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Learning from BristolThe DH Response to the Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995Chapter 7 THE REGULATION AND EDUCATION OF HEALTH CARE PROFESSIONALSThis chapter considers the means by which well- trained and competent health care staff are developed to meet the needs of patients in a modern NHS and the system of regulation for enforcing those standards. 7.1 The quality of care delivered to patients depends crucially on the calibre of staff working in the NHS. This means identifying the needs of the service now and for the future, setting clear standards, and working with the training organisations to ensure education and training programmes meet those standards. NHS patients need to know that the staff that care for them are well- trained and competent; education, training and development must meet the needs of the NHS now and in the future; and above all it must produce and support health care professionals who are equipped with skills, knowledge and values set out in both The NHS Plan and the Kennedy Report. Our approach to regulation
7.2 The public and patients are entitled to expect that the health care professionals with whom they come in contact are well-regulated and that there is consistency across the professional boundaries. The Kennedy Report calls for a single body for each health care profession, charged with overseeing all aspects of the regulation of professional life and a single body to co- ordinate the various professional bodies. We signalled our intention to modernise the regulation of health care professions in The NHS Plan in July 2000. In August 2001 we published a consultation document Modernising Regulation in the Health Professions, outlining our proposals for the creation of the Council for the Regulation of Health Care Professionals. The new Council will work with the regulatory bodies to build and manage a strong system of self regulation which:
7.3 These proposals are designed to replace the current fragmented arrangements for the regulation of health professions with a modern framework that puts patients at the heart of the process; gives them stronger safeguards and protection against poor performance; and rebuilds public confidence in the ability of the regulatory bodies to set acceptable standards for the quality of health professionals’ work and to deal effectively and fairly with individuals who do not meet these standards. Accountability and membership7.4 It is essential that the health care regulatory bodies work together to develop common approaches across the professions and agree standards that put patients’ interests clearly at the centre of all they do. The regulatory bodies need to reflect the changing nature and character of the NHS workforce and the way that health care is delivered on the ground. This can be best achieved under the effective co- ordination of the new Council, with the support of reformed regulatory bodies. 7.5 We are working with the existing bodies to ensure that they become more responsive to the views of stakeholders so that they meet reasonable patient expectations and the changes in service delivery that have taken place in recent years. We have consulted widely on the reform of the regulation of nursing, midwifery and health visiting and the allied health professions. Parliament has recently confirmed our proposals for the establishment of the Nursing and Midwifery Council and the Health Professions Council. We are discussing proposals with the General Medical Council (GMC) for the reform of its governance and changes to the registration of doctors including the introduction of revalidation and fitness to practise. We will be reforming the General Dental Council, introducing a compulsory continuous professional development for dentists and reforming disciplinary procedures for pharmacists. The proposals add up to the biggest reform of health care professional selfregulation and demonstrate our commitment to providing an independent statutory framework for health care professions in which the public and patients can have full confidence. 7.6 We have given careful thought to the view that the various bodies whose purpose is to assure the competence of health care professionals should be independent of and at arm’s length from the Department of Health. Regulation of professional staff goes beyond employment in the NHS and regulates the competence and ability of an individual to work in a range of settings both in NHS and private practice. We accept that regulation of professionals should properly be at arm’s length from Ministers. We propose that the Council for the Regulation of Health Care Professionals should be accountable to Parliament. The regulatory bodies will be accountable to the new Council and through it to Parliament. Arrangements for each body will be reviewed once the new Council is in place. Managers
7.7 Careful consideration has been given to the recommendation in the Kennedy Report that managers should themselves be subject to a new regulatory professional body. We endorse the view that managers should be subject to a code of behaviour and have the appropriate skills and competence to discharge their roles. Since the events at Bristol, managers have become subject to a wide range of monitoring and inspection systems. CHI explicitly inspects the statutory duty of quality placed on chief executives through its clinical governance reviews and service managers are now explicitly accountable for the quality of patient care and patient services. 7.8 We agree, that more needs to be done to improve the quality of NHS management. Raising standards and raising the value of managers go hand in hand and will lead to the better management of services for the benefit of patients. We do not think it practicable, however, at this stage to establish a formal regulatory body. Rather we propose to establish the safeguards for patients and the service through the introduction of a seven point action plan, which will include:
The education of health care professionals
7.9 The Kennedy Report calls for a broadening of the social and academic base from which health care professionals are drawn and for more joint training courses between professions to foster multi- disciplinary working. We are committed to widening access to medical schools. Our programme to increase the number of places by 2010 is based on medical schools demonstrating an active commitment to recruiting students from a broad range of social and ethnic backgrounds, to reflect the patterns of the population that they serve. The increases included a number of places for existing graduates to enter shorter courses, as part of our strategy to encourage people from a broader range of backgrounds, including other health care professionals, to move into medicine. We are exploring other means of attracting people from backgrounds which have not traditionally gone into medicine. 7.10 We recognise that there should be greater public involvement as recommended in the Kennedy Report in the selection of those entering training as health care professionals. NHS managers and practitioners are already frequently involved in aspects of the selection process for nursing, midwifery and allied health professional students. We are taking steps to strengthen this further through Workforce Development Confederations and following the strategies for nursing, midwifery and health visiting (Making a Difference), allied health professionals (Meeting the Challenge) and health care scientists (Making the Change). Whilst it is for the regulatory bodies and higher education institutions to set their requirements for admission to professional training, we are committed to encouraging broad and diverse participation in selection procedures. 7.11 The aim of undergraduate medical education is to produce doctors who are able to meet the nation’s present and future health care needs. The expansion of places in existing universities, together with the brand new medical schools will create generations of new doctors equipped to meet the challenges of twenty first century medicine. New, modern curricula will mean that tomorrow’s doctors will be skilled not just in management and treatment of disease, but in communicating with their patients, in assuring the quality of the care they provide, in realising the potential of e-medicine and in helping people stay healthy. No longer will medical education be a ‘doctor only world’, students of medicine, nursing and other professions will have more systematic opportunities to learn together in practice based settings, supporting better teamwork, which will be essential in the day to day care of patients. 7.12 We need to make full use of new developments in teaching methods. As part of their CPD, doctors are increasingly using the Internet to learn about clinical advances in other countries and to communicate rapidly with professional colleagues. Other electronic advances in methods of training doctors include an electronic arm on which doctors can practise taking blood and a computer generated surgical theatre to accustom doctors to theatre practices, which, for example, allows them to learn and experiment with different stitching techniques without risk to an actual patient. Common learning for health care professionals
7.13 We fully support the Kennedy view that health care professionals need to be aware of and respect each others’ roles if they are to deliver modern health care together. The NHS Plan has already signalled our commitment in this area and we have already invited proposals from ‘leading edge’ Higher Education Institutions/ Workforce Development Confederation partnership sites to develop more undergraduate health care professionals programmes which incorporate more common and shared learning elements throughout the curriculum. This is key to our commitment to have common learning programmes in place for all health professions by 2004. It will also help to develop closer links between medical, nursing and other health professional programmes in university departments. 7.14 Central to this is the development of communication skills, not only between the health care professionals and patients but also between professionals themselves both within and outwith the NHS, as part of multi- disciplinary working. Only by engaging with and respecting the views of others can a true partnership be entered into and high quality care be delivered. We recognise that all professionals need an understanding of the contribution they each make to providing a safe, high quality health service. Clinicians can no longer ignore the wider resourcing and management framework within which they operate: managers must also have a proper understanding of what is needed to deliver a clinical service which meets patients’ needs and expectations. 7.15 To underpin recent decisions on major increases in medical school places, all universities were required to describe how their proposals would underpin the development of multi- professional education - to ensure that care would be delivered to patients by the staff best able to give it by skill rather than professional label and to ensure that the doctors of the future are team workers. 7.16 We accept, therefore, the Kennedy recommendations that greater priority should be given to non- clinical aspects of care in the education, training and development of those working within the NHS. As part of The NHS Plan action agenda we are working with the regulatory and professional bodies and the educational providers to ensure that these skills, knowledge and values are included in all NHS funded professional programmes, and undergraduate medical, nursing, dental and pharmacy training by the end of 2002. Post-qualification training and continuing professional development
7.17 The delivery of modern health care is highly skilled and complex: the limits of what can be achieved in modern medicine and health care are continuously expanding and the demands placed on health care professionals are increasingly more challenging. In this context, the importance of continuing development and life long learning for all who work in the NHS is self evident. 7.18 The Kennedy Report recommends making the proposed Medical Education Standards Board (MESB) part of and answerable to the GMC. After careful thought we have decided not to accept this recommendation. The use of the considerable resources which go into post- graduate medical education should reflect the needs of the service, as well as individual clinicians and it is right that there should be closer ties between the MESB and the NHS as the Kennedy Report suggests. 7.19 The MESB will set standards for post- graduate medical education and training. To become a consultant or a general practitioner, doctors will have to be assessed by the Board to see whether they have met those standards. For the first time, the Board will bring together patients, the NHS and the medical profession in making key decisions about how doctors are trained. The Board will provide a managed and quality assured framework for the training of doctors, to ensure that doctors get the training they need to deliver the services patients deserve. Our detailed proposals for the Board are being published separately. 7.20 CPD is clearly an important component in maintaining and updating skills and expertise. The Kennedy Report recommends that it should be compulsory. All regulated professionals have a duty to maintain their knowledge and keep their skills up to date as part of the requirement of their professional code and failure to do so puts their continued registration (and hence employment) at risk. We believe that CPD requirements should be identified on the basis of the needs of individuals, within the context of the needs of the organisation and local clinical guidance. The key focus for this is the formal appraisal process together with a personal development plan agreed between the individual professional and their manager with the commitment of the necessary time and resources. Our proposals for modernising the NHS pay system require that appraisal and development should become a regular part of working life for all NHS staff, and the pay modernisation proposals in Agenda for Change suggest a link between appraisal and pay progression to reward staff who develop new skills and knowledge. 7.21 In April 2001, as part of our commitment to CPD in The NHS Plan we allocated £20m to support development of the learning infrastructure for CPD. The NHS Lifelong Learning Framework and the implementation of the NHS Improving Working Lives Standard will further reinforce our plans in this area. Workforce Development Confederations will lead this work locally, ensuring that national criteria for investment fit with local needs and priorities and cover all settings including primary care. The National Clinical Governance Support Team launched a programme in October 2001 which will support staff in developing communication and team working skills and shared learning across professional boundaries. Appraisal
7.22 The Kennedy Report rightly highlights the importance of appraisal. Appraisal is an essential tool in reviewing performance and is a crucial component of reflective practice and the systems which assure competence, quality and the safety of care. Appraisal for consultants was introduced on 1 April 2001 and GP appraisal is under negotiation. Appraisal for all other NHS doctors will be rolled out in the coming year. All staff should already have a personal development plan and we are committed to introducing an appraisal process which will cover all NHS staff. Development work is now beginning and we intend to build on existing good practice. Revalidation
7.23 The Kennedy Report calls for compulsory rigorous systems of revalidation and registration, with public involvement in the process of revalidation. We are already committed to the principle of revalidation and are actively working with the GMC to introduce revalidation for all doctors. Medical revalidation includes lay involvement in assessing individual doctors and this should be a benchmark for other professions. The Council for the Regulation of Health Care Professionals will have a role in the development of common approaches to revalidation across the professions. Clinical excellence awards
7.24 The Kennedy Report draws attention to the role of clinical excellence awards in motivating doctors. We issued proposals for consultation last year on a new NHS Clinical Excellence Award Scheme to replace the current distinction awards and discretionary points schemes. We will be implementing a new scheme designed to reward those who make the biggest contribution to delivering and improving local health services. The new scheme will provide a further powerful incentive to high quality practice by using assessment criteria based on patient centred service and care. Patients will be represented on local awards committees. Fuller proposals are being developed in the light of consultation and the Kennedy recommendations will be taken into account as part of this work. Professional codes of conduct
7.25 The Kennedy Report recommends that the codes of professional conduct should be included in the contracts of employment for health professionals, with employers dealing with breaches independently of the actions of the professional body. The required national documentation for consultants’ contracts explicitly included the headings in Good Medical Practice, so that evidence against all these areas can be considered during appraisal and then by the GMC during its own revalidation process, due to start in 2003/ 4. The same principles will apply to other NHS doctors. 7.26 Other health professionals have contracts of employment based on the premise that they are properly registered with their regulatory body which itself requires them to meet their professional code of practice, and a professional code of practice for managers is being developed. Compliance with professional codes of conduct are therefore already implicit in employment contracts: we do not believe that we need to go further. Discipline
7.27 The regulation and disciplining of health care professionals is a shared responsibility between the employer and the regulatory bodies. We support the view that local employers should be able to deal with breaches of the relevant professional code by a health care professional. New guidance is being prepared to ensure that employers take into account professional codes of practice in their local codes of conduct. 7.28 Supporting doctors, protecting patients, recognises that early intervention by health authorities, NHS Trusts and PCTs is needed when concerns about a doctor’s practice first arise and before patients are harmed. The National Clinical Assessment Authority (NCAA) will assist health authorities, NHS Trusts and PCTs achieve this. We intend that its scope will be extended to include dentistry and we will also give consideration to extending this approach, under similar arrangements, to other health care professions. Our proposals for the new Nursing and Midwifery and Health Professions Councils include the expectation that they will both develop and operate their policies in partnership with employers. 7.29 In cases where local action has not been able to ensure the protection of the public the matter must be reported to the appropriate regulatory body. We envisage a key role for the Council for the Regulation of Health Care Professionals in ensuring that efficient and effective mechanisms are in place for protecting the public from unacceptable risks presented by those health professionals who are, for whatever reason, unfit to practise. Conclusion7.30 It is essential that the public should have confidence in the system of professional self- regulation and the competence of the health care professionals involved in their care. We agree that the process of regulation should be at arm’s length from government and that there should be greater public involvement in the regulatory processes. But assuring competence is a continuous activity, and one which has a strong relationship with the quality of service we wish the NHS to deliver. For this reason we are committed to continuing professional development and lifelong learning for all staff, linked to systematic appraisals, personal development plans and revalidation. In this way the public can be confident that the individual is appropriately registered with his or her professional body, that skills have been updated to take account of changing clinical practice and that this is a continuing and ongoing process which recognises changes and development in clinical practice over time. 7.31 In responding to the Kennedy report’s recommendations we will:
Source:
Response to the Bristol Inquiry Report: Executive Summary
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