The changing role of the healthcare assistant
Healthcare assistants (HCAs) are an 'army of unsung heroes' who deliver outstanding care on a daily basis, said the then Health Secretary Patricia Hewitt in 2005.1 In contrast, today there is a clamour for better training and closer supervision for HCAs. Diane Baylis, a registered nurse and Clinical Risk Manager at MPS, looks at the role of the HCA and how it is developing to meet the increasing pressures in general practice.
Since the introduction of the 'new' GP contract in 2004, the number of HCAs has mushroomed in response to the increased level of work. HCAs are now an important part of the primary health care team and contibute to the care and services provided in general practice.
DEVELOPING ROLE
In the UK, 'Healthcare assistant' is the title officially applied to staff working at National Vocational Qualification (NVQ) level 2 or 3 in healthcare.2 Their contribution was formally recognised by the Royal College of Nursing (RCN) in 2005 with their admission as associate members.
The development of the HCA role is emerging in response to the increasing pressures and demand for extra staff in general practice. This is contributing to changing roles within the practice nurse team as practice nurses are taking on additional responsibilities that were previously the preserve of doctors, and their role is becoming increasingly more specialised. In turn, more support staff are needed to relieve the practice nurse of routine healthcare and administrative tasks. HCAs are a useful contribution to the skill mix in general practice. However, it is vitally important that they have clearly defined roles, that are clear to staff and patients.
The recent Francis report into the care failings at Mid Staffordshire hospital has made a number of recommendations specific to healthcare assistants.3 They included recommendations for the introduction of a set of common national standards for their education and training, registration and a national code of conduct.
'Skills for Health' (commissioned by the Department for Health) has recently developed a Code of Conduct and National Minimum Training Standards for healthcare support workers in England.4 The Code describes the standards of conduct, behaviour and attitudes expected of HCAs and The National Minimum Training Standards define the minimum knowledge HCAs must have. Working within these guidelines will ensure that new HCAs have the key knowledge and understanding required for their role from the start.
TRAINING
HCAs are commonly trained to undertake specific procedures such as blood pressure recording, new patient checks, health promotion and phlebotomy. Increasingly HCAs are undertaking 'extended' roles such as ear syringing, vaccinations and wound dressings. The RCN recommends that HCAs should be trained up to National Vocational Qualification (NVQ) level 3, in order that they can work independently.5
HCAs should work to clearly defined, evidence-based, up-to-date protocols and they should not be asked to make clinical judgements. They must have the knowledge, skills and competence to undertake the delegated tasks, including communication and interpersonal skills, as well as clinical competance.
DELEGATION
There is no definitive list of tasks that a HCA can undertake. HCAs do not assess patients; however, they can be delegated tasks after a clinician has undertaken the assessment. The healthcare professional delegating a task must ensure the HCA is trained and has the necessary knowledge, skills and competence to undertake the tasks delegated to them, and that accountability is clear. The HCA must understand the required outcome of the task and that they should not attempt to perform any further duties beyond what has been instructed, as well as being aware of their responsibility to raise issues of concern and seek support when appropriate. Delegation must always be in the best interest of the patient and not performed simply in an effort to save time or money.
The Nursing & Midwifery Council (2008) summarises the delegator's accountability:
'If the nurse or midwife is delegating care to another professional, health care support staff, carer or relative, they must delegate effectively and are accountable for the appropriateness of the delegation.'6
The Code requires that nurses must:
- Establish that anyone they delegate to is able to carry out their instructions
- Confirm that the outcome of any delegated task meets required standards
- Ensure that everyone they are responsible for is supervised and supported.
ADMINISTERING VACCINATIONS
In many practices, GPs delegate the task of administering certain injections, such as flu and pneumococcal vaccinations and vitamin B injections, to HCAs. Some HCAs are now being asked to administer pertussis vaccination for pregnant women.7
When a HCA undertakes the administration of vaccinations, this must be done with the use of a Patient Specific Direction (PSD). The NMC states: 'A PSD is a written instruction from a qualified and registered prescriber for a medicine including the dose, route and frequency or appliance to be supplied or administered to a named patient.'8
Prior to administration of any vaccine by a HCA to a patient, the HCA must obtain a signed authorisation by GP or independent prescriber to administer the vaccine and complete the vaccination record sheet that details the patient's name, date of birth, vaccine given, dose, batch number and expiry. This is a legal requirement under the Medicines Act (1968). Where a HCA is unsure about any aspect, they must refer to a clinician for advice before proceeding.
The PSD must:
- State the name of the patient
- State the name and dose of the prescription-only medicine to be administered
- Show evidence to confirm that the patient has been considered as an individual
- Be signed by an independent prescriber/GP and the HCA and scanned into the patient's record.
INDEMNITY
In general practice, HCAs are required to work in situations where constant close supervision is not always possible. This means that HCAs need to be able to share in the responsibility for working safely and correctly. Education, training and assessment will help to give them the confidence to do this successfully.
Employing GP partners are vicariously liable in law for the acts and omissions of the HCA. Their own indemnity arrangements are unlikely to extend to their vicarious liability for HCAs, so it is important that they ensure that all HCAs have adequate indemnity arrangements in place for the tasks they undertake. It is essential that practices inform their medical indemnity organisation, such as MPS, of tasks that the HCA is undertaking to ensure that adequate indemnity arrangements are in place.
CONCLUSION
Appropriately trained and supported HCAs bring huge benefits to patient care in general practice. In order to ensure patient safety, it is important that general practices have effective systems for the training and development of competent HCAs.
REFERENCES
1. What's it really like to work as a HCA? Nursing Times (2008)
http://www.nursingtimes.net/whats-it-really-like-to-work-as-a-hca/1883653.article
2. Skills for health; Key elements of the career framework.
http://www.skillsforhealth.org.uk/workforce-transformation/customised-career-frameworks-services/
3. The Mid Staffordshire NHS Foundation Trust ,Public Inquiry - Chaired by Robert Francis QC http://www.midstaffspublicinquiry.com/report
4. Skills for health: Code of Conduct and National Minimum training standards for healthcare support workers 2013
5. S Hopkins, L Young, Employing health care assistants in general practice, RCN paper (2003)
6. NMC (Nursing & Midwifery Council) Advice on Accountability for registered nurses (2010). http://www.rcn.org.uk/__data/assets/pdf_file/0003/381720/003942.pdf
7. Health Protection Agency (2013) Pertussis vaccination programme for pregnant women
ttp://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1317136400742
8. Nursing and Midwifery (2010) Standards for medicines management
http://www.nmc-uk.org/Documents/NMC-Publications/NMC-Standards-for-medicines-management.pdf
9.The Health Protection Agency (HPA) National Minimum Standards and Core Curriculum for Immunisation Training of Healthcare Support Workers http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1196942164323
