These values are expressed in professional codes of practice, for example, the NMC (2015) and Health and Care Professions Council (2015a) setting out the ethical standards to which practitioners are held to account, guiding day-to-day practice decisions. Having privileged access to service users, codes are an important way of assuring the public that professionals are regulated so that they can have confidence in them as part of the social contract.
The traditional model pre-dates formal codes of practice; it reflects the utilitarian principle of best interest that bypasses the service user undermining the principle of autonomy. Autonomy is further codified in the Human Rights Act (1998). Conflict may arise between service users’ rights and the professionals’ duty of care – that is confidentiality, right to privacy or freedom from discrimination (Thompson et al., 2006; O’Keefe et al., 1992).
Discussion point
Analyse a professional code of practice from a professional group in relation to the four ethical principles above.
ACTIVITY 3.5
Box 3.6 Excerpts from HCPC, NMC and GMC codes of practice HCPC (2016)
1.1 You must treat service users and carers as individuals, respecting their privacy and dignity.
2.2 You must listen to service users and carers and take account of their needs and wishes.
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Professional Codes of Practice
While there has been increasing convergence in these codes (Box 3.6), there is a need for a shared code of practice for health and social care professionals based on common ethical principles and values, reflecting a human rights approach.
Health and social care professionals are required to keep confidential service users’
information, which is reinforced in the respective professional codes of practice (NMC, 2015; HCPC, 2016; GMC, 2013) and legislation (Data Protection Act, 1998). However, failure to share vital information with other professions about service users may not only be inefficient but harmful and in some cases fatal, most notably in child protection (Laming Lord, 2003) and mental health (Cold, 1994). Paradoxically, professionals may use their codes of practice or legislation inappropriately, practising defensively and inhibiting partnership working.
Such codes may inadvertently reinforce boundaries and stereotypes between professional groups and represent a conflict of values. Although confidentiality is a common value it does not mean that service users’ information can be shared automatically. The Data Protection Act (1998) governs the way in which information is collected, stored and shared (Box 3.7).
5.1 You must treat information about service users as confidential.
NMC (2015)
1. Treat people as individuals and uphold their dignity.
2. Listen to people and respond to their preferences and concerns.
4. Act in the best interests of people at all times.
5. Respect people’s right to privacy and confidentiality.
GMC (2013)
31. You must listen to patients, take account of their views and respond honestly to their questions.
47. You must treat patients as individuals and respect their dignity and privacy.
48. You must treat patients fairly and with respect whatever their life choices and beliefs.
50. You must treat information about patients as confidential. This includes after a patient has died.
Box 3.7 Data protection
Under the Data Protection Act, you must
•
Only collect information that you need for a specific purpose•
Keep it secure•
Ensure it is relevant and up to date•
Only hold as much as you need, and only for as long as you need it•
Allow the subject of the information to see it on request(Information Commissioner’s Office (ICO) (n.d.) Health Data Protection – Looking after the information you hold about patients. (Accessed 3 July 2016) https://ico.org.uk/for-organisations/health/.)
Although professionals must understand the law to ensure it is correctly implemented, it is essential that health and social care professionals share information in the best interests of service users. The Caldicott Principles (Dimond, 2015) have been introduced to help practitioners determine what information should be shared and under what circumstances (Box 3.8).
In the case of Miss Davies, the district nurse and social worker may share information through the SAP, and in practice formal agreements are made between organisations with shared service responsibilities. Barriers between organisations and interprofessional working are increasingly being addressed through integrated services (Cameron et al., 2012).
In the community professionals hold a great deal of power over service users due to the invisible nature of the work, staff must be completely trustworthy and uphold codes of practice, to which they are held to account. Staff too may be vulnerable to accusations that may be hard to defend, such as elder abuse or stealing from patients. The expected altruism by professionals working in a service user–centred approach may be countered by how professional power continues to be exercised and maintained beyond direct practice (Box 3.9).
Can professionals be trusted?
Trust and professionalism are closely associated (Evetts, 2006a,b). Service users want safe and effective treatment delivered by trusted professionals, but there has been a
Box 3.8 Caldicott Principles
These good practice principles were updated in 2013 to ensure confidentiality and security of service users’ information held by professionals and
organisations:
1. Justify the purpose.
2. Don’t use personal confidential data unless it is absolutely necessary.
3. Use the minimum necessary personal confidential data.
4. Access to personal confidential data should be on a strict need-to-know basis.
5. Everyone with access to personal confidential data should be aware of their responsibilities.
6. Comply with the law.
(Dimond B, Legal Aspects of Nursing, Pearson Education, Edinburgh, 2015.)
Box 3.9 Critique of professionals
•
Are self-interested•
Maintain status quo•
Are incapable of self-regulation•
Retain power•
Block change including policy implementation•
Hide behind rules and regulations or may flout them as a defensive practice57
Professional Codes of Practice
profound loss of trust in professionals (Evetts, 2006b). Confidence was undermined after a series of scandals where public servants, including health professionals, breached standards (Dimond, 2015). In the community, this was brought to a head by a now seminal case where in 2000 Harold Shipman, a GP in Greater Manchester, was found guilty of murdering 15 patients and forging a will – most of his victims were elderly women living alone, killed by a lethal injection. A subsequent investigation revealed that he had murdered between 215 and 260 patients over a period of 23 years, despite being highly respected by many patients. This rocked the nation’s trust in doctors, leading to questioning of the extent of their professional power and that of others. Public confidence has further been shaken by systemic abuse and neglect in hospitals and care homes exposed by the media, leading to public inquiries and calls for radical change to protect the vulnerable (DH, 2012; Francis, 2013). The Francis Inquiry (2013) recommendations led to a change in legislation via the Care Act (2014) providing greater protection from organisations with among others the requirement to disclose failings through a duty of candour (Dimond, 2015). Professionals too are facing greater scrutiny to ensure continuing competence and fitness to practice through more stringent regulation (DH, 2007).
Professional regulatory and statutory bodies such as the NMC, HCPC and GMC have legal powers to regulate their respective professions. They set the standards for education and practice, maintain a register of eligible practitioners, have powers to investigate breaches in professional conduct and revoke the practitioner’s licence to practice. Post-Shipman, professional self-regulation has come under greater scrutiny and exposed the lack of transparency, complacency and the reluctance of peers to remove unfit practitioners from the register. This has been addressed through reappraisal of codes, changes to professional education, strengthening the requirements for fitness to practice, including renewal of registration, return to practice and revalidation, and ensuring that more laypeople sit on the professional regulatory boards (King’s Fund, 2007).
Traditionally, professionals qualifying were not required to undertake additional training or keep up to date. This does not mean that practitioners did not do this voluntarily and in many cases this was a requirement for specialisation. However health and social care regulators have introduced revalidation requirements and fitness to practice procedures to ensure public protection, which is their central remit (NMC, 2017; HCPC, 2012). For example, all nurses must be able to evidence completion of 450 practice hours over 3 years to be eligible to renew their registration as well declaring themselves fit to do so and need to complete a minimum of 35 hours of continuing professional development activities over a 3-year period (NMC, 2017):
Revalidation
•
is the process that allows you to maintain your registration with the NMC;•
demonstrates your continued ability to practice safely and effectively, and•
is a continuous process that you will engage with throughout your career.Revalidation is the responsibility of nurses and midwives themselves. You are the owner of your own revalidation (NMC, 2017: 6)
Professionals are responsible for maintaining and demonstrating their continuing fitness to practice by submitting evidence to the professional body for scrutiny, usually a portfolio of evidence. Increasingly, self-reported evidence for revalidation is corroborated through peer review exercises and endorsements from employers though service user endorsement is not formally required.
There is now greater convergence across health and social care professions through professional codes of ethics and revalidation of practice (Thistlethwaite, 2007). This reflects a change in language with more active involvement of service users and greater emphasis on teamwork.
The hallmarks of professional practice are summarised in Box 3.10.
Service users are generally less reliant on professionals as sole experts or keepers of professional knowledge. Access to the Internet, promotion of self-care and the need to involve service users more means that professionals are less able to hide behind jargon or use terminology that excludes service users. However, for more vulnerable service users this should not be assumed and all patients have a right to be consulted (DH, 2015).