This article relates to the CQC key question: Is your practice safe? and Is your practice well-led?
The role of unregistered health care professionals and has grown in recent years as practices consider how to improve access to services.
Unregistered roles in general practice would include healthcare Assistants (HCAs) and assistant practitioners. This article describes the role, challenges and employer responsibilities for the HCA in general practice. ‘HCA’ covers both the roles of healthcare assistants and assistant practitioners.
HCAs have a duty of care and therefore a legal responsibility with regards to the patients they see. Although they are not registered with a professional body, HCAs are accountable to their employer to follow their contract of employment. In turn, employers have a responsibility to ensure the HCAs they employ are trained and supervised properly until they can demonstrate competence.
Employers accept vicarious liability for their employees; they are accountable for the actions and omissions of the employee. It is therefore vital that employers ensure that employees only work within the limits of their competence.If a registered nurse is responsible for delegating tasks to an HCA, the registered nurse is responsible under the Nursing and Midwifery Council (NMC) Code of Conduct for the safe delegation of that task.
The potential isolation of the primary care environment presents different challenges for HCAs who may have previously worked within larger teams in social care or hospitals. The scope and nature of the HCA’s responsibilities vary between practices and depends on the individual needs of the practice. Tasks may include blood pressure management, venepuncture, recording ECGs and health promotion such as smoking cessation.
Regardless of the task being undertaken, the principles of delegation remain the same:
- the HCA should have been trained and assessed as competent
- the HCA’s job description should specify their role
- the practice should ensure they have appropriate medical indemnity for the HCAs they employ and that the cover provided is sufficient to cover their scope of practice.
Although the nature of general practice means that HCAs will be carrying out care for patients independently, they should have access to a registered nurse or GP who can provide advice and support when necessary. The level of supervision required will depend on the task being undertaken. The key is that the degree of risk must have been assessed because ultimately the patient has a right to the same standard of care, whoever delivers it.
Administration of vaccines
HCAs can administer vaccines to patients in certain circumstances and are a valuable part of the team, especially for example during the annual flu vaccination campaign. Specific training and assessment of competence must have taken place.
The Royal College of Nursing (RCN) supports the role of HCAs in administering specific vaccines to adults and the nasal influenza vaccine to children, providing they are appropriately trained and have the support of a registered health care professional (GP or nurse in primary care).
The RCN does not support HCAs administering other vaccines such as the remainder of the childhood vaccination programme or travel vaccines. This is due to the clinical decision-making involved.
In all cases, Patient Specific Directions (PSD) should be in place. A PSD is a specific, written order by a qualified prescriber who retains responsibility for the safe administration of the vaccine.
Only registered health care professionals can administer vaccines under a Patient Group Direction and they are therefore not appropriate for HCAs.
- Public Health England updated guidance on minimum training standards for HCAs administering vaccines
- Patient Group Directions (PGDs)/Patient Specific Directions (PSDs)
Sample-taking for the cervical screening programme
Taking samples from women for the screening programme involves more than the practical task and specifically includes a level of judgement on the appearance of the cervix. Therefore this is not appropriate for HCAs. The contract between NHS England and GP providers specifies that only qualified staff should perform this procedure. The training for sample-takers is insufficient for those without a previous clinical background to undertake this task.
From April 2015, all employers appointing HCAs should incorporate the standards contained within the Care Certificate into the induction process.
An independent review by Camilla Cavendish in February 2013 investigated how care assistants and support workers in health and social care could be better valued and supported. Since then, Health Education England, Skills for Care and Skills for Health have developed the Care Certificate which contains 15 standards and outlines what health and social care workers should know and be able to deliver in their daily jobs. It aims to address inconsistencies in training and competencies so that all staff have the same introductory skills, knowledge and behaviours to provide safe, high quality and compassionate care of the highest standards.
For HCAs employed since April 2015, we expect to see evidence of how the Care Certificate standards are being included in induction programmes.
- Care Certificate: Skills for Life website
- Further information about implementing the Care Certificate on Medeconomics
CQC inspections of GP practices
When we inspect GP practices we check that staff have the skills, knowledge and experience to deliver effective care and treatment, as part of considering how effective a GP practice is. GPs should therefore be prepared to demonstrate how they have trained HCAs for all aspects of their role and assessed their competence, both when they initially undertook the task and throughout their employment.
This could be achieved by a range of methods and could involve a combination of directly-observed and recorded clinical encounters, external training events / updates and in house reflection on practice with a mentor who has appropriate expertise.
- Elaine Biscoe is national nursing advisor at the CQC
More CQC resources
- View the full CQC Essentials series on Medeconomics
- CQC's recommended reading to help practices meet regulations and prepare for an inspection
Picture: JH Lancy