This site is intended for health professionals only

The great healthcare assistant debate: time for regulation?

Louise Naughton
Reporter, Nursing in Practice

Calls for HCA regulation have become increasingly louder and more frantic as the government revealed its intention to steer toward voluntary regulation. Could a mixed model be the perfect way to appease all parties?

The issue of healthcare assistant (HCA) regulation has become a controversial, headline-grabbing topic in recent months, following the Nursing and Midwifery Council's (NMC) Chair Dickon Weir- Hughes' comments that a "ghastly national disaster" is heading the government's way if the lack of HCA regulation is to continue.

The NMC is joined by other professional bodies, such as the Royal College of Nursing (RCN), in the call for HCA statutory regulation and they have taken their chance to shout that bit louder as the Health and Social Care Bill makes its way through Parlia- ment, believing the reforms could provide a vehicle for change. However, such calls appear to have once again fallen on deaf ears, as Health Minister Earl Howe has made it clear the government has no plans to introduce statutory regulation.

During the House of Lords' Second Reading of the bill on 11 October, crossbench peer Baroness Masham spoke of the danger of HCAs "dressed up in uniforms that make them indistinguishable from nurses".

Citing research from King's College, London, which shows there are "no consistent UK-wide training standards" for HCAs, she backed calls for the registration of HCAs to be made mandatory.

Yet, in addressing peers during the first day of the Committee Stage of the bill on 24 October, Earl Howe argued there is no "blanket prescription" in the area of HCA regulation. He said the government has included a provision in the bill to enable the establishment of an accredited assured voluntary registration for HCAs.

The voluntary scheme is said to build on existing safeguards and will include the setting of national standards for HCA training, their conduct and competencies.

In his address, Earl Howe said it must be taken into account that people in healthcare professions are currently subject to numerous tiers of regulation. The onus has also been placed on employers to ensure no HCA carries out their duties unsupervised and unregulated - a move that would not change "one jot" under statutory regulation, said Earl Howe.

Under the plans, it was confirmed nurses who have previously been struck off could continue to work for the NHS under a different capacity. Earl Howe argued that, if a nurse was struck off for prescribing errors but has other demonstrable skills, for example, bathing patients - depending on the circumstances and with the right supervision - they should be able to work in a HCA capacity. This is an argument even the fiercest supporter of statutory regulation agrees with.

Howard Catton, Head of Policy and International at the RCN, told NiP that regulation should be introduced on a case-by-case basis. "You expect different levels of training, competencies and experience from HCAs," he said. "Therefore, it is feasible that a nurse can be deemed unfit to work as a registered nurse but flourish under more supervision, fewer responsibilities and decreased competencies."

The danger of such nurses returning to work "under a different guise" is one that has struck the biggest emotive chord with the public, as it is seen in some way as deceiving patients. Dickon Weir-Hughes has claimed there is currently nothing preventing this practice and is "begging the Health Select Committee to allow the NMC to regulate HCAs".

He told The Times newspaper that, even though hundreds of complaints are made about healthcare assistants each year, officials have no power to act. "All we can do is to say you either have to go to the person's employer, or if it's sufficiently serious call the police. There are no other mechanisms," he said.

"This isn't just about waiting for some ghastly national disaster, it's about saying, 'How long do we leave this issue? How do we really value our elderly people in care homes? What value do we place on the care of vulnerable people in their own homes?'"

Shadow Health Minister, Baroness Thornton, was equally unimpressed by the proposals for voluntary registration, warning of the "juggernaut" facing the government on this issue and telling Earl Howe the plans offered "no cure".

'The RCN will continue to lobby for regulation, claiming there will be no closure if the amendment to introduce mandatory registration isn't made.'

Baroness Thornton also deemed it "unsatisfactory" that the new rules would allow there to be a chance some patients would never know that a nurse they are in contact with is a struck off nurse. The RCN's Catton claimed there are "weaknesses" in a voluntary regulation-style framework, as the people that are most likely to register may well be those who do not pose the greatest risk or harm.

Speaking of the historic change in the RCN's membership structure, in which members "overwhelmingly" voted to allow HCAs full membership and two seats on its council, Catton said this reflected the more sophisticated and dynamic partnership between registered nurses and HCAs.

"Many HCAs have extended their roles," he said. "The boundaries between where registered nurses' roles end and HCA roles begin have clearly changed. We have to deal with that reality now."

Although the RCN's stance on HCA regulation is clear - man- datory is the only way to go - Catton told NiP his personal opinion is that a mixed model of regulation should not be excluded. "There could be mixed models of regulation going forward, which combine a voluntary approach with a statutory role for employers," he said.

Catton cites an example of such a model in which employers could have a voluntary role in terms of education and training for HCAs in Bands One and Two, and statutory regulation would be required for HCAs working as assistant practitioners. When asked whether the RCN is optimistic the government will provide the u-turn it is so desperately calling for, Catton is non-committal.

However, he promised the RCN will continue to lobby for HCA regulation, claiming there will be no closure if the amendment to introduce mandatory registration isn't made.

"We would be naïve to think the government's decision is not informed on ideological factors and cost," he said. "But once you begin to unpick these concerns, you find the answers. It is possible to build a low-cost statutory regulatory approach that does not go down the route of a Big Brother-style tone."