Examination of Witnesses (Questions 525-539)
MR MARC
SEALE, MR
FINLAY SCOTT
AND MS
SARAH THEWLIS
15 JUNE 2006
Q525 Chairman: Good afternoon, I am sorry
we have started a few minutes later. Could I ask you, for the
sake of the record, to introduce yourselves and the organisation
that you come from?
Ms Thewlis: I am Sarah Thewlis,
Chief Executive at the Nursing and Midwifery Council.
Mr Scott: I am Finlay Scott, I
am the Chief Executive at the General Medical Council.
Mr Seale: I am Marc Seale and
I am the Chief Executive at the Health Professions Council.
Q526 Chairman: Thank you very much
for coming along and to help us. Could I declare my interest,
as I am currently a lay member of the General Medical Council?
Could I ask an opening question to all of you? How are regulators
helping to develop a workforce that is fit for purpose for the
21st century, as opposed to just developing more of the same?
Ms Thewlis: You have three regulators
here and one of the things as a team—and I think we do work
collaboratively across it—is very much looking at seeing
regulation in its broadest context and not just seeing it dealing
with unfitness to practise issues. So very much looking at the
individual registers we keep and making sure that people who come
on to those registers are capable of what we call safe and effective
practice. We all do that in very different ways because obviously
we have different professions that we work with, but I think very
much when you are working at workforce planning it is about making
sure that people that come on to the register are competent—but
that is obviously something that the individuals themselves have
responsibility for—and also to work with employers. At the
Nursing and Midwifery Council as a new body we have worked very
hard with employers about making sure that we can provide a flexible
workforce. I am sure we will go on to some more detail, but just
for the record there was some conversation about the emergency
care practitioners and I think it would be helpful to say what
our position on that is, and I am sure that Marc will come in
and do some of the detail. Some of those people who are nurses,
who have gone into emergency care practitioners, one of the important
things to say is that if people are on a professional register
then obviously they have signed up to a professional set of standards
and a Code of Conduct by which they are regulated. So I think
the argument about who regulates them is probably a secondary
point. The important thing is that somebody regulates them, and
I think one of the discussions that we are going to have for the
review of non-medical regulation is looking at some of these emerging
roles that come out and how those get managed. But I would very
much want to put it on the record, I would not want you to think
that there are people out there doing things and nobody is actually
controlling that.
Mr Scott: Good afternoon. To answer
your question, to recall that we have four statutory functions,
although to read the Press and listen to the radio and television
you would often think it was only one, namely dealing with doctors
who are impaired. The other three functions, that is Standards,
Ethics, Education and Registration, all help us to contribute
to the shaping of the workforce through influencing not only undergraduate
medical education and training, but also the attitudes, the ethics
and principles that doctors take to their work day by day and,
as with the Nursing and Midwifery Council and other regulators,
the very direct control over who joins our register from outside
the UK and the EEA. In addition we ensure that we always consult
widely on any proposals that we wish to make. For example, when
we laid down new guidance in 1992 on the undergraduate medical
curriculum that was the result of extensive work involving others,
and as we are revising that at the moment again we are ensuring
that we fully involve representatives of the public, employers,
and of course representatives of the profession, to try to ensure
that the public's expectations of doctors can be reflected in
the way that the doctors of today are educated.
Mr Seale: In addition to the points
that Sarah and Finlay have raised, I think one of our roles is
very much to ensure that regulation is not a constraint for development
of the healthcare system in terms of what individual practitioners
can do. The Health Professions Council also has a specific role
in advising the Secretary of State of which new professions should
become statutorily regulated, and that, I think, is vital in terms
of protection of the public. I think the last thing is that all
three of us have participated in the Foster and Donaldson Review
and we are eagerly awaiting the outcome of that because I think
that will that enable the regulators to be fit for purpose as
we move forward into the existing century.
Q527 Chairman: Could you tell us,
as well as setting professional standards—and it probably
relates to what you have just said, Marc—should regulators
be involved with regulating the activity levels and clinical outcomes
of professional staff? Is it more than just setting standards?
Mr Scott: Volume levels, I am
absolutely convinced, are no concern of the regulator; the regulator
is clearly concerned with the quality of outcome. I think that
is a different dimension. First of all, can I explain that we
have found it helpful to think of regulation in terms of a four-layer
model, the four layers being personal regulation, which reflects
the set of values, ethics and principles that every professional—not
just doctors—should take into their work; a team-based regulation,
reflecting the fact that, in our case, doctors increasingly work
as part of teams and not on their own; workplace regulation provided
by employers and other healthcare providers; and finally national
regulation is provided by us and by, say, the medical Royal Colleges.
Our role in terms of the quality of outcome is to lay down broad
principles through our core guidance, Good Medical Practice,
which influences how doctors approach their interaction with patients
and their relationships with colleagues. The definition of specific
standards in relation to outcomes is best left to those with specialist
knowledge, and that is generally not the province of the GMC in
our case but of the medical Royal College and faculties. So our
job is to work with the medical Royal Colleges to ensure that
those standards are available and understood by the profession,
and in the event that allegations are made by doctors on the lowest
of the standards, to draw in appropriate expert help in making
a decision as to whether that is true or not.
Ms Thewlis: I think building on
from that it is the whole issue of what evidence individual practitioners
will produce as far as when they are coming to re-register. At
the Nursing and Midwifery Council, building on our successor body,
the UKCC, we have something called PREP, which means that every
three years people have to produce whatever evidence they have
done to make sure they have kept themselves up to practice. We
accept that we have to do some work on that and it is not as robust
as it should be, but I think that there is an important philosophical
point that people recognise that they do not just get on to the
register and stay there for life and are only taken off if there
is some sort of misconduct or lack of competence within that,
and I think very much what we are looking to do—looking
at some of the work that the GMC have done—is looking at
how we can accept the four-layer model that Finlay talks about,
and recognising that we, as the regulator, have a part in that
along with things such as are happening on a local basis and also
with individual teams, rather than actually just producing something
and expecting somebody to do that completely independent of what
is happening within the workforce. One area that I think is quite
a good example is some of the work that we have done with the
Royal Pharmaceutical Society around extended prescribing, where
very much if you are looking at that spreading across a wide range
of professions, looking at what are some of the core standards
that we should all work together around, how you can train people
to actually take on the extra responsibility as far as prescribing
is concerned, and I think that is a good example of where you
can see regulation working across the regulators, seeing how we
are looking to improve patient care.
Mr Seale: The only other point
I would like to add is that while we are a regulator of health
professionals and not the environment those individuals work in,
under our standards of conduct and performance ethics our registrants
are also required to only undertake action if it is safe and effective,
and therefore we would not expect a registrant to be working in
an environment that they thought was unsafe, whether it was to
do with, let us say, infection control, or indeed the workload
was so heavy that they could not deliver appropriate healthcare.
So in a sense we do indirectly have an influence on the working
environment of those registrants.
Q528 Charlotte Atkins: Sarah, your
evidence stated that the involvement of regulators in workforce
planning is "vital but frequently overlooked". Can you
give us some examples of that happening, please?
Ms Thewlis: I think a good example
would be the whole area of international recruitment. I joined
the Nursing and Midwifery Council in 2002 and obviously I think
there had been a policy direction about looking to increase capacity
within the whole of the NHS, but I do not think anybody had a
discussion with the regulators about what that was going to mean
about people coming on to the register. So just to give you some
figures, in 2000 we were looking at about 5,000 people coming
on to the register, and then at the peak in 2002 it was up to
15,000 that were looking to come on to the register. The system—and
I think this is partly a responsibility for us as regulators—is
really looking at some of the trend analyses and how really we
could have looked at a different way of how we were going to handle
some of those applications; and what we wanted to do was to make
sure, as the regulator, that we could actually say, "Yes,
safe and effective practice," and I think some early discussions
would have been quite helpful around that. That is the first point.
The second point would have been around some of the treatment
centres that people were looking to build in. We are driven by
legislation—that is what you do when you are a regulator—and
one of the things we are not able to do is to actually offer temporary
registration, and I think part of the thing with the overseas
teams that were coming over was that that was one of the things
that they were looking to do. But I think if they had had a conversation
with us at the beginning then we could have said, "We cannot
deliver on that, we are not able to do that. We actually have
core European standards where people have to have met some minimum
competences and unless they have done those it is no good you
telling us that this is a fantastic nurse. If they have not delivered
around the core European directive we are really sorry, we cannot
help." So those were two examples I would give you.
Q529 Charlotte Atkins: Thank you
for that. It sounds a bit as if you are poor wilting flowers,
waiting to be asked. I have to say that you are regulators and
you do not look the sort of person to me that is a wilting flower.
Ms Thewlis: I think you are right,
and that is one of the things where, in fairness, individually
we have all worked with the respective Departments of Health at
a much earlier stage. But you are quite right, I think sometimes
regulation did see itself as rather isolationist and maybe did
not get involved, but I think all three of us now recognise that
we do need to work more closely with employers and actually get
there at the beginning. Around some of the new roles' work, what
I saw happening was the regulator was dragged in at the end and
said, "Would you approve this?" which really is not
terribly helpful because I think regulation needs to be there
at the beginning and work with employers; and also what the policy
direction is that you are looking to drive forward. The third
bit in that is really looking at where education fits within that
because I think that at the NMC we have responsibility for quality
assuring education, which our predecessor did not. So I think
it is important that there is a very active dialogue because to
actually change educational programmes takes quite some time.
So I think from the policy direction it is important that the
regulator does have responsibility for education in the way that
they do at the GMC, but that was new for us. You are right, we
cannot afford to be wilting flowers and I would not say we are.
Q530 Charlotte Atkins: Finlay and
Marc, are you punching your weight as regulators or are you sitting
back and wilting?
Mr Scott: We are certainly not
a wilting flower; where I come from you do not survive if you
are a wilting flower! In fact our experience, perhaps because
we are a longer established body, contains really good examples
of cooperative working with the Departments of Health, and I can
particularly mention the Department of Health programme for recruitments
of specialists internationally. We were involved in that from
the outset and very successfully so. Also, when the ISTC programme
was first launched we were involved in that from the outset to
ensure that registration was not an impediment and that those
who were proposing to tender for ISTCs understood our requirements.
So there have been quite good examples. On the other hand, I think
that some of the current controversy around international medical
graduates who have been unable to find jobs might have been avoided
if there had been a clearer national picture of workforce requirements
which could have been communicated to IMGs who were thinking of
coming to this country. So I would say that it was more of a mixed
picture with some success but some work still to be done.
Q531 Charlotte Atkins: So the GMC
are getting their slice of the action. How about the health professionals?
Mr Seale: I think it is very important
as a regulator we work with all our stakeholders, I think particularly
in healthcare where in fact you are beginning to get a very different
Scottish NHS and also I think Wales is beginning to go in a slight
direction. So it is important that we have good contacts with
the four different administrations. I think also that some of
our professions, for example chiropodists and pharmacists, over
60% of them do not work in the NHS but work in the private sector,
so it is important that we influence that process. To give you
an example, with a new profession coming on stream, emergency
practitioners, I think it is vital that when those individuals
are trained they can work anywhere in the NHS, and one of the
roles as a regulator that we must do is ensure that those skills
are transferable throughout the UK and you do not end up with
a situation that somebody who trains in Kingston finds that they
cannot work in Cardiff because their training has been very different.
So it is very important that we are brought in at an appropriate
time, but at the same time we are not seen as a blot on the system.
Q532 Charlotte Atkins: It just seems
a bit odd from the evidence we had earlier—and I think you
were in the audience to hear the evidence.
Mr Seale: Yes.
Q533 Charlotte Atkins: On the emergency
care practitioners it did seem somewhat vague. It has been developed
in London and I know it has been developed elsewhere within the
country, and that must be a concern for regulators, is it not?
Mr Seale: Yes. I listened to the
discussion that you had a few minutes ago on this particular subject
and maybe I can give you some background information that might
be of some assistance? In essence it is a new emerging profession,
there are very few people currently on courses and there are a
number of courses that have now been set up. What essentially
is happening is that the people who are going on those courses
are already regulated because they are either nurses or indeed
they are paramedics. So in a sense we can wait for a short period
of time because those individuals will be regulated when they
go back into the workforce because we regulate by protection of
title, and the principle is that as long as you are educated and
you are working within your scope of practice your Code of Practice
comes into play. The issue coming down the road is that at some
point these new courses will want to recruit people who are not
necessarily nurses or paramedics and therefore if they are not
statutorily regulated when they finish their courses there will
be nobody to regulate them, there will be nobody setting standards
of training, conduct and ethics, et cetera, and, more importantly,
we will not be able to protect the public because of the outside
regulation. Again, if we go back to Foster and Donaldson, certainly
in the Foster review, coupled with the themes that we discussed,
there is an issue about how do we regulate these new professions
and how do we set standards, et cetera? Hence the desire to see
the results of those two reviews as soon as possible.
Dr Taylor: Going on with that, I am a
bit alarmed because I was under the impression that there were
emergency care practitioners actually working in my area and I
think in Charlotte's as well.
Charlotte Atkins: They are not called
that; it is a slightly different role—certainly not the
university training in Staffordshire.
Q534 Dr Taylor: No, there is certainly
no university training in my part. So should you not already be
involved in the regulation of the training of these people who
are seen as absolutely crucial with loss of emergency services
across the country? Should you not, and the NMC as well, as nurses
are going to be in this role too?
Mr Seale: How we currently treat
a group like this is that we would regard it as a post-registration
qualification in those individuals who have already qualified
as a paramedic or a nurse, have gone through their training and
in very small numbers are now going out into the workforce. But
the ideal situation is that they should be regulated at the post-registration
level and that we should set the standards of that level. It is
one of those issues that we want to move ahead but currently we
are working for developments within the Department of Health on
these other two reviews.
Ms Thewlis: I would concur with
what Marc says. I think one of the things that we talk about being
on a professional register is about ensuring that people work
within what we call their scope of practice. So obviously people
do not extend into areas where they are not competent, so I think
that is the first bit. But as Marc said, one of the bits that
we are waiting for is obviously what is going to come out from
the Foster Review, because these emerging roles will have some
clarity around the system that we are going to need to take this
forward.
Q535 Dr Taylor: In your evidence
you make a distinction between extension of existing roles and
the establishment of new roles.
Ms Thewlis: Yes.
Q536 Dr Taylor: Will the ECPs be
new roles or extended roles?
Ms Thewlis: I think that is one
of the things where it is talking about not tying things down
so tightly that you do not have a flexible workforce, and I think
that is one of the things where we are very conscious that sometimes
regulation is seen as a barrier to progress rather than actually
something about where you can manage it going forward. I have
given you two answers on that one really, Dr Taylor, because I
think some of it you will see where it is just an extension of
role, whereas some of it you will actually say, "No, this
is a significant jump that you are talking about, it is something
different." What we are very keen on at the Nursing and Midwifery
Council—we are having discussions with the Department of
Health at the moment—is actually having what we call an
advance practice part of the register because I think there is
that step change where you are saying, the individual has moved
on to do something at a higher level than their initial training.
I think some of the roles that we are talking about, particularly
if you have responsibility for total patient care, that that is
very different from doing the normal nursing that you would do.
So we are having very fruitful discussions, I hope, with the Department
of Health about having this level. Almost in the same way that
the GMC has the Specialist Register, then we are looking at something
along those lines. What we would be doing would be having a set
of broad competencies where we would work with some of the specialist
areas around particular clinical areas where obviously we would
need to take their input because it is not our responsibility
to set up the detailed clinical standards, but we are responsible
for the competencies.
Q537 Dr Taylor: So nurse consultants,
nurse practitioners, nurse specialists would all be in this?
Ms Thewlis: They could, and one
of the things from a public protection point of view is that none
of those titles that you have just mentioned are regulated or
protected, so anybody could call themselves one of those where
they have perhaps done a two-week course or they may have done
a Masters level of education. But the difficulty is, if you say,
"I am a nurse consultant" or "I am a nurse practitioner"
a member of public would think that must mean that you have some
sort of training. That is why, from a public protection point
of view, the NMC feels very strongly that there should be a regulated
part of the register where you could only use that title if you
got to a certain level of competence. We have a little bit of
a joke about this as to what is the longest name you can get for
a title for a job that you are doing, will it fit on the name
badge?
Q538 Dr Taylor: I find that surprising.
So some people who are labelled as nurse consultants probably
are not?
Ms Thewlis: It depends how you
define what a nurse consultant is.
Q539 Dr Taylor: How do you define
it?
Ms Thewlis: We actually talk about
nurse practitioners and we have worked with the Royal College
of Nursing, we have worked internationally—because obviously
nursing is a very global profession—looking at setting a
series of what we would call competences, that when you have reached
that level there should be some protected title that comes with
that to allow yourself to call yourself that. I think from a public
protection point of view, when people use the word "doctor"
of whatever they have a kind of understanding that that means
you have done some sort of training, that you are safe, and "We
think it is okay, we trust you."
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