Modernising regulation in the health professions

In August 2001 the UK Department of Health (DoH) published outlines of a new regulatory framework for health professions.1 These include the establishment of a new body – the Council for the Regulation of Healthcare Professions (CRHP) - with an overarching role with respect to all health related professional regulatory bodies. Although the CRHP would have multiprofessional and lay representation, it is not clear what the new Council’s role will be. Indeed, some might question whether it should have a role. A consultation process will inform ‘the extent to which responsibilities for the functions of education, training, continuing professional development, revalidation and fitness to practise should be held by the individual professional regulatory bodies and the scope of the new Council’s powers in co-ordinating such functions’.1 However by invoking the Bristol Report2 (into delivery of childrens’ cardiac surgery at Bristol Royal Infirmary) the DoH would appear to support an even more radical option: that the Council ‘should have wider functions, for example education, training and development of all staff in the healthcare professions, and for promoting common curricula and shared learning across the professions’.1 What effects on healthcare education are bound up in these proposals? The CRHP could act as a quality assurance mechanism for existing Councils. However, the need for this has arisen largely through failure of mechanisms in many older professional bodies. The newer ones have gone to great lengths, both constitutionally and practically, to harmonise patients’ rights and practitioners’ needs. Most have been making rapid progress, in adopting modern ideas about education and training, in developing rigorous monitoring and assessment procedures,3 and in restructuring themselves. For example, the lay-chaired General Osteopathic Council, has virtually revalidated its entire profession during a 2-year initial registration period. The General Medical Council (GMC) has developed performance review procedures involving trained lay-assessors that are now regarded as being at the forefront of such initiatives worldwide.3 Both these developments have taken painstaking and detailed work over 5–6 years to ensure they are effective, reliable, valid and feasible. Even so they are not perfect – how could they be? Even if they were, it is unlikely they could have competently handled the type of major systems failure alleged by Bristol. But will an overarching Council, starting from scratch, be any more effective? We already have the Council for Health Improvement, the National Institute for Clinical Excellence and the National Council for Clinical Assessment all of which are, or will be, capable of rapping knuckles. More importantly, all available ‘modernising’ expertise is already being utilised by these existing bodies. While the DoH may have taken these developments into account in preparing its consultation, it is not at all evident that Bristol sampled views widely enough to make robust statements about statutory regulation. The discussion of statutory regulation is only a small part of the whole report, which has focused largely on medical and hospital management issues, yet Bristol is given much credence on this issue by the DoH. The role of the CRHP will not be without costs and constraints. Imposing another layer of bureaucracy over already difficult, cumbersome and sometimes lengthy procedures will mean even further delays and convolutions in processing individual cases, and institutional audits. Part of its role is described in terms of attempting to streamline procedures in consultation with constituent bodies and legal authorities. But making current Councils accountable to an overarching CRHP will, in addition to the constraints outlined above, effectively remove the principle of professional self-regulation. The final arbiters will be a mixture of all health professionals and lay people. This may be consonant with the Government’s wish to introduce a multiprofessional agenda, but it will remove the ‘self’ from self-regulation (i.e. by knowledgeable peers from the same profession and walk of life). Many would suggest this is a good thing, as it would sharpen interprofessional talons. But it might be a particular threat to newer and maturing complementary therapies if the Council espouses some topical principles and ideologies – for example evidence-based or managed health care. This arrangement, where individual Councils are accountable to the CRHP, would be radically different to the current situation where Councils are individually responsible to Privy Council. Currently the education, training and assessment of doctors up to pre-registration level are the responsibilities of individual Medical Schools, the GMC and the Quality Assurance Agency (QAA). After that the situation is more complex, with Royal Colleges, postgraduate deaneries, Trusts and the Department of Health and the GMC all involved. A visitor from another planet could be forgiven for being a little confused by all this. Hence the new Council may be an attempt by the DoH to sort out this plethora of regulatory obfuscation. For example the Consultation document asks what elements of education and training could or should be transferred to the CRHP. The Bristol report is far from clear on that point. In one part of a paragraph,2 it suggests that an overarching view of education and training needs to be taken by the CRHP. However in another part, this function is placed squarely within the remits of individual professional bodies, without any analysis of how responsibilities should be split. The DoH seems to place more emphasis on the former part. This emphasis may just be an indication that roles of Colleges and Schools should be more subservient to the Council, but either way it is unclear and/or impractical at present. The new Council would need to be enormous to accommodate the expertise needed to achieve coherence and ‘harmonisation’. Nevertheless the advantage is that by establishing a CRHP to include this remit the Government will be able to legitimise multiprofessional and publicly accountable shared learning. However, what would this mean for the QAA? This agency, funded by the Higher Education Funding Council, is currently also responsible for assuring the public that undergraduate and masters’ programmes in healthcare disciplines are appropriately delivered. It does this by using the services of academics and professionals that also constitute much of the pool of peers that are used by Councils themselves to regulate educational provision. Following Bristol’s recommendations, it would seem inevitable that any regulation of quality of education for health professionals would be passed from the QAA to the CRHP, or to individual Councils. How else would a continuum from undergraduate to continuing education be monitored by a single body? At present many UK Universities, especially the Russell Group (non-Oxbridge, established institutions), are ferociously challenging the right of the QAA to be so intrusive – they require ‘a lighter touch’.4 However, the one indisputable message from the Bristol enquiry is that in healthcare in the UK today more, not less, intrusion is needed. In Bristol’s case this intrusion had to be very heavy handed. Notably, the QAA has not included lay members on any of its medicine review panels, but the GMC and the GOsC have. This in itself illustrates the qualitative and social differences between the education of the health care professionals and those destined for other walks of life. The education of healthcare professionals is too important to be guided by a light touch and too complex to be managed by a federal Council. At the postgraduate level we need proper systems of accreditation such as those operating in the USA and Canada. Give these statutory roles to the Councils and let the CRHP make sure they do it right.

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