FIONA DALZIEL
MA(Hons) CIHM FIHM
Independent Consultant in Practice Management
Fiona is an experienced primary care trainer and facilitator. She is the national RCGP QPA Adviser and has advised on both the original and the review of the Quality and Outcomes Framework of the 2004 GP contract
Over roughly the last 10 years, and especially since the introduction of the new General Medical Services (nGMS) contract, the introduction and expansion of the role of the healthcare assistant (HCA) has been a significant change in general practice.
Alongside the development of the role of the practice nurse has come a shift in skill mix in practices, with qualified nurses concentrating more on chronic disease management clinics, and a consequent need to ensure that treatment room and other tasks are carried out by the appropriate post and in the most cost-effective way possible.
This isn’t going to go away. Indeed, recent Access and Responsiveness workshops run by the Royal College of GPs (RCGP) across England, in partnership with the Department of Health (DH) and the Practice Manager Network, reinforced the importance of analysing skill mix in order to ensure that patients can access the right healthcare team member at the right time.
And this is not just theoretical management-speak being pushed at us by the DH. The reality of life in the health service, including general practice, over the next few years is that we will be forced by financial pressures to concentrate very hard on cost-effectiveness; we all know that our biggest cost centre is staffing.
The role of the HCA, then, helps us to deliver improved access and does it economically, leaving other team professionals to concentrate on working at the level most appropriate to their skills and training. HCAs are a valuable and complementary alternative to nurses for a lot of tasks.
So far, so good. But what should practices step back and consider if they are about to introduce the role of the HCA or, indeed, have done so already? What’s important in terms of protecting the safety of patients and minimising risk?
Regulation, roles and training
The Royal College of Nursing (RCN) has developed a useful framework, including competencies, advising GP employers on the employment of HCAs. However, the role is not yet regulated. There are no statutory requirements in terms of education and training or qualifications, although this is being progressed at national levels.
The time lag between the introduction of the role of HCA into general practice and regulation of the role has led to the risk that distinctions between nurses and HCAs may be blurred, with consequent risk to patients:
- Boundaries may become unclear, with a lack of proper definition of what an HCA can and cannot do.
- Delegation may not be effectively managed.
- There is no framework for managing professional conduct.
- Someone who has been struck off the nursing register and/or dismissed could work as an HCA.
Regulation would:
- Protect patients.
- Protect HCAs themselves.
- Clarify the roles of HCAs in relation to other professionals.
Agreement is presently being sought over which professional body would regulate HCAs. Both the Nursing and Midwifery Council (NMC) and the RCN are involved in considering this.
Many local education providers will be able to deliver a suitable qualification for HCAs on- or offsite, and many practices have used this in conjunction with the RCN’s HCA competencies to train their staff. However, many have not; there is presently no statutory requirement to do so, but this is looking likely to change.
Nurses justify their actions based on a knowledge base and core competencies. This means that they are accountable; they are responsible for the outcome of their actions and take the blame if something goes wrong and there is potential or actual harm to a patient. Although HCAs are accountable to the public through criminal law, to patients through civil law and to the employer through the contract of employment, they do not yet have the benefit of a code of conduct against which their care and behaviour can be measured.(1)
Introducing HCAs to the practice
Job description
If you have undertaken skill-mix analysis in your practice, considered how to improve access, decided to make your staffing as lean and effective as possible, had a nursing vacancy or perhaps a combination of these, then it is likely that you will have – or will soon be considering employing – an HCA.
Introduction of this role will work best if you maximise opportunities to consult with the nurse team. You may find it useful to conduct a job analysis:
- Which nurses do what tasks?
- How many tasks do they do per week?
- How long does it take each time?
- What is the cost of delivery of that task at that grade?
- What is the most cost-effective grade to which that task could safely be delegated?
From this, a job description will start to evolve, along with new job descriptions for your nursing staff. Further assistance with defining an HCA’s job description will be available from your defence union and from the RCN website (see Resources). It is advisable to check directly with your defence organisation what duties they are willing to cover for an HCA, as this can vary from one defence organisation to another.
The following list of tasks is suggested by the RCN:
- New patient registration.
- Blood pressure checks.
- Urinalysis.
- Height/weight/BMI.
- Ordering supplies/stock control.
- Cleaning sterilisation.
- Equipment.
- Phlebotomy/venepuncture.
- Ordering vaccines.
- ECG recording.
- Peak-flow measurement.
- Spirometry.
- Audiometry.
- Smoking cessation.
- Restocking of clinical area.
- Health promotion.
- Supporting practice.
- Nurse triage.
- Minor-illness clinics.
- Assisting with minor operations.
- Infection control.
- Health checks when working to a protocol.
- Summarising patient records.
- Acting as a chaperone.
- Helicobacter testing.
- Patient recall.
- Helping with specific long-term conditions, eg diabetes, asthma.
It is possible that a defence organisation might cover the following as well. Practices should take advice about the inclusion of the clinical activities in the job description:
- Diet and health promotion.
- Administrative tasks, eg, entering data onto the computer.
- Footcare.
- Retinal screening.
- Removal of sutures.
During the swine flu epidemic, many practices and primary care organisations were unclear about whether it was acceptable to include flu immunisation in an HCA’s job description. Practices should seek advice about this. In general, they will find that defence unions consider that an HCA should only administer vaccines or B12 injections under a Patient Specific Direction or if a GP has given an individual prescription to the patient. So, unless this is the case, this duty should not be delegated to an HCA.
Other conditions around training, competence and supervision will be highly relevant in the case of administering vaccines and injections, and may be stipulated by the defence organisation. Again, check this thoroughly before proceeding.
Defence organisations may ask for a copy of the HCA’s name and job description so that they have a record of the indemnity they are providing. The GPs retain vicarious liability for the actions of the HCA, as they are liable for the wrongful acts of an employee in the course of their employment. If the staff member has followed their training and practice protocols or procedures, then the employer is responsible if they are sued.
Being part of the nursing team
It is important that both the HCA and the patient for whom they are caring are clear about the role of the HCA and where they fit into the team. Many practices take action to inform patients of the addition to the nursing team and what this might mean. HCAs must make it clear to patients what their role is in order that patients are clear that the HCA is not a nurse.
It is useful to consider establishing an explicit visual differentiation between nursing and HCA staff. In addition to badges, most practices issue a different uniform/tunic to their HCA and develop an introductory explanation for patients attending appointments with them. These actions help to protect both the patient and the HCA themselves. Patient expectations of the role will be realistic, and the HCA will find it easier to refer the patient on to another appropriate team member if necessary.
Delivering care
The RCN provides clear guidance on establishing the HCA in the delivery of care. As well as having a clearly defined job description, the HCA must then be given training to undertake these tasks. The HCA should have a clear understanding of the boundaries of the role, ie, should understand what is part of their job and under what circumstances they must involve a nurse or doctor in the care of the patient.
This means that guidance should be given on lines of accountability/reporting, so that the HCA is not left in doubt about where to turn for help. An organisational chart may be useful here. It is important that a doctor or nurse/nurse practitioner is on the premises with the HCA to offer advice at all times, especially in case of an emergency.
Competency in delivering care must be assured by the appropriate team member, usually a nurse, from whom the task is being delegated. The qualified health professional remains responsible for the tasks delegated to the HCA and for the overall care of the patient. Consequently, if legal action is taken against the HCA, the person doing the delegating may be at risk of legal action as well. As well as providing adequate training and assessment of competence, the HCA must receive ongoing support and supervision.
Effective delegation consists of the following:
- The person delegating the task should ensure the HCA can carry out the instruction given.
- They should make sure that the outcome of the delegated task meets the standard set (see below).
Clear protocols for every procedure should be developed, training given, and access to that guideline made available. Protocols should be regularly reviewed by the clinical team, new training delivered and recorded and competence assessed every time something significant changes or a new task is introduced. Practices may find it useful to use risk assessments to review protocols and ensure that patients and team members
are protected.
Once protocols are defined, standards should be set and made explicit, and performance monitored against them. This does not need to be complex, but will be most effective if the standards
are measurable.
Keep a note of all the training that has been delivered and make sure that the ongoing support and supervision offered to the HCA allow time to keep training up-to-date and competence monitored and assured.
Additional support is available to HCAs from the RCN. If the HCA’s routine work is delegated to them by a registered nurse (which it will be), or if they have a qualification in health and care level one of the National Qualifications Framework in England, Wales and Northern Ireland, or level three of the Scottish Credit and Qualifications Framework in Scotland, then they can join the RCN.
Additional training and understanding
HCAs should also receive training in the following areas:
- Consent and capacity.
- Record keeping.
- Confidentiality and data protection law.
- The role of the chaperone (if in the job description).
Reference
1. Dimond B. Legal Aspects of Occupational Therapy. Oxford: Blackwell Science Limited; 2004.
Resources
Royal College of Nursing – HCA toolkit
www.rcn.org.uk/development/hca_toolkit
Ingram P, Lavery I. Clinical Skills: a handbook for Healthcare Assistants. Chichester: Wiley-Blackwell; 2009.
