory framework that is both proportionate but which also delivers effective public protection. That means you start with a fairly broad entry gate and you narrow it at the point of renewal.Therefore, you give the service and the individuals time to obtain the correct standard.’
Pilots of employer-led regulation of healthcare support workers have been running in Scotland - on behalf of the whole UK - since 2007, but are still to report back.
The Scottish pilots at three NHS board areas have involved testing a set of standards for induction that focus on public protection, using a code of conduct for employees, and a code of practice for employers with the possibility of a centrally held list - a register - of names of people who meet the standards.
‘We are keen to look at the outcomes from the Scottish pilot, but UNISON does not support an employment-led model of regulation,’ says Ms Adams.
However, she believes that employers have a vital role to play in public protection, and some aspects of the Scottish model may be useful, such as national standards and a code of conduct.
UNISON’s official policy still favours the Health Professions Council - the regulator for allied health professionals - to lead regulation of HCAs, because this group of staff work with a variety of different healthcare professionals, not just nurses.
‘Once the government’s working group review comes out, we will consult with our members once again to see whether they still feel that is the best policy,’ says Ms Adams.
Many questions remain outstanding, such as the cost of regulating HCAs. Ms Adams says: ‘Our survey showed overwhelmingly that HCAs accept they will have to pay for regulation, but we have to take into account that their level of earnings is dramatically different from that of those who are already on a professional register.
‘I think there needs to be a discussion about who pays. My opinion is that public protection is, in the main, a statutory function and a government responsibility. I think staff would be prepared to contribute.’
At a summit on healthcare support workers held by the NMC last year, a questionnaire completed by delegates immediately after the event revealed different opinions.
Many (71%) thought that the government should fund the start-up costs of regulation for HCAs, but 91% felt HCAs should pay a registration fee. More than 90% of the delegates thought HCAs should be regulated but just 8.8% felt employers should lead it. Most (85%) thought a regulatory framework should be UK wide and 85% felt that regulation should not be voluntary.
Delegates said that statutory regulation would provide common standards to work to, boost employer understanding and help avoid potential harm to patients.
They also felt that components of a regulatory framework should include:
- Fitness to practise;
- Code of conduct;
- Training not completely focused around NVQs;
- Use of KSF;
- Clarity around delegation.A recent small RCN survey of 350 of its own HCA members published in March backs UNISON’s argument. It showed that 85% felt they should be regulated and 89% were prepared to pay towards it.
Ms Adams believes that the regulation of HCAs will happen eventually, but adds: ‘My concern is that they will only regulate a proportion of the workforce and not all of it.
‘We will be doing little justice to public protection if we don’t come up with something that is robust and which has the capacity to grow as roles and responsibilities change.
‘I am slightly worried we are going to fall into the professional elitist trap of wanting to control and restrict what HCAs do, rather than looking at the patient journey and the quality of care that patients need and the HCA contribution to that and what training they need.’
‘Nurses struggled for years to get the recognition for the role they were doing against the medical profession. I don’t want to do the same thing to HCAs.’
How should HCAs be regulated?