‘It is negligent of the government to let people practise in nursing, giving hands-on patient care and drawing up care plans when they are not regulated. It is morally wrong,’ says Lucia McKever, a nursing assistant at Southern Health and Social Care Trust in Northern Ireland.
‘In every profession there is good and bad. At the moment nurses who are struck off the NMC register can come and work as a nursing assistant.’
Ms McKever says all patients are entitled to the highest standard of healthcare. ‘That would include a healthcare assistant being regulated and on a register,’ she adds. Currently, they only undergo a police check for a criminal record.
Karen Alexis, a nursing clinical support worker at Udston hospital in Hamilton, Scotland, says all HCAs should have to meet a minimum standard, especially given the increasing complexity of their role.
‘What my job description is now and what it was 18 years ago is vastly different. We are basically enrolled nurses. They have done away with enrolled nurses and we are picking up enrolled nurse chores.’
The overwhelming majority of HCAs – known as clinical support workers in Scotland and nursing assistants in Northern Ireland – agree. A UNISON survey of almost 1,400 of them published in July this year showed 79% want to be regulated.
The government is considering the issue. In 2007 the Department of Health in England set up the UK-wide Extending Professional Regulation Working Group to look at options for currently unregulated healthcare roles, including HCAs.
Its recommendations for HCAs will be informed by a two-year pilot of a voluntary employer-led scheme in Scotland, due to complete this year. The four devolved health departments could then choose radically different approaches.
This is not what HCAs want. In the UNISON survey three-quarters called for a UK-wide system, and Gail Adams, the union’s head of nursing, says this would be best for public protection.
But Audrey Cowie, professional adviser for regulation and workforce standards at the Scottish health directorate, does not believe different systems would cause problems.
‘These are not professional staff,’ she says. ‘It is not a registered nurse who needs to move from Edinburgh to London. What we find in Scotland is that the healthcare support workers tend not to be very mobile. They tend to stay in a job for a long time.’
Ms Cowie, who is a member of the Extending Professional Regulation Working Group, adds: ‘Many groups want statutory regulation but it is normally on the grounds of recognition rather than public protection.’
She emphasises that the purpose of statutory regulation is public protection.
The Scottish pilot involves three health boards – NHS Lothian, NHS Ayrshire and Arran, and NHS Lanarkshire – and individuals’ participation is voluntary.
Those who take part must meet a set of public protection standards tied to the Agenda for Change Knowledge and Skills Framework in areas such as communication, confidentiality, whistleblowing, recognising and dealing with abuse, reporting health and safety incidents, and team working.
They are assessed on the standards then asked to sign a code of conduct saying they will uphold them. Their name is then added to a register held by the employer and shared with other employers.
Ms Cowie says the process usually takes three to six months but does not know how many HCAs have been through it so far.
Ms Alexis, who has been involved with the Lanarkshire pilot, says two cohorts have gone through. In the first, 90 of 104 nursing assistants took part and in the second 88 out of 120. A total of 35 observational and 27 oral assessments have been completed, and 16 codes of conduct signed.
Regulation has benefits for both staff and patients, Ms Alexis says. At the moment trained and untrained staff do the same jobs, so it gives staff confidence in their colleagues’ abilities and patients ‘the knowledge that this person has not just walked in, having worked in a chip shop on Friday night and started on Monday’.
However, Ms Alexis has reservations about the employer-led aspect of the pilot. ‘It is like the police investigating the police. I don’t think that’s a good idea,’ she says.
She would like to see an impartial regulatory body and would not be averse to paying a small fee for this. ‘RGNs have to pay for it and I think it would open up a whole can of worms if we didn’t,’ she says.
Making an existing regulatory body responsible for HCAs was the most popular option in the UNISON survey, although 59% of respondents said they would prefer not to pay a fee.
Ms Adams says HCAs are worried about employers having so much control over their careers – effectively being able to sack them then bar them from working elsewhere.
‘As a nurse I could do something wrong, I could have a warning issued against me or I could be dismissed but ultimately if I was sacked and my employer felt I was an unsafe practitioner, they would report me to the Nursing and Midwifery Council,’ she says. ‘An independent regulator would judge my actions and my explanation against the code of conduct and what you would require from someone in my role.’
She adds that HCAs generally feel less valued by employers than other healthcare staff and this increased their concerns about employer-led regulation. In UNISON’s survey 45% said they felt very poorly or poorly valued.
‘Unless they feel valued, unless they feel their skills are recognised, they are never going to be comfortable with the employer making a decision which would have such an impact on their future working life,’ Ms Adams says.
Bridget Hunter, UNISON’s lead officer for nursing care in Scotland, says the demand on employers to provide a service would
conflict with a regulatory role.
‘There is always the demand from employers “we need this job to be done and we want you to fulfil it”. That does not always necessarily run in parallel with the criteria you would say was measurement of a professional standard. Very often nurses and doctors come into conflict with their employers and say “I know you want me
to do this, but this is against the ethics of my profession and I don’t think that would be appropriate”.’
Ms Hunter says the further down the chain of responsibility you go the harder it is to challenge employers. This would be even more difficult if the employer was also the regulator. ‘Healthcare assistants, who are much more in contact with patients than other professionals, are more in danger of being asked to stretch beyond a level of their competency or what would be ethically correct,’ she warns.
Ms Hunter also doubts that HR departments would be able to break from their focus on employment rules to consider professional standards. ‘I think it is a different set of skills,’ she says.
Ms Adams warns that there would be inconsistencies in the way HR departments implement regulation. ‘They already don’t have a consistent approach to disciplinary procedures,’ she says. ‘There is big difference in the way that people apply employment policies and practices. What would be a dismissal offence in one organisation would not in another and that is why there is this level of fear among healthcare assistants if the employer
She emphasises that a regulatory system must fulfil two objectives – the public’s right to protection from unsafe practitioners and an individual’s human right to a fair hearing.
‘Healthcare assistants want a system that is equitable with others who are already on a professional register,’ she says. ‘There is something distinctly unfair about something being good enough for one group of staff who hold a professional qualification but not quite being in the in crowd if you don’t hold a professional qualification.’