The Cavendish Review: a missed opportunity to consider statutory regulation of healthcare assistants?

6 August 2013

The Cavendish Review, an independent review into healthcare assistants and support workers in the NHS and social care settings commissioned by the Secretary of State for Health in the wake of the Francis Inquiry into Mid-Staffordshire NHS Trust was published on 10 July 2013.  

The stated  purpose of the Review was to ‘consider what can be done to ensure that all people using services are treated with care and compassion by healthcare and care assistance in NHS and social care settings’ and ‘to make recommendations about the recruitment, training, management, development and support of those staff’.  The importance of the need for such a review cannot be underestimated; there are over 1.3 million frontline staff who are not registered nurses but who now deliver the bulk of hand-on care in hospitals, care homes and the homes of individual.

The Review was based upon information gleaned by its author, former management consultant and journalist Camilla Cavendish, from a number of focus group meetings across the country, an online survey for social care employers, meetings with staff in hospitals and care homes around the country and an informal consultation which received over 100 responses from organisations and individuals.

The main recommendation is the implementation of a ‘Certificate of Fundamental Care’, which would encompass the minimum competencies that support workers in health and social care should achieve before they can start working in intimate care roles.  This is in response to a concern picked up throughout the investigation of a fundamental lack of training.  It is said that this should ‘build on what nurses already learn, rather than being developed and delivered in a separate silo’.  The Care Quality commission should require healthcare assistants in health and support workers in social care to have completed the Certificate of Fundamental Care before they can work unsupervised. 

We are told that ‘there is a blurring of lines between the registered nurse and the support worker, with some home care workers being asked to undertake tasks which used to  be the preserve of the district nurse, and hospital HCA’s doing jobs that were not the remit of nurses.’  It was found, for example, that HCAs are carrying out the jobs nurses are trained to do, such as inserting IV drips, withdrawing blood and plastering.  Perhaps flowing from that finding is a further recommendation that employers should allow HCA’s to use the title ‘Nursing Assistant’ on completion of the ‘Certificate of Fundamental Care’, where appropriate. 

How to police the new standards?  We are told that the Secretary of State should commission the Professional Standards Authority for Health and Social Care for advice on how employers can be more effective in managing the dismissal of unsatisfactory staff, the legal framework around this and the ‘relationship with referrals to progressional regulators’.

Will this be sufficient?  If an employer relieves himself of the services of an incompetent or dishonest member of staff, what is to prevent them from moving into another role, entirely unchecked?

It appears that there is a gaping hole that the writer of report was precluded from answering; the Review’s terms of reference expressly did not include statutory regulation, which the Government felt ‘would not add sufficiently to the general assurance provided by the CQC’.  Given the comparison drawn throughout the Review between the role of HCA’s and nurses, who of course are regulated, it is perhaps surprising that the Review was prevented from even considering this as a potential option.  Whilst there are clearly a number of counter arguments that would mean that statutory regulation may be entirely inappropriate for HCAs, for example their size and disparity, the absence of any discussion about this is interesting.

One of the explicit recommendations made by Robert Francis QC in the Mid Staffordshire NHS Foundation Trust Public Inquiry published in February 2013  was that HCAs should be subject to a registration system.  It was suggested that there should be a uniform code of conduct prepared and maintained by the NMC and that there should be a means by which members of the public can clearly identify and distinguish between registered nurses and registered healthcare workers.  It seems that this recommendation may have fallen on deaf ears.

The Government is expected to provide a formal response to the Review when it releases its response to the Mid-Staffordshire Inquiry later in the year.   Whether statutory regulation will remain summarily discounted without being fully ventilated remains to be seen.

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