Consultation analysis - draft standards for the foot health workforce - discussion and recomendations

The results demonstrate that amongst respondents there is diverse opinion and views about the development of the foot health standards. To make sense of the responses two types of analysis have been completed. The most straightforward deductive analysis has informed the amendments to the standards (see questions 1-3 fig.1) prior to finalising (see section 8&9). The second part of the analysis is less straightforward as it deals with views and opinions, many of which do not correspond to the questions posed within the consultation. For these responses, an inductive thematic analysis has been conducted. The discussion and recommendations section focusses on further exploring the main themes and sub themes. Providing context and further detail to help capture the essence of the sentiments shared within the responses follows. This approach helps to make sense of the data in a constructive way that can then be used to inform further work in this area. The recommendations (see section 7) pick up on the key findings from the consultation, suggesting a possible route for stakeholders and leaders to consider.

Implementation Theme

The implementation theme provided the most diverse responses. Positive benefits have been identified by responses, and there is general support for implementation of the Standards within the NHS sector. Perhaps unsurprisingly there was a sense of anxiety when it came to implementation within the private and independent sector.

Podiatry responders saw implementation of the Standards as a threat to podiatry, and some respondents shared concern about how assurances would be provided that the Standards are being met. Conversely FHPs indicated that that in the independent sector there is a hostility from the regulated workforce towards the non-regulated sector.

Furthermore, respondents demonstrated a sense of disappointment that the Standards were only NHS focussed. Some responses call for the Standards to be implemented across both the NHS and the private/independent sector.

Notwithstanding the sentiment conveyed by respondents it is important to recognise the function of HEE when putting into context the findings of the consultation. HEE is part of the NHS, and works with partners to plan, recruit, educate and train the NHS health workforce. The emphasis of the consultation is NHS focussed because HEE have commissioned the development of the standards. The Standards are intended to support the NHS in utilising the full skills mix of the foot health workforce to meet demand, by providing a clear understanding of the footcare treatments that foot health practitioners and the podiatry support workforce can safely perform. The needs and safety of patients has been central in this work.

For both sectors (NHS and independent/ private) views and opinions were shared about how the Standards will be implemented and what the implications are for those already practising at the level described.

Some responses suggested that regulation of the non-regulated sector should be considered. While some called for preventative measures to stop independent practice in the non-regulated workforce.

The development of the Standards is needed to recognise what contribution the non-regulated workforce can make to the footcare needs of patients within an NHS setting. The standards therefore seek to recognise what is currently being provided by the support workforce. Since there are no standards currently available that provide a comprehensive understanding of what level of care and interventions the non-regulated foot health workforce do provide, HEE is unable to assess how this group of practitioners can assist in providing NHS foot care to patients in an NHS setting.

Through collaboration with representative stakeholder groups, for the first time, a detailed profile of the work of the non-regulated foot health sector is being captured. Moreover, the Standards provide the opportunity to document a reliable and accurate understanding about what the non-regulated sector can contribute to the support workforce within an NHS setting.

As an organisation, HEE has no powers to legislate how the independent/private sector of non-regulated practitioners operate. Further discussion is needed with foot health leaders and stakeholders surrounding implementation of the Standards in the independent/private sector. Furthermore, before the implementation stage, the Standards must be finalised and published. Once published the Standards could be used to support implementation within the independent sector (See section 7 for more information).

Responses calling for regulation of the non-regulated sector must also be considered here. HEE has no function in regulating or making recommendations to regulate either the independent sector and/or the non-regulated sector. The following statement is taken from the HCPC website:[1]

“The most up-to-date statement of Government policy on professional regulation is 'Enabling excellence – Autonomy and accountability for health care workers, social workers, and social care workers. This says that the Government will in future only consider regulating further groups ‘in exceptional circumstances’, where there is a ‘compelling case’ and where voluntary registers are considered insufficient to manage the risk involved.” They go on to explain:

Accredited registers

“The Professional Standards Authority (PSA) holds a list of accredited voluntary registers which they have independently assessed against their own standards. They cover professions that are not regulated by law, with professionals working within and outside the NHS.”

Within the consultation documentation the function of the PSA was explained (see section 2, 2.5 Consultation on standards for the non–regulated foot health workforce p.14)[2]

Training Theme

Responses allied to the Training theme have highlighted the diverse views and opinions toward the level of training provision for the non-regulated foot health communities. Calls were made for the training to be standardised, and for there to be a much increased clinical ‘hands on’ component. HEE recognises there is huge variation in the education and training of foot health practitioners (Consultation on standards for the non–regulated foot health workforce p.15)[3]. This discrepancy in levels of training prevents the NHS recognising the contribution from this community towards NHS foot health services.

HEE acknowledges some foot health practitioners are educated to level 3 or level 4 (recognised as completing the equivalent of half of the first year of an undergraduate programme). Some training programmes have not been accredited to an educational level. Some of these training programmes include no practical training, others require two weeks of assessed practical training.

The consultation responses demonstrate opinions and often controversial suggestions on how these discrepancies could be dealt with. Within the consultation documentation there is evidence of how the Standards could help to standardise the training of the non-regulated workforce. The NHS already has an established apprenticeship route at level 3 and level 5. The Standards could be used to map to these existing educational routes, and thus provide a standardised training route to help upskill and facilitate greater skill mix within the NHS footcare workforce.

Regarding standardising training of both training provider courses and individuals there is discussion on this within the consultation documentation (Consultation on standards for the non–regulated foot health workforce section 3, 3.3.1 p.20)[4].  It is proposed that the Standards would form the basis of an accreditation process.

Education providers delivering foot health practitioner programmes that choose to participate would be quality assured against the Standards. This would provide assurance that programmes produce practitioners who have met the threshold educational and clinical standards required for patient safety. A similar mechanism could also be put in place to assess and recognise existing foot health practitioners who can demonstrate that they meet the Standards.

Further commentary highlights concern and issues around clinical supervision and support for those nonregulated practitioners working in independent practice. The standards provide detail on supervised practice and the need to make onward referrals to the regulated sector (also see section 8 on proposed amendments to the Standards). In an NHS setting there are existing support arrangements that would ensure that the requirements for supported practice are upheld.

However, responses from the consultation from the regulated sector highlights concern about how both the training and the supervision of non-regulated individuals translates into independent practice in a meaningful way demonstrating how the standards are being upheld.

Should the Standards be adopted within the independent sector, further collaboration with stakeholders and foot health leaders would be required to ensure the equitable level of support was available to the independent sector. In this context perhaps a ‘clinical support framework’ is needed as a way of supporting FHPs working autonomously in independent practice and to ensure patient safety can be assured if the Standards were adopted in the independent sector.

Further collaboration with foot health leaders and stakeholders, as well as education providers, both within the public sector and those providing foot health education in the private sector, would be required should the Standards be adopted within the independent sector.

Consultation responses also indicated perceived confusion of the public and patients about the differing role titles for the non-regulated sector, with further comments around what level of practice the title permits. The established educational routes within the existing apprenticeship framework provides some consistency of role titles. The ‘foot health care map’ within the Standards (see p. 13 for details)[5] adds further clarity about role titles and how this maps across to different sectors. Should the Standards be adopted in the independent sector there would need to be a signposting campaign to raise awareness so that patients and the public have a clearer understanding (see amendments on the proposed changes to the foot health care map).

Independent Sector theme

This theme deals mainly with responses surrounding the implementation of the Standards within the independent sector. Some of the comments have shown a level of frustration and anger toward the lack of inclusion of the independent/ private sector in the context and introductory section of the Standards. This had led to comments voicing concerns surrounding the effects that implementation of the Standards may have on this sector of the foot health workforce.

While HEE has collaborated with a range of stakeholders – including the independent sector in the development of the Standards, HEE themselves are not able to dictate how the Standards are adopted outside of an NHS setting (see section 6.1). However, through continued collaborative working with foot health leaders and stakeholders, much of the issues raised under the ‘Independent Sector’ theme could be addressed. For example, some of the concerns raised in this section, including how the standards will affect individual FHP’s already practicing, standardising education routes, supporting independent practitioners within the non-regulated sector, creating referral pathways and consolidating existing patient referral pathways, could be addressed by the suggestion in section 6.1 and 6.2 above.

Finally, it is important to refer to the demographic spread of the data responses. The standards have been commissioned by HEE with the NHS workforce in mind. Given that most responses (68%), were from the independent sector it is unsurprising that the responses are focussed on this group, particularly when it comes to implementation of the Standards. This demonstrates the strength and passion within this sector to ensuring that their voice is heard. Despite the context of the consultation being around the NHS support workforce and routes into the regulated sector within the NHS, the voice of the independent sector cannot be ignored.

Considering this, the next section details recommendations about what further engagement might look like and how this may be achieved.

Foot health stakeholder leaders have an opportunity here to take the work forward. The consultation analysis provides a solid bedrock, on which to build. The work so far to harmonise the podiatry workforce – both the regulated and the unregulated within the NHS could be expanded to include the independent/private sector.