New body may feel old pains

February 4, 2000

Proposals for a new Health Professions Council have drawn some strong and opposing views. Claire Sanders reports.

A bitter response has greeted a long-awaited consultation document on a new Health Professions Council. The council will replace the Council for Professions Supplementary to Medicine, the statutory body that was set up to regulate these professions in 1960, and has been overtaken by changes in the health service and in higher education. In particular, the powerful boards representing the various health professions within the CPSM will go - and they are not happy.

Many chiropodists, radiographers and others in the remaining ten professions supplementary to medicine say the new arrangements will undermine their attempts to maintain standards and protect the public.

"They will be able to put on my tombstone that I fought to the bitter end," says Raymon Ariori, chair of the chiropodists board of the CPSM.

"Only a madman or a fool could possibly believe that the new arrangements will help patients," he says.

He argues that the new council - which will establish common procedures for the different professions- will undermine the status of individual professions and will make it easier for universities to get approval for poor-quality courses.

Other boards are more sanguine. "We will go ahead and work with the new structure in as positive a way as possible," says Sandra Benson, chair of the occupational therapy board of the CPSM.

But for others in the professions, and for the academics who teach them, the new council will be a more powerful body that will bring a much-needed streamlining of quality assurance procedures to higher education. Far from eroding the influence of the professions themselves, it will give them a more effective council to counter the powers of the Quality Assurance Agency, the body responsible for assuring quality in universities.

Mike Hall, registrar of the CPSM, supports the proposals. But he says the consultation document "gives plenty of opportunity for some to focus their replies on their own preconceptions, misconceptions and personal hobby horses rather than standing back and taking this opportunity to see what is best for public protection."

These professions have been waiting for a new council since 1996, when management consultants J. M. Consulting carried out a review of the Professions Supplementary to Medicine Act (1960) for the government. In the same year, the then Higher Education Quality Council and the National Health Service executive published Improving the Effectiveness of Quality Assurance Systems in Non-Medical Health Care Education and Training.

Only now is the J. M. Consulting document bearing fruit, while many argue that the HEQC/NHS document has been ignored by the HEQC's successor, the Quality Assurance Agency.

The informal consultation on the Health Professions Council (it will be followed by a formal consultation in the spring) proposes a council along the lines that were suggested back in 1996. It will radically alter how these professions are regulated: in particular, those in universities will find themselves dealing with a multi-professional education committee.

In 1996, J. M. Consulting confidently concluded: "Almost everyone agrees that the current arrangements are flawed. Most support our view that the problems are so severe that new legislation is required."

Mr Hall agrees: "The act was totally flawed from the day it was formed."

The 1960 act, J. M. Consulting argued, had been overtaken by NHS reforms, changes in higher education and the changing role of professionals in society. The education of the professions supplementary to medicine had moved from in-service training in the NHS to universities.

The move had not been without its critics, particularly in the then Department of Education and Science, but after the University of Ulster started awarding degrees in physiotherapy in the late 1970s, others followed. The number of professions covered by the act had also increased - and is expected to increase still further.

The CPSM has long been struggling to regulate this fast-changing world. The council acts as an umbrella body, bringing together powerful professional boards.

J. M. Consulting argued that the council does not have sufficient powers to protect the public. On education it argued that the council had no procedures for continuing professional development, was too inflexible and duplicated work through its many boards.

"The CPSM's professional boards are powerful, autonomous and dominated by the profession being regulated. This can lead to unnecessary differences of approach between professions, which may add to costs for education and the NHS. In the absence of effective checks and guidance, there is a risk of the boards pursuing sectional interests." The council had consequently been unable to establish strong cross-professional strategies, it said.

J. M. Consulting also said that the privy council was involved at too great a level of detail.

In June last year the government passed the Health Act, which, among other things, paved the way for the establishment of a new council. It was not until late last year that the informal consultation document began circulating.

"This paper does not seek to re-open discussion of the decisions already agreed in 1996 ... that new legislation was needed to enhance public protection and provide for one multi-professional body with a single register," says the document.

Mr Hall is relieved: "We are particularly pleased that on the whole the consultation document does not try to revisit old, tired and sterile arguments - although there will no doubt be those that will."

Mr Ariori, however, is furious: "The whole consultation exercise is phoney - we are merely going through the motions."

The government has agreed with J. M. Consulting that the CPSM should be replaced by a new council, with stronger powers to decide matters currently referred to the privy council. It will be a United Kingdom-wide body, but subject to debate by the Scottish Parliament, the National Assembly for Wales and the Northern Ireland Assembly, should they choose to. It will have four fundamental functions: preparing, maintaining and publishing a register of members; setting the standards of education and training for entry to the profession; providing guidance on standards of conduct and performance; and administering the rules for fitness to practise procedures.

It is planned that the new council, because of its size, should delegate many of its duties to four statutory committees - an investigating committee, a professional conduct committee, a health committee and an education committee. The education committee will deal with pre-registration qualifications (that is, setting the standards for entry to the register), continuing professional development and registration criteria for both UK and non-UK applicants.

The government is leaving it to the new council to decide on the composition of the education committee, but says: "The government expects the HPC both to take account of the distinctive contribution which each individual profession is able to make and to recognise those areas where a multi-professional approach could be adapted."

The new council will be able to approve courses and institutions in relation to entry into training and admission to the register.

The consultation document also tackles quality assurance. "The NHS, the regulatory bodies, the professional bodies and the Quality Assurance Agency all share responsibility for quality assuring the training of health professions."

It makes it clear that the government wants to see a "streamlined approach to quality assurance involving all the key partners", but recognises that "the HPC should have the right of inspection of courses and institutions".

The review also recommended the establishment of a panel of professional advisers to carry out detailed work on education and other areas. It saw this as more efficient, effective and flexible than creating a series of sub-committees for each profession.

Mr Ariori argues that the removal of power from the boards will hit quality. "We can support heads of schools in their bids for more resources by threatening to withdraw approval if courses do not meet our requirements," he says. "Now such matters will have to go through the education committee, and then if there are difficulties, to the council. This will be too slow."

He also argues that a multi-disciplinary education committee will not work. "Tell me what is common to an orthoptist and a chiropodist?" he says. "It is ridiculous to look for commonality in such a diverse group of professions."

J. M. Consulting acknowledged these arguments in its review, but concluded: "We have been unable to identify much work at a policy rather than operational level that is truly profession-specific. Most of the issues about curriculum strategies; assessment methods for clinical training; validation procedures for courses; principles of CPD schemes; registration criteria for overseas applicants etc are generic to all these professions." The areas, such as the curriculum, that clearly relate to particular professions would not, J. M. Consulting proposed, come to the education committee anyway.

Jackie Campbell is the educationist member of the arts therapists board of the CPSM and head of research and consultancy at the University College of Northampton's centre for health-care education. "I have always been a great believer in multi-disciplinary working and have long been frustrated that the boards replicate each other's work and don't share experiences with each other. This represents a lost opportunity and results in duplication of documentation," she says.

Peter Bowker is dean of the faculty of health care and social studies at the University of Salford.

"I think the new structure for the council looks very good, it is a vindication of the work of J. M. Consulting, which I thought took a very civilised approach," he says.

Professor Campbell argues that the new council will better coordinate the various quality assurance procedures that have hit higher education just as the professions supplementary to medicine moved into universities and colleges.

"The 1996 HEQC and NHS executive report outlined ways of streamlining quality assurance procedures," she says. "I was very active in the workshops that contributed to that report. I think it has been totally ignored."

The QAA "did not notice that report", she says.

Others argue that the QAA has suffered from a "not-invented- here syndrome".

When the report was published, Roger Brown, then chief executive of the HEQC, said: "The report very clearly demonstrates the potential value of identifying common ground in an area of externally funded education provision where there are a number of legitimate and hitherto largely separate perspectives on quality."

The QAA argues that its work on standards and outcomes can be used by professional and statutory bodies to inform their own decisions on accreditation. It has also set up a joint committee with the NHS to minimise duplication.

The contract being drawn up by the QAA and NHS executive will streamline quality procedures by identifying areas where the work of the professional bodies overlaps with that of the QAA and the needs of employers.

The NHS is also in discussions with the QAA on how its work on benchmarking might be extended to include those health-care programmes that the NHS now funds.

"If this is possible," said a QAA spokesman, "the QAA would need to work very closely with professional and statutory bodies, in drawing on their extensive experience, so that practitioner standards as well as academic standards could be benchmarked."

The professions supplementary to medicine are not represented only by the CPSM and its boards. There are also other professional bodies such as the College of Occupational Therapists and the Society of Chiropodists and Podiatrists. Some of these, such as the chiropodists, have views closely in line with the boards, others are more distanced.

But whatever partnerships develop, Mr Hall is clear where the real power lies.

"We will work with the QAA but it is the CPSM and its successor body that ultimately have the power to open or close a course. As the Health Act makes clear, one of our core functions is determining standards of education and training for entry to the professions."

The introduction of the proposed council and the new NHS/QAA contracts should complete some of the work started in 1996. "We are on the right track," says Mr Hall. Those at the sharp end at universities seem rather resigned.

"We've always accepted that we are not like the ancient historians or the philosophers who can just please themselves," says Professor Bowker. "But then we have more money than them," he concludes.

PROFESSIONS SUPPLEMENTARY TO MEDICINE

The Council for Professions Supplementary to Medicine regulates 12 professions:

Arts therapists

Chiropodists

Clinical scientists

Dietitians

Medical laboratory scientific officers

Occupational therapists

Orthoptists (the correction of sight defects)

Paramedics

Prosthetists and orthotists

Physiotherapists

Radiographers

Speech and language therapists.

The number of professions regulated by the CPSM has almost doubled in the past ten years. These professions are part of a larger family called Professions Allied to Medicine, which evolved

from a group known up to 1960 as medical auxiliaries.

According to Peter Burley, deputy registrar of the CPSM, the professions supplementary to medicine have a number of common traits: "All share a formal relationship with conventional medicine, a base in the public sector and a professional identity enabling them to work autonomously," he says.

"Another feature most share is that graduation is coterminous with state registration (or licence to practise), which creates a

very special relationship with higher education. Graduate entry now reinforces these characteristics."

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