Which Francis recommendations did government decline, accept and which did it amend?
Our traffic-light summary makes clear what government decided to do with the recommendations most relevant to the nursing profession.
- 209 – Registration of healthcare support workers
Francis put forward the recommendation that any person providing direct physical care to patients should be regulated (he notes that this doesn’t apply to informal carers, such as family members).
The government did accept that all persons providing personal care should have the right skills to do so. However, an argument was put forward that regulating healthcare support workers will not necessarily prevent poor care and would not improve on the safeguards already in the system.
Instead, Health Education England, Skills for Care, Skills for Health and other stakeholders have been commissioned to develop a mandatory “Certificate of Fundamental Care” for healthcare assistants.
- 212 – Developing standards for healthcare support workers
The report suggests that the NMC take responsibility for developing a code of conduct, education and training standards and requirements for registration of HCAs.
As above, the government have decided not to regulate healthcare support workers. It also argues that the NMC do not have remit for developing codes of conduct for social care or health care support workers.
- 213 – Dismissing unsatisfactory staff following breach of code of conduct
Francis called for the Department of Health to develop a nationwide system for dismissing healthcare support workers, in order to protect patients from harm. This should provide fair due process for staff dismissed for breaching the code of conduct or due to being deemed unfit for the post.
Again, this recommendation was not accepted as the government does not feel regulation of healthcare assistants will improve quality of care. The disclosure and barring service has instead been implemented, to help with recruitment decisions and prevent unsuitable people working with vulnerable groups.
- 183 – Criminal offence to obstruct statutory duties
This recommendation was for it to be made a criminal offence for any registered medical practitioner, nurse, allied health professional or director to knowingly prevent anyone from performing their statutory duties.
The government has declined to make this a criminal offence. Instead, it plans to improve openness about care failing by ensuring providers abide by this as a requirement of registering with the CQC. Professionals who attempt to stop others performing their statutory duties will be breaching their professional responsibilities and the GMC, NMC and other professional bodies are asked to make this clear.
- 195 – Ward nurse managers’ responsibilities
Ward managers should be supervisory and not office-bound.
The government response states that it has accepted this in principle. However, the crucial part of this recommendation was for all ward managers to not be counted in the numbers and this has not been mandated. Instead, care providers are asked to have “local flexibility” in delivering nursing care. The government accepts that supervisory status and visibility on the wards is important for nurse leadership.
- 188 – Values-based aptitude test for aspirant nurses
Before being allowed to qualify as a registered nurse, individuals should be given an “aptitude test” that assesses their attitudes towards caring, compassion and other necessary professional values.
The government is instead making it mandatory for all NHS funded training posts to include testing of values, rather than testing at the end of the course. NHS England is working with Health Education England and NHS Employers to encourage “values-based” recruitment and appraisals for all staff.
- 194 – Nurses’ annual learning portfolios
Nurses should show, at their annual appraisal, documented evidence of how they have kept their knowledge of nursing practice and its implementation up-to-date. This should include feedback from patients and relatives to demonstrate commitment, compassion and caring. This should be signed by the nurse, and countersigned by their appraising manager.
The government feels that nurse revalidation will better achieve the aim of keeping nurses’ practice up-to-date. The NMC is to introduce this model of revalidation, which will require evidence that the nurse or midwife is fit to practise. The NMC’s code and standards are also to be revised to ensure they are compatible with revalidation.
- 200 – Registered older person’s nurse
The report recommended that a Registered Older Person’s Nurse role should be created.
The government accepts that older people often have complex needs, however rather than creating a separate branch of training, it plans to strengthen this area of training in the existing education programme. It also acknowledges that nurses should be able to specialise in the care of older people and proposes offering access to practical, continuous professional development post-registration in order for nurses to do so.
- 207 – Uniform description of HCAs
There should be a uniform description of healthcare support workers, made clear by their title.
The government acknowledges that this role can be so varied that a uniform title may not be appropriate. However, the Chief Nursing Officer, Jane Cummings, is going to work on developing simplified job roles as part of the career development framework.
- 201 – Dividing the functions of the Royal College of Nursing
The Francis report suggested that the RCN considers dividing its functions so one body take on the trade union functions and a separate bogy acts as employee representation.
The government believes this move would enhance the authority of the RCN’s work. However, the RCN itself has decided that it is stronger as a single organisation as its elements are complementary.
- 211 – Training standards for healthcare support workers
There should be a common set of national standards for the education and training of healthcare support workers.
The National Minimum Training Standards were published earlier this year. Health Education England has been asked to lead work with the Skills Councils, other delivery partners and health and care providers to develop a “Care Certificate” for healthcare support workers.
- 229 – Revalidation system for nurses and midwives
The NMC should introduce a system of revalidation, similar to that of the General Medical Council, to reinforce the status and competence of registered nurses.
The NMC has agreed to introduce a “proportionate and effective model of revalidation”. Guidance for this is to be developed and the NMC’s code and standards are being reviewed to ensure they are compatible with revalidation.
- 185 – Nurse training to involve practical requirements of compassionate care giving
The practical requirements of delivering compassionate care should be given more focus in nurse education. Individuals should be recruited in to the profession who have the desired values and attitudes. Leadership should reinforce compassionate values and nurses receive constant support in providing this.
The government has come up with several ways to meet this recommendation.
Firstly, the NMC has introduced new education standards to test students’ literacy, numeracy and communication skills, as well as their “health and good character” before they are accepted on to a nursing course.
Students will need to pass all assessments during their course – they will not be able to make up for poor performance in one area with strong performance in another.
The government also mentions “on-going” work in to making the career more accessible for staff who already give care.
Pre-degree care experience is currently being piloted, see below.
- 187 – Pre-degree care experience
Student nurses should spend a minimum period of time, at least 3 months, working on the direct care of patients under the supervision of a registered nurse, before starting their course.
With the aim of placing emphasis on values from the outset, the government has committed to a pilot programme that sees aspirant nurses working in HCA positions for up to a year before they are interviewed for a place on a nursing course. By working as a HCA, the government believes students will be able to find out if they really do want to be a nurse.
- 199 – Named nurses for patients
Each patient should be allocated a named key worker responsible for their care each shift. Where possible, this key worker should be present during every interaction between doctor and patient.
The government supports this recommendation. Organisations have been given the option to take action locally on this, although it has not been made mandatory. The Academy of Medical Royal Colleges is producing key principles with worked examples on how this recommendation can be implemented.