Interpreting Professional Self-Regulation

A History of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting

Abigail Beach, Celia Davies

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134581870
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Interpreting Professional Self-Regulation analyses the contribution made by the UKCC to the development of the nursing profession in this country over the last 30 years.It details the key issues the council grappled with during this time and provides in-depth analyses of the complexity of these issues.
There is a general consensus that the current view of nursing's regulatory body will culminate in a major shake up of the way the nursing profession is governed and in which the UKCC will be radically transformed. This publication of the history of the UKCC will mark the close of a very significant period in nursing's history and the opening of wider debates about ensuring the safety of the public through regulation of health professionals.
This is an important text for all those who teach on professional and policy issues in nursing, giving them a factual background that has never been brought together before, enabling them to bring discussion of post-registration education, discipline and other professional matters more firmly into the curriculum.

Part I
The importance of context

1 ‘All is not well with nursing’

The Briggs Committee and a new statutory framework¹

There is a paradox at the heart of the history of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC). The origins of the regulatory structure set out in the Nurses, Midwives and Health Visitors Act of 1979 are firmly associated with the Report of the Briggs Committee on Nursing published in 1972, and yet Briggs barely discussed the matter of professional regulation at all.²

Set against the background of intense industrial unrest among nurses and other public-sector staff, uncertainty over the consequences of the planned reorganisation of the NHS and growing government pressure for cost containment in the delivery of health care, the Briggs Committee focused its deliberations on the nature and purpose of nurse training, and the management of limited nursing and midwifery resources. Reform of the ‘organisational framework’, as Briggs termed the existing statutory and training bodies, was discussed only at the end of the document, and in less than ten of the report’s 220 pages.³ This chapter will explore the importance of the Briggs Report, the turmoil that followed and the lobbying that created the UKCC and the four National Boards. The period was one of intense professional disunity, the resulting legislation shot through with compromise. It was a difficult legacy on which to build a completely new structure of professional self-regulation.

The Committee and its context

The establishment of the Briggs Committee in April 1970 came at the end of a decade of disquiet within nursing. The profession’s concerns were varied, and included the structure of the nursing service, its status within the NHS and arrangements for, and the standard of, nurse training. In 1964 an increasingly vocal Royal College of Nursing (RCN) published two reports outlining arguments for change.⁴ The first, Administering the Hospital Nursing Service, argued for a better career structure for senior nurses and greater recognition of the role of nurse administrators: a position that was broadly endorsed by the government following the report of its own Committee on Senior Nursing Staff Structure (Salmon Committee) in 1966.⁵ The second RCN report, A Reform of Nursing Education, received a much less positive response. Known to the profession as ‘Platt’ after the chairman of the College’s committee of inquiry, the document was an uncompromising statement of the need for radical change, calling for full ‘student’ status for trainee nurses, higher educational qualifications for entrants, a lower age of entry and fewer, more independent, schools of nursing.⁶ To the profession’s leadership at the RCN, Platt was an attempt to free nurse education from the worst elements of its historic compromise with the nursing service. Ministers, however, saw an inflexible approach to nurse training that would sit uneasily with plans for health service reorganisation, and a woeful neglect of the cost and manpower implications of such major change.⁷ The Platt recommendations were not pursued.⁸

Pressure for a comprehensive review of nurse education, however, refused to go away. Indeed, by the end of the decade the issue had become subsumed within a much wider demand for improved pay and conditions.⁹ Ten years of public-sector pay restraint had taken its toll. In 1969, the RCN launched its ‘Raise the Roof’ campaign, demanding a salary increase amounting to around 28 per cent. For a Labour government committed to the modernisation of major British institutions by discussion and consensual change, this was a major source of embarrassment. Direct industrial action by nurses, together with the ‘quieter protest’ of high rates of wastage and turnover, now forced the government’s hand.¹⁰ In the summer of 1969, the DHSS acceded to the RCN’s wish for an independent review of nurse education.¹¹ The initial plan was for a ‘modest exercise’ with deliberations confined to basic nurse training in England, Wales and Scotland (not Northern Ireland), and excluding post-registration training, midwifery, health visiting, district nursing and the national statutory arrangements.¹² By the end of the year, however, Richard Crossman, the Secretary of State for Social Services, and Prime Minister Harold Wilson had decided that only ‘a completely new study of nursing’, embracing such issues as ‘the nurse’s place in society, her status, training, pay and working conditions’ would suffice.¹³

On 2 March 1970 Crossman announced the establishment of the Committee on Nursing to the House of Commons. Professor Asa Briggs, Vice-Chancellor of the University of Sussex, was appointed as chairman.¹⁴ It was to be a small committee, with nurses and midwives constituting around half of its membership. The rest were to be drawn from the fields of medicine, health service administration and further and secondary education.¹⁵ While the health departments expected that those appointed would cover a broad range of experience and expertise, members were selected for the individual contribution they could make, rather than as representatives of particular interests.¹⁶ Nevertheless, following a number of representations, the Department did accept the late inclusion of a registered mental nurse, believing that the absence of a member from this distinct and politically sensitive specialty would cause problems if, and when, the committee made recommendations affecting this sector. Similarly, the Department was concerned that all levels of nursing experience were seen to be included. The resignation from the committee of ward sister Susan Cooper in October 1970, for instance, re-opened the issue of the ‘balance’. ‘Junior nursing staff from the provinces’, it was argued, were a significant section of the profession and such a ‘gap’ could seriously hinder the effectiveness of the committee.¹⁷ The question of membership was to remain a sensitive issue during the lifetime of the committee and beyond. Midwives were uncomfortable with the inclusion of only one practising midwife. The committee, though, was perhaps most vulnerable in the area of primary care. Throughout the period of its deliberations, groups of health visitors and district nurses expressed concern that their work was not being discussed with sufficient specialist expertise.¹⁸ This was to have an enduring impact, creating a wariness long after the publication of the report.

The Briggs Committee began work in April, just days before the 1970 General Election, which returned the Conservatives to power under Edward Heath. Its remit was broad but deliberately focused to reflect key elements of government health policy, particularly the commitment to integrate hospital and local authority health services under a single administrative structure, and to effect this change within existing staffing constraints.¹⁹ The terms of reference were: ‘to review the role of the nurse and the midwife in the hospital and the community and the education and training required for that role, so that the best use is made of available manpower to meet present needs and the needs of an integrated health service’.²⁰ The Committee immediately adopted a ‘big picture’ approach, seeking opinions on the role of the nurse, the nature of her duties and her relationship to others engaged in the delivery of health care. It was also agreed that evidence should be collected from as wide a range of interested bodies as possible.²¹ The signals within the terms of reference, though, were unmistakable. The requirement to work within existing resource levels meant that the Committee’s principal focus would be issues of demand rather than supply, and the needs of the service rather than those of the profession.

An important starting point was the high levels of wastage and turnover within nursing. While total nursing and midwifery numbers had risen during the 1960s, the general impression was of a looming crisis. Doubts were reaching the Committee about the ‘adequacy and suitability’ of current arrangements for nurse and midwife education for a fast-developing health service.²² One of the most pressing questions identified by the Briggs committee, therefore, was how to develop programmes of education and training that would equip nurses for their varied and changing responsibilities.²³ So, while the Briggs Committee did not explicitly address the activities of the bodies responsible for standards of nurse, midwife and health visitor training in England, Wales and Scotland, its attention was immediately drawn to what could be seen as the failings of the existing statutory arrangements, namely the inflexible system of training and registration that had developed under its auspices.

Three problems, in particular, were identified. First, it was clear that educational resources were inefficiently deployed. In the early 1970s, training for nurses and midwives in Great Britain was taking place ‘in a wide range of places, in contrasting conditions and with different teaching strengths, educational methods and social amenities’. By the time the Briggs Committee reported, for instance, there were 665 schools approved for training by the General Nursing Council (GNC) for England and Wales, and sixty-two in Scotland. In addition to these were the ‘various centres for the education of midwives, district nurses and health visitors, as well as the numerous places in which different kinds of post-basic courses’ were held. Given the marked shortage of tutors and clinical teachers, manpower as well as equipment was particularly ‘thinly spread’.²⁴

Second, and even more concerning, was the in-built inflexibility of the existing training regime. Nursing’s long history of early specialisation, whereby trainees were prepared to care for particular groups of patients – such as children or mentally handicapped people in hospitals – appeared to be grossly out of step with the demands of a reorganised and administratively integrated NHS.²⁵ If nursing care was to be planned across the current dividing lines of hospital and community, and delivered with as much continuity as possible, then education and training needed to produce ‘all-rounders’: nurses with a good enough basic education to enable them to function satisfactorily within the nursing team at basic level and to progress from basic to specialist nursing skills with further education.²⁶

Third, the Briggs Committee was unconvinced of the value of maintaining two discrete ‘portals’ of entry to nursing: ‘registration’, following a three-year training programme; and ‘enrolment’ following a shorter (usually two-year) and less theoretical course of preparation.²⁷ Since first accepting the concept of a second level of nurse during the war, the profession’s leadership had insisted that a ‘sharp distinction’ exist between registered and enrolled nurses (though in practice, the level of work assigned to enrolled nurses was often very similar to that assigned to registered nurses in the staff nurse grade). In 1962, for instance, the GNC regained the right to impose minimum educational requirements for those seeking entry to courses leading to registration. Entry to courses leading to enrolment were not to be restricted in this way. The RCN was particularly keen to see an increase in the educational standard of entrants but also campaigned for the development of clearer distinctions between those trained for state registration and those prepared for entry to the roll. The members of the Briggs Committee, however, were convinced that a more flexible approach to training was essential. Given the increasing emphasis on teamwork within nursing and the enormous range of duties expected of the professional nurse, the committee felt that programmes of nurse education should cover ‘a range of standards catering for different types of entrant motivated towards and capable of performing different nursing activities’.²⁸ Moreover, recent experience had demonstrated the growing importance of the State Enrolled Nurse (SEN) grade: between 1962 and 1970 the proportion of trainees who were ‘pupils’ (i.e. trainees for the roll) rather than ‘students’ (trainees for the register) had increased from 13 per cent to 42 per cent. Future programmes of nurse training would have to reflect the significance of this source of recruits.²⁹

The Committee rejected the RCN’s desire to increase the formal qualifications required of recruits, arguing for more attention to be given to the identification of ‘motivation’ as distinct from ‘academic ability’.³⁰ Educational developments outside the fields of nursing and midwifery were cited in support of this shift. For instance, the ‘comprehensive’ model of learning, with goals reached through different tracks and at a varied pace, strongly influenced both the substa...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures
• Foreword
• Acknowledgements
• Abbreviations
• Introduction
• PART I The importance of context
• PART II The agenda develops
• PART III Stakeholders and standards
• Appendix 1: Chairmen, Presidents and senior officers
• Appendix 2: The work of registration
• Appendix 3: Professional conduct: procedures, cases and statistics
• Appendix 4: UKCC publications
• Appendix 5: Notes on sources
• Index