29th May 2012
Unite evidence to the joint England and Wales, Scotland and
Northern Ireland Law Commissions’ consultation on the
Regulation of Health and English Social Care Professionals
LCCP 202/ SLCDP153/NILC 12 (2012)
This evidence is submitted by Unite the Union - the country’s largest
trade union with 1.5 million members. The union’s members work in a
range of industries including manufacturing, financial services, print,
media, construction and not-for-profit sectors, local government,
education and health services.
Unite represents approximately 100,000 health sector workers. This includes
seven professional associations – the Community Practitioners’ and Health
Visitors’ Association (CPHVA), Guild of Healthcare Pharmacists (GHP), Medical
Practitioners’ Union (MPU), Society of Sexual Health Advisers (SSHA), Hospital
Physicists’ Association (HPA), College of Health Care Chaplains (CHCC) and the
Mental Health Nurses’ Association (MNHA).
Also members in occupations such as allied health professions, healthcare
science, applied psychology, counselling and psychotherapy, dental professions,
audiology, optometry, building trades, estates, craft and maintenance,
administration, ICT, support services and ambulance services, and, most recently,
the British Veterinary Union which represents veterinary practitioners.
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Executive Summary
•
Unite welcomes the opportunity to contribute to the consultation on the
regulation of health care professionals in the UK, and social care
professionals in England.
•
Unite has consulted widely across all its professional groups on the
proposed changes.
•
Of the nine statutory regulators for health professions in the United
Kingdom, Unite has members regulated by eight of the regulators. Unite
also has members regulated by voluntary regulators, some of which will
be seeking accreditation by the CHRE.
•
Unite has social workers in membership, currently registrants in the four
GSCCs across the UK with the English GSCC soon to become HPC
registrants.
•
Unite supports the aspirations of regulatory reform in respect of promoting the safety and quality of care for patients, sustaining the
confidence of the public and professionals through impartiality, improving
and assuring professional standards of health professionals and
identifying and addressing poor practice or bad behaviour without
creating unnecessary burdens, and being proportionate to the risk
addressed and the benefits it brings.
•
Unite values the role of the overarching body, currently the CHRE, in its
support of the regulators, its sharing of best practice in the interests of
the well-being of patients and its work and advice to regulators on best
practice.
•
Unite has within its membership a number of professional groups that
aspire to become CHRE quality assured registrants.
These groups are - Community Nursery Nurses, who have yet to form a
register, Health Care Chaplains where an embryonic regulator has
been formed – the United Kingdom Board for Healthcare Chaplaincy.
The third group is the Dance Movement Psychotherapists. They have
met all requirements and have been recommended for registration by
HPC for a number of years but the parliamentary time required has not
been afforded to enable this to happen. This is a particular anomaly
where all other forms of arts therapies i.e. drama therapy, music therapy
and art therapy are registered. Any parliamentary time provided to enact
the outcome of this consultation should include time to enable this
group to become registered.
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•
In addition we have Clinical Physiologists, for whom the Registration
Council for Clinical Physiologists puts a strong case, and the Society of
Clinical Perfusion Specialists. These groups have sought statutory
regulation for over 8 years without success and are being told that the
Academy of Healthcare Sciences will address the matter in time which
would probably mean being an assured voluntary register – which they
do not feel to be appropriate.
•
Unite is concerned on behalf of health visitors who as a group were once
registered but now are only registered by entry qualification – i.e. nursing.
Unite/CPHVA have argued that this creates a major risk to the public. We
strongly believe that health visiting should be returned to statute, as it
was previously for nearly 100 years!
Unite’s position on professional regulation
Privy Council
The role of the Privy Council in relation to statutory regulators involves such
matters as the appointment of lay members to these bodies and the approval
of rules.
The Judicial Committee also has a role in relation to certain appeals against
disciplinary procedures. The allocation of responsibility for these matters to
the Privy Council rather than to the Secretary of State with the major policy
interest builds in wider cross-Government participation. In this, as in other
ways, the Privy Council is an important part of “joined-up Government”.
Unite believes that role of the Privy Council is important in relation to
regulation and that the independent scrutiny of the Judicial Committee
should not be lost to any government of the day.
We believe that the CHRE and subsequently the Professional Standards
Authority for Health and Social Care, as an independent body, should be
responsible for setting standards for the regulators, rather than exposing the
professions to political interference.
Protection of title
Unite believes that it is important for the protection of the public and of
health practitioners that titles are protected. At present we have a situation
where all 15 professions regulated by the HPC have their titles protected, and
the title of “osteopath” is protected, but within the NMC the title of “nurse”
is not protected although “registered nurse” is. The title of “health visitor”
or the other roles on part 3 of the NMC register such as “sexual health
adviser” are not protected although “specialist community public health
nurse” is.
The situation for health visiting is particularly anomalous because it is not
even mentioned on the NMC or CHRE websites, or in any of their literature,
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so members of the public wanting to make a complaint would have difficulty
identifying which is the designated regulatory body.
We have examples of childrens’ centre staff being perceived by the public as
health visitors, who do not correct their title when working with families.
Further confusion is caused when we see, for example, podiatric surgeons
being “passed off” as “doctors”, and patients then believing that they are
being treated by a medical practitioner, or (as often happens, sanctioned by
organizations implementing skill mix) registered nurses being “passed off” as
health visitors despite not holding the relevant qualification. We have
debated the issues and detailed why we believe the removal of health visiting
from legislation has had a negative effect in terms of public protection.
*See Appendix A – Professional Briefing: public safety and statutory
regulation of health visitors, and Appendix B – Regulatory Issues and
the future legal status of the health visitor title and profession.
Standards
The goal to bring all regulatory bodies to the same standard and expectation
is positive but the good process and practice that some regulators are striving
to achieve should not be undermined.
CHRE
Equally, good practice promoted by CHRE should not be ignored by
regulators. Why, for example, has the CHRE for two consecutive years,
recommended that the HPC should review its “case to answer” procedure to
allow complainants to see the practitioner’s response to a complaint when it
is already the case that the practitioner sees the complaint?
CHRE has just made 16 recommendations to the NMC. The NMC have
accepted the recommendations but there is no obligation for them to do so.
CHRE ignored health visitors’ complaints about risk to the public from the
anomalous regulatory process since the health visitors’ dedicated register was
closed in 2004, suggesting only that worries stemmed from a ‘factional
issue’. That does not protect the public.
Unite/CPHVA lodged a formal complaint/vote of no confidence in NMC in
2009, because of the disregard of their views regarding the conduct of the
third part of the NMC register. This was ignored and the public remain at
risk – but there is no mechanism for redress.
Regulatory bodies, including CHRE, can only function if they retain the
confidence and trust of the professions they regulate, so this should be an
expectation and requirement.
What will be the purpose of the newly independent Professional Standards
Authority for Health and Social Care if regulators can pick and chose which
bits of best practice to adopt?
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Registration Fees
It is unclear how new arrangements for the CHRE will impact on registration
costs. Currently health professionals have to pay registration fees ranging
from £375 in your first year on the register, £500 in your second year and
£675 per year in subsequent years for osteopaths to £76 per annum for
nurses. Most of our practitioner members are employed and for these
practitioners registration fees are perceived by some to be a tax on jobs!
This government’s aim is to get rid of QUANGOs. The CHRE has existed as a
QUANGO. The new Professional Standards Authority for Health and Social
Care is required to be financially independent and will seek its funding from
the statutory regulators and from the newly accredited non-statutory
registers. This will inevitably mean an increase in registration fees for
practicing health professionals, and will create a hardship for practitioners at
a time of pay freezes and increased pension contributions.
The NMC has recently announced that it is considering increasing its
registration fee from £76 per annum to £120 per annum – and this before
any element of money towards the Professional Standards Authority for
Health and Social Care is factored in.
Protection of public and of practitioners
• Unite believes that it is not possible to protect the public without also
supporting the professionals to maintain high standards of service. Unite
therefore argues that most, if not all, health care professions should be
regulated in order to protect professionals and the public from bad
practice.
•
Regulation is needed to address the power imbalance that exists between
people delivering the service and those with more power that make
decisions about the resourcing and structure of services that impact on
service standards and public safety.
•
The Health and Social Care Act will make the need for properly enforced
professional standards much greater, to counter the negative impacts of
bidding down service quality to win contracts.
•
Regulators should be used to support and develop professionals,
providing a range of services including whistle blowing and regulation of
providers. They should not be driven into the role of only punishing
professionals for failings, especially if these failings are beyond the control
of the practitioner.
Pharmacists
•
The Guild of Healthcare Pharmacists is a professional association
within Unite. It has made its own submission to this consultation, but,
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as it is part of Unite, a copy of that submission is attached to this
response as “Appendix C”
Unite’s response in detail:
PROVISIONAL PROPOSALS AND CONSULTATION QUESTIONS
PART 2: THE STRUCTURE OF REFORM AND ACCOUNTABILITY
Provisional Proposal 2-1: All the existing governing legislation should be
repealed and a single Act of Parliament introduced which would provide the
legal framework for all the professional regulators.
Provisional Proposal 2-2: The new legal framework should impose consistency
across the regulators where it is necessary in order to establish the same core
functions, guarantee certain minimum procedural requirements and establish
certain core requirements in the public interest. But otherwise the regulators
should be given greater autonomy in the exercise of their statutory
responsibilities and to adopt their own approach to regulation in the light of
their circumstances and resources.
Provisional Proposal 2-3: The regulators should be given broad powers to
make or amend rules concerning the exercise of their functions and governance
without any direct oversight, including Privy Council approval and Government
scrutiny (subject to certain safeguards).
Question 2-4: Would the perceived status of legal rules be less clear or certain
without Parliamentary approval? Should the CHRE be given an active role in
scrutinising new rules, or should a limited number of the rules be subject to
Secretary of State approval and contained in a statutory instrument?
Unite response to question 2 – 4. We believe that the Secretary of
State/Parliament, should retain authority contained in a statutory
instrument.
Provisional Proposal 2-5: The power of the regulators to issue standing orders
should be abolished.
Provisional Proposal 2-6: The regulators should have the ability to implement
their statutory powers by making rules, instead of a mixture of rules and
regulations.
Provisional Proposal 2-7: The statute should require the regulators to consult
whenever issuing or varying anything which is binding, anything which sets a
benchmark or standard, and a competency. The regulators should be required to
consult such persons it considers appropriate, including:
(1) members of the public, patients and service users;
(2) registrants (including business registrants);
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(3) employers of registrants;
(4) the other health and social care professional regulators, the CHRE, the
health and social care inspectorates, the independent safeguarding authorities
and any other regulatory bodies;
(5) the Department of Health, Northern Ireland Executive, Scottish
Government and Welsh Government;
(6) professional bodies that represent registrants;
(7) persons or bodies commissioning or funding the services provided by
registrants or at a registered premises/business.
(8) Trade unions should be added to this list. Perhaps at item 6 which
could be amended to read “professional bodies and trade unions that
represent registrants”
Provisional Proposal 2-8: The formal role of the Privy Council in relation to
health and social care professional regulation should be removed entirely.
Provisional Proposal 2-9: The House of Commons Health Committee should
consider holding annual accountability hearings with the regulators which
should be co-ordinated with the CHRE’s performance reviews. The Scottish
Parliament, National Assembly for Wales and Northern Ireland Assembly should
also consider instituting similar forms of accountability.
Provisional Proposal 2-10: The Secretary of State should be given formal
powers to make decisions on matters that require a political policy decision to be
made, including matters where there is a sufficient public interest and matters
that give rise to questions about the allocation of public resources.
Provisional Proposal 2-11: The statute should place a duty on each regulator
to provide information to the public and registrants about its work.
Provisional Proposal 2-12: Each regulator and the CHRE should be required to
lay copies of their annual reports, statistical reports, strategic plans and accounts
before Parliament and also in all cases the Scottish Parliament, the National
Assembly for Wales and the Northern Ireland Assembly.
Provisional Proposal 2-13: The statute should not require the regulators to
send
a copy of their accounts to the Comptroller and Auditor General or to the
Auditor General for Scotland.
Provisional Proposal 2-14: The order making power in section 60 of the Health
Act 1999 should be repealed and instead the Government should be given
regulation-making powers on certain issues.
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Provisional Proposal 2-15: The Government should be given a regulation
making power to abolish or merge any existing regulator, or to establish a new
regulatory body. This power would also enable the Government to add new
professional groups to, or remove professional groups from, statutory regulation.
Question 2-16: Should the CHRE be given a power to recommend a profession
for statutory regulation, or the removal of a profession from statutory
regulation? If the Government decided not to comply, it would be required to
issue a report setting out its reasons.
Unite response to question 2 – 16. We believe that the CHRE should be
given the power to recommend a profession for statutory regulation, or
the removal of a profession from statutory regulation and that the
government should give its reasons should it disagree.
Provisional Proposal 2-17: The Government should be given powers to issue a
direction in circumstances where a regulator has failed to perform any of its
functions, and if the regulator fails to comply with the direction, the
Government may itself give effect to the direction (see also provisional proposal
13-2).
Provisional Proposal 2-18: The Government should be given powers to take
over a regulator which is failing to carry out its functions.
Provisional Proposal 2-19: The Government should not have express powers in
the statute to initiate a public inquiry. This would continue to be provided for
under other existing Government powers.
Provisional Proposal 2-20: If the Scotland Bill 2010 does not become law, any
use of the proposed regulation-making power set out in provisional proposal 213 in respect of a profession for which the Scottish Parliament has legislative
competence, must be consulted on by Scottish Ministers and laid before the
Scottish Parliament as well as the UK Parliament.
Question 2-21: Should the Pharmacy (Northern Ireland) Order 1976 be
reconstituted and retained as a separate part of the new statute? No
Question 2-22: Should the proposed regulation-making power set out in
provisional proposal 2-15 include a general provision to incorporate the
Pharmaceutical Society of Northern Ireland into the main legal framework of the
new statute (following approval by the Northern Ireland Assembly)? Yes.
Question 2-23: Which, if any, of the specific proposals which follow in this
consultation paper should be applied to the Pharmaceutical Society of Northern
Ireland?
Question 2-24: How should the new legal framework deal with cases left over
from the previous legal regimes? What practical difficulties are likely to arise
from the repeal of existing legislation and rules? (See above for comments on
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the registration of dance movement psychotherapists as arts therapists
within the HPC).
PART 3: MAIN DUTY AND GENERAL FUNCTIONS OF THE REGULATORS
Question 3-1: Should the statute specify the paramount duty of the regulators
and the CHRE is to: (1) protect, promote and maintain the health, safety and
wellbeing of the public by ensuring proper standards for safe and effective
practice; or (2) protect, promote and maintain the health, safety and well-being
of the public and maintain confidence in the profession, by ensuring proper
standards for safe and effective practice?
Unite response to question 3 - 1 Option (2).
Provisional Proposal 3-2: The statute should not include a statement setting
out the general or principal function(s) of the regulators.
Question 3-3: Should the statute include guiding principles which would apply
to all decisions made by the regulators, and if so what should they be?
Unite response to question 3 – 3. Yes - principles should include right
touch and to be as open and transparent to public as possible
Question 3-4: Should the statute include a general power for the regulators to
do anything which facilitates the proper discharge of their functions?
PART 4: GOVERNANCE
Question 4-1: Should the statute: (1) reform the existing structure to encourage
Councils to become more board-like; and/or (2) reform the existing structure by
establishing a statutory executive board consisting of the chief executive and
senior directors; and/or (3) establish a unitary board structure which would move
away from a two-tier approach based on a Council and officials?
Provisional Proposal 4-2: The statute should establish each Council as a body
corporate. The regulators should continue to be able to apply to become
registered with the Charity Commission if they wish to do so.
Provisional Proposal 4-3: The statute should require that each Council must be
constituted by rules issued by the regulators.
Provisional Proposal 4-4: Each regulator should be required to issue rules on
the appointment of Council members and chairs, terms of office, duration of
membership, grounds for disqualification, quorum for meetings, circumstances
in which members (including chairs) cease to hold office, are removed or are
suspended, education and training of Council members, and attendance
requirements of Council members.
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Question 4-5: Is an additional form of oversight required over the appointment
of the General Council members? For example, should the Government have
powers to remove members in certain circumstances?
Question 4-6: Should: (1) the statute specify a ceiling for the size of the
Councils of and the proportion of lay/registrant members; or (2) the Government
be required to specify in regulations the size of Councils and the proportion of
lay/registrant members; or (3) the regulators be given general powers to set the
size and composition of their Councils and the Government be given default
powers to intervene if this is necessary in the public interest?
Unite response to question 4 – 6 Option 3.
Provisional Proposal 4-7: The statute should define a lay member of the
Council as any person who is not and has not been entered in the register of
that particular regulatory body, and a registrant member as any person who is
entered in the register of that particular regulatory body.
Question 4-8: Should Council members be prohibited from concurrent
membership of another Council?
Provisional Proposal 4-9: The regulators should be given broad rule-making
powers to determine their own governance arrangements, including the ability
to establish committees if they wish to do so.
Provisional Proposal 4-10: The regulators should be able to make rules for
committees or any other internal groups it establishes, including their size and
membership.
Provisional Proposal 4-11: Each Council should be given powers to delegate
any of its functions to any Council member, officer or internal body. Any
delegations must be recorded in publicly available scheme of delegation. There
should continue to be a prohibition on delegating any power to make rules.
PART 5: REGISTERS
Provisional Proposal 5-1: The statute should set out a core duty on all the
regulators to establish and maintain a professional register.
Provisional Proposal 5-2: The regulators should have the ability but not a duty
to appoint a Registrar.
Provisional Proposal 5-3: The statute should specify which registers must be
established by the regulators, including any different parts and specialist lists.
The Government would be given a regulation-making power to add, remove or
alter the parts of the register and specialist lists.
Provisional Proposal 5-4: The Government should be given a regulationmaking power to introduce compulsory student registration in relation to any of
the regulated professions.
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Question 5-5: Should student registration be retained in the new legal
framework, and/or how can the legal framework help to ensure that the
principles and practices of professionalism are embedded in pre-registration
training?
Question 5-6: Should the regulators be given powers to introduce voluntary
registers?
Unite response to question 5 – 6 No - being registered is either a matter
of public protection or not, therefore compulsory or not required. No
need for voluntary registers (unless this is part of the preparation for a
profession to become registered).
Question 5-7: If the regulators are given powers to introduce voluntary
registers, should the CHRE be given a formal power to recommend to the
regulator in question that a group should become or cease to be voluntarily
registered? If the regulator decided not to comply, it would be required to issue
a report setting out its reasons.
Unite response to question 5 – 7 No - see above.
Question 5-8: Should non-practising registers be retained or abolished?
Provisional Proposal 5-9: The regulators will be required to register applicants
on a full, conditional or temporary basis. In addition, the regulators will be given
powers to introduce provisional registration if they wish to do so.
Provisional Proposal 5-10: The statute will provide that if the Secretary of State
advises that an emergency has occurred, a regulator can make certain temporary
changes to the register.
Provisional Proposal 5-11: The statute should specify that in order to be
registered on a full or temporary basis the applicant must be appropriately
qualified, be fit to practise, have adequate insurance or indemnity arrangements
(except for social workers), and have paid a prescribed fee. The regulators
should have broad rule-making powers to specify the precise detail under each
of these requirements.
Provisional Proposal 5-12: The regulators should be given powers to establish
separate criteria for the renewal of registration and for registrants proceeding
from provisional to full registration.
Question 5-13: Should the statute provide that in order to be registered an
applicant must demonstrate that they are a “fit and proper person” to exercise
the responsibilities of their profession?
Question 5-14: Should the legislation state that applicants are entitled to be
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registered provided that they satisfy the relevant criteria or that the regulator
must register the applicant provided that they satisfy the relevant criteria? Does
either formulation make any difference in practice?
Provisional Proposal 5-15: The statute should require the regulators to
communicate expeditiously with registrants and potential registrants. The
regulators would be given broad rule-making powers concerning the processing
of registration applications.
Provisional Proposal 5-16: The statute should require each regulator to
establish an appeals process for when registration applications are refused. The
regulators would have broad powers to decide the precise process it wants to
introduce.
Provisional Proposal 5-17: The statute should provide a right of appeal when
registration applications are refused, to the High Court in England and Wales,
the Court of Session in Scotland, and the High Court in Northern Ireland.
Provisional Proposal 5-18: The regulators should have broad powers to
establish rules concerning the upkeep and publication of the register.
Provisional Proposal 5-19: The statute should require each regulator to
establish process for dealing with fraudulently procured or incorrectly made
entries. The regulators would have broad powers to decide the precise process it
wishes to introduce.
Provisional Proposal 5-20: The statute should provide a right to appeal against
registration decisions relating to fraudulently procured or incorrectly made
entries, to the High Court in England and Wales, the Court of Session in
Scotland, and the High Court in Northern Ireland.
Provisional Proposal 5-21: The statute should provide that applications for
restoration in cases where a registrant’s entry has been erased following fitness
to practise proceedings must be referred to a Fitness to Practise Panel or similar
committee.
Provisional Proposal 5-22: The statute should provide a right to appeal against
restoration decisions by a Fitness to Practise Panel to the High Court in England
and Wales, the Court of Session in Scotland, and the High Court in Northern
Ireland.
Question 5-23: Should the statute set a consistent time period before which
applications for restoration cannot be made (in cases where a registrant’s entry
has been erased following fitness to practise proceedings), or should this matter
be left to the regulators to determine?
Provisional Proposal 5-24: The statute should require each regulator to
establish in rules a process for considering applications for restoration in cases
which are not related to fitness to practise proceedings. The regulators would be
given broad discretion to determine the precise process it wishes to adopt.
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Provisional Proposal 5-25: The regulators should have broad powers to make
rules concerning the content of the registers. The only exception to this
approach would be that set out in provisional proposal 5-27.
Question 5-26: Should the regulators be given broad powers to annotate their
registers to indicate additional qualifications or should this power be subject to
certain restrictions?
Provisional Proposal 5-27: The statute should require all current fitness to
practise sanctions to appear in the public register.
Provisional Proposal 5-28: The regulators should have discretion to include
details of undertakings, warnings and interim orders in the public register
(subject to the main duty of the regulators to protect the public by ensuring
proper standards).
Question 5-29: Should the regulators be required to publish information about
professionals who have been struck off, for at least 5 years after they have been
struck off?
Question 5-30: Should the regulators be required to include in their registers
details of all previous sanctions?
Provisional Proposal 5-31: All the existing protected titles and functions that
are contained currently in the governing legislation should be specified in the
new statute.
Provisional Proposal 5-32: Government should be given a regulation-making
power to add to or remove any of the protected titles and functions.
Question 5-33: How appropriate are the existing protected titles and functions?
Please see Unite comments in paragraph “Protection of Title” above.
Provisional Proposal 5-34: The regulators will have powers to bring
prosecutions and will be required to set out in a publicly available document
their policy on bringing prosecutions (except in Scotland).
PART 6: EDUCATION, CONDUCT AND PRACTICE
Question 6-1: Should our proposals go further in encouraging a more
streamlined and coordinated approach to regulation in the areas of education,
conduct and practice? If so, how could this be achieved?
Provisional Proposal 6-2: The statute should require the regulators to make
rules on:
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(1) which qualifications are approved qualifications for the purposes of
preregistration and post-registration qualifications;
Unite agrees.
(2) the approval of education institutions, courses, programmes and/or
environments leading to an award of approved qualifications and the
withdrawal of approval;
Unite agrees.
(3) rights of appeals to an individual or a panel against the decision of the
regulator to refuse or withdraw approval from an institution, course or
programme;
Unite agrees.
(4) the quality assurance, monitoring and review of institutions, courses,
programmes and/or environments; and
(5) the appointment of visitors and establishment of a system of inspection of
all relevant education institutions.
Provisional Proposal 6-3: The statute should require the regulators to establish
and maintain a published list of approved institutions and/or courses and
programmes, and publish information on any decisions regarding approvals.
Unite agrees.
Provisional Proposal 6-4: The statute should require education institutions to
pass on to the regulator in question information about student fitness to practise
sanctions.
Unite agrees.
Question 6-5: Should the powers of the regulators extend to matters such as a
national assessment of students?
Unite response to question 6 – 5 No we do not agree. A Code of
Conduct and Standards are sufficient in our view with newly qualified
registration applicants required to agree to meet the codes. The
inevitable increase costs of first time registration if a national assessment
of students approach was adopted also makes this an undesirable
proposal.
Guidance about educational standards needs to be by the national
regulator, though, to prevent it differing from one university/area to
another
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Also, there is a need for some formal national oversight to ensure the
professions are signed up to and contribute to decisions about what
goes into those national standards.
There used to be national boards for nursing, midwifery and health
visiting, which oversaw curriculum development and research and this
has been less satisfactory since the Boards were abolished. In medicine
this function is undertaken by the Medical Royal Colleges – whoever
does it, it needs doing and is the basis for successful regulation
Question 6-6: Should the regulators be given powers over the selection of those
entering education? No.
Question 6-7: Could our proposals go further in providing a framework for the
approval of multi-disciplinary education and training, and if so how? Yes.
Question 6-8: Is too much guidance being issued by the regulators and how
useful is the guidance in practice?
Unite response to question 6 – 8 In practice settings where staff are
working with unregistered staff for example healthcare support workers
there may be a need for more guidance.
Provisional Proposal 6-9: The statute should require the regulators to issue
guidance for professional conduct and practice.
HPC registrants responded - We would warn against removing
statements about core values, for example “act kindly”, not least due to
the public relations issues of removing them. Our experience with the
employers Code of Conduct for unregistered staff has been widely
welcomed.
Provisional Proposal 6-10: The statute should provide for two separate types
of guidance: tier one guidance which must be complied with unless there are
good reasons for not doing so, and tier two guidance which must be taken into
account and given due weight. The regulators would be required to state in the
document whether it is tier one guidance or tier two guidance.
Unite believes that tier two guidance should not be reduced to “nice to
do if we have the money”, which would mean that it would be unlikely
that it would be done
Question 6-11: How should the legal framework deal with the regulators’
responsibilities in relation to professional ethics?
Unite response to question 6 – 11 The regulator should ensure that
professional ethics are clearly signposted in the relation to protection of
the public. However the legal framework should ensure that regulators
are not solely relying on professional body guidance as membership of
a professional body is optional.
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Provisional Proposal 6-12: The statute will require the regulators to ensure
ongoing standards of conduct and practice through continuing professional
development (including the ability to make rules on revalidation).
Our AHPs recommend HPC’s approach to regulating CPD which is
Standards based and emphases application of knowledge to practice
and insists on a mixed format of continuous learning. We have found
this to be a successful way to encourage portfolio development.
PART 7: FITNESS TO PRACTISE: IMPAIRMENT
Question 7-1: Should the statute: (1) retain the existing two-stage approach for
determining impaired fitness to practise; or (2) implement the recommendations
of the Shipman report; or (3) remove the current statutory grounds which form
the basis of an impairment and introduce a new test of impaired fitness to
practise based on whether the registrant poses a risk to the public (and that
confidence in the profession has been or will be undermined)?
Question 7-2: If a list of statutory grounds of impaired fitness to practise is
retained, should it refer to a broader range of non-conviction disposals?
Question 7-3: How adequate are the powers of the regulators to require
disclosures from the Independent Safeguarding Authority and Disclosure
Scotland? What practical difficulties, if any, arise as a result of differences
between the protection of vulnerable groups schemes in England, Wales,
Northern Ireland and Scotland?
PART 8: FITNESS TO PRACTISE: INVESTIGATION
Question 8-1: Should the new legal framework remove the concept of an
allegation entirely and instead give the regulators broad powers to deal with all
information and complaints in such manner as they consider just (subject to a
requirement that cases where there are reasonable prospects of proving
impairment must be referred for fitness to practise proceedings)?
Unite believes that allegations should be based on codes of conduct and
standards and it is fair that the practitioner and the complainant should
be clear and have clear issues addressed.
Provisional Proposal 8-2: The statute should provide that all the regulators will
be able to consider any information which comes to their attention as an
allegation and not just formal complaints.
Unite feels the need for a definition of the difference between
“allegation” and “formal complaint”.
16
Provisional Proposal 8-3: The statute should contain a clear statement that
there is no set format for allegations.
Question 8-4: Should the statute prohibit the regulators from setting a time
limit for bringing an allegation against a registrant or should there be a
consistent time limit for allegations across the regulators (and if so, what should
it be)?
Provisional Proposal 8-5: All the regulators should have the power to establish
a formal process for the initial consideration of allegations (such as screeners).
Unite agrees.
Provisional Proposal 8-6: The regulators should have the power to prohibit
certain people from undertaking the initial consideration of allegations and
specify that only certain people can undertake this task.
Unite agrees.
Provisional Proposal 8-7: The regulators should have powers to establish
referral criteria for an investigation and specify cases which must be referred
directly to a Fitness to Practise Panel.
Unite agrees.
Question 8-8: Should the statute impose more consistency in relation to the
criteria used by regulators to refer cases for an investigation or the cases that
must be referred directly to a Fitness to Practise Panel?
Unite agrees.
Provisional Proposal 8-9: The statute should enable but not require the
regulators to establish an Investigation Committee.
Provisional Proposal 8-10: The regulators should be given broad rule making
powers concerning how and by whom an investigation is carried out.
Provisional Proposal 8-11: The statute should give all the regulators a general
power to require the disclosure of information where the fitness to practise of a
registrant is in question.
Unite agrees.
Question 8-12: Are the existing formulations of the power to require disclosure
of information useful and clear in practice?
Provisional Proposal 8-13: The power to require information should be
extended to include the registrant in question.
17
Question 8-14: Should any enforcement powers be attached to the power to
require information?
Provisional Proposal 8-15: The statute should provide that the test for all
referrals to a Fitness to Practise Panel across the regulators is the real prospect
test.
Provisional Proposal 8-16: The regulators should have powers to issue or
agree the following at the investigation stage: (1) warnings; (2) undertakings; (3)
voluntary erasure; and (4) advice to any person with an interest in the case.
The regulators would be given broad powers to make rules governing the use of
such powers. This would include rules governing who or which body can issue
them and the circumstances in which the powers can be agreed or imposed.
Unite agrees.
Question 8-17: Should the statute require that any decision to use any power
listed in provisional proposal 8-16 at the investigation stage must be made or
approved by a formal committee or Fitness to Practise Panel? Alternatively,
should the powers of the CHRE to refer decisions of Fitness to Practise Panels to
the High Court be extended to cover consensual disposals?
Unite agrees.
Provisional Proposal 8-18: The Government should be given a regulation
making power to add new powers to those listed in provisional proposal 8-16,
and to remove any powers.
Governments should be able to express a view.
Question 8-19: Does the language used in the proposed list of powers
contained in provisional proposal 8-16 convey accurately their purpose?
Yes.
Question 8-20: Is the use of mediation appropriate in the context of fitness to
practise procedures?
Should not mediation be used prior to reaching fitness to practise
process?
Provisional Proposal 8-21: All regulators should be given rule and regulation
making powers to introduce a system of mediation if they wish to do so.
Unite agrees.
Provisional Proposal 8-22: The statute should provide for a right to initiate a
review of an investigation decision in relation to decisions: (1) not to refer a case
for an investigation following initial consideration; (2) not to refer the case to a
18
Fitness to Practise Panel; (3) to issue a warning; or (4) to cease consideration of
a case where undertakings are agreed.
Unite agrees.
Provisional Proposal 8-23: Anyone who has an interest in the decision should
be able to initiate a review of an investigation decision, including but not limited
to the Registrar, registrant, complainant and the CHRE.
Unite agrees.
Provisional Proposal 8-24: The grounds for a review of an investigation
decision should be that new evidence has come to light which makes review
necessary for the protection of the public or the regulator has erred in its
administrative handling of the case and a review is necessary in the public
interest.
Unite agrees.
Provisional Proposal 8-25: The statute should give the regulators broad rule
making powers on all aspects of the process for the review of an investigation
decision, except those matters specified in provisional proposals 8-22, 8-23 and
8-24.
Unite agrees.
PART 9: FITNESS TO PRACTISE: ADJUDICATION
Question 9-1: Should the statute require the regulators to ensure that they
establish a structure which is compliant with Article 6 of the European
Convention on Human Rights without taking into account the role of the higher
courts?
Question 9-2: Should the new legal framework ensure the separation of
investigation and adjudication, and if so how?
Question 9-3: Should the statute allow for the option of the regulators’
adjudication systems joining the Unified Tribunals Service?
Provisional Proposal 9-4: The statute should give all the regulators a broad
power to establish rules for case management.
Unite agrees.
Provisional Proposal 9-5: The statute should provide that the overriding
objective of the Civil Procedure Rules – that cases must be dealt with justly – is
made part of the regulators’ fitness to practise procedures.
Provisional Proposal 9-6: The statute should require each regulator to establish
Fitness to Practise Panels of at least three members for the purpose of
19
adjudication.
Unite agrees.
Provisional Proposal 9-7: The statute should: (1) require the regulators to
establish a body which is responsible for all aspects of the Fitness to Practise
Panel appointment process and which is separate from the Council; and (2)
prohibit Council members and investigators from membership of Fitness to
Practise Panels; and (3) require that each Fitness to Practise Panel must have a
lay member.
Unite agrees.
Provisional Proposal 9-8: Other than on those matters specified in provisional
proposals 9-6 and 9-7, the regulators should have broad powers to make rules
on the constitution of their Fitness to Practise Panels.
Provisional Proposal 9-9: All regulators should be given broad rule-making
powers on most procedural aspects of fitness to practise hearings.
Question 9-10: Should the statute require that fitness to practise hearings must
take place in the UK country in which the registrant is situated or resides?
Provisional Proposal 9-11: The statute should apply the civil rules of evidence
to fitness to practise hearings. The relevant rules should be those that apply in
the part of the UK in which a hearing takes place.
Unite agrees.
Provisional Proposal 9-12: Fitness to Practise Panels should be able to admit
evidence which would not be admissible in court proceedings if the admission of
such evidence is fair and relevant to the case.
Unite agrees.
Provisional Proposal 9-13: The statute should require the civil standard of
proof in fitness to practise hearings.
Unite agrees.
Provisional Proposal 9-14: The statute should require that all fitness to practise
hearings must be held in public unless one or more of the exceptions in the Civil
Procedure Rules apply.
Unite agrees.
Provisional Proposal 9-15: The statute should provide that a witness is eligible
20
for assistance if under 17 at the time of the hearing if the Panel considers that
the quality of evidence given by the witness is likely to be diminished as a result
of mental disorder, significant impairment of intelligence and social functioning,
physical disability or physical disorder. In addition, a witness is should be eligible
for assistance if the Panel is satisfied that the quality of the evidence given by the
witness is likely to be diminished by reason of fear or distress in connection with
testifying in the proceedings.
Unite agrees.
Question 9-16: Should the statute provide for special measures that can be
directed by the Panel in relation to witnesses eligible for assistance, such as
screening witnesses from the accused, evidence by live link, evidence in private,
video recoded evidence, video cross examination, examination through
intermediary, and aids to communication?
Unite agrees.
Provisional Proposal 9-17: The statute should require the regulators to
establish a system for imposing and reviewing Interim Orders.
Unite agrees.
Provisional Proposal 9-18: The statute should require each regulator to
establish panels of at least three members for interim order hearings (including a
lay member). In addition, Interim Order panels must be appointed by a body
which is separate to the Council and there would be a prohibition of Council
members and investigators from sitting on such Panels.
Unite agrees.
Question 9-19: Should the statute prohibit Interim Order Panellists sitting on a
Fitness to Practise Panel (either in relation to the same case or more generally)?
Unite agrees.
Provisional Proposal 9-20: The test for imposing an Interim Order should be
that it is necessary to protect, promote and maintain the health, safety and well
being of the public (and maintain confidence in the profession).
Unite agrees.
Provisional Proposal 9-21: On all procedural matters in relation to Interim
Order hearings (except for those specified in provisional proposal 9-18) the
regulators should have broad rule-making powers.
Question 9-22: Should the statute guarantee the right of registrants to give
evidence at Interim Order hearings?
21
Provisional Proposal 9-23: The right of appeal against an Interim Order should
continue to be to the High Court in England and Wales, the Court of Session in
Scotland and the High Court in Northern Ireland.
Provisional Proposal 9-24: All Fitness to Practise Panels should have powers to
impose the following: (1) erasure from the register; (2) suspension; (3)
conditions; and (4) warnings.
Unite agrees.
Provisional proposal 9-25: The Government should be given a regulation
making power to introduce systems of financial penalties and cost awards.
We would require clarification on this proposal!
Provisional Proposal 9-26: All Fitness to Practise Panels should have powers to
agree undertakings and voluntary erasure.
Unite agrees.
Provisional Proposal 9-27: The regulators should have powers to introduce
immediate orders (or use Interim Orders for this purpose).
Unite agrees.
Provisional Proposal 9-28: The test for imposing any of the sanctions listed in
provisional proposal 9-24 and consensual disposals in 9-26 should be to protect,
promote and maintain the health, safety and well-being of the public (and
maintain confidence in the profession).
Unite agrees.
Provisional Proposal 9-29: The regulators should be given broad powers to
make rules in relation to the sanctions listed in provisional proposal 9-24 and
consensual disposals in provisional proposal 9-26.
Unite agrees.
Provisional Proposal 9-30: The Government should be given a regulation
making power to add new sanctions and consensual disposals to those listed in
provisional proposals 9-24 and 9-26, and to remove any sanctions and
consensual disposals.
Recommendation only.
Question 9-31: Does the language used in the proposed list of sanctions and
consensual disposals contained in provisional proposals 9-24 and 9-26 convey
accurately their purpose?
22
Unite agrees.
Provisional Proposal 9-32: The statute should require all the regulators to
establish a system of review hearings for conditions of practise and suspension
orders. In addition, the regulators should have powers but would not be
required to establish review hearings for warnings and undertakings.
Provisional Proposal 9-33: The regulators should have broad rule-making
powers to establish the procedures for review hearings.
Question 9-34: Should the regulators be given an express power to quash or
review the decision of a Fitness to Practise Panel where the regulator and the
relevant parties agree that the decision was unlawful? If so, should complainants
and other interested parties be able to prevent or contribute to any decision to
use this power?
To review only!
Provisional Proposal 9-35: All professionals should continue to have a right of
appeal against the decision of a Fitness to Practise Panel to the High Court in
England and Wales, the Court of Session in Scotland and the High Court in
Northern Ireland.
Unite agrees.
PART 10: THE COUNCIL FOR HEALTHCARE REGULATORY EXCELLENCE
Question 10-1: How effective is the CHRE in performing the role of scrutinising
and overseeing the work of the regulators?
Unite response to question 10 – 1 CHRE annual reports on the
regulators are comprehensive and helpful but unfortunately sometimes
ignored. There needs to be a requirement for regulators to adopt best
practice.
Provisional Proposal 10-2: The current powers and roles of the CHRE
(including those introduced by the Health and Social Care Bill 2011) should be
maintained in as far as possible.
Unite agrees.
Provisional Proposal 10-3: Appointments to the CHRE’s General Council
should be made by the Government and by the devolved administrations.
Appointments would be made in accordance with the standards for
appointments to the health and social care regulators made by the CHRE.
23
Unite agrees.
Provisional Proposal 10-4: The CHRE’s general functions should be retained,
but modernised and reworded where appropriate.
Unite agrees.
Question 10-5: Is the CHRE’s power to give directions still necessary?
Unite response to question 10 – 5 Yes.
Provisional Proposal 10-6: The existing power for Government to make
regulations for the investigation by the CHRE into complaints made to it about
the way in which a regulator has exercised its functions should be retained.
Unite agrees.
Question 10-7: Should the CHRE’s power to refer cases to the High Court in
England and Wales, the Court of Session in Scotland and the High Court in
Northern Ireland: (1) be retained and exercised alongside a regulator’s right of
appeal, in cases when the regulator’s adjudication procedure is considered to be
sufficiently independent; or (2) be removed when a regulator’s right of appeal is
granted in such circumstances; or (3) be retained and rights of appeal should not
be granted to regulators, although regulators should have a power to formally
request the CHRE to exercise its power?
Unite response to question 10 – 7 Option 1.
PART 11: BUSINESS REGULATION
Question 11-1: To what extent does regulation in a commercial context make a
difference to how the regulators approach the task of professional regulation
and does the law provide adequately for professional regulation in a commercial
context?
Provisional Proposal 11-2: The statute should retain the existing premises
regulation regimes of both the General Pharmaceutical Council and the
Pharmaceutical Society of Northern Ireland.
Question 11-3: Are any further reforms needed to the premises regulation
regimes of the General Pharmaceutical Council and the Pharmaceutical Society
of Northern Ireland?
Question 11-4: Should the statute retain the existing systems for the regulation
of bodies corporate?
Question 11-5: Should the regulators have powers to finance or establish a
complaints service?
24
Provisional Proposal 11-6: The Government should be given a regulation
making power to extend to any regulator the powers given to the General
Pharmaceutical Council or the General Optical Council to regulate businesses.
PART 12: OVERLAP ISSUES
Question 12-1: How could the legal framework establish clearer interfaces
between the various regulatory systems?
Question 12-2: What practical difficulties arise as a result of parallel criminal
and fitness to practise proceedings?
Employers and regulators should retain their own integrity and act as
necessary in these circumstances.
Question 12-3: What are the practical and legal difficulties associated with joint
working?
Professional body or trade union might not be able to support a
members who is under criminal investigation.
Provisional Proposal 12-4: The statute should include a permissive statement
to the effect that each regulator may carry out any of its functions in partnership
with another organisation.
Unite agrees.
Provisional Proposal 12-5: The statute should enable formal partnership
arrangements to be entered into between any regulator and one or more other
organisations (including the other professional regulators) in relation to the
exercise of their statutory functions. The statute should provide that any such
arrangements do not affect the liability of the regulator for the exercise of any of
its statutory functions.
Provisional Proposal 12-6: The statute should impose a general duty on each
regulator to make arrangements to promote cooperation with other relevant
organisations or other persons, including those concerned with the:
(1) employment of registrants;
(2) education and training of registrants;
(3) regulation of other health or social care professionals;
(4) regulation of health or social care services; and
(5) provision/supervision/management of health or social care services.
Unite agrees.
25
Question 12-7: Should the statute specify or give examples of the types of
arrangements that could be made under provisional proposal 12-6?
Unite agrees.
Provisional Proposal 12-8: The statute should impose a specific duty to
Co-operate, which would apply when the regulator in question is:
(1) considering registration applications and renewals;
(2) undertaking the approval of education and training;
(3) ensuring proper standards of practice and conduct; and
(4) undertaking an investigation into a registrant’s fitness to practise.
This duty would apply to the same list of organisations and persons contained in
provisional proposal 12-6. The requested authority would be required to give
due consideration to any such request made by the regulator, and if it refuses to
co-operate, must give written reasons.
Unite agrees.
Question 12-9: Are there any other circumstances in which the specific duty to
co-operate contained in provisional proposal 12-8 should apply?
This evidence was submitted on behalf of Unite the Union by;
Rachael Maskell
Unite the Union,
National Officer
For further information, please contact:
Obi Amadi
Lead Professional Officer, Unite the Union
[email protected]
Unite House, 128 Theobald's Road, Holborn, London, WC1X 8TN
26
29th May 2012
Tim Spencer-Lane
Law Commission
Steel House,
11 Tothill Street
London SW1H 9LJ
[email protected]
27
PROFESSIONAL
BRIEFING:
Unite
CPHVA
128 Theobald's Road
Holborn
London WC1X 8TN
Tel: 020 7611 2500
www.unitetheunion.org
(JN3099) HB160810
PUBLIC SAFETY AND STATUTORY
REGULATION OF HEALTH VISITORS
Unite/CPHVA Unite Health Sector: 2010
FOREWORD
The Community Practitioners’ and Health Visitors’ Association
(CPHVA) is a professional association in the 100,000 strong
health sector of the Union Unite. It represents health visitors
and registered nurses who are employed in primary and
community health settings. The organisation’s National
Professional Committee (NPC) is made up of representative
health visitors, school nurses and other community and
public health nurses and practitioners.
PROFESSIONAL BRIEFING:
PUBLIC SAFETY AND STATUTORY REGULATION
OF HEALTH VISITORS
Published by Unite the Union/CPHVA
Joint General Secretaries Derek Simpson and Tony Woodley
Unite Health Sector
128 Theobald's Road
Holborn
London WC1X 8TN
020 7611 2500
This professional briefing is downloadable in PDF format from
www.unitetheunion.org/health
2
CPHVA members are represented at local, regional and
country levels through a committee structure which feeds into
the NPC. Through this mechanism, amongst others, members
working on the front line ensure that their professional
concerns and experiences are discussed and addressed.
The NPC also holds an annual professional forum at its
conference where members can discuss important
professional issues. Over recent years these feedback
structures and the annual omnibus telephone survey of
1000 members have alerted the committee to the many
professional concerns which have arisen since the health
visiting profession was taken out of statute in 2001 and its
register closed in 2004.
The CPHVA firmly believes that it was this removal of health
visiting from legislation that was the catalyst for the situation
in which the profession now finds itself. There are now
depleted numbers of health visitors, diminished recruitment,
caseloads stretched way beyond safe boundaries and the
resulting inevitable risks to the health and wellbeing of very
young children.
3
Professor Sarah Cowley kindly agreed to prepare this
important paper in response to a request from myself as
Chair of the National Professional Committee of the
Community Practitioners’ and Health Visitors’ Association.
This paper provides the evidence as to how, and why, public
safety has been compromised by the removal of health
visiting from statute.
We hope that the Nursing & Midwifery Council (NMC), other
professional colleagues and policy makers will give this
document the close scrutiny it deserves. Furthermore, we
hope they will agree that in order to protect children and
their families at such a vulnerable time in their life cycle, it is
essential to return the health visiting profession to statute
and re-open the health visitor register.
Angela Roberts FHEA MA
Chair National Professional Committee
UNITE/CPHVA
SUMMARY
1. Introduction
1.1
It is the contention of Unite/Community Practitioners’
and Health Visitors’ Association (CPHVA) that public safety
has been compromised by changes in the statute governing
health visitor regulation, enacted in the Nursing and Midwifery
Order 2001. The Nursing & Midwifery Council are asked to
explore how the anomalous position of health visiting as a
profession, currently existing outside statute, can be
regularised.
1.2
Public protection is the primary concern and purpose
of statutory regulation, but the line between professional
regulation and client safety and vulnerability is complex and
indirect. The relationship between professional and client, in
most instances, is mediated through large organisations, such
as the NHS, who are responsible for providing services. Even
so, the ‘vulnerable public’ who need services at a time of
relative weakness, disadvantage or uncertainty should be able
to depend upon the suitability of those professionals with
whom they are in contact.
2. Occupations and professionalisation: the case of
health visiting
2.1
Key markers distinguish an established profession
from a single role or function, and health visiting is an
established profession. Removing health visiting from statute,
and the associated closure of the dedicated register in 2004,
implied that health visiting is no longer valued as a distinct
profession and qualification.
4
5
2.2
Removing health visitors’ professional qualification
from statute called it into question and delegitimised it. This
affected views about the service delivered by health visitors,
setting the scene for a steep and devastating decline in the
workforce, which has yet to be halted. The staff shortages, in
turn, have led to a range of adverse decisions and omissions
that cause a major risk to the public.
3. Do we need health visiting?
3.1
Safe and effective health visiting services are
required to deal with increasing health and social need. This
is recognised in policy and across the political spectrum, but
removing health visiting from the framework of statutory
regulation has created much confusion for service users,
commissioners, employers and practitioners.
3.2
Ambiguity and uncertainty about the meaning and
existence of a health visiting qualification, whether it is
needed and when, has led to a number of employers and
commissioners making very risky choices in staff deployment,
often using personnel with insufficiently developed skills.
3.3
Confusion about the regulatory status and need for
a health visiting qualification has led to unsafe lines of
accountability and unclear decision trails in many organisations.
The substitution of personnel with different skills to those of
a fully qualified health visitor, and who may be inappropriately
confident, creates a considerable risk. This practice differs
from standard, safe skill mix or teamwork, but it has
proliferated since health visiting was removed from statute.
4. Is health visiting recognised as a health profession,
or should it be?
4.1.
Specific criteria were established in 2001 by which
aspiring health professions that need statutory regulation
6
could be recognised. Health visiting meets these criteria, yet
was removed from the framework of statutory regulation in
the same year. This perverse decision has left the public at risk
from a range of problems arising from the current regulatory
arrangements.
4.2.
The NMC has no legal mechanism for dealing with
professional difference, which perhaps leads them to overstate
the degree of similarity between nursing and health visiting,
and to obscure, or even negate, the extent and distinctiveness
of health visiting knowledge. In turn, this poses a risk to the
public, because it encourages the substitution of registered
nurses, who are qualified to work in a different way, for
health visitors.
4.3.
There is a lack of transparency in the regulatory system,
so any member of the public wishing to lodge a complaint
about a health visitor would be hard pressed to identify a
regulatory body responsible for the profession.
5. Is the health visiting profession regulated?
5.1.
Despite being included in the Specialist Community
Public Health Nursing (SCPHN) part of the NMC register, the
health visiting profession is not regulated as such, nor in a
manner that can protect the public. Current arrangements are
unsatisfactory because of the format of the third part of the
NMC register, its lack of specificity for health visiting and the
absence of protection for health visitors’ professional title.
5.2.
There is no official mechanism for ensuring that
standards of preparation are appropriate for health visiting,
leading to doubts about the suitability of official programmes,
and fitness for practice of new registrants. In turn, this is
leading to the development of a range of ad hoc and
unregulated mechanisms for training.
7
5.3.
Arrangements for revalidation and continued
registration are confusing and convoluted, undermining the
health visiting qualification and encouraging registrants to
claim proficiency in the different fields of nursing and
midwifery, regardless of their self-assessed competence.
6. Conclusion
6.1
Removing the health visiting qualification from
statute is identified as the root cause of the downturn in
health visiting numbers, of preparation and recruitment
difficulties, and of the numerous adverse and risky decisions
made by commissioners and service managers.
CONTENTS
1. INTRODUCTION
13
1.1. Key points
16
2. OCCUPATIONS AND PROFESSIONALISATION:
THE CASE OF HEALTH VISITING
17
2.1. Development of a profession
17
2.2. Hallmarks of a profession
17
2.3. Statutory regulation and the legitimacy of a profession 19
6.2
Deregulation of health visiting has encouraged an
atmosphere of disrespect and devaluing of the profession,
without regard for research evidence, or for the effect of such
attitudes on service provision for the infants, children and
families left with inadequate or inappropriate support as
a result.
Example 1: Service users ‘Left fending for themselves’
21
Example 2: Recruitment
22
2.4. Naming a profession
22
2.5. Summary
24
2.6. Key points
24
6.3
It is the belief of Unite/CPHVA and many others
that the situation for practice and for service users will only
improve when health visiting is able to resume its rightful
place as a fully regulated health profession, with a
qualification recognised in statute.
3. DO WE NEED HEALTH VISITING?
25
3.1. Health and social need
25
3.2. Need for health visiting in current policy
29
3.3. Need to name an occupational group
30
3.3.1. Skill-set
30
Example 3: Dilute skill-mix: practitioners’ perspectives
31
Example 4: Inappropriate confidence
32
3.3.2. Clarity and accountability
33
Example 5. Health visiting by numbers: protocols
35
Example 6: Who is visiting?
36
3.3.3. Organisational convenience
38
3.4. Summary
38
3.5. Key points
39
8
9
4. IS HEALTH VISITING RECOGNISED AS A HEALTH
PROFESSION, OR SHOULD IT BE?
40
Table 1: Use of professional titles
55
4.1. Health visiting covers a discrete area of activity
displaying some homogeneity
41
5.2. Standards of proficiency
56
Example 9: Official preparation programmes are
not always sufficient
57
4.2. Health visiting applies a defined body of knowledge
44
5.3. Revalidation
58
4.3. Health visiting practice is based on evidence of efficacy 45
5.4. Summary
59
4.4. Health visiting has at least one established professional 46
body, which accounts for a significant proportion of that
occupational group
5.5. Key points
60
6. CONCLUSION
61
4.5. Health visiting has operated a voluntary and a
statutory register
46
6.1. Key points
62
63
4.6. Health visiting has a defined route of entry to
the profession
47
APPENDIX 1: PREPARATION AND REGULATION
OF HEALTH VISITING
66
4.7. Health visiting has an independently assessed
entry qualification
48
APPENDIX 2: TREATING HEALTH VISITING AS A
POST-REGISTRATION NURSING QUALIFICATION
EXACERBATES RECRUITMENT DIFFICULTIES
4.8. Health visiting has standards of conduct,
performance and ethics
48
Issues concerned with nursing careers
66
Issues related to finance
67
4.9. Health visiting has disciplinary procedures to
enforce those standards
48
Issues related to a lack of health visiting voice
67
Issues related to the restricted entry gate
68
Example 7: Brief internet search for register or
regulation of nurses, midwives and health visitors
49
APPENDIX 3: A DISCRETE AREA OF PRACTICE
WITH SOME HOMOGENEITY
68
68
4.10. Health visiting is committed to continuous
professional development (CPD)
49
1. Prime Research and Development Review
70
2. Assessment of health visiting practice
70
4.11. Summary
49
3. Nursing and health visiting practice in public health
70
4.12. Key points
50
Figure A3.1:
Polarised concepts and priorities in public health
70
5. IS THE HEALTH VISITING PROFESSION REGULATED? 51
5.1. The form of professional register
52
4. The principles of health visiting
71
5.1.1. Specificity of the register
52
5. What characterises an effective health visitor?
72
5.1.2. Statutory title
53
ACKNOWLEDGEMENTS
72
Example 8: Bogus health visitor
54
REFERENCES
73
10
11
1. INTRODUCTION
It is the contention of Unite/Community Practitioners’ and
Health Visitors’ Association (CPHVA) that public safety has
been compromised by changes in the statute governing
health visitor regulation, enacted in the Nursing and Midwifery
Order 2001. This paper builds on an earlier one1, explaining in
detail the reason for this concern. The Nursing & Midwifery
Council is asked to explore how the anomalous position of
health visiting as a profession, currently existing outside
statute, can be regularised.
Statutory regulation began long before the National Health
Service and the existence of large employing organisations for
delivering professional services, so its purpose was relatively
simple and clear. If a person posted a plaque on their door
announcing themselves as qualified to work as a professional,
such as a doctor, lawyer or midwife, the ‘vulnerable public’
needed to be assured that the person claiming such skills
would, indeed, have a suitable, peer approved qualification,
and would also practise within an ethical framework that
stopped them from taking advantage of the clients who
needed their services at a time of relative weakness or
uncertainty. Public protection continues to be the primary
concern and purpose of statutory regulation. In today’s far
more complex world, there is rarely a direct linear relationship
between professional and client, in that most services are
delivered through large organisations, such as the NHS.
Likewise, the line between professional regulation and
client safety and vulnerability is complex and indirect.
This paper aims to unravel this complexity and justify the
contention that public safety is being compromised by current
arrangements for regulating health visitors. It builds the
12
13
argument through the next four sections, which explain the
regulatory situation for health visiting and the attendant risk
to the public.
After this introductory section, Section 2 relates health visiting
to our understanding of occupations and professionalisation
in the modern world, identifying key markers that distinguish
an established profession from a single role or function. It
explains our basic claim, that removing health visiting from
statute in 2001, and the associated closure of the dedicated
register in 2004, implied that health visiting is no longer
valued as a distinct profession and qualification. This affected
views about the service delivered by health visitors, setting the
scene for a steep and devastating decline in the workforce,
which has not yet been halted. The staff shortages, in turn,
lead to a range of adverse decisions and omissions that cause
a major risk to the public.
Section 3 refutes the idea that health visiting is no longer
required, detailing the increasing extent of health and social
need. This need is recognised in policy across the political
spectrum, but removing health visiting from the framework of
statutory regulation has created much confusion. Ambiguity
and uncertainty about the meaning and existence of a health
visiting qualification, whether it is needed and when, has led
to some very risky decisions being taken by employers and
commissioners, as well as a lack of clarity in decision trails and
forms of accountability in practice.
Section 4 picks up the question of whether health visiting is,
or should be, recognised as a health profession, as opposed
to a single role or a post-registration nursing qualification.
The perversity of the decision to remove health visiting from
statute in 2001 is shown by examining criteria for recognising
whether or not an occupational group should be regulated as
14
a health profession, which were established in the same year.
This examination shows clearly that health visiting should be
regulated as a health profession. Furthermore, of direct
relevance to the points being made in this paper, it uncovers
specific risks and problems arising from the current
regulatory arrangements.
Section 5 confronts the key question of whether or not the
health visiting profession is currently regulated, and concludes
that it is not. Health visitors are included in the Specialist
Community Public Health Nursing part of the NMC register,
but this is unsatisfactory because of its format, its lack of
specificity for health visiting and the absence of protection
for health visitors’ professional title. There is no official
mechanism for ensuring the standards of preparation are
appropriate for health visiting, leading to doubts about the
fitness for practice of new registrants. Arrangements for
revalidation and continued registration are confusing and
convoluted, undermining the health visiting qualification
and encouraging registrants to claim proficiency in the
different fields of nursing and midwifery, regardless of their
self-assessed competence.
Finally, the concluding section summarises the key points,
which illustrate harm to the public, stemming from the lack of
statutory regulation. It identifies removal of the health visiting
qualification from statute as the root cause of the downturn
in health visiting numbers, of preparation and recruitment
difficulties, and of a series of adverse and risky decisions made
by commissioners and service managers.
Deregulation of health visiting encouraged an atmosphere of
disrespect and devaluing of the profession, without regard for
the evidence or for the effect of such attitudes on service
provision for the infants, children and families left with
15
inadequate or inappropriate support as a result. The situation
will only improve when health visiting is able to resume its
rightful place as a fully regulated health profession, with a
qualification recognised in statute.
1.1. Key points
•
It is the contention of Unite/CPHVA that public safety
has been compromised by changes in the statute governing
health visitor regulation, enacted in the Nursing and Midwifery
Order 2001. The Nursing & Midwifery Council is asked to
explore how the anomalous position of health visiting as
a profession, currently existing outside statute, can be
regularised.
•
Public protection is the primary concern and purpose
of statutory regulation, but the line between professional
regulation and client safety and vulnerability is complex and
indirect. The relationship between professional and client, in
most instances, is mediated through large organisations, such
as the NHS, who are responsible for providing services. Even
so, the ‘vulnerable public’ who need services at a time of
relative weakness or uncertainty should be able to depend
upon the suitability of those professionals with whom they
are in contact.
2. OCCUPATIONS AND
PROFESSIONALISATION: THE CASE
OF HEALTH VISITING
2.1. Development of a profession
Statutory regulation usually occurs late in the development
of a profession. Occupational groups begin because there
is a need for a particular skill or service, only becoming
professionalised over a period of some years, even decades,
if the need persists. An occupation becomes professionalised
if their provision is shown to be effective, successful,
acceptable and cohesive over a lengthy period, with an
accompanying need for the high level of education generally
regarded as necessary for professions, and for an ethical code
of practice to protect clients from misconduct.
Health visiting began in the second half of the nineteenth
century, because of a perceived need for support and health
education for families living in impoverished conditions2.
It was part of the Victorian public health movement, being a
voluntary sector response to a belief that the prevalent
engineering solutions to squalor and disease would not
succeed without a commensurate focus upon the home and
family. Current evidence increasingly supports the view that
home visiting3,4, and early interventions that include support
for parenting and family life5, are essential components in
combating health inequalities6 and many modern-day public
health concerns, such as obesity7, interpersonal violence8,9,10
and mental health problems4,11.
2.2. Hallmarks of a profession
Longevity and flexibility are hallmarks of a profession,
established beyond the requirements of a single role or
16
17
function, which are more short term. Their baseline education
equips professionals to practise across a range of activities,
changing as required, perhaps with some additional
on-the-job training, to meet emerging needs and expectations
from the public and in policy. As an example, devolution has
created a situation in which each of the four parts of the UK
use health visitors in slightly different ways12, albeit with
discernibly similar themes and purposes13, and there were
major shifts in expectations even within countries during the
Labour administration from 1997-2010. English health visitors
were initially expected to focus on supporting families14,
which shifted to community-based activities (called ‘public
health’ at the time)15,16, then to emphasise intensive home
visiting17, then to combine18 leading teams to deliver the Healthy
Child Programme19 with a focus on safeguarding children20.
All these changes occurred within little more than a decade.
It would clearly be impractical to deliver full on-the-job
training for each role as policy shifted in such a short time
frame, but as fully qualified professionals, health visitors are
able to incorporate new expectations into their established
work patterns. These forms of practice include health visiting
delivered through traditional home visiting and centre-based
activities21, but also using modern approaches such as
telephone and web-based provision22,23. Although the NHS is
the main employer of health visitors, some of them work in
local government (particularly in Sure Start Children’s Centres),
others the third sector and, increasingly, in private practice23,24,25.
The need for a high (professional) level of knowledge and
skill to both co-ordinate and deliver the forms of practice and
service provided by a health visitor is widely recognised, with
a minimum of a degree, and increasingly, Masters level
preparation being considered necessary26,27. Indeed the need
for a professional (now often referred to as ‘specialist’) level of
18
education to cope with the complexities involved in this form
of activity was first established more than a century ago. In
1891, Florence Nightingale famously wrote in support of the
first known programme of education, commenting that ‘It
seems hardly necessary to contrast sick nursing with this
[health visiting]. The needs of home health require different
but not lower qualifications and are more varied. She [the
health visitor] must create a new work and a new profession
for women’28.
2.3. Statutory regulation and the legitimacy
of a profession
In 1919, some 50 years after the first health visitors were
employed, the Ministry of Health established a national set of
standards for their preparation, which is often regarded as the
point at which the qualification was established in statute29.
So, health visiting was very well established by the time the
Local Government Act 192930 formally legitimised the
qualification through a linked statutory instrument. The
profession continued to be regulated through a series of
different regulatory bodies and laws (see Appendix 1), until
the Nursing and Midwifery Order 2001 was passed through
secondary legislation linked to the Health Act 199931. This
new regulation removed the terms ‘health visitor’ and ‘health
visiting’ from statute, so they ceased to have any official
(i.e. legal) status. It formally de-legitimised the health visiting
qualification and removed statutory regulation of the
profession, with existing health visitors being officially
relabelled as specialist community public health nurses
(SCPHNs) when their former register was closed in 2004.
At that point, the newly developed requirements for
pre-registration health visiting programmes32 were
discontinued, and generic community public health
proficiencies33 were introduced, through which future health
visitors would be educated; these remain in place now.
19
A different profession became regulated through statute for
the first time at the end of the twentieth century, which
illustrates the slow and indirect impact on the progress of a
profession, and on availability of services. The Osteopaths Act
199334 led to a new General Osteopathic Council, established
in 1999. It is highly unlikely that any service users will have
noticed any immediate difference in their treatments at that
time. However, legitimising the profession paved the way for
osteopaths to be employed or commissioned by the NHS,
which had previously been very rare. Their form of practice
was included for the first time in a NICE clinical guideline35
in 2009, which is likely to extend availability further.
We contend that a similar, but reverse, impact has adversely
affected health visiting services and professional progress
since it was removed from statute. As noted, when the
Nursing and Midwifery Order was passed in 2001, the terms
‘health visitor’ and ‘health visiting’ were removed from all the
laws in which they formerly appeared, and the dedicated
register was closed in 2004. Again, it is unlikely that service
users will have noticed any immediate impact, although one
soon became apparent, as the services delivered by health
visitors began to be reduced. Within five years, the number
of health visitors employed by the NHS in England had fallen
by 16.5%, from 10,137 whole time equivalents (WTE) in
September 2004, to 8519 WTE in September 200936. In some
areas, the fall in workforce numbers has been far greater,
with qualified health visitor vacancies averaging 8% and up
to 45% in some areas37. Service users soon began to register
an increasing uncertainty about the skills of those delivering
health visiting provision38,39 and a noticeable rise in difficulties
accessing a reliable service40 (see Example 1). In Wales and
Northern Ireland41, robust measures have been taken to
ensure the workforce is maintained, but in Scotland a similar
large eduction in the number of health visitors has been
blamed for an increase in children’s mental health problems42.
20
Example 1: Service users ‘Left fending for themselves’
Netmums survey of 6000 mums40 found:
o 60% of new mums didn’t see enough of their health
visitor in the first year
o 46% saw their health visitor only once or twice in the
vital first two months
o 70% were not contacted at all by their health visitor
after the first two months
Selection from the 1300 comments
Comment 15: After an initial home assessment that placed us
at 'low risk' my only way of contacting the health visitor was
at a weekly GP drop in afternoon where you had to turn up
and wait to be seen. This was completely unsatisfactory as my
baby was quite difficult and hence sitting in a stuffy GP surgery
for 3 hours was not easy. They would often arrive late as they
had been dealing with a problem elsewhere, and sometimes
the clinic would not happen with no back up provided.
Comment 65. I have had no contact from a health visitor
unless I go to get my baby weighed and ask to speak to
someone...there is no privacy at these sessions and health
visitors are trying to see lots of people that you have to
rush/only deal with the priorities!! Not a great service.
Comment 112. My health visitor for my first child was great. I
trusted and valued her opinion, she was available both at my
GP's surgery and my local maternity clinic, and she visited me
at home often enough in the first few weeks to allow me to
get to know and like her. When I had my second child two
years later, I couldn't believe how the service in my area had
declined. My old health visitor was no longer there, and I
don't remember being visited at home by anyone on the HV
team. I rarely went to the weigh-in clinic as it was no longer
done individually in a separate room where you could talk in
private, but done by a team of two in what had been the
waiting room. When I phoned to book my baby's 8-month
check (letter inviting me for this didn't even arrive ‘til baby
was 10 months old...) it took ages for the receptionist to even
find a HV available to put a meeting in her diary. I never saw
the same HV twice.
21
As the service has become increasingly stretched, so the
reputation of health visiting as an attractive career has been
challenged, leading to difficulties in recruiting to vacant posts
(see Example 2). The calibre of potential students is often
unsuitable, and recruitment to training posts is further
exacerbated by a reduction in funding and associated
reduction in newly qualified health visitors. Many of the
difficulties in student recruitment and arrangements for
education have been attributed to the way the health
visiting is treated for regulatory purposes as a
‘post-registration nursing’ qualification43, as explained
in Appendix 2.
Example 2: Recruitment
Health visitors:
It is common to receive no response at all to advertised posts,
which subsequently remain vacant. An increasing number of
Trusts offer recruitment and retention incentives of up to
£1500.
Student health visitors:
Response to standard recruitments advertisements is often
initially high, but the number of suitable applicants is low:
e.g., there were 100 applicants to one university advertising
six funded places, but only four were deemed suitable by the
joint (NHS and university) panel. The two remaining places
were not filled.
2.4. Naming a profession
There was a sudden drop in reference to the profession in
policy and presentations by civil servants and ministers
immediately after the register was closed in 2004, which
helped to fuel the inaccurate impression that health visiting
was no longer supported as a form of service provision.
22
Although this tendency has largely reversed, the resulting
reduction in the health visiting workforce, and in the numbers
of students preparing for the new (SCPHN) qualification, has
persisted. The terms health visitor and health visiting continue
to be in common use, becoming once more the title of choice
in recent government policy documents despite having no
legal standing. This may be because another marker for an
established profession lies in use of its title in everyday
language. Services and forms of practice are often associated
with the professionals delivering them; physiotherapists
practise physiotherapy, nurses practise nursing, midwives
practise midwifery, and so on. Likewise, health visitors
practise health visiting, and deliver a health visiting service.
The use of a professional label to describe services was
officially discouraged through the ‘Next Stage Review’44
process and ‘Transforming Community Services’45,46 with
health visiting being given as one specific example of a service
that should not be commissioned using the name of the
profession47,48. However, consumers prefer to use the term
with which they are familiar40, and there is evidence to
suggest that no acceptable, alternative label has yet been
identified to replace the term ‘health visiting service49.’
Health visitors deliver the public health part of provision for
children, and provide a child, family and community focus for
public health services. The lack of a statutory label for health
visitors adds to the confusion for policy makers, employers,
practitioners and service users alike, and suggests there is no
legitimate place for their practice. It is now extremely difficult
to access clear, unequivocal information about the education,
skill-set and regulation of this occupational group. This point,
and the impact of the lack of full statutory regulation of
health visitors, is picked up in the following sections.
23
2.5. Summary
New occupations develop often in response to a short-term
demand, but professions take far longer to become
established. Health visiting developed gradually over the
second half of the nineteenth century, and shows all the
hallmarks of an established profession. It is flexible, being able
to respond to changing needs, and requires a high (specialist)
level of education and practice. The first statutory qualification
was agreed early in the twentieth century, and the Local
Government Act 1929 confirmed health visiting as a
profession to be regulated in statute.
In 2001, the Nursing and Midwifery Order reversed this
position. Health visiting ceased to be recognised as a
profession in statute and the dedicated register was closed
in 2004. This implied that the health visiting service was no
longer valued and the qualification no longer legitimate or
required, as shown by the steep decline in the workforce.
There were 16.5% fewer health visitors employed in 2009
than five years earlier, which has led to a significant fall in the
safety of services and difficulties recruiting. This has been
exacerbated by a reduction in educational places and the
number of newly qualified health visitors, which has been
attributed to the way the NMC treat health visiting as a
post-registration nursing qualification. Employers, service
users and practitioners are confused by the lack of clarity
surrounding the qualification and its title.
2.6. Key points
•
Key markers distinguish an established profession
from a single role or function, and health visiting is an
established profession. Removing health visiting from statute,
and the associated closure of the dedicated register in 2004,
implied that health visiting is no longer valued as a distinct
profession and qualification.
24
•
Health visitors’ professional qualification was called in
question and delegitimised when it was removed from statute.
This affected views about the service delivered by health
visitors, setting the scene for a steep and devastating decline
in the workforce, which has not yet been halted. The staff
shortages, in turn, have led to a range of adverse decisions
and omissions that cause a major risk to the public.
3. DO WE NEED HEALTH VISITING?
The question of whether we need health visiting is important
because professions do not exist for their own sake, but only
because there is a health or social need for their service.
Recognition and naming in policy occur later in the
development of professions.
3.1. Health and social need
We recognise that the NMC has no direct responsibility for
maintaining staff numbers, but it is expected to work with
employers, who are required to ensure that their workforce
has the necessary skill-set to deliver services that are needed.
Also, we contend that removing the statutory regulation of
health visiting as a profession created an impression that there
is no longer a need for this form of practice and service. The
ensuing staff shortages, in themselves, have put the public at
risk because of an absence of provision for many, and because,
all too often, inappropriately prepared staff are used as
substitutes for qualified health visitors. This is explored
further under Section 3.3.
25
In contrast to the inaccurate impression that health visiting is
no longer needed, current public health and social needs are
such that, if health visiting did not exist already, it would be
necessary to invent it. This is indicated in a range of policy
documents and eminent inquiries. The Independent Inquiry
into Health Inequalities in 1998 identified the importance of
supporting parents (especially mothers) and babies, specifying
that the health visitor role should be strengthened to achieve
this50. A decade later, the updated, independent Marmot
Review on health inequalities6 pointed out that:
‘A key challenge is the recruitment of appropriately
skilled and qualified staff in the context of critical
shortages of some professionals, such as health
visitors.’ (page 97)
A Parliamentary Health Committee Inquiry into health
inequalities51 also identified the need for health visiting-type
of services, stating:
‘We have been told repeatedly that the early years
offer a crucial opportunity to ‘nip in the bud’ health
inequalities that will otherwise become entrenched
and last a lifetime. While there is little evidence about
the cost-effectiveness of current early years services,
it seems odd that numbers of health visitors and
midwives are falling, and members of both those
professions report finding themselves increasingly
unable to provide the health promotion services
needed by the poorest families, at the same time
as the Government reiterates its commitments to
early-years’ services.’ (page 7)
In Scotland, child and adolescent mental health services
were subject to inquiry42, and their parliamentary committee
identified that:
‘At the crux of whether statutory services are able to
identify mental health problems in the very young is
26
the way in which those services interact with that
group. This key role was traditionally fulfilled by the
health visiting profession, who would uncover such
problems in the course of general, unstigmatised
interaction with families with young children.’
(para. 112)
Further, in relation to children’s speech and language
development, crucial for later learning and settling at school,
the same committee heard evidence:
‘that “one real problem” was that health visitors were
no longer doing much in the way of universal services
and were instead focusing from the outset on additional
services and on the children who have complex and
intense needs. The universal service that has been
provided is beginning to slip away. As an illustration,
I can tell the committee that traditionally about half 40 or 50 per cent - of referrals to speech therapists in
the pre-school period used to come from health visitors.
The Royal College of Speech and Language Therapists
carried out a review at the end of last year about how
much had changed post “Health for all Children,”
and it found that the figure is now about 15 per
cent.’ (para. 114)
In terms of safeguarding children, Lord Laming20 stated
clearly: ‘There is a desperate need for more health visitors,’
(page 43), before going on to recommend urgent action to
achieve this. He explains:
‘Of greater challenge still is the need to address the
status, training and responsibilities carried by health
visitors. Evidence to this progress report makes clear
that there are a number of challenges to be addressed
in this service. The work of health visitors requires
immediate action to increase the numbers, confidence
and competence of staff.’ (page 6)
27
This wide range of substantial, independent reports show
there is a clear need for health visitors, even though the
qualification is no longer regulated in statute. Indeed, the list
of reports pointing to a need for health visitors could be
longer: domestic violence, asylum seekers and refugees,
accidental and non-accidental injury, looked after children,
teenage pregnancy, alcohol and drugs, the obesity epidemic,
the rise in autistic spectrum disorder, children and young
people with disabilities, increasing referrals to Child and
Adolescent Mental Health Services (CAMHS), popularity of
books by unqualified, self-styled ‘parenting experts’ and the
overall public health need for prevention and promotion.
There is further evidence of need from a rising birth rate and
an exponential rise in admissions to hospital of children with
preventable diseases such as dental decay, obesity and
respiratory conditions, and the higher risk faced by rising
numbers of expectant mothers who were themselves born
outside the UK.
These harms arising in children and families suggest that
reduction of the health visiting service is now being
demonstrated in the very population the profession is
designed to protect. Evidence of the full list of issues affecting
families with young children that would be best ameliorated
by health visitors working with families in the home and
community is too long to include in this paper, but we would
happily furnish details if needed. There is also evidence that
health visitors (given the opportunity and sufficient staff) can
help older children and young people, vulnerable adults such
as travelling or homeless families, and older people3. Taken
together, these examples indicate clearly that health visitors
are needed, and their numbers should be expanded,
not reduced.
28
3.2. Need for health visiting in current policy
The existence of a health or social need does not always give
rise to government policy to meet it, and family policy is
traditionally one of the most contested political spheres. The
coalition government formed in May 2010 is too recent, at
the time of writing this paper, for their views to be known.
However, it appears likely that they will acknowledge the
continued need for health visiting, because of a broad
agreement across the political spectrum that health
visitors are needed.
In 2007, the Labour government set up an independent
review of the role and function of health visiting18, and
accepted most of its recommendations52. In 2009, the
Conservative Research Department published an enthusiastic
endorsement of the part health visitors could play in helping
new families53, which led to a policy commitment to increase
the number of health visitors by 4,200 (that is, by around
50%), should they be elected. The Liberal Democrats,
likewise, developed a commitment to increase the number
of health visitors54. The Scottish Parliament abandoned plans
to introduce a generic community nurse to work across the
spectrum of health needs in all age groups12 following a
critical report from their Health and Sport Committee42.
In 2009, the Labour government responded to the challenge
identified by Lord Laming, and announced a joint (Department
of Health and CPHVA) Action Plan on Health Visiting, to be
led by the Chief Nursing Officer. The first phase led to
publication of a guide setting out the contribution of health
visitors to both children’s services, and to services directed at
promoting well-being and reducing health inequalities, even
29
though health visiting services are no longer commissioned
by name46. The second phase is under way, focusing on
career structures, recruitment and workloads. This Action Plan
led to an instruction in the NHS Operating Framework55, that
Primary Care Trusts (PCTs) should monitor workforce and
caseload figures (ratio of health visitors to pre-school children)
in their local area. These data have been collated, but not
yet released.
Overall, these changes in policy direction suggest an increasing
awareness of the harm caused by the fall in the health visiting
workforce. However, the workforce is continuing to shrink,
and recruitment of both qualified health visitors and students
remains problematic. These difficulties, and the attendant
harm to the public in receipt of reduced services, seem likely
to continue until the profession is returned to statute.
3.3. Need to name an occupational group
There has been a recent shift in national policy away from
naming specific occupational groups as responsible for meeting
identified health needs, along with a relabelling of services
according to their purpose and population served, rather than
the professionals delivering them. This is intended to enhance
flexibility, but there are still occasions when it is appropriate to
identify an occupational group by name.
3.3.1. Skill-set
Service providers need to demonstrate that they have staff
with appropriate skills to deliver services as commissioned,
and specifying the number of staff with a recognised and
appropriate qualification is one way of doing this. It would be
impractical for a manager to separately assess each person’s
whole skill-set every time a policy changes or a new member
of staff is taken on. Instead, a recognised qualification, along
with good employment practice, provides clarity about what
can be expected from a named employee or group of staff.
The Laming Report, for example, linked the need for more
30
health visitors explicitly to the skill-set required for safeguarding
children. Substituting staff with inappropriate skills, or
inadequate capacity to carry out the full range of functions
and activities for which health visitors are prepared is
extremely risky, but all too common since the health visiting
qualification has been removed from statute. Sometimes this
is a response to staff shortages and the CPHVA fully support
the use of carefully developed skill-mix, in which a health
visitor who is in a position to accept full accountability for
the work, delegates activities to team members, who may be
qualified in other fields or not56. However, the dilution of skills
is often too great for safety (see Example 3).
Example 3: Dilute skill-mix: practitioners’ perspectives
Unite/CPHVA’s annual survey of 829 health visiting members
in England (2008)57 revealed:
o 29% were responsible for more than 500 children
o 35% said the level of skill-mix did not allow for safe and
effective practice
o 47% said they were not involved in decisions regarding
the mix of staff
As yet unpublished CPHVA survey data from 2010 suggests
that 45% of health visitors now have responsibility for more
that 400 children and 26% for more than 600 children. Lord
Laming advised in 2009 that the optimum caseload should
not exceed 400 children29. The CPHVA regard this as the
absolute maximum, recommending an average of 250
children per health visitor, and fewer in areas of high need58.
Furthermore, the expanding use of colleagues with different
skills creates two potential problems that place the public at
risk: inappropriate confidence and confused lines of
accountability. These have become increasingly frequent
since the health visiting qualification was removed from
statute, leading to the inaccurate impression that anyone
can do health visiting work.
31
The problem of inappropriate confidence arises when team
members ‘don’t know what they don’t know.’ Close supervision
is not possible when staff work alone in the home, so careful
delegation and reporting back are both important. Inappropriate
confidence is particularly likely to develop in situations where
staff (such as community nursery nurses) have no clear career
ladder, so remain in the same post gaining more and more
practical experience without the breadth or underlying
theoretical knowledge to support decisions. The lack of
statutory regulation prevents the development of career
routes for such staff. Also, when team members have a
different qualification, notably a first level nursing registration,
lack of awareness of one’s own limitations can become
problematic, leading to inappropriate and unknowingly
risky practice (see Example 4).
Example 4: Inappropriate confidence
When a family with a pre-school child moves house, a contact
is required to assess and transfer records. Some organisations
specify that a community staff nurse must always carry out
this ‘removal in visit’ instead of a health visitor, unless the
family is known to have particular high level needs. Such a
protocol was in place in the case example below.
Unite/CPHVA health visitor member comment:
‘Three months after my staff nurse completed the removal-in
visit and reported all was well, I visited a family when a child
protection concern was raised. I found a three year old
showing significant signs of undiagnosed autism. The staff
nurse insisted the child had been fine when she saw him,
despite the fact that autism is a developmental disorder that
does not arise suddenly. The mother reported having no
opportunity to raise her concerns before I visited.’
32
Inappropriate confidence has become a common concern
since the SCPHN qualification (now the only way that
health visitors can qualify) was designated as a form of
post-registration nursing, instead of health visiting being
regulated through its own statutory register. The skills
required for health visiting practice are subtle, complex and
sophisticated, but not easy to articulate. Removing the
qualification from statute has created the wrong impression
that they do not exist separately from those required by
nurses, so exacerbating the problem of inappropriate
confidence.
3.3.2. Clarity and accountability
Confusion surrounding the need for a health visiting
qualification, when it is required and who should decide
has increased exponentially since closure of the register.
Importantly, since the legitimacy of the health visiting
qualification has been undermined by closure of the register
and statutory regulation, it is not always considered essential
to have input from health visitors themselves about such
decisions. There is an unacceptable risk when an organisation
derives a protocol requiring a staff member to undertake
activities that they are not qualified to complete in a safe
manner. This form of protocol, which encourages inappropriate
confidence (see Example 4 above), has become more prevalent
since the dedicated health visiting register closed. Whilst there
are a number of reasons for developing such protocols, of
interest to the NMC is when they are developed because of a
belief that health visiting is ‘predicated on nursing,’ suggesting
that all registered nurses must, therefore, be competent to
function as junior health visitors. This is unsafe and presents
a significant risk to the public.
33
The requirement for student health visitors to have a nursing
qualification creates an anomaly, once summarised in the
statement that ‘Health visitors are nurses, but health visiting is
not nursing.59’ There is no pre-registration (first level) nursing
programme linked to the SCPHN part of the register, and
neither pre-registration nursing nor midwifery qualifications
prepare students to function as health visitors. Within each of
the four nursing branches, there are some proficiencies that
are helpful (particularly in the proposed new programmes), so
staff nurses are able to carry out delegated activities where a
health visitor is able to first assess both client needs and the
particular skills of the nurse. In such situations, of course,
the nurse is accountable for carrying out those delegated
activities and the health visitor retains case responsibility
and accountability as the senior, delegating practitioner.
However, this form of accountability is over-ruled where an
organisational protocol requires, for example, that staff nurses
complete all new birth visits (i.e., first contact visits), all
removal-in visits (where clients are new to an area), or
perhaps specified developmental checks where a family may
not have been seen by a health visitor for a year or more
(see Example 5). In such cases, the health visitor who has case
responsibility may have no knowledge of the person being
visited or of the activities being carried out, so is not in a
position to know whether the activity should be undertaken
by the nurse or any other team member, such as nursery
nurses, family support workers, psychology graduates and
so on. This situation may also arise where heavy workloads
prevent the health visitor from maintaining knowledge about
all the families for whom she is responsible, even if there
is no protocol in place.
34
Example 5: Health visiting by numbers: protocols
o CPHVA were recently informed of a PCT where the
health visitors had been told that they must meet the
PCT protocol for home visiting. This included staff nurses
carrying out new birth visits to so-called ‘non vulnerable’
clients, with first or subsequent births. The expectation
was that this would include 70% of the births. Health
visitors were also asked to ensure all necessary assessment,
support and advice was completed in this single contact
and to reduce later checks in respect of perinatal
mental health.
o Health visitors consider the new birth visit to be one of
their most important contacts with new families as it
provides the base line for subsequent contacts.
It requires a highly trained and skilled professional to
conduct an efficient new birth visit where sensitive issues
are examined such as the parent’s response to their new
infant and the effect of the baby on family dynamics
both in the nuclear and extended family.
o Both issues may be significant to the parenting style and
should help to determine future visiting patterns and
suitable delegation to more junior members of the team
such as staff nurses. In the view of the CPHVA this
contact should never be delegated to a more junior
team member.
Whatever the cause, the health visitor cannot protect the
client or adequately exercise accountability as required by
the NMC Code of Conduct, unless she has knowledge of the
family situation to predict which activities are needed, and can
be sure the nurse (or other team member) is competent to
carry them out. The CPHVA has opposed protocols that involve
the blanket substitution of nurses into health visiting roles60.
Where these protocols exist, registered nurses are expected
to function according to their scope of practice; but their
35
different skill-set and knowledge base means (as in Example
4) that they may not know they are working beyond their
level of competence, thus placing the client at risk. Also,
CPHVA officers regularly encounter situations where employers
have failed to ensure that health visitors are aware of their
accountability for the practice of junior team members, or
managers may be unaware themselves.
Furthermore, clients may be unaware of the qualification of
the person visiting them. In one example, a ‘staff nurse pilot’
is being carried out in which staff nurses with some additional
training are being used to carry out all new birth visits, unless
a midwife has raised concerns. Yet a series of focus groups
commissioned by the service and reported to the local
authority scrutiny committee identified that parents were
often unaware that the person visiting was not a health
visitor61. Some suggested that this would only matter if they
were given inappropriate advice, but the point is that parents
may be unable to assess its credibility or suitability; this reverts
to the key reason for having professional regulation; which is
to protect the public when they are vulnerable.
Example 6: Who is visiting?
Comment 41 from Netmums survey40
o
‘After my youngest was born I started suffering from
panic attacks after a bad experience while giving birth to my
son (later realised through your site that it was anxiety - postnatal illness - very grateful for your site) I thought it was a
health visitor that came out for the routine check-up but
turns out she was a community nurse. She was very nice but
didn't give any definite help for me - kept saying she would
get me this or that but never came back with anything. She
stopped contacting me after about a month - turns out she
went off sick for months - when my anxiety was at its worst
and a new health visitor took over but never contacted me at
all as she wasn't aware of any problems I was having.’
36
These examples of adverse leadership and confusion
surrounding health visiting practice have increased since the
dedicated register was closed. It is no longer clear where
professional leadership should come from, even within the
NMC, where the lack of a SCPHN committee and absence
of health visitors on any of the practice committees or as
Council members was the subject of an earlier CPHVA
professional briefing1.
In terms of health visiting provision it is, likewise, not clear
that there is a need for leadership or representation from
within their own profession, to lead the development of
suitable forms of service organisation, negotiate commissions
and ensure updating and supervision of practising health
visitors. Where these functions are carried out as a generic
function, or as part of a nursing remit without sufficient
health visiting leadership, we are regularly witnessing the
development of inappropriate procedures and policies (such
as the one highlighted in Example 5), which cause potential
harm to the public. Also, poor practice may develop on the
part of individual health visitors, simply because they are given
insufficient opportunity to update themselves, or to access
supervision at a senior enough level.
Professional leadership is not the direct responsibility of the
NMC, but we contend that removing statutory regulation has
led to an impression that there is no need for health visitors
to be involved in the commissioning, management and
development of protocols used to deliver the health visiting
service. As a result, we see a number of organisations
requiring staff to carry out or delegate activities in a way that
health visitors believe to be unsafe. Distressingly often, these
protocols or expectations require substitution of a registered
nurse into an experienced health visiting role, with health
visitors being threatened with disciplinary action if they
disagree or attempt to use professional judgement in the
37
interests of their clients. The NMC offers no support or
guidance in such circumstances, perhaps because of the
(unjustified) belief that registered nurses are capable of
operating as junior health visitors.
3.3.3. Organisational convenience
Organisations need to be able to identify which personnel are
in a position to carry out required functions. It makes sense,
therefore, to name health visiting as the occupational group
responsible for leading the Healthy Child Programme, because
they are in regular contact with this age group and national
policy indicates this is the government’s expectation. It is
unusual to specify occupational groups in policy or at a
national level. However, it is part of the everyday functioning
of provider organisations to take such decisions. Organisations
need to be able to segment their workforce for purposes of
description, recruitment, management functions and future
planning. Without occupational titles, including those
associated with professional qualifications, these functions
would be impossible. Despite being in common use, the title
‘health visitor’ is no longer protected in law, an issue that is
picked up under Section 5. Conversely, the SCPHN title, which
is not specific to health visiting and has no common currency,
is protected.
3.5. Key points
•
Safe and effective health visiting services are required
to deal with increasing health and social need. This is
recognised in policy and across the political spectrum, but
removing health visiting from the framework of statutory
regulation has created much confusion for service users,
commissioners, employers and practitioners.
•
Ambiguity and uncertainty about the meaning and
existence of a health visiting qualification, whether it is
needed and when, has led to a number of employers and
commissioners making very risky choices in staff deployment,
often using personnel with insufficiently developed skills.
•
Confusion about the regulatory status and need
for a health visiting qualification has led to unsafe lines of
accountability and unclear decision trails in many organisations.
The substitution of personnel with different skills to those of a
fully qualified health visitor, and who may be inappropriately
confident, creates a considerable risk. This practice differs
from standard, safe skill-mix or teamwork, but has proliferated
since health visiting was removed from statute.
3.4. Summary
Health visiting is still needed, which is recognised in national
policy, but the workforce has been in freefall since the
qualification was removed from the system of statutory
regulation. The title ‘health visiting’ is still in common use,
despite having no meaning in law, which leads to considerable
confusion. The staff shortages and lack of clarity about use
of the title ‘health visiting,’ and about the status of the
qualification, lead to working practices that create a risk to
the public. The next section examines the question of whether
health visiting is a profession that should be regulated.
38
39
4. IS HEALTH VISITING
RECOGNISED AS A HEALTH
PROFESSION, OR SHOULD IT BE?
The Health Professions Council (HPC) was set up at the same
time as the Nursing & Midwifery Council, under a parallel
statute (Health Professions Order 2001), also linked to the
Health Act 1999. The powers of the two organisations differ
somewhat, although both share a common aim of protecting
the public by regulating certain named professions. Because it
was specifically set up to regulate some professions that had
not previously been named in statute, the HPC developed
clear guidance about how to distinguish which occupational
groups should be recognised as ‘health professions’ and
regulated as such62.
Health visitors are occasionally involved with the first two of
these, and almost all of their practice involves the unsupervised
exercise of judgement, which can substantially impact on
patient health or welfare. The level of independence is
stressed by the HPC, who generally regulate health workers
who are not otherwise supervised, practising autonomously,
making professional and independent judgments on
treatment, and taking full responsibility for their actions.
We contend that this description applies to health visitors,
who are independently responsible for an undifferentiated
caseload, but not to the team members with different
qualifications such as nursery nurses, or first-level registered
nurses working in the context of health visiting teams. The
HPC do not regulate occupations that are already regulated
by other means, and Section 5 will consider the question of
whether health visitors are currently regulated or not;
we think not.
We offer a comment on each of these criteria to provide some
validation of our belief that health visiting is, indeed, a health
profession that should be regulated. It has been suggested
that health visitors may prefer to be regulated by the HPC
under some circumstances63, but this is not the reason for
drawing attention to these criteria. We use the HPC criteria
because the NMC do not have any similar guidance, and
because they provide an officially recognised way of
understanding professional regulation in the
contemporary world.
Once it is established that an occupational group requires
regulating, the HPC then applies certain criteria to establish
whether or not it is sufficiently mature and distinct from other
occupations to merit its own register. We contend that health
visiting meets these criteria, and that it is perverse to have
removed health visiting from the regulatory statute at the
same time as establishing a mechanism showing it is a health
profession that should merit its own register. Considering
each of the criteria in turn, below, explains our view that
health visiting is a profession that should be regulated in
statute, and also shows how some difficulties have arisen
that lead to a risk to the public, as a result of closing their
dedicated register.
The HPC deems an occupation eligible for regulation if it is
engaged in at least one of the following activities:
• Invasive procedures
• Clinical intervention with the potential for harm
• Exercise of judgement by unsupervised professionals
which can substantially impact on patient health or welfare
4.1. Health visiting covers a discrete area of activity
displaying some homogeneity
This criterion is concerned with the profession’s scope of
practice, and that the applicant occupation practises activities
that:
• Are distinctly its own
40
41
• Are common across the occupation
• Are distinct from the scope of practice of other
occupations, although there may be some overlap
Health visiting has been a distinct profession for almost 150
years (see Appendix 1). Its provenance has been continually
contested and changing during that time, varying according
to prevailing health needs, contemporaneous knowledge and
policy expectations. It developed separately from nursing,
initially having much in common with ‘sanitary inspectors’
who were the forerunners of today’s environmental health
officers64. Health visiting drew closer to midwifery, and
through that route to nursing, in the middle years of the
twentieth century65, although a nursing qualification did not
formally become a legal pre-requisite until the 1960s2. In the
third quarter of the twentieth century, health visitors seemed
to have much in common with social work, but after some
debate, separate Councils were established for the Education
and Training of Heath Visitors, and for Social Work66. The
emergence of Health Promotion Specialists led to suggestions
of overlap between their work and that of health visitors, with
their focus on educational rather than clinical concepts67.
Public health models of practice have been used and applied
to health visiting with some success68,69. Most recently, health
visiting seems to have much in common with Early Years
Practitioners and Parenting Practitioners27, not least because
of expectations that the children’s workforce should all
acquire a ‘common core’ of competences70.
Through all of these shifts and changes, and through the
rapidly changing policy expectations listed in Section 3.2,
health visiting has maintained a cohesion and clarity about its
practice, often providing stability in services that would be
otherwise subject to a destructive level of turbulence. However,
the variations and changes outlined above provide a basis for
considerable flexibility and independence in the profession,
42
and also contribute to the view that nursing knowledge is
only one part amongst many in the whole health visiting
repertoire71. There is agreement that health visiting and
nursing overlap somewhat, but the extent has been contested
and the subject of continuing debate since the inception of
the two professions72. Shortly after the health visiting register
closed in 2004, a survey of 1459 health visitor registrants
asked what respondents felt was the relationship between
nursing and health visiting. On a four point Likert scale, only
8% regarded them as the same, whereas 18% regarded them
as completely different. Between those two extremes, were
35% who thought them somewhat similar and 39% who
said they were somewhat different71. There has been
relatively little research comparing the two occupations, but
some reviews identifying the distinctive nature of health
visiting are included in Appendix 3.
It is interesting to consider, as a different example, the extent
of shared knowledge and forms of practice between doctors
and nurses. Again, the amount is contested, with agreement
that there is some overlap, but that is not considered sufficient
reason for suggesting that medicine and nursing are the
same, and should be regulated as if they were a single profession.
Likewise, some shared knowledge and forms of practice
between health visitors and nurses should not be considered
sufficient reason for suggesting that those two occupations
are the same. Many of the recent difficulties have arisen
because of the difference in practice between the two groups,
which are not well accounted for within the regulatory
framework. In themselves, the continuing difficulties and
debates attest to the difference between the two groups,
and to the distinctive nature of health visiting practice.
Restrictions within the Nursing and Midwifery Order 2001
prevent the NMC from recognising health visiting as a
profession, so they treat it as a type of nursing (the SCPHN
43
proficiencies are said to be ‘predicated upon nursing’).
Unlike the HPC, the NMC has no legal mechanism for dealing
with difference, which perhaps leads them to overstate the
degree of similarity between nursing and health visiting, and
to obscure, or even negate, the extent and distinctiveness of
health visiting knowledge. In turn, this poses a risk to the
public, because it encourages the substitution of registered
nurses, who are qualified to work in a different way, for
health visitors. This substitution is being undertaken without
being researched in a robust way, and with no evidence to
show that it is a safe or effective (see Examples 4 and 5 above).
4.2. Health visiting applies a defined body of knowledge
There is a large body of knowledge specifically about how
health visitors practice, including their distinctive approach to
implementing the considerable generic evidence base
(about child and family health, mental health and well-being,
epidemiology and health inequalities, community practice and
so on) upon which they draw. This profession-specific research
includes a large number of theory-building qualitative studies,
showing how health visitors practise. A comprehensive review
of this literature was carried out as part of a curriculum
development project commissioned by the UKCC in 2001,
to inform development of competences for pre-registration
health visiting programmes13. Some of the vast number of
studies about how health visitors implement evidence in their
practice come from an ‘insider perspective,’ that is, carried
out by health visitors themselves, but a great deal has been
carried out by other disciplines, across the medical and
social sciences.
The defined body of knowledge used by health visitors is too
extensive to be summarised in a single paper, but can be
found in a large number of health visiting text books73,74,75,76,
and in a short guide for commissioners produced by the
44
CPHVA in 200777. In particular, the so-called ‘principles of
health visiting’ are used as a unifying mechanism for education
and research, as they illustrate how the skills, ethos and
knowledge base of health visiting are combined into a unified
form of practice across the profession78,79. Regulating health
visitors as if they are the same as nurses undermines and
damages this careful knowledge base, which has developed
over many decades. In terms of the vulnerable public, the
health visiting emphasis on the value of health and the
accompanying responsibility to identify and deal with recognised
and unrecognised needs provides an assurance that the
practitioner will focus sensitively and thoroughly on prevention
and promotion of health. There is a risk of ‘failure to prevent’
once this assurance is removed, which is of particular relevance
to the NMC, since it represents a risk of harm to (particularly)
children whose preventable conditions, health difficulties or
need for safeguarding may not be identified or adequately
dealt with.
4.3. Health visiting practice is based on evidence of efficacy
The extensive body of knowledge and evidence base about
preventive and public health needs is generic, in the sense
that much of it is shared across professions. Evidence about
how to deal with these needs is less well developed, but still
extensive enough to demonstrate efficacy3,80. The scope of
health visiting is broad, but focuses particularly upon child
and family health, including mental and physical health,
development and safeguarding, public health and health
inequalities, including work with individuals, groups and
communities. Their main area of practice is in the area of
promoting health in pre-school children and their families for
which there is good evidence of efficacy81, but there is broad
evidence of the effectiveness of their work with other age
groups, and defined vulnerable populations3.
45
In terms of this paper, there are two key issues. One is the
complete lack of evidence of efficacy for the forms of role
substitution and dangerously dilute skillmix (detailed in
Section 3) that have developed since health visiting ceased to
be a statutory qualification. Second, some commissioners
and service managers prefer to promote practice that is not
evidence based in order to reduce immediate costs, which
creates considerable risk for the public. We contend that the
lack of statutory regulation, and accompanying lack of
support for the health visiting qualification, promotes
acceptance of such irresponsible approaches and inhibits
development of support for practitioners who try to protect
service users by resisting them.
4.4. Health visiting has at least one established
professional body, which accounts for a significant
proportion of that occupational group
The majority of health visitors are members of the CPHVA,
which was founded in 189629. This association began with
a professional and educational remit, and has always
maintained these elements along with its trade union
functions, increasing this focus after the Council for the
Education and Training of Health Visitors (CETHV) was
disbanded in 1983.
The National Standing Conference of Health Visitor Training
Centres was established in 1945, and continues to function
as the UK Standing Conference on Specialist Community
Public Health Nursing Education (UKSC). Higher education
establishments that run health visitor programmes belong
to the UKSC.
4.5. Health visiting has operated a voluntary and a
statutory register
The Royal Sanitary Institute, now the Royal Society for Public
Health, maintained the first register for health visitors on what
would be regarded now as a voluntary basis in the first
46
instance and after regulation was established in statute in
1929. The CETHV took over as the statutory regulating
authority from 1962 to 1983, and then the UKCC (following
the Nurses, Midwives and Health Visitors Act 1979) until 2002.
The NMC maintained the statutory health visiting register
through the transitional phase of its inception from 2002
until 2004. At that time, the health visiting register closed
and registrants from there were transferred to the Specialist
Community Public Health Nursing (SCPHN) part of the
register. A voluntary system of annotation was developed by
the NMC, initially to differentiate those registrants who
qualified under the former system, but also to distinguish
between health visitors and others on the SCPHN part
of the register.
There are two risks to the public from this form of voluntary
identification. First, its continuity is not assured because it
was developed by the NMC and is not a statutory requirement.
Concern about the possible loss of this annotation is enhanced
by the lack of recognition of health visitors, and the absence
of health visiting (or SCPHN) representation on any of the
relevant NMC committees. Second, this form of voluntary
annotation, instead of statutory regulation, implies a minimal
difference between the various qualifications now regulated
through the SCPHN register, promoting inappropriate role
substitution.
4.6. Health visiting has a defined route of entry to the
profession
The entry route to the health visiting register has been
through completion of a recognised programme of preparation
and examination since early in the twentieth century. Officially,
entry is now through completion of the SCPHN programme,
with all practice experience in the field of health visiting.
However, staff shortages and a lack of clarity about the need
for, and meaning of, a health visiting qualification is giving
47
rise to a variety of optional routes, either through role
substitution or by the development of ad hoc and unregulated
educational options. This variation creates a risk to the public
since the quality of the programmes is not assured. It adds to
confusion about the direction for health visiting and the risk
to the public from unregulated programmes of preparation.
4.7. Health visiting has an independently assessed entry
qualification
As above, NMC validated programmes for a SCPHN qualification
are independently assessed. However, there is considerable
discontent about the suitability, specificity and length of the
programmes. Unlike other programmes validated by the
NMC, no ‘essential skills cluster’ has been specified for health
visiting, which suggests a lack of value attached to the
programme (a start was made on developing this information,
but the work was discontinued before completion). This
increases the risk of variation in the qualification across the
country and strengthens the belief of some local providers
that they could improve upon the official programmes.
4.8. Health visiting has standards of conduct,
performance and ethics
Health visitors are expected to adhere to the NMC
Code of Practice.
4.9. Health visiting has disciplinary procedures to
enforce those standards
The NMC disciplinary procedures are supposed to apply to
health visitors. However, unless service users are aware that
the NMC is their regulatory body, it would be extremely hard
for them to identify this, as shown by the results of the brief
internet search shown as Example 7. Indeed, a document
downloaded from the NMC website entitled ‘Who regulates
health and social care professionals?82’ makes no mention of
health visiting, nor does advice for the public on their
webpage, about referral to the NMC83. Any risks to the public
may go unreported, because of the lack of transparency
about which organisation, if any, regulates health visitors.
48
Example 7: Brief internet search for register or regulation
of nurses, midwives and health visitors
o Google.co.uk: top response to search for ‘nursing
register’ or ‘midwifery register’ is NMC, followed by
many other contemporary (mainly NMC) pages.
• Google.co.uk: top response to search for ‘health visiting
register’ is an agency for private health visitors, followed
by many historical references to health visiting register
(pre-2001)
o Ask.com: who regulates nurses? NMC features under
‘NHS careers’ and in its own right, within top five
responses (others outside UK)
o Ask.com: who regulates midwifery? NMC is top
response, also features lower down page and under
‘Jeeves suggests’
• Ask.com: who regulates health visitors? Top response is
the review of Nurses, Midwives and Health Visitors Act
1997. NMC features in an article lodged in University of
West of England library, at the end of the first page
Date of search 08-04-10
4.10. Health visiting is committed to continuous
professional development (CPD)
The NMC requires registrants to complete at least 35 hours
of learning relevant to their area of practice in the preceding
three years, as part of the requirement to revalidate their
registration84. Concerns about the unsuitability of the
revalidation requirements are explored further under
Section 5.
4.11. Summary
This section has highlighted a number of concerns about
current regulatory arrangements made by the NMC, by
focusing on nationally recognised criteria for identifying
whether or not an occupational group is a profession that
49
should be regulated in statute. There is a clear distinction
between a profession, capable of carrying out multiple
functions and with the flexibility to adjust to changing needs,
and a single job or role. Health visiting is a profession, which
meets the criteria for regulation. We contend that it is
perverse to have removed health visiting from the group
of occupations regulated in statute at the same time as
establishing a mechanism for other, newer professions
to be recognised in this way.
a risk to the public, because it encourages the substitution of
registered nurses, who are qualified to work in a different
way, for health visitors.
Since health visiting has been regulated under a law designed
only for nursing and midwifery, the standards of education
are increasingly compromised and the body of knowledge
diluted, because there is no formal mechanism by which
health visitors can influence the development of their own
profession. In turn, this adversely affects standards of practice,
which leads to a risk for the public. However, any member of
the public wishing to lodge a complaint about a health visitor
would be hard pressed to identify which regulatory body is
relevant. The key question this raises is whether health visiting
is, in fact, regulated through the current arrangements.
5. IS THE HEALTH VISITING
PROFESSION REGULATED?
4.12. Key points
•
Specific criteria were established in 2001 by which
aspiring health professions that need statutory regulation
could be recognised. Health visiting meets these criteria, yet
was removed from the framework of statutory regulation in
the same year. This perverse decision has left the public at risk
from a range of problems arising from the current regulatory
arrangements.
•
The NMC has no legal mechanism for dealing
with professional difference, which perhaps leads them to
overstate the degree of similarity between nursing and health
visiting, and to obscure, or even negate, the extent and
distinctiveness of health visiting knowledge. In turn, this poses
50
•
There is a lack of transparency in the regulatory
system, so any member of the public wishing to lodge a
complaint about a health visitor would be hard pressed to
identify a regulatory body responsible for the profession.
The preceding sections focused on the continuing need for
health visiting, and showed that, if it were assessed by the
criteria applied to any other occupational group, it would be
regarded as a health profession that should be regulated in
statute. When the health visiting register closed in 2004,
health visitors migrated on to the Specialist Community
Public Health Nursing (SCPHN) part of the NMC register, but
this has not proved a satisfactory alternative to statutory
regulation, as detailed below.
We contend that health visiting is not regulated, because it is
regarded as a subsection of SCPHN, which is regulated as a
sub-part of nursing, which is a different profession to health
visiting. The NMC carries out its constitutional remit to
regulate nurses and midwives but does not regulate health
visiting. There are three central requirements of statutory
regulation, which are the form of register, standards of
proficiency and revalidation of individual practitioners. The
NMC use such a perverse and inhibitory approach in meeting
these requirements in respect of health visiting, that the
profession is no longer regulated.
51
5.1. The form of professional register
A register of practitioners approved to practice, and therefore
to use the title of the profession, is the first formal requirement
for statutory regulation. This form of registration is necessary
to avoid confusion, enabling employers and colleagues to
recognise the approved skill-set and proficiencies held by a
practitioner, and to inform the vulnerable public of what to
expect from this particular health professional. Pre-requisites
for these functions are a specific route to entry, including
preparation and examination, and a title that is formally
recognised in law.
5.1.1. Specificity of the register
Entry to the register is through preparation and examination,
with standards (considered below) agreed by the profession in
conjunction with employers and service users, and validated
on their behalf by the regulating authority, in this case the
NMC. A profession may carry out a number of roles and
functions, but the register needs to be specific to the
profession rather than a single role. Arrangements for joint
qualifications, accreditation of relevant prior learning (APL)
and so on, are common across professions.
The SCPHN part of the NMC register is unique in placing a
greater importance on qualifications required at entry to the
preparation (ie, the nursing or midwifery registration) than on
competence demonstrated at entry to the third part of the
NMC register (ie, the health visiting/SCPHN qualification).
The NMC could have worded their documentation to
acknowledge that some relevant learning required by health
visitor students will have been acquired by entrants with a
nursing or midwifery qualification; that is they could have
regarded the prerequisite as a form of accreditation of prior
learning. That approach would have valued the nursing
elements of the work, and acknowledged the distinctiveness
of the health visiting qualification, without changing any
52
proficiencies or programme arrangements. Instead, the NMC
chooses to treat the prior registration and education as more
important than the preparation needed to function as a
health visitor. This approach compromises the specificity of
the register and the requirement for practitioners to be fit to
practice on obtaining their health visiting qualification, thus
undermining the whole process of ‘registration’ as a form
of regulation.
The process adopted by the NMC means that, despite being
labelled a ‘part of the register,’ the SCPHN part operates as a
sub-part of the nursing and midwifery parts of the register.
The health visiting qualification is an insecure and poorly
acknowledged subsection of that sub-part. The development
of appropriate standards for qualification as a health visitor,
and new approaches to career development, are prevented
because the programme is treated as a form of minor ‘top
up training,’ instead of a full professional preparation. In turn,
that inhibits recruitment, with increasing reports of difficulty
in attracting recruits of a suitable calibre, which adversely
affects standards of practice and creates a risk to the public.
An additional risk arises (see Section 3), because the
arrangements create the inaccurate impression that any
qualified nurse or midwife can be substituted for a health
visitor, despite their lack of appropriate preparation for this role.
5.1.2. Statutory title
Employment of a range of different occupations into health
visiting posts and teams, with inappropriate substitution and
lack of full preparation for the role, has come about in part
because anyone is allowed to call themselves a health visitor
whether or not they are suitably qualified. Although it is
relatively unusual to hear of ‘bogus health visitors’ (see
Example 8), occasionally individuals present themselves in this
way for purposes of gaining access to children.The title of a
register is formally noted in statute so the qualification has a
53
Example 8: Bogus health visitor
12-01-10. News release. Police in Lymington are
appealing for information from local residents about
a possible bogus health visitor.
Context
‘Officers have received a report from a resident in Norley
Wood, claiming that a woman called at her home in
December stating that she was from the local doctor’s surgery
and had come to see her child or children. When challenged
about which surgery she was from, the caller stated that she
was there to do the weights and measures of the woman's
child or children. The caller did not appear to know anything
about the family and tried to push the door open but was
refused entry. ‘
Professional Name of register
leads to protected
regulation
title. Should
always be used
accurately to
describe
registrants and
their professional
qualification.
Not varied unless
changed in law.
Protection of the public
stems from absolute clarity
and expectations about the
standard, skills and conduct
of the named professional;
it provides ‘kite-mark’ in
terms of qualification.
Illegal for anyone who is
not a registrant to use the
statutory title.
Job titles
Usually, but not
necessarily, linked
to statutory title.
Sometimes used
with stem or
suffix, or may be
omitted from job
title altogether.
In some posts (especially
in multi-disciplinary or
multi-agency working), the
stem or suffix might explain
the role more clearly than
statutory title. Flexibility is
important.
Services
Services no longer
commissioned or
labelled according
to the title of the
professional
providing them.
Modernised services focus
on the needs of those using
them, not the professionals
providing them.
http://www.lymingtonandpennington-tc.gov.uk/News/2010/January/
Police_in_Lymington-warn_of_possible_bogus_health_visitor.html
meaning in law; that is, it is a statutory qualification, which
protects the public by preventing misuse of the professional
title. Unlike the Health Professions Council, the NMC are not
permitted to protect titles other than those used to label the
parts of their register. The HPC, for example, protect both the
titles ‘podiatry,’ preferred by the professionals, and ‘chiropody,’
in common use by the public for the same profession. The
title ‘Specialist Community Public Health Nurse’ is protected in
statute, but it has no common currency. Neither health visitors
nor any of the other registrants on that part generally use it as
a label, and the public do not recognise it. In contrast to
SCPHN, the professional title of ‘health visitor’ is in common
use. It is recognised as the ‘preferred brand’ title by the
public, yet it has no legal standing. The statutory title is the
one that is supposed to bring clarity about the qualifications
and employment expectations (as shown in Table 1), but in
this case, it creates confusion.
54
Table 1: Use of professional titles
Statutory
professional
title
Rationale
Source: adapted from Cowley 200385
There are an increasing number of private/independent health
visitors, who may be completely unregulated, but there is no
legal right for the NMC or other organisations to question
their work or qualifications. Health visitors may have any one
of a range of employers (NHS, local government, Children’s
55
Centres, social enterprise, voluntary sector etc), who, likewise,
may or may not require their health visiting employees to hold
a regulated qualification without contravening any laws. The
current casual approach to naming of the profession creates
an unacceptable risk to the public and shows that the
profession of health visiting is not regulated.
5.2. Standards of proficiency
The key purpose of professional regulation is to ensure that
practitioners are capable of functioning fully and competently,
demonstrating so-called ‘fitness to practice’ on entry to the
specific register. This is generally achieved through a
programme of preparation designed for the specific
profession. In the case of health visiting, when the register
was closed in 2004, the carefully developed ‘requirements
for pre-registration health visiting programmes’32, ratified in
2002, were discarded. In their place, a set of proficiencies33
based on the generic standards for public health was
implemented.
These (current) proficiencies are very broad and abstract,
with no accompanying essential skills cluster, so there is wide
latitude about the manner in which they are taught or applied
in practice. Again, this adds to the impression that specific
health visiting knowledge is not required to function as a
health visitor. The wording of the principles of health visiting78,86
has been used without acknowledging the source, and they
have been relabelled as ‘domains,’ which distorts their
meaning. There are no specific requirements for the extent of
learning about maternal or mental health, infants, children,
families or positive health and well-being, about the particular
evidence or relational and communication-based skills
required for health visiting practice; nor about the organisational
skills required for independently managing an undifferentiated
caseload. In short, if a person wants to know about the skills
and proficiencies required by a health visitor, they will find
very little useful information by looking at the NMC guidance
for SCPHN programmes.
56
Universities running the programmes often compensate for
the deficit, using the skills of experienced programme leaders
who ensure relevant information despite many other
pressures on the compressed one-year timetable27. However,
ad hoc dependence upon the availability of staff with the
seniority to develop and insist upon the content of programmes
does not count as full and proper regulation, and there is a
popular view that newly qualified health
visitors may not be ‘fit for practice’ (see Example 9).
Example 9: Official preparation programmes are not
always sufficient
There have been a number of studies demonstrating that
programmes of preparation are not always sufficient. In one
recent example, a doctoral study87 examined preparation for
practice, bearing in mind the strong evidence of need for
mental health promotion and policy imperatives for health
visitors to be able to intervene in these areas. It contained
two parts:
1.
A survey of data from higher education institutions
responsible for educating and training health visitors
in 2006, which found considerable variability in the
content of the curriculum for interventions in fields
such as postnatal depression, domestic violence and
promoting positive parenting practices.
2.
A survey of 931 health visitors in 2005, which found
that reasonable numbers rated the adequacy of their
formal training in these areas as being ‘very adequate’
or ‘good;’ 70% for managing postnatal depression,
61% for managing domestic violence and 49% for
promoting positive parenting. However, there were
very significant numbers who believed their
preparation to be poor or inadequate.
Part of the survey was repeated in 2010, and the numbers
rating formal training in these areas as good or adequate had
fallen by around 10%.
57
The CPHVA, as the main organisation representing health
visitors, is invited to comment on NMC consultations and
the professional officer responsible for SCPHN attends UKSC
meetings. Such liaison occurs as a courtesy rather than a
right, and there is no established, formal mechanism by which
the health visiting profession can ensure standards used for
qualification are suitable. Experience of attempts to
communicate concerns is that comments tend to be ignored
or, worse, regarded as promoting ‘factional interests,’ rather
than protecting the public served by health visitors.
5.3. Revalidation
The contentious requirement for SCPHNs to maintain their
prior registration as a nurse and/or a midwife was the subject
of an earlier paper from the CPHVA1. That document noted
the requirement for health visitors to show they can meet the
criteria of being a midwife or nurse rather than their specific,
specialist practice competencies, in order to renew their
health visiting registration every three years. Guidance on
the NMC website explains how health visiting duties can be
treated as nursing activities in order to justify this dual
revalidation. As with entry to the SCPHN register, the
emphasis is upon meeting nursing or midwifery criteria,
and the ability to perform appropriately as a health visitor is
regarded as of secondary importance only. This places the
public at risk, because the system downplays professional
competence and knowledge of health visiting by practicing
health visitors. Return to practice programmes for health
visitors, likewise, are based upon requirements for a return
to nursing. Practical experience may occur within a health
visiting setting, but there appears to be no expectation or
requirement to update relevant theoretical knowledge. This
lack of regulatory safeguards means there is a risk to the
public from the application of outdated or inappropriate
theoretical information, even if the practitioner has recently
been returned to the SCPHN register.
58
Quite apart from the many concerns about the risks to health
visiting service users identified in this paper, there is a risk to
the public stemming from the way skilled health visitors are
automatically re-registered as competent to practice as
nurses1. Under the NMC Code of Practice, registrants are
expected to ensure they do not practice beyond their areas
of ability, yet practitioners who state that they are only
competent in the health visiting field are automatically
re-registered as nurses. This is deeply contradictory and goes
against the stated philosophy of requiring reflective honesty
and awareness of one’s professional competence. The NMC
is reviewing its revalidation procedures at present88, but the
question of enforced re-registration in an unfamiliar field,
against the wishes and professional beliefs of individual
practitioners, is not under consideration.
5.4. Summary
The NMC regulate nursing and midwifery, but they do
not regulate health visiting. Health visiting stopped being
regulated as a profession when the register closed in 2004.
The replacement arrangements regulate registrants by virtue
of their nursing or midwifery qualification, which has not
provided a satisfactory alternative.
The SCPHN part of the NMC register operates as a sub-part
of the nursing and midwifery parts, and health visiting is a
subsection of the SCPHN part. The health visiting title is not
protected, so anyone can claim to be a heath visitor, which
encourages unsafe substitution of unsuitably qualified
practitioners into health visiting roles. There is no clear
method for including health visitors in developing
programmes, and the proficiencies for the SCPHN part of
the register are too generic to guarantee fitness for practice.
Revalidation arrangements are confusing and convoluted, and
encourage practitioners to claim proficiency in a different
profession, regardless of their self-assessed competence and
wishes. This amounts to condoning dishonesty and is unsafe.
59
5.5. Key points
•
Despite being included in the Specialist Community
Public Health Nursing part of the NMC register, the health
visiting profession is not regulated as such, nor in a manner
that can protect the public. Current arrangements are
unsatisfactory because of the format of the third part of the
NMC register, its lack of specificity for health visiting and the
absence of protection for health visitors’ professional title.
•
There is no official mechanism for ensuring that
standards of preparation are appropriate for health visiting,
leading to doubts about the suitability of official programmes,
and fitness for practice of new registrants. In turn, this is
leading to the development of a range of ad hoc and
unregulated mechanisms for training.
•
Arrangements for revalidation and continued
registration are confusing and convoluted, undermining the
health visiting qualification and encouraging registrants to
claim proficiency in the different fields of nursing and
midwifery, regardless of their self-assessed competence.
6. CONCLUSION
The lack of full and proper regulation of the health visiting
profession has created confusion for service users, practitioners
and employers, as outlined in this paper. In turn this has led
to a dramatic reduction in the workforce, inappropriate role
substitution, and the emergence of various ad hoc forms of
training that, collectively, create a considerable risk to
the public.
Unite/CPHVA recognises that much of this risk stems from
staff shortages and from poor commissioning and
management decisions about how to handle that.
However, we contend that removal of health visiting from
the regulatory framework sent a public message that misled
decision makers and created an atmosphere in which
disrespect and devaluing of the profession has become the
norm. There has been neither regard for the adverse effect of
that on children and families using health visiting services,
nor attention to the lack of evidence to support the unsafe
decisions taken about alternative forms of service
organisation and provision.
Removal of the profession from statute can, therefore, be
regarded as the root cause of the downturn in health visiting
numbers, of problems with the preparation and recruitment
difficulties and with a significant risk to the public. We have
noted with satisfaction that since the workforce crisis arose,
the former government and mainstream political parties have
all made unequivocal statements of support for health
visiting. However, neither these statements, nor the ongoing
CNO’s Action on Health Visiting programme (which CPHVA
actively supports as a co-partner) have so far reversed the
downward trend in the health visiting workforce. They have
60
61
not improved recruitment or retention, nor reduced the flow
of adverse and dangerous management decisions in respect
of the health visiting profession. The root cause of the
difficulties must be dealt with.
The time has come to renew the statutory nature of the
health visiting qualification, and to regulate the profession
once more, to protect the vulnerable public – infants, children
and families – who so badly need the services of this
once-proud profession.
6.1. Key points
•
Removing the health visiting qualification from
statute is identified as the root cause of the downturn in
health visiting numbers, of preparation and recruitment
difficulties, and of the numerous adverse and risky decisions
made by commissioners and service managers.
•
Deregulation of health visiting has encouraged an
atmosphere of disrespect and devaluing of the profession,
without regard for research evidence, or for the effect of
such attitudes on service provision for the infants, children
and families left with inadequate or inappropriate support
as a result.
•
It is the belief of Unite/CPHVA and many others
that the situation for practice and for service users will only
improve when health visiting is able to resume its rightful
place as a fully regulated health profession, with a
qualification recognised in statute.
Appendix 1:
Preparation and regulation of health visiting
• 1862: Manchester and Salford Ladies Sanitary Reform
Association agree to begin employing working women to
visit homes to offer practical help, advice and education about
health; this is usually cited as the start of health visiting.
• Late 19th/early 20th century: Courses of lectures run by
Medical Officers of Health and various institutions
throughout the country. Qualified women sanitary
inspectors (forerunners of today’s environmental health
officers) were employed to undertake health visiting duties
in addition to their other work.
• 1890s onwards: Increasing number of certificated courses
for health visitors; these were usually for 2 years, or 6
months for graduates, qualified teachers or nurses.
• 1907/1915: Birth Notification Acts: beginning of a national
service based on home visiting to new-born infants. Local
authorities were permitted to raise revenue via the rates to
pay for health visiting; so qualifications began to be stipulated.
• 1909: Health visitors’ (London) Order for London CC Area.
First mention of qualification in statute, in London area only.
• 1916: Royal Sanitary Institute (now Royal Society of Public
Health) began co-ordinating qualifying courses for health
visitors; still 2 years or 6 months for graduates/nurses.
• 1919: First statutory qualification established by Ministry of
Health, based on scheme set up by Royal Sanitary Institute.
• 1925: Ministry of Health took over responsibility for training
of health visitors. At this stage, qualifications were definitely
required for the work; midwifery qualification was a
pre-requisite. Royal Sanitary Institute designated as
examining body.
• 1929: Local Government Act required provision of a health
visiting service. Associated Statutory Rules and Orders
(1930 No. 69.) laid down qualifications for health visitors
and tuberculosis workers; later adjustments in Public Health
Act 1936 and Education Act and School Health Service
Regulation 1959. Register of those holding the qualification
maintained by Royal Sanitary Institute.
62
63
• 1945: Establishment of 1-year Health Visitor Tutors course
at Royal College of Nursing.
• 1945: National Standing Conference of Health Visitor
Training Centres (now UKSC) established.
• 1948: National Health Service (Qualifications of health
visitors and tuberculosis visitors) Statutory Instrument No.
1415; possession of health visitor certificate confirmed as
a statutory requirement for practice as a health visitor;
updated in 1972 when health visitors moved from local
authority to NHS employment.
• 1950: Royal Society of Health revised health visiting
syllabus and extended training from 6 to 9 months
minimum for qualified nurses and midwives.
• 1956: Jameson Committee reports on health visiting:
recommends establishment of the Council for the
Education and Training of Health Visitors (CETHV).
• 1992: Restructuring of the functions of the Council and
Boards following the Peat-Marwick-McClintock review
removed the Health Visiting Joint Committee with no
replacement safeguards for health visiting.
• 1994: New framework for preparation of specialist
practitioners sets out syllabus for ‘Community Health Care
Nurses’ to include health visiting as one area of practice.
Programmes to be a ‘minimum of 32 weeks’ long. Further
guidance (1998) confirmed the statutory requirements for
health visitors must still be met.
• 1998: J M Consulting Ltd Review of Nurses, Midwives and
Health Visitors Act.
• 1999: Government rejected two of JM Consulting’s
recommendations: that the health visiting register
should be closed, and that they should cease to have
representation on new Council (HSC 1999/030).
• 1962: CETHV established as the regulating authority. They
developed a curriculum for a ‘new breed of health visitor’,
based on a 51-week course (implemented 1965). Nursing
qualifications became a statutory pre-requisite for entry
into health visitor training. CMB Part 1 or Registered Midwife
still required prior to entry to the training at this stage.
• 2000: UKCC set up curriculum development project to
develop new competences for health visiting, ratified
in 2002.
• 1964: National Health Service (Qualifications of Health
Visitors) Regulations (para. 2a). Wording updated and
statutory status of qualification confirmed in NHS
Reorganisation Act 1973.
• 2001: Nursing and Midwifery Order passed through
Parliament. Health visiting removed from regulatory
framework and from all laws in which it had previously
been mentioned.
• 1972: Health visiting was included in the remit of the
Commission on Nursing (Briggs Committee), which led to
the formation of the United Kingdom Central Council for
Nursing, Midwifery and Health Visiting (UKCC).
• 2002: Nursing & Midwifery Council set up. Newly
developed requirements for health visitor registration
ratified.
• 1979: Nurses, Midwives and Health Visitors Act 1979
established the UKCC. This became fully operational in
1983, at which time the CETHV ceased to function.
• 1983: Health visiting register transferred from CETHV to
the UKCC + regulation of health visitor education and
training transferred to the four National Boards. Under
64
Clause 7 (2) of the 1979 Act, health visiting matters
needed to be approved by a Health Visiting Joint
Committee (i.e. ‘joint’ between Council and Boards)
before they could be implemented.
• 2004: Health visiting register closed and registrants
migrated on to Specialist Community Public Health Nursing
part of the register. 2002 health visiting requirements
discontinued; replaced with new generic public health
proficiencies.
• 2006: NMC restructured, so there is no SCPHN
representation on Council or major committees.
65
Appendix 2:
The UK Public Health Association hosted an ‘expert consensus’
project through a series of working groups, multi-disciplinary
and multi-agency discussions and consultation of experts, to
investigate the reasons for the rapid decline in health visiting,
and identify what would be needed to regenerate it43. The
group concerned with education and regulation looked in
detail at issues of recruitment and concluded that treating
health visiting as a post-registration nursing created systemic
problems for recruitment and workforce management. Whilst
these difficulties would be readily resolved by changing the
system, that is, by recognising health visiting as a professional
qualification in its own right once more, there would no other
simple solution to the interconnected problems caused by
placing health visiting within the system designed for nursing.
Their deliberations are summarised below.
Issues related to finance
The mechanism for funding post-registration qualifications
assumes ‘on-the-job’ training, whereas initial health professional
qualifications are funded on the basis of students being
supported through protected learning time and a full
educational programme leading to a regulated qualification.
Conditions for health visitor students have been standardised
at a less favourable level than once pertained, so it is hard to
attract nurses or midwives who are very experienced, as they
would need to take a fall in salary to gain the qualification.
Comparatively, salaries of health visitors are lower than those
of clinical specialists or for other equally high responsibility
posts, whilst stress levels and lack of respect for their
professional expertise means that the conditions of service
seem far less desirable. Despite seeming unattractive to
recipients (health visitors and potential nursing recruits into
the training), the salary costs for the service seem prohibitive
to commissioners, because they are inappropriately compared
to different nursing services (e.g. in hospital teams).
Issues concerned with nursing careers
Nursing career frameworks89 tend to assume the starting
point is at the initial, pre-registration qualification point,
whereas the initial qualification for health visiting is the point
where practitioners gain the SCPHN qualification. Traditionally,
health visiting has been viewed as a desirable senior post to
which nurses may aspire, but this has broken down in recent
years, partly because of many other competing senior clinical
roles and because students’ learning experience with health
visitors (if they occur at all) may be negative due to current
stress in the service. A health visiting qualification (SCPHN) is
designated at a specialist level. However, since it was removed
from statute, the need for such a qualification is taken less
seriously, with an increasing degree of substitution of other
workers into health visiting roles. In turn, this diminishes the
overall attractiveness of health visiting as a potential career.
Issues related to a lack of health visiting voice
Education is the major instrument for workforce planning, yet
the way it operates is both unwieldy and unsuitable for health
visiting. This is because the system is based on an assumption
that all post-registration qualifications build upon a prior
pre-registration qualification, yet there is no first level health
visiting qualification. It is very difficult for managers to develop
or raise workforce planning models at PCT level, because
numbers are comparatively low, so issues get lost within the
wider nursing workforce. This also has an adverse effect on
the ability of managers to adequately influence educational
programmes and conditions for students’ learning, such as
practice support or contract setting with universities, where it
differs from that required for pre-registration nurse education.
Although the system is supposedly in place, it is constantly
under pressure to conform to requirements suited to other
parts of the workforce.
Treating health visiting as a post-registration nursing
qualification exacerbates recruitment difficulties
66
67
Issues related to the restricted entry gate
Recruitment from within the nursing workforce has become
increasingly difficult, but other potentially suitable entrants
cannot be considered, because the statute governing health
visitor education (i.e., the Nursing and Midwifery Order 2001)
prohibits it. Yet, salary levels and student support regarded as
unattractive by experienced nurses are likely to appeal to new
graduates in other similar fields, such as psychology and
family studies. Calls to widen the entry gate to health visitor
education are not about removing all nursing elements from
the programmes. Instead, they are largely about removing
health visitor education from a restrictive system that is
unsuited to the task of promoting and developing the
workforce85. The Nursing and Midwifery Order also creates
complex re-registration constraints that particularly affect
midwives who do not hold a nursing qualification. This
inhibits recruitment from that field, whereas midwives were
traditionally a major recruitment pool for health visiting.
1. The underpinning philosophy and professional perspective:
a) A health-focused perspective with health being treated
as a process (not a state of being) and a consideration
of health in its overall socio-cultural context
b) Maintaining an openness to others’ concepts of health
and wellbeing and how they wish to live
c) Providing an accessible and non-stigmatising service
2. Service provision:
a) A focus on social groups, with families being one form
of social group
b) Provision of a service to address the factors that are
likely to affect health and wellbeing (i.e. often working
at the ‘pre-need’ stage)
c) Acting as an interface between groups and individuals
in the population and population-based approaches
d) Developing the capacity and confidence of groups and
individuals to improve their own health and wellbeing
e) Improving service provision for groups and communities
The amount of qualitative research, and number of literature
reviews and syntheses that describe and explain health visiting
practice, is too large to be included here in full. A small selection
of specific reviews and studies is included as an illustration of the
range of work and specific approaches to practice.
3. Capabilities and skills:
a) An ability to develop effective relationships based on
trust and openness
b) An ability to work in a range of settings acting flexibly
with other services
c) An ability to assess risk in complex situations
d) An ability to deal with conflicting priorities and
ambiguous situations, knowing when to use different,
sometimes contradictory theories and perspectives.
1. Prime Research and Development Review
As part of the curriculum development project initiated by
the UKCC in 2000, Prime Research and Development13
(which was later incorporated into Skills for Health) carried
out a rapid review of recent literature. Eleven key points and
descriptors were put out to consultation, after which a
twelfth point was added (as 3(d) below). They are listed
below, under three added headings:
These elements have obvious relevance for the kinds of
competences required by health visitors, and were used to
inform the 2002 ‘requirements for pre-registration health
visiting programmes32’. Although these were superseded
when the SCHPN proficiencies33 were introduced in 2004,
the more detailed and directly relevant health visiting
requirements appear to be still influential in many current
programmes27.
Appendix 3:
A discrete area of practice with some homogeneity
68
69
2. Assessment of health visiting practice
A major educational study, completed in 2001, focused on
identifying and classifying key components of health visiting
practice, as a means of identifying whether students were fit
to practice on qualifying90. A range of necessary capabilities
was identified, which demonstrate the unique combination of
knowledge and skills required by health visitors. Importantly,
health visitor students needed to demonstrate the capability
of knowing when to use particular elements of their overall
repertoire.
3. Nursing and health visiting practice in public health
A secondary analysis91 of three research studies involving health
visitors and community nurses identified four areas of practice
that are often viewed as ‘either/or,’ dichotomous, concepts
(see Figure A3.1). The analysis suggested that these concepts
might be better regarded as lying on a continuum, with the
nursing focus at one end, and the health visiting focus at the
other. The point is not that either profession always, or never,
apply one end of the conceptual continuum or the other.
Instead, the frequency, familiarity and use of approaches, ethos
or attitudes to practice tend to distinguish between them.
Figure A3.1:
Polarised concepts and priorities in public health
70
Individual/
population
This encompasses not only service responsibilities,
but also points to the dilemmas inherent in
choosing between personal rights and collective
responsibilities within society as a whole.
Public/
private
Access and use of public services such as health
and nursing care is related to both personal
perceptions and wider social views about
what they should be for, and what remains
‘properly’ private.
Figure A3.1:
Continued....
Determinants/
treatments
Services may be designed to directly target
the determinants of health (‘root causes’) or
to treat established problems by offering
clinical treatments to affected individuals.
Social/
biomedical
model
Views are changing and contested about
whether a social or biomedical view of health
is considered paramount in promoting the
public health.
4. 4. The principles of health visiting
These were first identified in the 1970s, through a lengthy
process of investigation led by the Council for the Education
and Training of Health Visitors86. The principles are:
•
•
•
•
The search for health needs
The stimulation of an awareness of health needs
The influence on policies affecting health
The facilitation of health-enhancing activities
These statements were initially described as principles through
which the process of health visiting is carried out, and they
have become a valuable framework for integrating health
visiting knowledge, skills, research and practice. Specifically,
the principles show that health visiting is concerned with
health promotion, not assistance, which is the usual focus of
clinical nursing. They provide an integrating framework,
rather than a list of competences or skills, and they are all
underpinned by a particular value and view of health79. The
principles continue to be used as intended, in practice,
education and research and their value has been repeatedly
reaffirmed in the years since their inception77,78,92,93.
71
5. What characterises an effective health visitor?
Research (www.mendas.com) has been commissioned to
carry out a review of the characteristics of an effective health
visitor, to inform the CNO’s Action on Health Visiting
Programme of career development work. Results are not
yet available from this work in progress.
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79
PROFESSIONAL
BRIEFING:
REGULATORY ISSUES AND THE
FUTURE LEGAL STATUS OF THE
HEALTH VISITOR TITLE AND
PROFESSION
Unite/CPHVA Unite Health Sector: 2009
PROFESSIONAL BRIEFING:
REGULATORY ISSUES AND THE FUTURE LEGAL STATUS OF
THE HEALTH VISITOR TITLE AND PROFESSION
Published by Unite the Union/CPHVA
Joint General Secretaries Derek Simpson and Tony Woodley
Unite Health Sector
128 Theobald's Road
Holborn
London WC1X 8TN
020 7611 2500
This guide book is downloadable in PDF format from
www.unitetheunion.org/health
2
SUMMARY
This paper explores the background to the removal of the
title health visitor from statute in 2001, and the resulting
issues, which are particularly pertinent to health visiting in
England and Scotland. It demonstrates the imperative to
once again protect the title health visitor in statute, to ensure
adequate resourcing of the service, relevant education and
training for health visitors to deliver the children’s policy,
particularly that ascribed to health visitor leadership i.e. in
Healthy Lives, Brighter Futures, 2009 and the Healthy Child
Programme (HCP) 2008 in England. This in turn would
ensure the public protection of children and their families
when health visitors are accountable for the delivery of such
programmes.
It makes clear that despite a new national initiative in
England, the ‘Action on Health Visiting’ programme to
increase health visitor numbers, and more clearly defined and
new roles for health visitors, health visiting will struggle to
re-establish itself as a profession, without a return to statute.
Such is the dramatic reduction in health visitor numbers since
2004 when the health visitor register closed, that there is
now a need for very urgent action to address the resulting
issues. These include the frequent failure to acknowledge
health visiting as a separate profession in related policy
initiatives, hence excluding its important public health voice,
to improve the disturbingly low morale of many of those
health visitors remaining in practice (DH, 2008) and to
respond to the failure of healthcare organisations to attract
and recruit the right calibre of applicants to education
programmes for student health visitors in England.
3
1.0 INTRODUCTION
1.1 Health visiting was first mentioned in statute in 1909,
although the title wasn’t protected until 1929. The
profession of health visiting was then protected by statute
until 2001, as a professional role distinct from nursing and
midwifery until 2001. When the Nursing and Midwifery
Order, 2001 was passed, and the Nursing and Midwifery
Council formed, despite losing its legal protection, ministers
promised health visiting equal representation to nursing and
midwifery on the new council and that health visiting would
be strengthened. However the opposite has happened and
the viability of the profession is increasingly uncertain.
1.2 Eight years on health visiting has no representation on
the NMC board and there was a 13.5% fall in the number of
health visitors between 2004, when the former health visiting
register closed, and 2008. Some education programmes for
health visitors have closed in England and nurses are
increasingly being employed as a substitute for health visitors,
creating serious accountability and safe practice concerns.
1.3 In 2008 Unite the Union/ Community Practitioners’ and
Health Visitors’ Association (CPHVA) found that 57% of health
visitors in England had caseloads of over 400 children, whilst
Unite the Union/CPHVA recommend an average of 250
children. Health visitors report that they can no-longer
effectively support many vulnerable families, and that they have
an increasing workload relating to safeguarding of children.
1.4 Nursing and Midwifery are first level registrations whilst
health visiting is a qualification at advanced and specialist
level. However the new NMC re-registration arrangements
emphasise the need for health visitors to re-register as a
nurse or midwife, rather than at their advanced and
specialist level. This further undermines the professional
status of the health visitor and does nothing to enhance
public protection.
4
1.5 Protecting a professional title in statute ensures:
•
that the title is used to describe the appropriate
professional activity
•
that the professionals using that title receive
education tailored to the occupational needs of their
profession and work to appropriate professional
standards
•
the title cannot be misused by others masquerading
as members of this professional group
•
the unique needs of the professional group are
identified in policy which helps ensure appropriate
investment in recruitment and education and training
of the professional
•
the profession is self regulating, setting and
maintaining its own standards to ensure clients’
needs are met appropriately and effectively.
1.6 Since the health visiting professional register was closed
in 2004, there has been very serious disinvestment in
recruitment to, and education of the profession. The impact
of this disinvestment, on outcomes for children and families
is becoming increasingly obvious.
1.7 Health visiting is a profession in crisis and it is increasingly
finding it impossible to fulfil its professional role in promoting
public health, public protection and safeguarding children.
Many of the difficulties it faces can be linked back to the title
being taken out of statute in 2001 and the promises made by
ministers to the profession then, not having been delivered on.
1.8 This paper should be read in the context of recent national
concerns regarding the failure in England to adequately address
health inequalities (Health Select Committee 2009), and to
safeguard our children (Laming, 2009), and the UNICEF
national league table of children’s wellbeing in Western
nations, which placed children in England at the bottom of that
league (UNICEF, 2007). It suggests the need to strengthen
rather than weaken universal services for families such as those
delivered by health visitors.
5
2.0 HISTORY OF THE HEALTH VISITING
PROFESSION
2.1
Health visiting, as a profession, will be 150 years old
in 2012 having its foundation in the public health movement
of the nineteenth century. Although health visitors work
closely with nurses and midwives and other members of the
Specialist Community Public Health Nursing (SCPHN) register,
health visitors are a distinct profession, with their own
principles and purpose. The profession had been recognised
in statute from 1909, with a national professional register
introduced in 1925. Health visiting became gradually
entwined with nursing from the mid-twentieth century,
although this was not confirmed in statute until 1962 from
which date nursing became a pre-requisite for entering
health visitor education programmes.
2.2
It was not until 1974 that the health visiting service
moved from local authority provision into the NHS. Until the
Nurses, Midwives and Health Visitors Act 1979, the three
professions each had their own separate regulating councils.
The Council for the Education and Training of Health Visitors
(CETHV) was the regulatory body from 1962-1979. The 1979
Act recognised the profession and protected the title.
6
3.0 THE STATUS OF HEALTH
VISITING PROFESSION IN 2009
3.1
Since 1998 there has been record investment in the
NHS and services specifically for children, with significant
increases in the numbers of qualified nurses and midwives
(27.57 %), but over the same time health visiting has lost
12.95% of its full time workforce (DH, 2008). This, despite
a rise of 8.5% in live births, and a population growth of
4.65%.
Figure 1: Fall in health visitor numbers 1999-2008
against a rise in midwives, birth rate and population
Over the past 4 years the fall in health visitor numbers has
been particularly dramatic with a 13.5% loss of full time
posts between 2004 and 2008 (DH, 2008), These are
average figures for England, in some areas the reductions in
posts have been as great as 45%. A recent review of
safeguarding procedures by the Care Quality Commission
(CQC, 2009) would suggest that the overall fall in numbers
and investment may now be considerably greater. This
review also found that health visitors in 62 primary care
trusts in England had caseloads in excess of 400 children,
7
the absolute maximum number recommended by Unite the
Union/CPHVA and endorsed by Lord Laming (2009).
Figure 2: Fall in health visitor numbers since the health visitor
register closed in 2004
3.2
Unite the Union/CPHVA members are telling the
union that they can no-longer meet the needs of vulnerable
families on their caseloads and a quarter fear a death similar
to that of Victoria Climbie where they work, as they nolonger have time to get to know the families for whose care
they are responsible (Adams, Craig, 2008). This situation is
very risky for families, and also places enormous stress on
health visitors, themselves. The recent NHS staff survey
(2008) revealed that they reported the second worse levels
of stress of any occupational group in the NHS. 40% of
health visitors are over 50 and 20% over 55 so able to retire.
The NHS staff survey suggested that they were the
occupational group second most likely to leave their jobs.
3.3
Meanwhile surveys of parents highlight a significant
parental desire for advice and support from health visitors,
preferably in the home, as they are seen as a ‘trusted’ brand.
(FPI, 2009, Russell, 2008)
8
4.0 OUTCOMES FOR CHILDREN AND
FAMILIES AND HEALTH AND OTHER
SERVICES FROM THE REDUCTION IN
HEALTH VISITOR NUMBERS
4.1
Unite the Union is very concerned by the level of risk
many health visitor services are responsible for, particularly
where families are vulnerable, but this is going undetected.
For example our members tell us many postnatal depression
services have been terminated due to staff shortages. It is
now well known that the consequences of depression in the
mother may be very significant in the longer term for her
new baby and family (Murray), and a significant risk factor
for maternal suicide and infanticide. There is strong evidence
for the effectiveness of health visitor intervention for
postnatal depression (Morrell, 2009). 31% of health visitors
have told this organisation that their reduced service does
not allow domestic violence to be identified and acted upon
(Adams, Craig 2008). The consequence of domestic
violence, not only for the mother, but for children who
witness it, or are victims of violence themselves, is immense
(Ramsey et al, 2002, DH, 2006).
4.2
There is also increasing evidence of other
unaddressed health and social issues due to under
investment in the health visiting service which may have long
term consequences for the health and wellbeing of children,
but also for the fiscal spend. For example:
•
•
Developmental delays going undetected is
widespread - speech therapists are reporting late
referrals of speech delayed and autistic children
(DCSF, 2008, Health and Sport Committee, 2009)
School nurses and teachers are reporting children
entering primary school with social, toileting and
nutritional problems (Puffett, 2009).
9
•
•
•
•
•
The uptake of MMR vaccine remains unsatisfactory. This
may relate to the fact that the crucial contact when
once health visitors would have discussed this with
parents, and been able to allay fears, is now undertaken
by other workers in their team or not at all.
The most recent review of serious case reviews
reported that many of the youngest children who died
were not known to social services, suggesting that
their level of risk was also not known to the health
visiting service (Brandon et al, 2009)
An increase in accidental poisoning in young children
(National Poisoning Unit, 2009)
An additional use of GP services by parents unable to
access the health visitor service (Independent Nurse, 2009)
Pressure on youth justice services
4.3
10% of children are now considered to suffer with
diagnosable mental health issues, but many might have been
prevented by early intervention in the pre-school years. There
is clear research evidence that the first two years of a child’s
life is very significant to the child’s future mental wellbeing
but most families now receive minimal contacts with a health
visitor during that period as part of the universal service
(Cowley & Adams, 2009).
4.4
In August 2008 40% of health visitors had responsibility
for over 500 children and 20% of over 1000 children (Adams &
Craig, 2008). From reports to Union the Union the signs are
that these figures are worsening daily as more posts go unfilled
due to under-investment in training. Unite believes on average
health visitors should be responsible for 250 children and no
more than a maximum of 400 children in areas of very low
vulnerability. The number should be around 100 in areas of
high vulnerability, such as in inner cities. Indeed in the well
researched Family Nurse Partnership programme, caseloads for
effective outcomes are maintained at a maximum of 25 families.
The current caseload figures in many parts of England challenge
the ability of the profession to protect the public and deliver its
safeguarding and public health functions.
10
5.0 CONCERNS AND REASSURANCES:
NURSING AND MIDWIFERY ORDER 2001
5.1
During the consultation period 2000-2001, on the
new Nursing and Midwifery Order, many concerns were
raised by health visitors regarding the loss of the legal
protection of the profession. Significantly they included:
•
•
•
•
Concern that removal of “health visiting” from the
title of the Order would remove the current
recognition of the profession and protection of the
title. Protecting the title protected the public, since
no person could at that time call himself or herself a
health visitor, or practice as such, unless registered as
a “health visitor”.
If health visiting was not mentioned in statute this
could lead to no health visitor representation on the
Nursing and Midwifery Council, hence no voice for
the profession.
Registrants not qualified or registered as health
visitors would establish the standards of education
and practice for health visiting. This would be as
inappropriate as a different professional group
deciding education and standards of practice for
nursing or midwifery.
There would not be a statutory “Health Visiting
Committee” as exists for the regulated professions
5.2
Many in the profession were reassured when
guarantees and assurances were given by ministers and
others as follows:
5.3
The then Health Minister, Lord Hunt stated:
“I make it clear that the order will regulate health visitors.
The words "health visitors" do not appear in the order
because we do not want to tie the new regulatory
11
body to only the health visiting function as it is now.
We recognise that health visiting is expanding into
other areas of community and public health practise.
We want to give the new council the flexibility to reflect that
changing role.” (Hansard 13-12-01, column 1498, added
emphasis).
5.4
Mr Hutton’s responses to questioning in Parliament
2001 are in italics, with what has happened since in bold:
•
“Health visitors will be equally represented with
nurses and midwives on that council, which is the
right way in which to proceed”
In 2009: The profession has no representation on the
Nursing and Midwifery Council board
•
“The measures that we have taken are designed to
strengthen the role of health visiting, not weaken it”.
In 2009: The viability of the profession of health
visiting and its public protection role is being seriously
challenged
•
“Our measures, including equal representation on the
NMC of health visitors alongside nurses and
midwives, are signals of the importance that we
attach to health visiting”
As soon as the NMC came into being in 2004 health
visiting was no longer considered to be a discrete
entity resulting in helath visiting no longer being
referred to in many releavant policy documents leading
to serious disinvestment in the profession in spite of
the public continuing to use the highly credible title.
•
12
“What matters are the arrangements that we put in
place under the order to ensure that health visitors
are properly represented, so that their views can be
ascertained properly and brought to bear on the
issues. The NMC will certainly do that. It is important
to have the opportunities to set up the register and
for the issues to be explored fully within the council
when it considers education and training standards”.
In 2009: Early arrangements for equal representation
are no longer in place and health visiting no longer has
a voice, and there is no obvious mechanism where
their views can be ascertained
•
“I have tried to reassure members of the Committee
that nothing in the order could be reasonably
interpreted as downgrading the importance of health
visiting. To say otherwise is not fair criticism”.
In 2009: The current ‘Commission into Nursing and
Midwifery’ does not recognise health visiting as being
a distinct profession and did not invite this
organisation to provide a commissioner.
5.5
In August 2001 the Head of Non-Medical Regulation
at the Department of Health issued guidance concerning the
“Regulation of Health Visitors under the Nursing and
Midwifery Council”. This was in response to concerns raised
by members of the Community Practitioner and Health
Visiting Association (CPHVA). The guidance stated; “The
profession will have:
1.
separate registration
2.
stronger protection of title
3.
stronger representation on Council
4.
a stronger voice in their own regulation”
5.6
A question about why the Order specified only
nurses and midwives was responded to as follows:
** “It does not. The Order specifically requires the
membership of Council to include health visitors [Schedule 2,
paragraph 3. 4 (b)]. There must be equal representation of
practitioners from each part of the register, so this facilitates
the Government’s commitment to establishing a health
visitor part, once the new Council is in place.”
13
5.7
The above reassured many in the profession, but
subsequent actions indicate they were seriously misled and
this has jeopardized the ability of the profession to deliver a
range of public health outcomes for children and families
subsequently. The turmoil faced by the profession since it
came out of statute has surpassed the concerns of even the
most vociferous opponents at the time.
5.8
The Nursing and Midwifery Order 2001 passed
through Parliament in December 2001 with Articles that
appeared to support the above assurances in particular:
Article 3
“(5) In exercising its functions, the Council shall (a) have proper regard to the interests of all
registrants and prospective registrants and persons
referred to in paragraph (4) in each of the
countries of the United Kingdom and to any
differing considerations applying to the
professions to which this Order applies and to
groups within them;
Article 6 (3) (g) the register to include a part or parts for
specialists in community and public health
Article 6 (5) Before making any proposal referred to in
paragraph (1) or (3), the Council shall consult representatives
of any group of persons who appear likely to be affected by
the proposed order”.
Schedule 1. Part 1 14 (1) Decisions of the Council and
committees shall be made by a majority vote of the members
present and voting
14. (3) Where a matter to be dealt with by the Council or
committee affects only one of the professions regulated
under this Order –
14
(a)
the Chairman shall be a member of the profession
concerned; and
(b)
a decision on the matter shall be reached on a
majority vote of the members of that profession
present and voting.”
5.9
Despite these assurances time has proven that the
concerns raised in relation to taking health visiting out of
statute have all come true. The profession has suffered a
devastating reduction in its numbers and with this a
reduction of its ability to protect public health and to
safeguard children. Rather than being strengthened the
profession no-longer has a seat on council and the SCPHN
part of the register has no representation on the professional
practice committee. Indeed, neither advertisements for
Council members or the professional practice committee
placed with any professional journal relevant to SCPHN
registrants during the recent round of appointments. This
was said to be an oversight, but it again reflects the status
given to the profession by the regulator.
15
6.0 SPECIALIST COMMUNITY
PUBLIC HEALTH NURSING
REGISTER
6.1
In 2002 the Nursing and Midwifery Council followed
due process as allowed within the Order to propose setting
up a third part of the register for public health practitioners.
At this point, the Department of Health stated that the title
must include “nurse” and entry to this register must be
through nursing or midwifery. Contrary to the Ministerial
reassurances given to the profession (as in points 5.3 and
5.4), this new stance was apparently non-negotiable. The
eventual outcome, after much debate and argument within
the profession and through Council, was the establishment
of the third part of the register for “Specialist Community
Public Health Nurses” (SCPHN). This was not the title that
representatives of the third part of the register wanted. They
saw no need for the title to include the word ‘nurse,’ since
practitioners included on that part would not be working in
a nursing model, and the term ’nurse’ was not mentioned in
Article 6 (3) (g); nor was it included in any of the example
titles suggested by Lord Hunt when he introduced the Order
in Parliament.
6.2
In 2005 the NMC conducted a wide, open and
transparent consultation process regarding changes to the
maintenance and renewal of registration as a specialist
community public health nurse. This was done in
accordance with instructions in the Nursing and Midwifery
Order 2001. The decision passed at Council was that
SCPHNs could renew their registration on that part of the
register, without renewing their nursing or midwifery
registration.
16
6.3
In December 2007 the NMC reversed this decision,
without it going out for consultation with registrants, as
required in rule, or indeed even through the SCPHN committee
within the NMC. Unite lawyers support our view that this is in
contravention of the terms set in statute within the Nursing
and Midwifery Order 2001. The NMC defence was that they
instigated this change at the behest of the Department of
Health as the ability to just be revalidated on the SCPHN
register was considered to be a irregularity. The NMC is a
statutory body which, Unite/CPHVA believes should be
independent of government and its officials. The above actions
of the Nursing and Midwifery Council further confirmed the
fears expressed by some health visitors in 2000-2001.
17
7.0 SUBSEQUENT POLICY AND LEGAL
CHANGES LEADING TO THE LOSS OF
HEALTH VISITOR OR SCPHN/PUBLIC
HEALTH REPRESENTATION ON NMC
7.1
The DH consultation document “Health Care and
Associated Professions (Miscellaneous Amendments) Order
2008” contained proposed amendments to the Nursing and
Midwifery Order 2001. These included the removal of the term
“registrant” throughout the Order, to be replaced by registered
nurses and registered midwives. After petitioning by Unite the
Union, the Minister, Ben Bradshaw, MP, overturned the
proposal and the term ‘registrant’ was not changed to ‘nurse or
midwife’.
7.2
In April 2008 – there was a unanimous view of council
that the 7 registrant members on the new council should be
made up of a representative from each of the 4 countries and
at least one representative of each of the 3 registers. Unite
supported this position believing that if it wasn’t in statute then
the voice of public health practice would not be heard in the
council. This was overturned following the consultation on the
NMC (Constitution) Order 2008, with a requirement that the
council should contain registrants from its many constituent
groups but not necessarily from each council register.
7.3
When the Council appointments took place there were
no appointments from the SCPHN register, either onto council
or onto the professional practice committee. This may in part
be as the posts were not advertised in the Community
Practitioner Journal, the main professional reading of these
professionals. This places public health practice in a very
vulnerable and unacceptable position in Council as it no longer
has a professional voice, despite the NMC’s recognition,
through the development of the SCPHN register, of its unique
form of practice.
18
8.0 CONSEQUENCES OF
PREVENTING STAND ALONE
REGISTRATION ON THE SCPHN
REGISTER
8.1
Health visitors and others on the third part of the
register must prove that they can meet the criteria of being a
midwife or nurse rather than their specific, specialist practice
competencies. This requirement inhibits development of
health visiting as a profession, because it emphasizes the
need for health visitors to develop competence in the
different fields of nursing and midwifery. Instead, we believe
re-registration should emphasize their competence and
continuing professional development specifically within the
highly skilled and specialized field in which they are
practicing, that is, within health visiting.
8.2
Many of our members have expressed concern that
they would no-longer be safe to practice as a nurse or
midwife but the NMC will re-register them anyway on one or
both of these parts of the register depending on their prior
pre-registration qualification. Health visitors who are
competent as health visitors, but not as nurses or midwives
(having perhaps not practiced in either of those two fields for
20 or 30 years) are accountable, through their scope of
practice, for applying for work only if they are fit to practice
in the field. However, forcing an unwelcome re-registration
upon these practitioners, then depending entirely upon their
honesty and integrity in employment matters, raises
questions about how (or even whether) the nursing register
maintained by the NMC performs its primary purpose of
protecting the public. It places registrants in a vulnerable
position for in order to practice. As a health visitor they must
state they are competent as a nurse which implies to the
public a level of competence commensurate with a single
registered nurse and does not equate to the skills a Health
19
Visitor may have as opposed to a registered general nurse. It
is understood that when the NMC made this decision they
considered the nursing skills that general nurses had that
were used by health visitors in daily practice e.g.
communication skills rather than clinical ones rather than
consider the additional skills required to be a health visitor
which would have drawn the opposite conclusion from the
one agreed and acted upon. This clearly demonstrates a
failure on the part of the NMC to protect some of the most
vulnerable in society, surely their raison d'etre?
8.3
In the case of midwives, the notification of intention
to practice is the document that must be signed as the ability
to revalidate must be signed off by a supervisory midwife, it
would require direct entry midwives to return to midwifery
practice to achieve this. Effectively this is now closing the
door to midwives, who took the direct entry route into that
profession, from entering health visiting. Not only does this
disadvantage the health visiting profession, who have
traditionally recruited from this source, it also closes a career
option for direct entry midwives. Those direct entry
midwives already working as health visitors have been given
a list of activities which the NMC say allow them to be
revalidated as health visitors, Unite considers this to be
unsatisfactory. We are increasingly hearing of Supervisors of
Midwives, quite legitimately, refusing to sign the revalidation
paperwork for health visitors who were previously midwives.
At least one higher educational institution which educates
health visitors is now reluctant to accept direct entry
midwives onto their programme.
20
9.0
PROFESSIONAL OUTCOMES
AND CONSEQUENT RISKS TO
PUBLIC PROTECTION FROM LOSS
OF HEALTH VISITOR AS A TITLE
AND PROFESSION IN STATUTE.
9.1
In the light of the recent case of Baby P and the new
Laming recommendations (2009) it is clear that a high level
of education and skill, and a well resourced health visitor
workforce must be available to safeguard children. There has
been a very significant fall in health visitor numbers since
health visiting was removed from statute, leading to many
reports and published concerns about the ability of the
profession to deliver quality and safety in their services (e.g.
Laming Review, Care Quality Commission and others).
Despite this, the NMC has distanced itself from these
extreme staff shortages describing them as a service, rather
than regulatory issue. This may in part be due to there being
no SCPHN representation on the NMC and hence a failure of
the current council members to fully understand public
health practice and make the link to public protection.
9.2
Of extreme concern is that as ‘health visitor’ is nolonger a title in statute, anyone can now call themselves a
health visitor and practice as such. Indeed, a number of
websites have been set up to provide health visiting advice,
but are not necessarily providing advice from health visitors.
Anyone can set up such a site and give the illusion it is run
by trained health visitors. As yet, commercial companies
don’t seem to have realised this, but there have been
incidences of bogus health visitors, and in terms of public
protection it is only a matter of time before private services
are set up by non health visitor educated individuals calling
themselves ‘health visitor’, as has happened in nursing. As
health visitors visit families in the home, unsupervised, this
potentially has very serious consequences.
21
9.3
The fact that policy now so often refers to nursing or
midwifery, but not health visiting suggests that their unique
contribution to public health practice (Cowley, Adams 2009)
is often not understood by policy makers and managers. This
is despite the fact that the guiding policy document for
community practice, ‘Liberating the Talents’ clearly sets out
the need for a public health workforce in the community.
Furthermore it has contributed to the under-investment in
health visiting and sometimes inappropriate skill mixing of
health visitor posts, substituting too many junior staff for
health visitors. This confuses the public, who often presume
the person in front of them, representing the health visiting
service, is indeed a health visitor.
9.4
Sponsored education places for health visiting have
consistently fallen over the past few years in England and
Scotland and seem to be at an all time low. This is despite
the age profile of health visitors and the government policy
to improve the health and well being of children and reduce
inequalities. Indeed this organisation believes that there is a
need to increase the workforce by at least 5000 full time
equivalent health visitors immediately, and another 4000
over the next 10 years to replace those retiring. The
government is encouraging further investment in training in
2009/10 through their ‘Action on Health Visiting’
programme, which is being taken forward in partnership
with Unite/CPHVA, but it would seem many areas of England
specifically can no-longer attract the caliber of students
necessary both in terms of personal and academic attributes.
It is not possible to widen the entry gate to attract more able
recruits, because of the statutory framework put in place
when health visiting was removed from statute.
9.5
As can be seen in Table 1 the number of new health
visitor registrants fell very significantly between 2004 and
2008 so that far fewer newly qualified health visitors are
entering the register than the number retiring. There is a
need for far greater support for the educational
22
infrastructure, including practice teachers, to ensure a large
increase in numbers qualifying. Support for health visitor
education has been reduced, because it has now designated
as a ‘post-registration nursing’ qualification, which is treated
as continuing professional development for funding
purposes, rather than as an initial professional qualification.
The funding reduction can, therefore, be directly attributed
to the removal of health visiting from statute.
Table 1: New Entries to Health Visiting Part of the UKCC Register (Part 11) UKwide 1989-2004 and to SCPHN part of NMC (annotated HV) 2004 - 2008
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
980
1028
909
814
768
640
609
629
738
758
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
186*
467*
721*
814
952
917
884
820
551
400
Source: 1989-1998: UKCC database; 1999-2008: NMC response to
Parliamentary Question 6th July 2009, Maria Miller MP,
NB*, the current IT system used by NMC was put in place at end of 2002; data
from 1999-2002 were added into the system through various data migration
projects.
9.6
The system of pre- and post-registration education
and training, in place for nursing and midwifery, works well
for those two professional groups, but not for health visiting.
Over the past five years, the heath visiting profession has
been treated, in legal, education and regulatory terms, as if it
were a post-registration nursing qualification, instead of a
profession with significantly different recruitment,
educational and practice needs. The many difficulties and
adverse experiences outlined in this paper have shown that
the system that works well for nursing and midwifery, fails to
serve the needs of the different profession of health visiting.
The resulting risks to the public are neither recognised nor
acknowledged by the regulatory body, because they are
wholly focused upon nursing and midwifery, and not at all
on health visiting. Ultimately children’s health has been put
at risk by these circumstances as in many areas they are
receiving a very suboptimal health visiting service.
23
10.0 CONCLUSION
10.1 The future viability of health visiting as a profession
able to protect child and family health in England, and
indeed Scotland, is uncertain. Strong public health policies
in the health departments of Wales and Northern Ireland
meanwhile, seem to be helping to buffer the effects of the
loss of regulation in those countries.
10.2 Unite the Union strongly believes, there is clear evidence
that the crisis in health visitor numbers in England, was in part
precipitated, and made worse, by the loss of the legal status of
the profession. An ongoing belief by some that health visiting
is a form of nursing, has proven counter productive to
delivering public health outcomes for children and families.
Health visiting is not task related, does not primarily address
illness, and it operates in a preventative health promotion and
public health context, particularly applying social and emotional
models of health. These differences have been clarified by
phase one of the ‘Action on Health Visiting’ programme.
10.3 There is significant proof that assurances given to the
profession by government, when it was taken out of statute in
2004, have not been delivered. Furthermore, that all the
concerns of many in the profession then, have come to fruition.
Rather than strengthening health visiting, this action has led to a
real possibility of its demise in some areas in the future.
10.4 Now that the profession has reduced internal
influence within the NMC it has become even more
vulnerable. As a result Unite the Union has well founded
fears regarding the direct and indirect consequences for
children and families. Without professional health visiting
24
representation the council will be vulnerable to inappropriate
decision making in relation to the education and training of
health visitors, which is shortly to be reviewed.
10.5 We would like to call on the NMC council board
members, the NMC Professional Practice Committee, the
government, peers and relevant others to consider the
dangers to public protection from the current legal status of
health visiting. There is now a very real threat to maintaining
a well educated and numerically adequate health visiting
workforce in many areas of England (Ly, 2009) and
consequently to addressing inequalities in child health and
wellbeing (Cowley, 2009).
10.6 The recent Laming report (2009) reiterated the
importance of a robust health visiting workforce to
safeguard children, as did the Health Select Committee on
Inequalities. The policy, ‘Healthy Lives, Brighter Futures’
(DCSF, 2009) called for an increase to the number of health
visitors and important new roles for health visitors in leading
the delivery of the Healthy Child Programme, and in working
with Children’s Centres. The ‘Action on Health Visiting’
programme was launched by the Department of Health in
England in March to help deliver an improved health visiting
service to respond to these policy imperatives. However, due
to the evidence cited in this paper, the union is increasingly
concerned that alone, this will not have sufficient leverage to
protect the professional contribution of health visitors to the
health and well being of children. Before the capacity of the
health visiting workforce can be strengthened, it must be
recognised as a distinct profession in statute.
25
10.7 Unite the Union, and a growing number of other
well informed commentators, agree, the legal status of
health visiting requires urgent re-examination. If the title
‘health visitor’ was protected in law and the profession was
to go back into statute, this would send a strong message to
commissioners that they must reinvest in these professionals.
This would in turn enhance public protection through a well
educated and resourced workforce, and lead to the delivery
of robust public health outcomes in line with current
evidence and children’s policy. It would also allow the
education and training of health visitors to be strengthened,
including mainstreaming health visitor preparation at
Master’s level. This would allow graduates from professions
other than nursing, to enter health visiting through fast
track, or a single entry route which would further strengthen
the profession. It is an imperative to increase health visitors
ability to contribute to reducing health inequalities and
promoting the health and wellbeing of pre-school children
through improved education and training and an increase
the numbers of trained health visitors.
Dr Cheryll Adams
Lead Professional Officer, Strategy and Practice
Development
Community Practitioners’ and Health Visitors’
Association
Unite Health Sector
October, 2009
26
ACKNOWLEDGEMENTS
The development of this paper has been informed by many
senior health visitors who have intimate knowledge of the
issues it refers to, in some instances through membership of
the NMC, Specialist Community Public Health Nursing
Committee when it existed. Our thanks are extended to
them for being so generous in checking drafts and providing
back ground papers and information.
27
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•
Adams, C & Craig, I (2008) A Service at crisis point.
Community Practitioner, 81:12 p 34-35.
www.commprac.com
•
Brandon, M. Beldrson, P. Warren, C. Howe, D.
Gardner, R. Dodsworth, J. Black, J. (2008) Analysing child
deaths and serious injury through child abuse and neglect:
what can we learn? A biennial analysis of serious case
reviews 2003-2005. DCSF Research Report DCSF-RRO23
London
•
Care Quality Commission. Safeguarding children:
A Review of arrangements in the NHS for safeguarding
children. CQC-027-2000-CWP-072009. Care Quality
Commission. London 2009
•
Care Quality Commission (2009) National Survey of
NHS staff 2008. CQC.
http://www.cqc.org.uk/publications.cfm?fde_id=10986
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Cowley S, Adams (2009) The Universal Health
Visiting Service. Unite/CPHVA
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DCSF (2008)The Bercow Report - Better
communication: Improving services for children and young
people with speech, language and communication needs.
DCSF
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Department of Health (2009), Department for
Children, Schools and Families (DCSF). The Child Health
Promotion Programme DH, DCSF. London
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Department of Health (2009), Department for
Children, Schools and Families (DCSF). Healthy Children,
Brighter Futures DH, DCSF, London
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Department of Health (2008) Children’s workforce
figures. Department of Health
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Department of Health (2003) Liberating the talents of
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Department of Health. (2007) Responding to
Domestic Violence. DH. London
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Family and Parenting Institute(2009) Health visitors:
an endangered species. Family and Parenting Institute,
London.
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House of Commons Health Committee. Health
Inequalities. Third report of session 2008-2009. HC 286-1.
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Independent Nurse (2009) News report. February
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The Information Centre (2009) NHS Hospital and
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Detailed Results 2008. The Information Centre, London
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Ly, K. (2009) Last chance for change. Community
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•
Morrell CJ, Warner R, Slade P, Paley G, Dixon S,
Walters SJ, Brugha T, Barkham M, Parry G, Nicholl J. (2009)
Clinical effectiveness of health visitor training in psychological
interventions for postnatal women – a pragmatic clusterrandomised trial in primary care. BMJ. 338: a3045
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Murray L, Cooper PJ. (1997) Effects of postnatal
depression on infant development. Arch Dis Child 77(2):99101.
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National Poisons Information Service - Annual Report
2008/2009 National Poisons Unit
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Neil Puffett (2009) Teachers given guidance on
children who still wear nappies. Children & Young People
Now 3 August 2009
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Ramsay J, Richardson J, Carter YH, Davidson LL,
Feder G.(2002) Should health professionals screen women
for domestic violence? Systematic review. BMJ
325(7359):314
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Russell S. (2008) Left fending for ourselves. A
report on the health visiting service as experienced by Mums.
Netmums: www.netmums.com
•
Scottish Parliament. Inquiry into child and adolescent
mental health and wellbeing: Health and Sport Committee
seventh report, (2009) (session three). Edinburgh: Scottish
Parliament
•
The Lord Laming. (2009) The protection of Children
in England: a progress report. HC 330. The Stationery
Office, London
•
UNICEF (2007) An overview of child well-being in rich
countries. UNICEF
30
Notes:
31
Unite
CPHVA
128 Theobald's Road
Holborn
London WC1X 8TN
Tel: 020 7611 2500
www.unitetheunion.com
FC/2381/10/09
31stMay 2012
SE1 7
JN
Tim Spencer-Lane,
Law Commission,
Steel House,
11 Tothill Street,
London SW1H 9LJ
Law Commissions review on regulation of healthcare professionals
Response from the Guild of Healthcare Pharmacists
Thank you for the opportunity to respond to this consultation. The Guild of Healthcare Pharmacists
represents UK wide around 4,000 pharmacists including the majority of hospital pharmacists, pharmacists
employed by NHS Primary Care organisations and pharmacists employed by other public bodies such as
Prisons and the Care Quality Commission. The Guild is part of the health sector of the union Unite.
The following pages set out our formal response and this should be taken in conjunction with the views
expressed at the engagement event at Unite House. Pharmacy in Great Britain has the newest of the nine
statutory health professional regulators created through the Pharmacy Order 2010 and uniquely remains
the only profession in the UK to have two regulatory bodies one of whom also has responsibility for the
registration and inspection of premises. We understand the desire for reducing complexity, potential
inconsistency and recognise the practical difficulties set out in Enabling Excellence for governments in
bringing forward legislative changes. We would also welcome improvements in performance, reduced
bureaucracy and reductions in fees to our members who are registrants. However we recognise that as a
profession having the “youngest” regulator who has undergone major changes there is little appetite for
further change, although we recognise the creation of the General Pharmaceutical Council (GPhC) has for
our profession brought about a regulator who is beginning to show improved performance and reduced
costs with a refreshing outlook on regulation focused on outcomes rather than process. They have shown
new leadership in seeking to enable and empower the profession and promote moves to a more
appropriate and just culture. However we also recognise that experience in other areas of regulation
particularly within the financial world has shown that innovation, creativity and adaptive modernisation
may not always be appropriate and there are many virtues in a staid and conservative regulatory
environment that enables only essential slow and gradual change for registrants. The difficulties in
changing the legislative framework through Section 60 orders ensure that changes have to be well
debated, explored and of sufficient priority to commence the process focused on a long-term need rather
than a short-term desire for change.
President: David Miller
Professional Secretary: Barry Corbett
Email: [email protected]
Website: www.ghp.org.uk
1
PART 2: THE STRUCTURE OF REFORM AND ACCOUNTABILITY
As pharmacy has only had reform of regulation for less than two years the GPhC appears to be operating
against many of the principles outlined throughout the consultation so as discussed our enthusiasm for
change is therefore diminished. Additionally as we commented at the engagement event this appears to
be the first time that the Law Commission, the Scottish Law Commission and the Northern Ireland Law
Commission have produced a UK wide review. Consequently we are disappointed that you did not seek
to address any issues of the effect of devolved responsibilities that have created in pharmacy a situation
whereby pharmacist regulation is a Westminster issue, pharmacy technician regulation is a devolved issue
such that they are now registered in only 3 countries and our members in Northern Ireland have a separate
regulator with a size that leads to reduced guidance for registrants and increased costs of registration. Our
members in Northern Ireland during the process of change from a joint regulator and professional body in
the other 3 home countries supported a move to a single UK regulator.
We remain unconvinced as stated of the need to change the current system of change based on section 60
orders and whilst we would expect the CHRE to promote good practice and oversee the existing
regulators we would not want to see that role enhanced as that could lead to duplication, increased costs
and inhibit the flexibility of existing regulators, who will have different challenges. We also have
reservations about changing the role of the Privy Council, it is important that registrants whose livelihood
is dependent on their registration have a system that is seen as independent of government and equally it
is important that the public feel that the oversight is fair and consistent. The requirement for Privy
Council approval ensures that changes are addressing long-term essential issues; they are well researched
using DoH resources across all devolved administrations and not at the registrants expense and it allows
an appropriate independent apolitical oversight that can be accessed and addressed by other parties with
an over-riding focus on the needs of the public.
In relation to the specific proposals we have no issues with the proposals to bring forward a Single Act
providing consistency across each of the regulators with the ability to adopt and utilise those powers
based on the needs of the public and the profession regulated, as we expect little change from the current
system. We also support the requirement in statue for regulators to consult on any changes that are
binding or set a standard, benchmark or competency although we would use the terminology in Para, 2.47
that includes not only professional bodies but also organisations seen to be representing registrants.
We would wish to retain the current oversight by the Privy Council on the need to change or amend rules
and the current system whereby governments can make changes through section 60 orders, as this
provides independence, long term stability and prioritises change in the interests of the public.
We do not believe the case has been made for the enhanced role of the CHRE or for the need for direct
government intervention in taking over the role of a regulator.
PART 3 - MAIN DUTY AND GENERAL FUNCTIONS OF THE REGULATORS
Until recently pharmacy had a professional body that undertook the regulatory duties, this remains the
position in Northern Ireland. This meant that in practice regulation became over-zealous with an
excessive focus on maintaining confidence in the profession due in part to the commercial nature of the
majority of the profession rather than the need for public safety. We are quite clear the paramount duty of
a regulator is to protect, promote and maintain the health, safety and well being of the public through
ensuring proper standards for safe and effective practice. It is only when this paramount duty is affected
by the behaviour of a professional such that a member of the public would not feel safe or secure with
that practitioner should there be intervention by the regulator. Thus if an individual had been convicted
of a serious criminal offence such that a member of the public would reasonably not feel safe in their care
would action be required.
Thus we would support a modified version of option 2 as largely described in Para 3.22.
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PART 4 - GOVERNANCE
Hospital Pharmacists and others in the public sector are currently regulated by a recently formed
regulator, with a Council and officials, this provides for us the appropriate structure and we remain
unconvinced on the need for change to a more board-like structure.
Pharmacy is a diverse profession having two groups of registrants and with the changes in healthcare
service delivery both within countries and sectors any Council should have access to expertise in all
sectors of the profession, reflect the separate professions and have geographical diversity in practice
settings. Therefore should the reforms proceed we would wish the maximum and minimum size of
councils to be stipulated to allow access to the appropriate range of practice environments and have an
equal proportion of lay and registrant members
We would oppose self appointment of council members within regulators including the Chair and wish to
support the existing process with management by the Appointments Commission with Privy Council
oversight, as providing independence, transparency and ensuring members of the appropriate competence,
quality and values. There should also be a limit on serving on another council as this has the danger of
reducing independence and begins to “professionalise” the lay member role.
We would take your definition of lay member further from a person who is not and has not been entered
in the register of that particular regulatory body to one that is or has not been on the register of any
healthcare regulator.
PART 5 - REGISTERS
We are supportive of the role of a registrar being appointed by council to manage the fundamental
responsibility of maintaining the registers of registrants with a licence to practice. As the role of the
register is to allow the public to check whether an individual practitioner is fit to practise we would see no
advantages in maintaining voluntary or non-practicising register, except potentially for a short period
prior to full registration for a new profession. This is in-line with our view that the role of regulator is
protection of the public not the reputation of the profession.
Taking the view of public protection rather than the inclusion of professional reputation as the basis of
registration it would be a decision for UK governments and increasingly European Councils to determine
the need for specialist lists. If it could be shown that a sector of pharmaceutical practice has a separate
and distinctive set of competencies that require a clearly defined educational or developmental
programme to ensure a specific practitioner can only undertake this additional clinical role then that needs
to be recognised by the public and this should precipitate appropriate action by governments.
In a similar vein we would take the same approach the issue of student registers and support their
potential inclusion. We are aware of the changes being proposed in Modernising Pharmacy Careers such
that undergraduate pharmacy students will have an increasing contact with patients and become
participate in care delivery, although not direct their care. The current method of ensuring education and
training providers ensure the sense of professionalism is developed and they have local fitness to practise
processes we believe could be enhanced by student registration and it may be that if the full costs of the
current processes for individuals, education providers and employers are studied student registration may
provide a simpler, more effective and economic method of ensuring public safety.
In regard to protection of titles and functions we recognise that to ensure free movement of professions
throughout the European Union these titles and functions have a meaning outside the UK borders.
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PART 6 - EDUCATION, CONDUCT AND PRACTICE
In is important that regulators continue to define the outcome standards for education and training for
those entering and continuing on the register and have quality assurance processes in place to ensure that
providers are delivering to those standards. It is also important that the standards for those entering the
register are consistent and equitable with those seeking to remain on the register. Even within pharmacy
we have two entry levels for each of the professions so it is important that regulators have flexibility to set
standards provided there is a degree of consistency based on a robust assessment of competencies
required and risks posed within and between each profession.
We are not supportive of the terms tier one and tier two guidance, as defined, as in many ways we would
expect guidance or advice on professional practice to come from professional representative bodies not
the regulator. We would expect mandatory standards of compliance to be set by the regulators. We find
the comment that non compliance with mandatory standards can be justifiable to be useful.
PART 7 - FITNESS TO PRACTISE: IMPAIRMENT
From a pharmacy perspective the current two-stage approach for determining fitness to practice should be
retained with the emphasis being on the future risk to the health, safety and well-being of the public based
on the five categories outlined in option 2. This provides clear criteria to enable assessments of fitness to
practice that are understandable to professionals and the public.
PART 8 - FITNESS TO PRACTISE: INVESTIGATION
The GPhC has had significant success with in dealing with a large number of legacy cases held over from
the previous regulator and we would support a system that provides prompt, consistent and high quality
decision making as being in the interests of the public and registrants. There are advantages in regulators
having an ability to consider cases without referral through an investigating committee provided the
process is open and transparent.
PART 9 - FITNESS TO PRACTISE: ADJUDICATION
We would support the continued separation between investigation and adjudication and wish to maintain
the independence of those statutory committees from the Councils and their officers. In relation to the
composition of panels we support the panels being appointed by a process separated from the Council,
ensuring that council members and investigators are not allowed to be a member of the panel and each
panel would be required to include a lay member. We would also seek another requirement that the panel
be required to have a member with detailed understanding of the sector/specialty of practice of the
registrant.
We would support the harmonisation of sanctions across the regulators and think it appropriate for
regulators to determine their own processes and would support the ability to review a decision if agreed
by both the regulator and the registrant.
PART 10 - THE COUNCIL FOR HEALTHCARE REGULATORY EXCELLENCE
We have no comments on this section
PART 11 - BUSINESS REGULATION
We concur with the view that regulation of individuals needs to be accompanied by a system of regulation
of the environment in which that practice occurs. Current regulation is based on services being delivered
either within a NHS environment or by individual practitioners. Increasingly many practitioners are now
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employees rather than contractors and this has created a power imbalance between those who deliver the
service and those with the decisions about resources and structure of the service that can have effects on
service standards and therefore public safety.
All regulators should therefore have the powers to set enforceable standards for owners and those
undertaking or managing the healthcare environment that can provide support to registrants to maintain
safe and effective practice. The public inquiry conducted by Mr Robert Francis QC into Mid
Staffordshire NHS Foundation Trust is likely to raise issues in this area and professional regulation and
the support of professionals working within an institution where patient care was routinely neglected by a
Trust that was preoccupied with cost cutting, targets and processes and one which lost sight of its
fundamental responsibility to provide safe care. Shortages of staff and a culture of bullying those
professionals who raised concerns were key factors in creating that unsafe healthcare environment.
PART 12 - OVERLAP ISSUES
We would like to see the general duty be expanded to include professional or trade representative bodies
recognised within the profession.
PART 13 - CROSS BORDER ISSUES
This is a difficult area and any proposed legislation will need to take due cognisance of the revision of the
professions directive currently being addressed within the EU. There will be a requirement for regulators
to ensure that they have appropriate processes in place to determine equivalence without barriers to the
freedom of movement of those professionals showing that any additional process is clearly for the benefit
of patient safety.
Barry Corbett
Professional Secretary
Guild of Healthcare Pharmacists
David Miller
President
Guild of Healthcare Pharmacists
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