The 5 W’s of the amended approvals process for supplementary and independent prescribing programmes

Head of Educational Development, Brendon Edmonds, summarises the HCPC’s recent review of the amended approval process for supplementary and independent prescribing (SPIP) post-registration programmes.

An introduction to independent prescribing

Independent prescribing is prescribing by an appropriately qualified practitioner responsible for the assessment of patients with undiagnosed or diagnosed conditions, and for decisions about the clinical management. Independent prescribers can prescribe any medicine for any medical condition within their competence.

In 2009, the Department of Health (DH) published a report looking at the use of medicines by the allied health professions (AHPs). The report looked at whether prescribing and medicine supply mechanisms for AHPs should change to address patient and service needs. It found a strong case for extending independent prescribing to chiropodists/podiatrists and physiotherapists. In July 2012, the DH announced that legislation would be passed to allow appropriately trained chiropodists/podiatrists and physiotherapists to act, and be annotated on our Register, as independent prescribers.

As a result of this new legislation, the HCPC developed and published standalone standards for prescribing. We also amended the approval process for supplementary and independent prescribing (SPIP) post-registration programmes, which was reviewed in the 2013-14 academic year.

Here, we summarise the review and its key findings. The full report is available to download here.

WHEN…
 
When did the HCPC’s standards for prescribing come into effect following the revised legislation?

As part of the legislative change, we produced standards for prescribing. These came into effect from August 2013, following the legislation passing.

To develop these standards, we engaged with stakeholders and undertook a public consultation. The standards cover two areas: standards for education providers and standards of SPIP prescribers. The standards for education providers are based on our standards of education and training, whilst those for all prescribers are proficiency based, and expand upon the standards of proficiency required of chiropodists/podiatrists, physiotherapists and radiographers who undertake supplementary prescribing.

WHY...
 
Why does the HCPC have an amended approval process for SPIP post-registration education and training programmes?

The development of this amended approval process was a direct response to the DH changes to prescribing legislation in 2012.

It was already commonplace for education providers to deliver independent prescribing (IP) programmes for professions that we don’t regulate (pharmacists and nurses) and supplementary prescribing (SP) for ones that we do (physiotherapists, radiographers and chiropodists/podiatrists).

However, we needed to be sure that independent prescribing could be supported for our professions and in relation to our prescribing standards.  As we already approve SP programmes, we were satisfied that new independent prescribing programmes would already meet some of the standards for prescribing. We were also satisfied we didn’t need to conduct a full approval visit to assess them - hence the need for an amended approval process.

This gave eligible education providers the opportunity to gain approval for prescribing programmes in a significantly shorter timeframe than our standard approval process. In fact on average, programmes were approved ten weeks after their documentary submission – less than half the average time taken for programmes via the full process (22 weeks).

This really demonstrates how we’re able to amend our processes to support the work and initiatives of health and care providers.

WHO…
 
Who did the legislative changes affect and how did this impact education providers?

The changes to prescribing legislation meant that our chiropodist/podiatrist and physiotherapist registrants could act as independent prescribers once appropriately trained and annotated on our Register.

Prior to, and soon after, the legislation being passed, we wrote to education providers which delivered approved supplementary prescribing (SP) programmes to let them know how the amended approval process would work. We also advised them we would assess their programmes against the newly published standards for prescribing.  

Our process reduced the burden of work required for education providers to evidence how they met the required standards when compared to the full approval process. This was because they were only required to focus on the standards which were directly impacted by the introduction of independent prescribing. 

WHERE…  
 
Where did the HCPC find its visitors for the approvals and monitoring work?

We work with visitors who make the assessments of programmes to ensure they meet our standards. For prescribing, we set rules about selecting visitors for this specific area of approvals and monitoring work.

Our visitors work together in pairs to make an assessment.  At least one of the visitors had to be from a non-medical prescribing profession which was entitled to undertake independent prescribing training (a nurse or pharmacist). This visitor was required to be registered, with the entitlement recorded on their respective register.

We also recruited independent prescribing visitors to competencies that were based on the competencies for the visitors of our 16 professions.

WHAT…

What were the key outcomes of the amended approval process?

We reviewed 100 prescribing programmes at the assessment days in November 2013.

Visitors were able to request further documentation if they were not satisfied that a standard was met following their review of the documentation. Visitors could also recommend a full approval visit if there were issues remaining following their assessment of a programme. 62 per cent of the programmes assessed met the standards for education providers without the need for additional documentation, as demonstrated in the graph below. This outcome contrasts with the full approval process, where only three per cent of programmes visited in 2012/13 were approved following our first assessment.

So why was this?

There are a number of reasons:

• Education providers were not fundamentally altering their existing prescribing provision to incorporate independent prescribing.
• All of the education providers that engaged with this process ran existing HCPC approved SP programmes, and many ran IP programmes for nurses and pharmacists.  
• The education providers were already familiar with our standards and processes.

Programmes required to submit further documentation were able to evidence how they met our standards, and all 100 prescribing programmes were approved by February 2014. None of the programmes required a follow up approval visit. Therefore, we have granted open-ended approval to these programmes and it will remain in place, subject to meeting our ongoing monitoring requirements.

The outcome of approving these programmes is that individuals from the relevant professions can have their registration record annotated as an independent prescriber, once they complete the relevant training. To date, we have updated the records of 150 registrants with the independent prescribing annotation. 

Preventing small problems from becoming big problems in health and care

I recently attended the 26th conference of the US Institute of Health Improvement, and had the privilege of hearing Don Berwick and Atul Gawande amongst many others sharing their reflections on the changing landscape of health and care. I was struck by the strong focus on looking for new ways to reduce staff burnout and to invest more in the human aspects of care. Having strong and resilient relationships at work was seen as key to providing sustainable care. Kindness and compassion were just as important to good care as technical skills and knowledge. Addressing these aspects of care, both for service users, patients and for professionals, was given great emphasis. Gerald Hickson spoke about the "power of an honest conversation" as an important part of this process.

Our work on professionalism reflects this pursuit of greater awareness and understanding of the interpersonal aspects of care. I am very pleased that our latest research in this area continues this exploration, and reflects the mood and direction of thinking in a wider arena. Preventing small problems becoming big problems in health and care explores the reasons behind incremental disengagement, where challenging circumstances appear to lead to concerns about practise, and eventually to a complaint. Patients and service users in the study recognised the pressures and challenges of delivering high quality care, and the need to ensure professionals were supported to do their jobs well.  They said they wanted to be seen by professionals who were compassionate, communicative, and consistent in the care they provided.

Feedback from professionals in the study highlight the links between poor supervisory structures, lack of peer support, professional isolation and disengagement from practise. Disengagement was characterised as a symptom of underlying, often longstanding issues in the workplace which could be addressed and might be resolved before complaints arose. Not rocket science to anyone working in health and care services, but nevertheless important to the debate about what needs to change.

I was struck by words from Atul Gawande who spoke about ways in which services and professionals must evolve in response to the changing needs and expectations of society. A strong advocate for team based care, and the need to break down hierarchies amongst professionals.

Gawande suggested that "The relationship between clinicians and institutions has been like a tenant and landlord relationship. Clinicians expected to be left alone by their landlords to do what they did. But now, it has changed. Thinking about what happens in hospitals and clinics, and allowing others in, has become crucial."

This notion of "allowing others in" is enormously complex. At one end of the spectrum, this means allowing reflection and self awareness to generate those honest conversations with trusted colleagues at an early stage, as a means of addressing problems early on. At the other end of the spectrum, it can mean investigation by a regulator. Between the two ends lie conversations and interventions by managers, educators, and professional associations. My hope is that our work with Zubin Austin, Carole Chistensen-Moore and Joan Walsh will help to generate more activities at the reflective end of the spectrum, and reduce the activities at the regulatory end. It is in everyone's interest to prevent harm, to reduce complaints, and to see more emphasis on support, kindness and compassion in health and care.

Anna van der Gaag

Time for a new Chair at HCPC

 Public appointments, quite rightly, require those who hold office to stand down after two terms. This is to safeguard against office holders becoming too stale, or too close to the organisation they are charged with governing. Although I feel great personal sadness that I stand down from my role as Chair in June 2015, I believe wholeheartedly that this principle is the right one.

The role of the Chair is to provide clear strategic leadership, working closely with the Council and the Executive to keep the objective of the organisation - that of public protection - at the heart of all decision making. On a day to day basis, financial and operational oversight are also key aspects of the work, but it is maintaining this clarity of purpose around what regulation is for, that is most central to the job. This manifests itself in many different ways, working closely with the Council and the Executive team and engaging with the very many stakeholders who have an interest in the work of the regulator.

The HCPC is unique amongst regulators. Set up in 2002, the organisation has established itself as a multi professional regulator with a worldwide reputation. In the last eight years, it has doubled in size, taken on four additional professions, and been proactive in its pursuit of delivering transparent and proportionate regulation. Amongst its defining characteristics lies a single governing Council, one set of standards and processes for all 16 professions, and a commitment to treating all professions as equal, regardless of size or perceived status. This sense of equality extends throughout the organisation - the Council members and the Executive team work as equals around the table, valuing diversity of opinion and experience, with a shared committed to continuous change and improvement. Dialogue with our colleagues in health and social care, in the four governments of the UK, in education, professional trade unions and associations, and other regulators is an important part of the day to day work.

Looking back over the years, there are a number of developments that illustrate the culture of the HCPC. I am proud of the way in which the organisation has pioneered an evidence based approach, arguing that if health and care professionals are being asked to be evidence informed, so should the regulator. We have focused our research efforts on many areas, notably on professionalism, and on creating a better understanding of the experience of regulation from different perspectives  - complainants, professionals, students, employers, educators and the perceptions of a wide range of patients, service users and the public. We have been fiercely defensive of using evidence to inform our decision making, even when those decisions were not in line with wider views and opinions of the day.

I am also proud of the way that HCPC has developed its engagement with service users and patients. Conscious of the trap of tokenism, we have worked hard to create authentic and meaningful forms of engagement, to listen and work closely with users in many different settings. Regulation is there for the public, and it must be intelligible, accessible, responsive, and visible for those who need it. We have worked hard over the years to improve our communications, so that individuals know where to find us, and judge us to be trustworthy to act when standards are not being met.

My final observation, for those who might be considering applying for this role is that the HCPC is quite simply a great place to work. It has a strong "can do" culture running through it. The people who work here are highly committed, hard working, and open to change and improvement. The Council work well as a team, clear about their role and of the territory best left to the Executive.

It was John Carver who observed that the role of a Chair is to protect and further the integrity of governance, as a servant of the Board and the organisation. I can think of no better place to pursue this goal, and no better team to work with.


  

5 key findings from social work programme approvals

Jamie Hunt, Education Manager at the HCPC, talks through some of the observations and trends following the second year of social work programme approval visits.

The 2013-14 academic year saw the Education team complete the second year of approval visits to social work programmes. In total we visited 113 programmes at 43 education providers, 16 of which were new programmes.

The purpose of the process is to ensure an education provider:

• has a robust framework to manage all aspects of their programme effectively;
• holds responsibility for all aspects of their programme, including placement environments;
• has curriculum and assessment which support the delivery of our standards of proficiency for social workers in England, and;
• can make good decisions about those individuals who receive the final approved award.

If we find areas which do not meet our standards following an approval visit, we will set conditions which must be met before it can be approved.

With other professions previously new to HCPC regulation, we’ve found that education providers better understand our quality assurance approach over time, and therefore work effectively to align their programmes to our standards. This usually means that as the series of approval visits progresses, the fewer issues we identify. This was certainly true of our approval visits to social work programmes in the 2013-14 academic year, in comparison to the previous year.

Here, we have summarised some of the key observations and trends. Our full report – Review of the Health and Care Professions Council (HCPC) approval visits to social work pre-registration education and training programmes in the 2013-14 academic year – is available to download on our website.

Social work programme approval visits 2013-14: 5 key findings

1. On average, we applied 1.8 fewer conditions per social work programme in the 2013-14 academic year compared to the previous year. 

This result suggests social work education providers are becoming more familiar with our regulatory requirements. They are successfully providing the evidence to meet our standards prior to and at the visit itself.

2. Education providers are more aware of the importance of managing issues regarding student consent.

SET 3.14 requires education providers to ensure that: “where students participate as service users in practical and clinical teaching, appropriate protocols must be used to obtain their consent”.

Last year, we found we applied conditions to 56% of programmes but this has dropped to 33% in year two. This suggests there is greater understanding amongst programme teams regarding getting informed consent from students where they are involved in role play or are sharing personal information. 

3. Many of the conditions we placed on programmes were linked to:

• Inadequate programme documentation

One way to demonstrate a robust framework is in place to manage a programme is ensuring all areas are clearly documented. This is why we ask education providers to submit copies of key programme documents (e.g. programme and placement handbooks). We commonly set conditions where we find inconsistency, or an absence of information, in these documents which could affect a stakeholder’s engagement with a programme.

• A lack of documented policies and systems, used to manage a range of programme areas

To approve a programme, policies and systems must be in place, written down and appropriately applied. As a regulator, we do not solely rely on the establishment of good will and long-standing relationships between various stakeholders to support a programme’s delivery. We need to be satisfied an education provider can effectively identify, manage, mitigate and learn from issues and risks and in doing so, maintain the level of quality that our standards require of them.

• Clarity regarding how the programme meets Standards of Education and Training (SETs) and supports individuals meeting our Standards of Proficiency (SOPs)

Education providers need to clearly identify how their programme aligns to our standards. This can take time and this is one of the reasons we provide education providers with a six month lead in time to the visit itself. Careful thought is needed to consider how the programme meets our SETs and SOPs and it is important that this is mapped clearly for the benefit of our visitors who will assess the programme. This process of mapping should also allow an education provider to identify any potential gaps in how they meet our standards prior to the visit.

4. A shift in the split between undergraduate and postgraduate programmes sees more social work programmes being delivered at postgraduate level.

At the point of transfer in August 2012, 47% per cent of programmes were delivered at postgraduate level. At the end of the 2013-14 academic year, 54% of programmes were delivered at postgraduate level.

5. All social work programmes visited in the 2013-14 academic year have now successfully completed the approval process.

This means that programmes with conditions placed on them have now evidenced that all conditions have been met. Once a programme has met all our standards through an approval visit it receives what is called 'open-ended' approval. This does not mean these programmes are approved indefinitely. They will need to continue meeting our standards through mandatory engagement year to year with our monitoring processes.

We prefer to keep regular engagement with the programmes we approve, rather than running a re-approval cycle. It allows us to assess incremental changes to programmes largely as and when they occur. Importantly, where significant changes are identified in our monitoring processes, we have mechanisms in place to enable a new approval visit to be initiated if required.

In conclusion

We are pleased to see that the work we have carried out with education providers is proving effective. Over the past two years we have delivered seminars aimed at those providers who were yet to undertake an approval visit, and have supported providers with guidance literature and through our newsletter, Education Update. We were also able to directly address any issues with members of programme teams before their visit. We also widely publicised the findings of our first year review and we’ll be doing the same this year, so have a read and share our findings.

Our second year report is not intended to be a comprehensive review of social worker education in England. We are still part way through our three year programme of visiting transitionally approved social work programmes, and it is too early to draw full conclusions about the impact of the standards of education and training (SETs) in assuring, and driving improvements in, social work education. We intend to begin a more comprehensive review at the end of the 2014-15 academic year.