Shifting the paradigm

The nine UK professional regulators are responsible for regulating in excess of 1.4 million professionals in the health and care workforce including nurses, midwives, doctors, paramedics and social workers. ¹ The regulators’ most high profile role is dealing with cases of poor practice or misconduct (known as ‘fitness to practise’). Most are experiencing increasing volumes of complaints in recent years, particularly from members of the public. On average, around 60% of the regulators’ expenditure goes to dealing with fitness to practise cases. ²

In response to the escalation of complaints, there has been a growing debate about rebalancing the work of the regulators – away from a focus on reactively dealing with instances of poor practice or conduct toward a focus on prevention. The Professional Standards Authority’s thought piece, ‘Rethinking regulation’, has highlighted the potential benefits of such approaches in reducing harm to patients and in reducing the financial and non-financial costs involved in fitness to practise action. ³ Research findings are also providing growing insights into the behavioural impact of regulation upon those regulated and are framing discussion in the sector. These findings have demonstrated that regulators are at best one influence among a myriad of influences upon the behaviour of those they regulate and has highlighted the risk that traditional approaches to implementing regulation may actually serve to undermine the behaviours we seek to ensure. ^4,5

The area of ‘prevention’ is altogether far messier than the well-embedded operational processes that flow from functions defined and prescribed in legislation. The toolkit at regulators’ disposal is limited, and across the sector, numbers of fitness to practise cases have increased despite the regulators’ well-established roles in setting standards and quality assuring education – functions already positioned at the preventive end of the spectrum. Prevention appears to lend itself to the contemplation of ‘softer’ regulatory interventions, such as improved engagement with health and care professionals, in contrast to traditional ‘reaction and sanction’ or process-led approaches, but these are activities which might be much harder to measure (outputs and outcomes) and to deliver ‘at scale’. There are no easy answers.

The challenge for regulators is to find the space, and confidence, to innovate – to do, review, learn and improve. In my view, one path to effective activity in this area requires being honest about the limitations of professional regulation – seeing the regulator instead as a ‘system leader’ – that is, one leader in an interconnected system of organisations with different responsibilities and influences upon health and care professionals. It lies in thinking about how the regulator, with the benefit of its role, and robust analysis of the data it collects as a result of its ‘reactive functions’, might work to harness that system.

My own organisation is attempting one such approach. Planned research will look at why two professions we regulate are over-represented in the fitness to practise cases we handle. Perhaps most novel is the inclusion as a core component of the research of a deliberative methodology which will bring together relevant stakeholders to discuss the findings of the research and to identify preventive action. It is anticipated that some of the potential actions might not be solely for the regulator, but might be about how all those involved in practice, education, employment, representation and regulation can work together – to prevent complaints occurring and to improve outcomes and experiences for service users and the public. We hope this might be a helpful first and tentative step into the messy world of prevention, the learning from which might indicate how work like this can in the future become a more mainstream part of our role.