Trust, Assurance and Safety – the
Regulation of Health Professionals in the 21st
Century
Assuring Independence: The governance
and accountability of the professional regulators
The first chapter of the White Paper
Trust, Assurance and Safety – the Regulation of Health
Professionals in the 21st Century is concerned with
ensuring the independence of the national professional regulators.
Regulators need to be seen to be independent and impartial in their
actions so that all stakeholders (here, "patients", the public, and
the professions themselves) will be assured of their effectiveness
and have confidence in them. In my view, the inclusion of this
chapter can be seen as directly resulting from the various
enquiries into malpractice of health professionals that have
critiqued the effectiveness of self-regulation in ensuring
impartiality and independence.
The first area of relevance is that
the councils that regulate health professionals need to have, as a
minimum, parity of membership between lay and professional members.
This is to ensure that purely professional areas are not thought to
dominate their work. There is considerable detail in the White
Paper about how to ensure independence, for example, a note that
having retired members of the professions as lay members of the
Boards may not be seen as sufficiently independent. The councils
here refers to the statutory regulating bodies. In the case of the
psychological therapies, it is proposed that we join the Health
Professions Council.
Much of this first chapter goes into
further detail about how to ensure good governance and
independence. So, it is proposed that all councils become more
accountable to Parliament, for example, through presenting annual
Reports to Parliament. Additionally, members of Councils need to be
independently appointed and the councils need to be smaller and
more board-like with greater consistency of size and role across
the professional regulatory bodies, which will not be merged for
the time being. There are currently nine councils that regulate
health professionals and the White Paper implies that this will be
reviewed in 2011.
Revalidation: Ensuring continuous
fitness to practice
The second chapter of the White Paper
sets out new proposals to ensure that all the statutorily regulated
health professions have in place arrangements for the revalidation
of their professional registration thus ensuring that they can
periodically demonstrate their continued fitness to practice.
Currently the Health Professions Council require revalidation every
two years and, as the White Paper states, have begun to link this
with continuing professional development. This is to ensure that
practitioners remain up-to-date with current developments in the
field and that they continue to apply the values to which they were
committed when they first qualified. The White Paper explicitly
states that the Department of Health [DoH] will discuss the most
appropriate arrangements with each profession and its
regulator.
Tackling concerns: The local
role
This Chapter of the White Paper
focuses on the local role in tackling concerns that are raised
about practice, and is very focused on NHS provision. The main
profession discussed are doctors. Other health professionals
employed in primary care are also mentioned in relation to the
effectiveness of the current Performers list arrangements. One
Section focuses on locum provision of all health professionals and
stipulates that the Department will consider, with stakeholders,
the issues involved in developing a more effective system of
registration and inspection of agencies that supply health
professionals.
Tackling concerns: The national
role
There are three methods of
tackling concerns, namely:
- A move towards a common standard of proof across all
professions is proposed
- Regulators need a wider range of options in dealing with
concerns to include the options of rehabilitation, remediation and
retraining
- Changes need to be made to the way a health professional’s
fitness to practice is judged.
These proposals are motivated by the
need to ensure public and professional confidence in the handling
of cases in which a health professional’s fitness to practice is
called into question. The issues are technical and some concern
legal aspects. For example, it is proposed that panels considering
fitness to practice should use the civil standard of proof rather
than the criminal. This standard of proof has a sliding scale which
is thought to be more appropriate in the case of assessing the
fitness to practice of health professionals. This is currently
used, for example, in child protection cases. The intention seems
to be to encourage earlier referral of complaints and concerns to
the regulator rather than the current situation where in some
professions (e.g. medicine and nursing) referral may be discouraged
because the burden of proof is too high. There is an
acknowledgement here that some consultation has indicated that this
may lead to health professionals practicing more defensively,
erring on the side of caution when difficult judgements have to be
made.
It is perhaps because of this that the
second part of the chapter advocates a wider range of interventions
when concerns are raised. This section recognises that, while the
protection of ‘patients’ is the key concern of regulation,
regulatory processes also have to have inbuilt mechanisms to help
health professionals retain or regain their fitness to practice.
The root cause of poor performance needs to be tackled and dealt
with by, for example, further professional training or
rehabilitation for mental ill health or addiction problems. To
ensure an integrated, affordable and cost-effective approach to the
health of all health professionals, the DoH will establish a
wide-ranging and inclusive national advisory group to inform the
development of a national strategy. This group will advise on
measures to ensure appropriate prevention and early intervention
for health professionals, to consider the role of health in
revalidation requirements about fitness to practice; to enable
easier and confidential uptake of services; the roles of all
concerned with ensuring the health of health professionals; and
more effective arrangements for the rehabilitation of health
professionals.
The final parts of this Chapter
concerns the need to separate out the investigation and
prosecution, in particular of doctors whose fitness to practice is
questioned, and the need for an independent body to adjudicate on
fitness to practice cases, particularly those involving the medical
profession. This independent body will establish a central list of
people, vetted and approved for all adjudication panels, chosen for
their expertise and specifically trained to undertake their duties
in a fair and impartial manner. This list will be available to all
the regulatory bodies, who will be able to draw on it to conduct
independent adjudication panels within their own organisations. The
intention is that this independent body may be adopted by other
regulators. For psychological therapies, as stated earlier, the
Health Professions Council is proposed as the statutory regulating
body. It is recognised that this list will need to include
professionals qualified in the specific professions involved. It is
unclear whether this list would be also available to professional
non-statutory regulating bodies such as the UKCP or whether only
available at the statutory regulation level i.e. the Health
Professions Council. The potential role of non-statutory regulatory
organisations like the UKCP in investigating concerns and
complaints is also not clear from my reading of the White Paper
because the term ‘regulatory bodies’ seems to apply to the
statutory regulating bodies.
Finally, the last paragraph of this
Chapter concerns the importance of any investigation of concerns or
complaints being respectful of diversity issues, given that
healthcare is provided by people from a rich and invaluable mix of
national, ethnic and religious cultural backgrounds.
Education: the role of the regulatory
bodies
There is agreement here that the
non-medical professional regulatory bodies should continue to be
responsible for the educational standards of the professions they
regulate. There is an expectation here that the regulatory bodies
will work in conjunction with the Sector Skills Council for Health.
The Sector Skills Council (SSC) for the UK health sector states on
its website that it helps the whole sector develop solutions that
deliver a skilled and flexible UK workforce in order to improve
health and healthcare. It conducted a consultation during the
latter part of last year and the initial months of this year into
the competencies that are expected of a practitioner in
psychological therapies. This is addressed later in the
article.
It is clear that the White Paper
advocates the single oversight of education but believes that this
should be done in a way that preserves the expertise and experience
of present organisations that undertake this role. Again the focus
is firstly on the medical profession with other professions
following on its tail. There is also a section in this chapter that
addresses the need for competence in the English language as an
important aspect of the education of health professionals. This
will include selective language testing for applicants to NHS
posts.
Information about health
professionals
Entry to any health professional
register depends ultimately on demonstrating fitness to practice by
securing the relevant educational qualifications and, in some
cases, levels of competence recognised by the relevant regulatory
body. It is noted that the different regulatory bodies have
similar, though not identical, requirements of people seeking new
registration. One aspect of fitness to practice is stated to be
that the health professional is seen to be of "good character".
There is no agreed definition of what this means in practice.
Therefore the Government will ask the Council for Healthcare
Regulatory Excellence (CHRE) to recommend a single standard
definition of good character, working with the regulatory bodies,
an encompassing wider work within Europe to promote information
sharing on the good character of professionals who cross national
boundaries.
Many of us may not know about the
CHRE
. It is
a statutory overarching body established in 2003, which promotes
best practice and consistency in the regulation of healthcare
professionals, covers all of the United Kingdom and is separate
from Government. Its website indicates that, as per the White
Paper, it will audit the preliminary stages of the fitness to
practise procedures of the regulators, in which regulators receive
and screen complaints against registrants. It is also identified in
the White Paper as taking forward a number of initiatives,
concerned with the promotion of good practice in regulation, and
facilitation of the interface between regulation and healthcare
providers and other stakeholders.
Closer co-operation and co-ordination
between regulators and employers when a health professional enters
employment for the first time is also advocated. The
CHRE
will
lead a programme of work with regulators and employers from across
the UK to investigate how this might feasibly be achieved – this
will report to Ministers in April 2008. Another body of work
proposed concerns the risk presented to patients by students and
trainees in particular professions. This is to be undertaken by the
regulators and will specifically look at whether students and
trainees should have closer relationships with their future
regulators prior to qualification.
New roles and emerging
professions
This Chapter is the one that details
the move towards statutory regulation for psychological therapies.
The Executive Summary of the White Paper states:
It is here that the priority for
regulating applied psychologists, psychotherapists and counsellors
is stated. Much of this Chapter also concerns the regulation of
emerging professions and states that the Government, with the
exception of new regulations for the regulation of pharmacy, will
not consider any new statutory regulators.
Implementation
The final chapter of the White Paper
concerns the implementation of the proposals in the preceding
chapters. It is clear that many of the reforms set out in the White
Paper will require primary legislation, while others may require
secondary legislation. There is a recognition in this Chapter that
implementation will require detailed consultation with
organisations involved. Implicitly, the White Paper commits itself
to this.
Concluding Comments about the White
Paper
Reading between the lines, it is clear
from the White Paper that the Government wants to move to
streamlining and centralising regulation of health professionals,
here understood to mean all those professionals engaged in the
delivery of health care whatever discipline they follow. There is
also recognition that this cannot be achieved overnight and that
considerable consultation is required to fulfil this objective. The
phrase ‘regulatory bodies’ in the White Paper seems to refer to the
nine statutory regulatory bodies. It is clear that the Government
wants to regulate the psychological therapies under the Health
Professions Council rather than setting up an additional body, e.g.
the Psychological Therapies Council as the UKCP, BACP and BPS had
advocated in all consultations prior to the White Paper. This
presents all of those engaged in the delivery of psychological
therapies with a number of challenges that are spelt out in the
next part of this paper.
Many issues outlined in the White
Paper are arguably ones with which the psychological therapies
would agree. The need for a greater transparency and independence
in regulation and for a process of dealing with complaints and
concerns that can be seen to be fair to all parties concerned
cannot be disputed. However, potential areas of dispute concern
some fundamental issues that are to do with how the psychological
therapies can be regulated as part of a wider framework that
includes other professions, who may have very different standards
for qualification and practice. This article now turns to these
issues.
Implications for the Future
This final section of the article
considers possible implications for the future in relation to
psychological therapies. While it in part draws on presentations
made at the March AGM of the UCKP (and this is acknowledged in the
text as appropriate), many of the issues here outlined are the
author’s own reflections.
Issues about Statutory
Regulation
This part of the paper considers the
potential implications of the White Paper for the psychological
therapies in line with the current context and development of those
therapies.
The UKCP has long supported statutory
regulation of psychotherapists, counsellors and psychologists in
the debate that started in 1971. It has worked particularly in
recent times with the BACP and the BPS as other non-statutory
regulating bodies on this issue. There are of course differences
between these organisations but there has been common agreement
about the need to differentiate between the psychological therapies
and other professions that might be described as under the umbrella
of ‘professions allied to medicine’. These psychological therapies
have not felt that the Health Professions Council was the right
umbrella to cover their work, and have advocated a separate
regulating body for the psychological therapies. However, it is
clear from the White Paper that this argument is not seen as
significant for the Government and policy makers. Regulation of
psychological therapies will come under the aegis of the Health
Professions Council. This has a number of implications. The
following sections discuss these and consist of my own personal
reflections on the issues facing the psychological therapies and
the UKCP.
Academic level of qualification and
the implications
The first concern is about the fact
that the academic qualification for psychological therapies has
been seen by the non-statutory regulating bodies, notably the UKCP
and the BPS, as at least being at Masters level, with psychology
fast moving towards being set at professional doctorate level.
Indeed psychotherapy is following on the heels of this, with a
growth of professional doctorates and the provision of PhD courses.
Work will be needed to ensure that the Health Professions Council,
which I am told involves mainly professionals whose qualifications
are set at first degree level, respects the need to maintain
practitioners of psychological therapies at this level.
The UKCP: facing an unknown future
yet has a key role at present
In my view, it is not yet clear what
the future of non-statutory regulatory bodies will be after
statutory regulation. My view is that they are likely to have an
important role as professional organisations similar to the Royal
College of Nursing and the British Medical Association.
In the meantime, the UKCP is
anticipating meeting the requirements of the White Paper in the
future, such as increasing lay involvement on the Registration
Board (Monk Steel 2007). It has also set up an ‘Independent
Complaints Organisation’ [ICO] to handle complaints from an
impartial point of view. However, this latter move has proved
controversial in practice in part because the independence of the
ICO has been questioned since, although allegedly an independent
company, a UKCP officer and elected representatives have been
integrally involved in its founding and implementation. Another
area of concern is funding of the ICO. Further, once statutory
regulation is introduced, estimated to be in three years time, it
is likely that complaints will be handled at the regulatory Council
level. Therefore the role of the ICO at that time will need to be
reconsidered. These issues have been raised with the UKCP which has
organised workshops with the ICO to explore these issues. Those
involved have been keen to engage in dialogue with UKCP members and
Member Organisations. A decision about the future of the ICO will
be reached at an EGM in November. At present some member
organisations, including Regents College, have not signed up to the
ICO because resolution of the above issues is needed.
Additionally, statutory registration
will happen at individual level. An individual practitioner will
register with the relevant Council rather than through a Member
Organisation as currently happens. In my view, this development is
to be welcomed since current regulation arrangements require being
of good standing with a Member Organisation. This is not always the
same thing as being fit to practice and can be subject to the
vagaries of the Member Organisation. It seems the UKCP is
anticipating individual registration and including this within
their future plans.
Post statutory registration the UKCP
may well retain (again in my view) a role in respect of training
standards and educational needs for practitioners in psychological
therapies. This is because training to practice as a psychological
therapist is complex given the number of modalities involved and
their different training requirements currently. It would seem that
the vision behind the White Paper is of common standards for
practice in each profession in line with their view of streamlining
and centralising their regulation. The last Chairs’ Day organised
by the UKCP involved very useful and interesting work on shared
training standards. As a participant, it was clear to me that
consensus was more likely to be reached on shared values rather
than on the standards themselves. This, however, would in itself be
an important development. The UKCP’s role in facilitating this work
is important at this time.
Mention is made in the White Paper of
the Sector Skills for Health (see above). Skills for Health have
been working on the competencies for psychological therapists and,
at the end of last year and the beginning of this one, conducted a
consultation about this to which Regents College responded. The
language of competencies is in some ways a difficult one for us
because the intention behind competencies is to stipulate
measurables in which practitioners can be trained. This is
important because it will form the baseline for assessing practice
in the future. However, it is difficult to measure the quality of
the therapeutic relationship which many of us feel is the central
most important aspect in therapy, and to delineate this in
practice. Again the UKCP anticipated this development and, funded
by the DoH, previously undertook key work towards defining relevant
competencies. This fed into the Skills for Health work.
The White Paper cannot be seen in
isolation from other policy initiatives, such as Improving Access
to Psychological Therapies (DoH 2007b). This is based on the
‘evidence-based’ research that indicates the contribution of
cognitive behavioural therapy [CBT] in achieving positive outcomes
for clients with mental health disorders and into its delivery
through new technology. Therefore, the computerised application of
CBT for mild to moderate depression and anxiety is being addressed
(DoH 2007b). The computerised package comprises an introductory
video of 15 minutes and eight one hour sessions that are usually
taken weekly. It is very important that CBT is seen as one
psychological therapy among several treatment options at this time.
The UKCP and the other non-statutory regulating bodies therefore
currently have a key role in presenting the research base of other
modalities to the legislators.
Therefore, while the future of the
UKCP post-statutory regulation is unclear, what is clear is that it
has a key role at present. It is involved in the policy discussions
about regulation and in representing our views to policy makers.
These are crucial at this time, and the UKCP is on top of the
issues. Therefore it needs our support and involvement to ensure
that, when statutory regulation happens, the learning from
non-statutory regulation of the profession of psychotherapy is
taken into the new arrangements and the best possible outcome for
our clients and for the profession is achieved.
References
- Department of Health. (2007). Trust,
Assurance and Safety- the Regulation of Health Professionals in the
21st Century. London: Department of Health.
- Monk Steel, J. (2007). Registration
and Regulation. Talk given at the UKCP AGM of March 2007 in
Torquay. Overheads available from UKCP website: www.
psychotherapy.org.uk.
- National Institute for Health and
Clinical Excellence.(2007). Computerised cognitive behaviour
therapy for depression and anxiety. Review of Technology Appraisal
51. London: NIHCE.