professions allied to medicine

If the Health Bill goes through Parliament on time, the professions allied to medicine will be far more closely regulated, benefiting patients and bona fide practitioners.

Nearly 100,000 NHS staff are members of the professions supplementary to medicine. This means they have completed approved training - now often to degree level - and are state registered with the Council for Professions Supplementary to Medicine, set up by statute in 1960 to regulate the professions.

But the standards, controls and sanctions for members of these professions, once qualified, reflect their status in 1960, when their potential to do harm was more of an issue for doctors who had to supervise their work. Little was expected of PSMs - still popularly known as PAMs, professions allied to medicine - and, legally, this situation has persisted.

Outside the NHS, it is easy to become a member of any of the professions partially regulated by the CPSM. You can put a postcard advertising your services in a newsagent's window. Your GP may even respond and invite you to work in the surgery. Avoid the term 'state registered' and there is no problem. Professional bodies urge the public to seek state-registered chiropodists, state-registered occupational therapists, chartered physiotherapists and the like. But regulation of these professions is archaic and ripe for reform.

Toughening up

Now reform looks likely, tucked away in clause 47 of the Health Bill, called Regulation of Health Care and Associated Professions.

Its provisions are very brief: the 1960 PSM Act will be repealed and replaced by new regulatory powers to be sorted out through an Order in Council. The CPSM will be replaced by a Health Professions' Council, initially covering up to 12 professions, most of which work in the NHS.

This might not seem much from decades of campaigning, but CPSM registrar Mike Hall is very pleased: 'We only need an order in the Privy Council to change, repeal or modify the regulations - we don't have to go back to Parliament every time, so the whole process is much, much quicker.'

Three professions - paramedics, speech and language therapists, and clinical scientists in health - are on a fast track to join the existing CPSM.

The underlying aim is to protect the public and improve standards of education, training and practice in line with CPSM requirements. One immediate result is that recently the CPSM has been taking an increasingly tough line with trusts over registration.

'Trust managers must have systems in place to ensure they are employing only state-registered professionals. Not everyone has those systems,' says Brian Edwards, professor of healthcare development at Sheffield University and a former NHS regional general manager, who chairs the CPSM.

'We have found that if a trust employs a health professional who turns out not to be registered with us, it is usually for reasons of sloth or a mistake. We are taking a very strict view of this. After all, what we are asking for is not rocket science.'

Fitness to practise

Another important reform is tighter controls on fitness to practise, which dovetails neatly with managers' concerns about clinical governance. The new council will require evidence of continuing professional development from individual members.

'Self-regulation and continuing professional development are going to be among the most challenging issues of the next few years,' says Professor Edwards.

'There are three main approaches: first, keeping a log book; second, observing clinical practice, and third, by examination. We are looking at a model which uses all three. Although for some of the professional groups the numbers involved and the range of duties make it difficult, we want the professions themselves to be debating what continuing professional development means.'

Mr Hall is more direct: 'It will be up to employers to make sure that healthcare professionals are up to date. Health professionals will have to show that they are capable, competent and keeping up with current practice. If not, we will strike them off the register.'

Disciplinary action

Currently, the CPSM can only discipline members of the professions found guilty of 'infamous conduct'. Since Mr Hall took over at CPSM a wider interpretation has been applied, using modern case law as precedent. In addition, through the Association of Chief Police Officers and the Home Office, the CPSM is routinely notified of possible registrants who have received police cautions or criminal convictions.

Of 82 convictions and cautions referred to CPSM, only 33 have related to practitioners on the state register. The rest have either never been registered or have been struck off and continue to practise outside the remit of the CPSM and the NHS.

But the current rules mean that, even if a state-registered professional is referred to the CPSM, its limited powers make sanctions unlikely. 'If you look at the words, 'infamous conduct' means the equivalent of serious criminal convictions or really gross behaviour towards patients. We regularly have to advise trusts that we cannot take on a case because the complaints they want us to investigate cannot be defined as 'infamous',' Mr Hall says.

New regulations will reflect the need for autonomous professionals to be accountable and the issue will be whether the practitioner is guilty of misconduct. Punishment options, currently restricted to striking an offender off the register, will also be extended to include reprimands, suspension pending retraining, and fines.

PSMs are to have a health committee for the first time, to deal with registrants who put the public at risk through their own ill-health. Its powers will include suspension until registrants have recovered.

'We know that infamous conduct alone is really not good enough,' Professor Edwards says. 'We need a way of dealing with a professional who is sick, and the way to do that seems to be to follow the model the General Medical Council uses.'

The new Health Professions' Council will share other similarities with the GMC. Its revamped format will include lay representation, and the balance of power will shift from the CPSM's professional boards - whose members include a disproportionately high number of doctors - to the central council.

Power struggle

The legislation to make this possible must get through the Commons and the Lords by 1 July. After that, separate legislation will have to be drafted appropriate to the devolved powers of Scotland, Northern Ireland and Wales.

Professor Edwards is confident that the deadline will be met. 'We met health minister Baroness Hayman at the beginning of February. We have some serious points of contention, but I think we will meet the 1 July deadline. If we miss it, no one is sure what will happen.'

The main area of disagreement is over who will control the Health Professions' Council. Baroness Hayman told the CPSM that the Department of Health might want to take over the order-making powers, rather than leave the professions under the Privy Council. The CPSM is not happy with this.

'Keeping the default powers with the Privy Council keeps the professions at arm's length from government, whereas the government sees this as an opportunity to get its hands on control of the professions,' says Mr Hall.

Common title

Less contentious is the need for protection of 'common title'. Limited protection given by the 1960 act restricts the use of the terms 'state- registered chiropodist', 'state-registered occupational therapist' and so on. It is a subtlety which, unsurprisingly, is lost on the general public and a confusion which those operating outside the NHS compound by offering training through correspondence courses and membership of alternative registers. The government and the CPSM agree that the new order-making powers, wherever they lie, will include protection of common title.

The key word is 'common'. It will mean that no-one may offer services as a speech and language therapist, chiropodist, dietitian, orthoptist, art, drama or music therapist, or any of the other healthcare professions, without being on the council's register. 'We had a complaint recently from a woman who had had part of her leg amputated following treatment from a private chiropodist,' Mr Hall says.

'When we found out that the chiropodist was not state registered, we had to say there was nothing we could do. That will not happen under the new act.'

Nursing and residential care homes, which currently advertise occupational therapy, may also be affected. These services are sometimes supervised or given by state-registered occupational therapists, all of whom now train to degree level. But sometimes they are offered by care assistants who are referred to as OTs.

Further, the 'occupational therapy' in question may be about keeping people occupied - very different from the work of state-registered OTs, which is to restore maximum function.

Protection of common title will make this illegal. Any establishment that says it has OTs running or supervising programmes must ensure that they are registered with the Health Professions' Council. And that will include GPs.

Critics might see the new council as high-profile and high-handed, but Professor Edwards is unconcerned. 'We have a year or two's work left ahead of us, once the statutory framework is in place. The CPSM is going to demonstrate that it can get better and protect the public more effectively than ever before. We've got a lot to do.'