The developing role of the HCA in general practice

The role of the health care assistant in the general practice setting has evolved rapidly in recent years, and continues to grow. We discuss the key factors in making the role a success and look at what the future may hold

The nursing support role can be traced back to the beginnings of modern nursing, from the presence of nurses' aides during the Crimean War, 1854-56, through to the 'nursing auxiliary' role of the mid-1950s and on to the health care assistant role that was identified around 1990.¹

In general practice, the evolving role of the practice nurse (PN) and the development of advanced nursing practice has resulted in nurses taking on much of the chronic disease management in GP surgeries. By the late 1990s phlebotomists were being employed to take on the increasing numbers of blood tests being performed in the practice setting.² But the introduction of the GMS contract in 2004 saw a realisation that introducing HCAs into practices could greatly enhance the potential for achieving targets as they could perform the blood pressure measurements, BMI and further routine monitoring required by the quality and outcomes framework (QOF).

Bosley and Dale³ note that traditional roles and responsibilities in primary care are being challenged by additional strands of healthcare policy alongside the introduction of the GMS contract. Delivery of care has been shifted from the secondary to primary care settings to support 'patient led services'. There is an increased emphasis on public health, disease prevention and health promotion. GPs have more flexibility in balancing their budgets.

In the past ten years or so we have seen the role of the HCA in general practice grow rapidly, with HCAs now performing many higher level tasks such as ear irrigation, wound dressings, diabetic foot examinations and influenza vaccinations (under the supervision of a regulated healthcare professional). We have seen the introduction of the assistant practitioner (AP) role, initially in mainly acute care from 2002 but more recently in a wide range of settings including general practice. It is estimated that there are now just over 7,500 HCAs working in GP surgeries in England alone.

HOW CAN PRACTICES MAXIMISE THE ROLE OF THE HCA?

It is now widely accepted that introducing an HCA into the practice team can improve practice capacity and efficiency. They help to reduce waiting times and enable practice nurses and GPs to make better use of their skills and time. Practice staff view the role positively, and HCAs report that they enjoy the role and feel that they contribute positively to the team.⁴

However, there are a few key issues that must be considered in order to ensure that the HCA can fulfil their role safely and effectively, and that patient safety is maintained. These include having clear role boundaries, appropriate competence-based training, protocols and procedures and a good understanding of accountability and delegation.

ROLE BOUNDARIES AND PROTOCOLS

Dale⁴ reports that there is a need for a greater understanding of the HCA role among the members of the whole practice team. Defining the scope of practice could usefully start with a skill mix audit, to identify which members of the team are currently performing what roles, and from there it can be calculated what could safely and effectively delegated to an HCA. Dale also notes that providing clear information about HCAs' responsibilities may help to ease anxieties and tensions of both staff and patients.

Bilton⁵ supports the concept of defining the HCA's role and backing this up with support, supervision and continuous professional development. She emphasises the importance of having clearly defined protocols which outline the procedure to follow, remove the need for the HCA to make clinical judgements which should be made by a registered practitioner, and state the arrangements for referring back to the registered practitioner when required.

TRAINING AND EDUCATION

The Royal College of Nursing (RCN) position on the education and training of health care assistants6 clearly explains the most important aspects of preparing an HCA for their role, and is applicable to all health care settings. The key points are summarised below:

• HCAs are valued and integral members of the nursing team. They must be supported to develop the knowledge and skills required to deliver competent and compassionate patient-centred care.
• Registered healthcare professionals are accountable for appropriate delegation in the best interests of their patients, and are ultimately responsible for the overall care of their patients.
• HCAs must not be expected to perform tasks for which they have not been trained or deemed competent to perform. They have a responsibility to work within their limits, and to inform colleagues if expected to perform a task for which they are not competent.
• Training should be competence-based, quality assured, and assessed against nationally recognised standards. It must be set at an appropriate level to the HCA's needs and role within the organisation.
• Competence should be assessed and documented regularly, in line with the annual personal development plan and appraisal.
• Staffing levels and skill mix should be determined appropriately using current recommendations and guidance.

As yet there is no national training programme or framework for HCAs working in general practice, although there are a growing number of education providers who are developing competence-based programmes that practices can access. Some are accredited, and provide the HCA with educational credit at UK wide Qualification and Credit Framework (QCF) levels. Many national occupational standards which are applicable to the HCA role in the GP practice can be found on the Skills for Health website www.skillsforhealth.org.uk as noted in the RCN position statement. National occupational standards provide the knowledge and performance criteria of a range of core skills and can be used to support education and assessment of HCAs.

ACCOUNTABILITY MATTERS

There are very few practices in the UK without an HCA, and some have a whole team of support workers including phlebotomists, HCAs and APs. Nursing teams work in many different ways, but essentially the registered nurses delegate aspects of nursing care to the support workers. This delegation is rarely formal. For example, if there are regular clinics for phlebotomy, this is the specific role undertaken by the phlebotomist or the HCA, and they would normally proceed with the clinic without any formalised referral by the practice nurse. However, they should be working within a protocol and if they have any concerns or queries requiring a clinical judgment then they should be able to contact the PN for advice or support.

HCAs should not be put in a position where they are required to make a stand alone clinical judgement.⁷ This is the responsibility of the registered nurse, and the HCA would need to be able to refer to their registered colleagues in situations such as a change in the patient's condition. A good example is in wound care, where the PN should make the initial assessment of the wound and plan the care to be given, such as which dressing is required and how frequently it needs to be changed. The PN may then delegate the wound dressing to the HCA, if he or she is confident that the individual has the knowledge and skills required to perform to the standard that would be expected of any health care practitioner carrying out this function.

The key question to ask is 'Is it in the best interest of the patient to delegate this role?'⁸ This is explained well by Chris Cox,⁹ who tells us that 'every patient should be entitled to expect a similar standard of care in relation to a particular healthcare intervention, irrespective of where, when and by whom the care is delivered.'

Therefore if the HCA, when dressing the wound subsequently, discovers a change in condition such as increased exudate or signs of inflammation, it is the HCA's role to refer back to the PN to make the judgment and change the plan of care according to the context of the situation. It is therefore almost impossible to describe a list of roles that can be performed by HCAs as some roles are appropriate in one situation but totally inappropriate in another. A dressing to a simple post minor-operative wound is a completely different matter to a dressing on the inflamed toe of a diabetic patient.

Practice nurses must be prepared to make decisions about whether or not an aspect of care can be appropriately delegated to an HCA. Frequently this decision is based on a gut feeling rather than a judgment about the competence of the HCA or the context of the situation. Studies by Spilsbury and Meyer10 and Knibbs et al11 indicate that tasks undertaken by healthcare support workers (HCSWs) can vary according to circumstances other than their experience and training. This remains true, and Kessler1 found that registered nurses continue to demonstrate concern over accountability issues and some lack confidence in delegating to HCAs.

The RCN provides extensive information, including leaflets and a short video, which can be accessed on www.rcn.org.uk/hcaaccountability.⁸

NATIONAL GUIDANCE

Guidance is slowly emerging for specific responsibilities such as the HCA role in influenza and pneumococcal immunisations. The Health Protection Agency (HPA) has recently produced National Minimum Standards and Core Curriculum for Immunisation Training of Healthcare Support Workers.¹²

The guidance was developed to define standards that may be considered a minimum for HCSW immunisation training and to provide assistance to those responsible for developing and delivering training. It is available on the HPA website www.hpa.org.uk and is a comprehensive document outlining the essential requirements of not only the training but also the implementation of the role of the HCA administering influenza and pneumococcal vaccines to adults.

THE FUTURE?

Probably the most widely debated subject in the world of HCAs is their regulation. This has been a hot topic for many years now, and as HCA roles develop it is becoming clear that they are indeed performing many roles previously considered to be the remit of the registered nurse. Regulation therefore remains top of the list of many key stakeholders, including the unions and professional bodies who agree that statutory regulation of support workers is the way forward. The RCN believes all HCAs and APs should be regulated in the interests of public safety and is committed to supporting steps towards statutory regulation.

Statutory regulation brings with it a code of conduct, standards for education and training, a clear career pathway and definition of the role. These functions of regulation contribute to building up a strong platform for the most effective means of assuring public safety, and it is well documented that HCAs themselves support statutory regulation.¹³

In Scotland and Wales there are codes of conduct for HCSWs and a code of practice for employers. Scotland also has induction standards, while Wales gives guidance in induction best practice. These employer-led methods of regulation were brought into practice in 2011.

In Northern Ireland the health and social care services are integrated. There is an independent health and social care regulatory body, the Regulation and Quality Improvement Authority (RQIA) who inspect and review all health and social care services providers. As yet there is no mandatory regulatory process for individual support workers. However, the Northern Ireland Social Care Council has a voluntary register for those providing social care.

The current UK Coalition Government proposes a system of voluntary regulation for health and social care support workers14 and has tasked Skills for Health and Skills for Care to develop codes and standards for HCSWs in England as a step towards this process. This work is due to be completed by the end of January 2013 and progress is charted on www.skillsforhealth.org.uk/about-us/news/consultation-continues-for-the-code-of-conduct-and-minimum-training-standards/

SUMMARY

The role of the HCA in general practice is rewarding and exciting. HCAs have established their value and are now recognised as key members of the practice team. With the support of their nursing colleagues, robust protocols and an understanding by the whole team of their role boundaries, HCAs and APs provide an excellent service to their patients. Regulation would help to standardise the role so that registered nurses would find it easier to delegate appropriately to HCAs and APs. But it is essential that education and training is relevant and competence-based so that this group of employees can grow and maintain their knowledge and skills in the rapidly changing environment of primary care.

The RCN provides professional advice and support, and many resources that support HCAs and APs in their role.

REFERENCES

1. Kessler I, Heron P, Dopson S, et al. The nature and consequences of support workers in a hospital setting. Final report. NIHR Service Delivery and Organisation programme; 2010

2. Hand T. Evolution - the health care assistant in primary care; British Journal of Healthcare Assistants 2007;1:1

3. Bosley S, Dale J. Healthcare assistants in general practice: practical and conceptual issues of skill-mix change. British Journal of General Practice 2008;58(547):118-124

4. Dale J. The role of healthcare assistants in general practice: Nursing in Practice 2010;52:68-72

5. Bilton J. Maximising the potential of healthcare assistants: Independent Nurse 2006;26-27

6. Royal College of Nursing. Position statement on the education and training of health care assistants. RCN, London; 2012. Available at: www.rcn.org.uk/publications

7. Royal College of Nursing. The nursing team: Common goals, different roles; RCN, London; 2012 Available at www.rcn.org.uk/publications

8. Royal College of Nursing. Accountability and delegation: what you need to know. RCN, London:2011 Available at www.rcn.org.uk/hcaaccountability

9. Cox C Legal responsibility and accountability; Nursing Management; June 2010; 17; 3; 19, 20

10. Spilsbury K, Meyer J. Use, misuse and non use of healthcare assistants: understanding the work of healthcare assistants in a hospital setting. Journal of Nursing Management 2004;12:411-418

11. Knibbs W, Smith P, Magnusson C, Bryan K. The contribution of assistants to nursing. Final report for the Royal College of Nursing. 2006; Healthcare Workforce Research Centre, University of Surrey, Surrey

12. Health Protection Agency. National Minimum Standards and Core Curriculum for Immunisation Training of Healthcare Support Workers; HPA; London;2012 Available at www.hpa.org.uk

13. Royal College of Nursing. Ipsos Mori quantitative telephone survey: Summary of findings 2008; available at www.rcn.org.uk/development/health_care_support_workers/professional_issues/regulation/rcn_work_on_regulation

14. Department of Health. Enabling Excellence: Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers. DH, London February 2011