5 The future of regulation
57. Several witnesses to our earlier inquiry into
complaints and litigation expressed concerns about care of older
people, particularly when they are undergoing treatment in acute
hospitals.[67] The Committee
has followed this up with the NMC in light of the transition to
an all-degree nursing profession by 2013 and the perception that
nurses may have "stepped back" from basic nursing care.[68]
58. The NMC told us about the recruitment and retention
benefits that have accrued from having an all-degree profession
in Wales,[69] where nurse
education has been to degree-level since 2004.[70]
The NMC also told us that there was "extremely positive"
evidence for an all-degree profession from other countries.[71]
In written evidence to the Committee they stated:
There is no evidence that a degree level nursing
profession leads to diminished standards of basic care in fact
quite the opposite. Studies from the USA reveal that a high proportion
of degree qualified registered nurses has been associated with
lower mortality in surgical units.[72]
59. However, the Committee raised the issue that
many basic nursing care tasks that used to be undertaken by registered
nurses are now undertaken by healthcare assistants. The NMC estimates
that there are 300,000 unregistered healthcare support workers
and an unknown number of assistant practitioners currently working
in the UK.[73] The NMC
has "growing concerns" that healthcare assistants (HCAs)
are increasingly working on tasks previously undertaken by registered
nurses but remain unregulated. This means that there is little
control over entry to employment and no final sanction of removal
from a register when competence or conduct are not of a sufficiently
high standard.[74]
60. The NMC commissioned a scoping review of HCA
registration which found that there is evidence of HCAs taking
up work having been dismissed from other roles for misconduct,
and that they are undertaking tasks for which they have not been
trained. Based on these findings, the report states that a strong
case exists for regulating HCAs. Voluntary registration was thought
to be too weak as it would "be avoided by the people about
whom there is most concern.[75]"
The recent scandal at Winterboune View in Bristol underlines the
issues around registration of healthcare assistants.
61. In its recent Command Paper on regulation of
the healthcare workforce, the Government has stated that statutory
regulation of health workers has often been the first rather than
the last resort.[76]
The Government now proposes to:
[…] enable a system of assured voluntary registration
to be developed for professionals and occupational groups which
are currently not subject to statutory professional regulation.[77]
62. The Committee notes that under clause 212 of
the Health and Social Care Bill that the Government is proposing
to give powers to the professional regulators to establish voluntary
registers for unregulated professionals and workers.[78]
The NMC expressed concerns about this proposed approach.
We believe that health care support workers should
be regulated, not necessarily in an identical manner to nurses
and midwives but there should be a regulatory framework that is
not voluntary. I do not believe that people who are unpleasant
want to join voluntary registers, so we believe it should be mandatory.[79]
They went on to tell us about assistant practitioners
who undertake complex procedures such as suturing and giving drugs,
but are also unregulated. In its written submission to us the
Patients Association has endorsed mandatory statutory regulation
of healthcare assistants and support workers.[80]
63. As
previously mentioned, the Committee has ongoing concerns about
the care and treatment of older people both in hospitals and care
homes. Of particular concern to the Committee is the lack of regulation
of a range of groups who undertake many basic nursing care tasks.
64. The Committee
endorses mandatory statutory regulation of healthcare assistants
and support workers and we believe that this is the only approach
which maximises public protection. The Committee notes that the
Government intends to give powers to the relevant regulators to
establish voluntary registers for non-regulated professionals
and workers, but would urge it to see healthcare assistants, support
workers and assistant practitioners as exceptions to this approach
who should be subject to mandatory statutory regulation. However,
the NMC needs to make significant improvements in the conduct
of its existing core functions (such as in how it manages fitness
to practise cases) before powers to register these groups are
handed to it.
67 Health Committee, Sixth Report of the Session 2010-12,
Complaints and Litigation, HC 786-I, Q 1 for example Back
68
Following on from the Darzi review of the NHS, the document "Framing
the Nursing and Midwifery Contribution" set out the trajectory
for the transition of nursing to a graduate-level profession.
The then Health Minister Ann Keen MP announced that the profession
would require a degree-level qualification for entry to the register
from 2013. Back
69
Q 105 Back
70
Swansea University, "Nursing. An all-graduate profession
- the Welsh experience", http://www.publicserviceevents.co.uk Back
71
Q 105 Back
72
NMC 02 Back
73
NMC 02 Back
74
Kings College London, Moving forward with healthcare support
workforce regulation. A scoping review: evidence, questions, risks
options, July 2010 Back
75
Ibid. Back
76
Cm 8008 Back
77
Ibid. Back
78
Health and Social Care Bill, Clause 212 Back
79
Q 108 Back
80
NMC 06 Back
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