HPC Listening Event

HPC Listening Event 13 February 2007 Aberystwyth 6-8pm

Panel Members: Mary Clark-Glass – Lay Council Member Tony Hazell – Lay Council Member Jacqueline Ladds – Communications Director, HPC Douglas Proctor – Alternate Registrant Council Member (Biomedical Sciences) Marc Seale – Chief Executive, HPC

Summary: Q1. What is the timescale for the recognition of ultrasonography Page 1 as a profession? Q2. Is there any move to regulate the use of acupuncture? Page 3 Q3. Can you explain the 2.5% sample size of the CPD audit and also Page 4 can you shed some light on how revalidation will fit into the process? Q4. Where will the funding come from for the CPD audit process and what Page 6 process have been put in place to carry this out? Q5. How will FTP, revalidation and CPD help to protect against rogue Page 7 practitioners? Q6. What is the justification for the increase of scrutiny fees to £100? Page 9 Q7. How would the HPC respond to a situation in which a patient dies due Page 10 to a lack of equipment? Q8. What guidance do the HPC provide to education establishments as Page 11 to whether an applicant to university would receive registration once they have completed the course?

Jacqueline: I want to start with a question which has been tabled in advance. It is about the timescale for the recognition of ultrasonography as a profession. Marc, do you want to answer that first?

Marc: This is a tricky question. Ultrasound is one of those groups of skills which are partly embedded in other professions and at the same time there are individuals who only have those certain skills. The HPC has been working very closely with the Society of Radiographers to work out what we can do about this problem, because in terms of public protection it could be clearly argued that ultrasound should become protected or a statutorily regulated profession. It is one of those issues where I think it is tricky because it is embedded in other professions, and it is tricky because there are no clear standards of training for what it should be. The Society of Radiographers is in fact due to see us again in a couple of month’s time. We meet with the professional bodies on a regular basis and the Department of Health has been closely involved in the negotiations. The discussion has been going on for something like four years. So it is one of those issues where yes there is an argument that it should be regulated, but there has been no conclusion so far.

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Ultrasonographer: Has there been any progress? It is the same question I have asked for the last four years.

Marc: I think a straightforward answer is that there has been little progress. I think this is partly because it is not on the agenda in terms of the Department of Health. It is certainly on the agenda for the Society of Radiographers and it is certainly on the HPC’s agenda.

Unknown: When I was appealing for Agenda for Change the first thing that was said to me was that it is not necessary to have a qualification to be registered to undertake ultrasound. For a lot of people that is one hundred percent of their workload.

Marc: The situation is that ultrasound is not a protected title, but in terms of individuals who are regulated with the HPC, in terms of corporate governance etc there is usually an expectation that if you can be regulated then you should be on the register, even though you are working in ultrasound and not necessarily in the whole radiography field. It does come up on a regular basis.

Tony: Can I just add one thing about a slightly different group just to say you are not the only ones. Genetic counsellors are another growing field where a lot of people in nursing particularly are undergoing training. But there are now genetic counselling programmes that people go straight into. They are another group that have been talking to the Department of Health. We think genetic counsellors should be regulated and some of the nurses who are already regulated by the NMC have said they would give up their nursing regulation in order to be regulated as a genetic counsellor. So it is an issue which affects a number or other groups, not just ultrasonography.

Unknown: Why do you think the Department of Health is not interested in ultrasonographers?

Marc: I think there is a huge benefit of being statutorily regulated because the regulator has the powers to protect the professions and that leads to good public protection. I think it is a combination of lack of resources, and I therefore think in terms of what they are doing for the next few years it always seems to be other groups that need to be regulated. I think also there has been a log jam over the last four years by the Shipman Review, the Foster Review and the Donaldson Review which has effectively been going on for three years. It has meant that no new legislation has been put on the statute books, so that has been a problem. I also think that in a sense they are more likely to put resources where there are large numbers, so they have given very clear indications that they want to regulate counsellors and psychotherapists. If unfortunately there is a small problem that has impacted upon patients, it tends to get put aside while they are dealing with bigger issues. This is an issue where rather than saying c’est la vie, that’s the way it works, I think the professional bodies and the

2 HPC Listening Event 13 February 2007 Aberystwyth 6-8pm regulator have got to say “well actually we don’t agree with that argument. Just because it is a small group doesn’t mean it shouldn’t be statutorily regulated”.

Mary: The Department acts reactively on a lot of these issues, and if something like Shipman happens and some of the other notorious cases in the last ten years, a lot of resources and a lot of time and political will goes into that. If you are not causing a problem and you are not on the front page of the tabloids, you slip. That is why, as Marc says, it is important that the registrants and their professional bodies try to work with us to try to take this issue forward. Otherwise it just gets pushed aside.

Marc: The applied psychologists have been looking for statutory regulation since the mid 1950s and have been bashing their heads against a very hard stone for the last forty-five years. But again even if the government says yes, they should be statutorily regulated, it would probably take at least another year before the register is given to the regulator to regulate them. It is an incredibly slow and very frustrating process, particularly for organisations and individuals who have committed a lot of voluntary time and effort to get regulation.

Acupuncturist: Is there any move to regulate the use of acupuncture? At the moment you can do a half day course or you can do a diploma standard course and you can practice. I was just wondering if there is anybody to regulate that.

Marc: Actually it is a bit like ultrasonography in terms of its issues. Again acupuncture is used by already statutorily regulated professionals, physiotherapists being the classic example. It is also used by nurses and doctors and I believe some dentists use it. They are already statutorily regulated. You also have individuals who have gone on pure acupuncture courses and then you get some people who say “well I have done a bit of acupuncture, I’ve got no training but hey, I can do it.” In terms of public protection it is the group at the end that we want to look at. But the good news is there is a DOH funded project being run out of Leeds which I suspect will report some time in the next eighteen months. In fact one of my colleagues at the Policy Standards Department is an active participator in that group so it is moving in the right direction.

Tony: There has been a change in the government stance on that. A couple of years ago they were actually proposing that acupuncturists and herbalists would have their separate regulatory council, but it seems that this has been decided against.

Marc: I think it is unlikely that they are going to set up any new regulators. The chances are if they do have regulation it will come towards HPC. But it is an issue that the Chief Executive and the President of the Chartered Society of Physiotherapists have brought up as well. It is a very slow, frustrating process.

Clinical Scientist: My question is about CPD and revalidation. Can you explain the 2.5% sample size, in particular what will happen to those who are not assessed, and also can you shed some light on how revalidation will fit into the process?

Douglas: Well I can start on the first part, what might happen to the people who aren’t assessed. I guess that really CPD should be built into any quality management process within an organisation. It should be part of ongoing personal development so the fact that they are not selected on the first audit doesn’t mean that they haven’t done it. I feel as a manager that we are duty bound to provide the resources to allow staff and professionals to complete their CPD. I think we should be duty bound as managers to go back to our finance people and say we need the resources and the time built into the system to accommodate this. I see no reason why not. It may be pie in the sky but at the end of the day it should be part of our duty as a manager to be looking at that and building it into our programmes of work.

Tony: Can I comment on the objectivity? I think you were commenting on how effective the process will be. The important message to get across there is that the audit of the sample will be peer based. So as a clinical scientist if you were lucky enough to be randomly selected and asked to submit your portfolio would be assessed by two people from the same part of the register. One very much from a practice background and one academic. It is not being done by council members or by council staff.

Marc: When we are talking about post registration standards, essentially, CPD is about getting skills and competences and experiences to improve the quality of treatment for patients going forward. So CPD is very much reflecting on skills now to improve your treatment. We have a threshold of standards which we’ve marked with the red line. If you ever go below those standards, and they are the threshold standards, then the regulators say that you have got to come off the register. Revalidation is saying “that is all very interesting, but should the regulator be testing you wherever you are during your career?” So if you are forty years into your career, you are a leading academic, the person who has got the most understanding of anybody in the world, and you are operating right up here, should the regulator somehow test you to make sure you are operating at that very high standard? That concept is revalidation. Revalidation raises many questions. The first is how do you select the standards to measure against for people in varying stages of their careers? What standards shall we use? The second question is what is the risk? How many incompetent registrants are there out there

4 HPC Listening Event 13 February 2007 Aberystwyth 6-8pm that we are not picking up through Fitness to Practise? Because if there aren’t many should we be spending all these huge amounts of time and effort and money looking for the problem? The third question is who is going to pay for it? Suppose one registrant of the 2.5% sample is at the very top of their profession. We will have to get two peer group professional reviews of you, we have to take you out of treating patients, we have to send you to some facility. You have to go through this process. If you didn’t like the answer there would be an appeal and it would probably end up in court if we said you were incompetent etc. It’s potentially going to cost a lot of money. Another question is who does revalidation? Should it be your employer? What about people in private practice? I think that government is going to leave regulators to resolve the issues and if this is the case, then I think what we would do is probably spend a number of years in a very thorough consultation process, to work out what the standards are and how we actually fund it. I think it is a big issue, and the public think that regulators check people’s standards very thoroughly, so it is a big issue. Again we are hoping the White Paper will provide clear direction on this. It is a difficult situation, and to achieve a solution we have got to move forward with the support of the professionals, the support of the professional bodies and the regulator. I think it is a question of watch this space.

Jacqueline: Just going back a step on a very practical level about CPD. We do have some brochures, a short guide and a long guide which give more information about the process. Also we have got some profiles on our website, so if you are interested to find out more about CPD then please take a look.

Mary: Do you think CPD and revalidation are overlapping? I shouldn’t be talking about them in the same group but this to me is a very overlapping area.

Douglas: I agree. I think they are overlapping. From the point of view of those working in the laboratory there are other objective measures of CPD, either through the college or the IBMS which I think are going to give us a robust way of defending revalidation if we ever are faced with that issue. It is just that not everyone at the moment is up to speed and we are keen, I am certainly keen, to see that happening in my laboratory. Following on from what has been said I think it is all very well for us to approach our finance people and ask for protected time. I think the reality is we are going to have to manage the laboratory in such a way that we provide some sort of protection for individuals. The way the Health Service is financed it doesn’t look in the foreseeable future like we are going to be able to secure a substantial amount of protected time because we can’t employ further members of staff to cover the gaps.

Tony: We talked this afternoon about the responsibility of the employer, however as we know a substantial percentage of our registrants don’t work in an employee situation. For those who do certainly the HPC is working very hard to get the message across, working also with professional bodies and employers. As you know here in Wales it is a requirement that if you

5 HPC Listening Event 13 February 2007 Aberystwyth 6-8pm are working in a professional capacity in the NHS you have to be registered. Well, if in order to retain your registration, you have to do CPD, then we have got to somehow get that message across. It is not going to be easy, but employers will wake up to the fact that if they don’t support the process of CPD their staff may not be able to reregister, maybe. Let’s be optimistic.

Radiology Service Manager: A question about the funding of the portfolios. Just doing some quick sums you have almost 200,000 registrants and if you want to do 2.5% that is getting on for 5,000. Where is the funding going to be coming from and what plans do you have in place for the logistics of the process?

Marc: Essentially we are funded by registrants’ fees. We put budgets together every year which have to be approved by the Finance and Resources Committee. We have then to send off the information to the Privy Council. How we think we are going to run CPD, the actual process is that the review of the portfolios will be done by partners. We have about four hundred health professionals who help us with things like international registrant assessments, grandparenting, and Fitness to Practise panels. What we are going to do with CPD is that rather than sending this thing out all over the UK, we will bring those assessors to us. So for example if we are reviewing the biomedical scientists, we will have a group of biomedical scientists working on a daily basis. All those portfolios will be reviewed collectively by those individuals. In terms of the cost of it, it is embedded in our current systems. What we are doing is investing as much in I.T. as possible. So we will start off with the paper actually having been sent in but in the future we will have an electronic receipt of information rather than mailing it out. The main cost is in fact that the professional fee that we will pay the partners who are doing those assessments.

Radiology Service Manager: So you don’t envisage an increase in cost to us as members because of that?

Marc: I am going to sound like a politician here, I do apologise. Fees undoubtedly are going to go up. The big issue that we have about fees and our costs is not so much CPD as Fitness to Practise. We are currently spending, in this financial year, more money just running Fitness to Practise than we did over the whole of CPSN in its last year of operation four years ago - roughly about £3 million. Those Fitness to Practise costs are continuing to rise and they haven’t plateaued out. So financially the biggest risk, the biggest concern to us is Fitness to Practise costs, not CPD costs. Again the issue about revalidation, depending on what the government says, may also have an impact in terms of registration fees. So CPD is important but compared to Fitness to Practise, it is relatively small.

Tony: Just on a very practical point. I’m sure your maths is better than mine, but clearly the fact that re-registration is staggered will mean that you are not doing a sample of the total number of registrants in any one year. It will be spread out. The burden won’t be quite as large as perhaps you are suggesting which is why I think Marc is confident that it can be managed.

Marc: The other thing is, again I am not a statistician, but the initial sampling is going to be 5% (as determined by the commercial statistics department at the University of Reading) and then we are going to investigate dropping it to 2.5%. In theory it could go down to an even smaller number if we have an incredibly high success rate in the sampling. However it could go in the other direction. If in fact we sample 5% and find that actually, and I’m pretty sure we won’t, there are pockets of people who are not doing CPD, or it is not up to standard, our sampling rate would go up because we will have to reassure ourselves that we are sampling at the correct rate.

Mary: In fact if the government decides to regulate the aspirant groups the HPC would have a large increase in the number of people paying fees and so the costs related to CPD would be spread amongst a greater number of people. I sit on the Fitness to Practise, the Conduct and Competence Committee and the Finance Committee and I am always going on and on and on about the uncertainty of the cost of Fitness to Practise. This is the worrying area, because, as other regulators have experienced, the costs and the likelihood of representation are increasing. However, it should be noted that the HPC’s costs are in fact very moderate compared to what the other regulators are paying, and the cases run for a much shorter time. I think the GMC are spending around £30 million a year on Fitness to Practise. Is that right?

Marc: £37 million a year I believe. It is a huge figure. We are spending about 20% of the registration fees coming in. To be a boring economist, the more registrants we regulate, the lower the cost per registrant it is to regulate. So if we end up having many more registrants, the good news is that those costs will be spread out over more people. But I think the chances are the fees are going to go up gradually.

Head of Occupational Therapy Services: One of the things that I noted about the Shipman case was that this was an individual who had very real mental health, attitudinal, and behavioural problems. One wonders if, in cases when people are working single handed, CPD, revalidation, and Fitness to Practise will weed out these people, unless of course we develop some sort of feedback mechanism.

Mary: I absolutely agree with you and I think that there are other mechanisms, as you have suggested. There are few single handed practitioners. If there are they have to work in

7 HPC Listening Event 13 February 2007 Aberystwyth 6-8pm partnership with others, and it is monitored so closely now, people’s drug patterns as against their populations and as against the patients on their lists. It is other people, patients who have been willing to complain. It is colleagues noticing and doing something. It is employers acting. It is listening. I don’t want us to live in a police state, but in a regulatory body where over half of the people might be working on their own you have to have better methods than there are currently.

Tony: I would agree with you entirely. I think that this again is where the HPC can actually take some credit for the way it has approached the issue, because one of the things it has done in terms of communication is that it has really tried to communicate with the public, with the users of those single handed practitioners. We may not be as aware of it as perhaps we should be, but a very effective campaign has been run for some time now by the Communications department. Getting across, in what some of may have thought initially was in a gimmicky way, but actually the market research that they have done shows that the message is getting home. In Birmingham where you have got a lot of stuff on the back of buses, there have been a lot of campaigns on local radio stations, all sorts of things. You have probably seen the pictures of the guy with the glasses and the big nose, which initially when it came round to me I thought was appalling. But it was because I wasn’t really in touch with the audience and it was actually very effective and it is getting the message across to people. That is the way we are going to get the message to the users of those individuals practitioners, and a lot of effort goes in from our communications division.

Mary: …and working closely with the professional bodies, because they are closer to their registrants, our registrants.

Jacqueline: Picking up on what Tony said about the advertising campaigns, which are obviously something that we do every year. It would be very good to get people’s feedback, but we do market test the campaigns that we run with a sample of the population. As well as the campaigns we do have public information leaflets that we send out to GP’s surgeries, to NHS trusts and to Citizen’s Advice Bureauxs, because it is important that the public have an understanding of regulation and also that health professionals are registered and that we do protect titles.

Unknown: I would hope then that the people in the south of England will finally put the toe doctor out of business.

Marc: The way I phrase it is that we want public patients or their advocates to make informed decisions. If I go and see a professional I get all these guarantees which mean it is sensible to go to a professional. If you are aware of the consequences of going to someone who is not a professional and you want to make that decision, at the end of the day it is your decision. It is a very slow process of informing the public, working with professional bodies, getting

8 HPC Listening Event 13 February 2007 Aberystwyth 6-8pm across the message “go and be treated by a professional, if you want to be treated by somebody else there are some big down sides. Go in that direction, not that direction.” We are talking decades. It is the professions, the regulator and the professional bodies working together to make sure the patients or their advisors make those decisions.

Tony: Just one group that you didn’t mention there, Jacqueline, in terms of getting information out. Of course here in Wales we still have Community Health Councils. I think they are a very important group of people that we should be using much more proactively to get the message across, because they also need to understand that their responsibilities as community health councils should relate not only to the NHS but to these people working outside of the system. That is something we need to focus a little bit more on here in Wales.

Marc: Again if registrants are aware of individuals out there who are pretending to be registrants and are not on the list, please let us know. Err on the side of caution. We do pursue these individuals but it is vital and we depend on your professional radar out there saying “there is somebody out there I should tell HPC about.” There are some bad ones out there and we want to know about them.

Radiographer: I would like to ask about scrutiny fees. What has changed in the scrutiny process for you to propose an increase from zero fees at the moment to perhaps £100 per person for new UK registrants?

Marc: When HPC were originally looking at the fees we estimated roughly how much we thought the registration process would cost and came up with a figure. We are now at a point however where we can see the overall costs and have completed a thorough costing exercise to allow us to apportion these costs much more accurately. It should be noted however that the council really wants to use a couple of guiding principles. One is that there should be no cross subsidisation. For example if an international applicant comes to the UK and applies to the HPC they should pay for the cost of that process. So we are proposing quite high scrutiny fees in terms of international applications. In terms of students coming onto the register for the first time however, there is actually quite a lot of work involved. We have proposed that this fee should either be £100, representing the cost of the work involved, or that there should be some cross subsidisation from existing registrants due to the fact that many students leave university with huge debts and we should not present a barrier to registration. The consultation has now finished and the proposals will be going to Council in March for them to make their recommendations. There are checks and balances in the system in that we have had to go off to the Privy Council, we have to get our legislation changed, and it has to be approved by parliament. We can’t just randomly put our fees up. I think the point is that we don’t want to subsidise too many processes.

Jacqueline: As mentioned we are collating responses at the moment and it will go to council at the end of March. We are going to produce a key decisions document which will give the outcome of the consultation. We will post that online, but we will also put information into the electronic newsletter to keep you up to date.

Paramedic: My question regards litigation. As paramedics we go on courses yearly and three yearly and are taught new clinical procedures. In practise however we may not actually be provided with this new equipment. What worries me is that if a procedure that we aren’t able to use would have been of benefit to the patient and subsequently the patient died and there was an investigation, how would the HPC look on us as healthcare professionals?

Tony: One has enormous empathy with your position of going off, enhancing your skills, knowing full well that that could benefit patients, but just not having the resources to do it. The reality is however that a situation that arises due to a lack of resources would not be something that is likely to lead to you being reported to the HPC. It may be something that might be looked at within the organisation but I am sure your professional body would be very equipped to defend you and protect you against that. You can only do what you can do given the resources you have. It wouldn’t be a case of you being hauled up in front of the HPC because you didn’t have equipment that the service hasn’t provided for you.

Douglas: I think that as a registrant I would certainly have the confidence that if an allegation was made against you in those circumstances, that the Fitness to Practise process within HPC is robust enough and fair enough to give you a fair hearing about it. I am absolutely certain that in those circumstances there would be no case to answer.

Marc: I absolutely reassure you as a regulator, you are a professional, we would expect you, and I am sure you would, to do the best you can under the circumstances. If the equipment is not available you as a professional make that decision and nobody is going to criticise you for making that very quick decision. We would support you.

Paramedic: If that is the case would you agree that as registrants, we would be able to contact you at the HPC for advice?

Marc: Within the regulation of paramedics it is a question we get quite frequently. I will give you my business card if you want to write to us or in fact if you want somebody, one of your representatives or somebody in your trust to write.

Unknown: What guidance do the HPC provide to the education establishment as to whether an applicant to university would receive state registration once they have completed the course? Thinking particularly in the case of police records.

Tony: I suppose there is a simple answer: none. The only way that the HPC can decide on whether an individual is eligible for registration is at the point that they apply. University programmes should have very robust systems in place to evaluate and decide on cases as people apply and should then have adequate processes for evaluation throughout the course. It is quite clear that if you put somebody into a practice situation the expectations are that that individual, in terms of criminal records, will need the same standards as anybody working in that service. The guidance that the HPC provide is in terms of the overall validation process and the systems in place for admission and selection. Student admissions have to be made on a very different and individual basis.

Unknown: What if the educational establishment has decided that a student is fine to enrol but then after three years of university the HPC says that it is not acceptable? Or do you work more closely with universities?

Tony: Again I don’t know whether this is coming up as a question because there are examples of people who have got to that point; I would be surprised if there were. During the validation process the HPC visits the programme and we look very carefully at what systems that university or that educational establishment has in place for dealing with issues to do with criminal bureau checks, the development of disability and illness etc. If they haven’t got those systems in place within the university right at the beginning it is unlikely that that programme would be validated in the first place. So there is a very close working relationship there.

Marc: Students have effectively a contract with the training organisation, the Higher Education Institution (HEI). It is the HEI that has to make the difficult decision. I am aware of cases, probably again about two or three where individuals are actually removed from programmes, or indeed they transfer to different programmes within the university context. But it is the responsibility of the universities in the sense that they can make that decision.

Close of meeting