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Francis report

Mandatory registration for healthcare assistants


One of the most debated recommendations in the Francis report is that healthcare assistants should be subject to mandatory regulation

Citation: Entwistle F (2013) Mandatory registration for healthcare assistants. Nursing Times; 109: 10, 25.

Author: Fran Entwistle is assistant practice and web editor at Nursing Times.


Healthcare assistants are far less regulated than other professionals. Robert Francis QC, in his inquiry into Mid Staffordshire Foundation Trust, pointed out that a minicab driver taking a patient to hospital is likely to be subject to strict regulation but the HCA who washes the patient and accompanies him or her to the toilet is not.

Currently, it is up to the ward or setting employing HCAs to decide how much experience and what qualifications they need. There are no minimum standards of training. Although the NMC code of conduct stipulates nurses must supervise junior staff, this depends largely on their judgement. Mr Francis highlighted much of HCAs’ work is unsupervised.


Mr Francis’ recommendations include:

  • All HCAs working in the UK should be listed on a professional register. Only those whose names are on the register will be permitted to provide direct physical care to patients under the care and treatment of a nurse or doctor.
  • HCAs who are deemed unsafe should be removed from the register and potential employers would be able to find out about any past concerns. A register would also record name changes.
  • A code of conduct relating to HCA work, training and standards should be drawn up and maintained by the Nursing and Midwifery Council. This would contain national minimum standards of education and training and require HCAs to undertake the same training and achieve common qualifications.
  • A code of conduct would also provide a common standard against which HCAs can be measured to assess their competency to do the job.
  • Until the NMC is able to write and maintain this code of conduct, the Department of Health should institute a national system. This should include a fair due process for HCAs who have been dismissed by employers because of a serious breach of the code or being otherwise unfit for the post.

Uniforms and name badges should ensure patients can distinguish between nurses and HCAs easily. The inquiry noted that patients are often unclear about staff roles. As well as common training, it suggested that HCAs should have a standardised job title. The report suggests “nursing assistant”, “community nursing assistant” and “midwifery assistant”.

The government has commissioned Skills for Health and Skills for Care to develop a code of conduct and standards of good practice, and it is considering a voluntary register. However, Mr Francis raised concerns that, unless there was an obligation to be registered, this might not raise standards. He does, however, concede that trusts are more likely to hire HCAs who are registered than those who are not.

The government has suggested mandatory regulation would be costly; however, Mr Francis has countered that saying the cost would largely be covered by registration fees. An amount that HCAs would be charged has not yet been put forward.

Box 1. Nursing times survey results

Do you welcome the Francis report recommendations on regulating healthcare assistants?

  • Yes: 95%
  • No: 6%

How far do you think regulation of HCAs will improve your working day?

  • Regulation of HCAs will be of great benefit to nurses: 73%
  • Regulation of HCAs will not affect nurses: 22%
  • Regulation of HCAs will disadvantage nurses: 5%

On a scale of 1 to 5, where 1 shows no benefit and 5 shows great benefit, how far do you think the regulation of HCAs will improve patient care?

  • 1 (no benefit): 4%
  • 2: 6%
  • 3: 24%
  • 4: 31%
  • 5 (maximum benefit): 35%

Key points

  • Healthcare assistants provide the majority of direct patient care
  • HCAs are subject to little regulation, despite their great responsibility
  • The Francis report suggests that HCAs should be subject to registration before being allowed to practise
  • The report also recommends that all HCAs undertake standard training
  • HCAs should have a common title - such as “nursing assistant” - which is used in all settings

Related files

Readers' comments (3)

  • I have worked with and learned from some fabulous HCAs. They should be recognised for this and the standard they already set should be striven for across the board. It's about time some credence was given to the important role these team members have. And, Brucey Bonus, those responsible for making people feel as though Dignity is meaningless and Compassion practically ethereal, will be called to account for the abuse they have dealt. About time, too.

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  • The registration of HCA's was all set to go ahead with the introduction of the General Social Care Council. Ironically this was put on hold as a costly qango when the current coalition came to power.....

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  • But what are you proposing to register? As an HCA, I had no previous health care experience. My preparation was 'in house' and perfunctory. It focused on doing tasks as I was taught, but I had no knowledge framework for what I did.

    I longed to do 'real' nursing work, so they let me sometimes. When I moved into longer term care settings, I was considered skilled enough to do anything patients needed.

    As a registered nurse, I now know I was delegated work well beyond my understanding. I know I probably harmed patients by my efforts to do care that was really nursing care. Patients needed more than we could offer, but we tried to cope anyway and sometimes we failed. It isn't enough to mean well and try hard!

    Some nurses also trained us badly and passed on their own bad training or bad habits. This didn't help, but I've seen it still happening today.

    I am glad to know that HCA registration is rejected and I hope it will never happen, just in case I end up being cared for by another exploited and uneducated HCA like my younger self. Patients deserve better.

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