When the novel coronavirus first appeared in Wuhan province in China in December 2019, few of those watching news bulletins would have believed how quickly the virus would sweep across the world and take over our lives. There is no doubt that, despite the sophisticated pandemic plans that have been put in place by individual NHS Trusts and the NHS as a whole, the service is being inundated like never before.
The pandemic crisis now facing the NHS has motivated the healthcare regulators across the UK to amend their strategies to help the NHS in its hour of need. This article will examine how the Care Quality Commission (CQC) and the Nursing and Midwifery Council (NMC) have responded to this unprecedented healthcare emergency.
This is not the first time that the country has had to deal with a pandemic, the last being the swine flu pandemic of 2009. Although highly virulent, there were only 138 deaths in England definitely attributable to the swine flu virus, although the Chief Medical Officer at the time was reporting that up to 65 000 people in the UK could die (Bowcott and Batty, 2009).
Mankind has been in a constant battle with micro-organisms and viruses throughout history, but it was the Spanish flu pandemic of 1918 which had the most similarities to the ongoing COVID-19 pandemic. The Spanish flu pandemic in the UK put public services under a huge strain at a time when the country was still engaged in fighting the First World War. Then as now the hospitals, mortuaries and undertakers were failing to cope with the ever-increasing number of patients who contracted and died from the illness. In the UK, more than a quarter of a million people died from Spanish flu, and it caused a huge impact on normal daily life, with imposed curfews and the banning of public gatherings (Johnson, 2020).
Care Quality Commission
On 16 March 2020, the CQC declared that it was going to suspend routine hospital inspections and commence a new and different phase of its regulatory activities in response to the COVID-19 pandemic. This decision was taken in recognition of how hospitals were being overwhelmed by the sheer scale of the illness, especially among the most vulnerable people in society. With approval from the Government, the CQC is now focusing on more responsive and targeted ways of supporting healthcare providers to keep people safe (CQC, 2020).
This decision recognises that the CQC as a regulator needs to balance its statutory responsibilities with the need to allow hospitals and other providers to concentrate on delivering care and not add to the pressure they are already under in coping with increased patient flow. The primary objective of the CQC during the period of the COVID-19 pandemic will be to support NHS Trusts and other healthcare providers to keep people safe, including staff, and to provide government, decision-makers, and local and national partners with an accurate picture of the pressures being faced on the frontline to inform the national response and planning. The CQC has depended on frontline nurses to act as specialist advisers during hospital inspections. Clearly, given the pressures on skill mix, it would not be possible or appropriate to take frontline staff away from clinical duties.
The CQC intends to develop an alternative methodology that does not rely on face-to-face inspections of discrete hospital services and care homes. Hence it will use its ongoing database of the empirical intelligence it gathers from NHS Trusts and social care providers to inform overall government decision making. The CQC has decided that the best way forward is to concentrate its efforts on safe care, infection control and governance related to regulations 12 and 17 of the Health and Social Care Act 2008:
The CQC is currently developing a questionnaire and a scoring mechanism which can be answered remotely.
Nursing and Midwifery Council
The predecessor to the NMC, the General Nursing Council (GNC), had to make adjustments to its register during times of national crisis, primarily related to the capacity of the nursing workforce. During the Second World War, the role of enrolled nurse was developed to boost the workforce.
Such is the virulence of the coronavirus that many nurses are currently sick or in self-isolation, leaving the remainder of the workforce beleaguered and struggling to cope with patient demand (BBC News, 2020).
Such is the staffing crisis that the healthcare regulator, the Health and Care Professions Council (HCPC), has been given powers to automatically register thousands of former healthcare professionals, including former paramedics, biomedical scientists, radiographers and other professions essential to testing and treating coronavirus patients (HCPC, 2020). The Government has also given the GMC the power to create and give temporary registration or a licence to practise to suitable doctors (GMC, 2020).
Under similar emergency legislation, the NMC has invited those nurses who had left the register within the previous 3 years to rejoin a temporary register. More than 7000 former nurses and midwives across all four countries of the UK are now on the NMC's COVID-19 temporary register (NMC, 2020a). Furthermore, the NMC is asking those nurses who are currently on the register but not working in clinical care to consider helping out the frontline nursing workforce during the period. For example, many nursing academics have volunteered to return to clinical practice, and retired academics who are not eligible to rejoin the register have volunteered to take over their teaching duties.
The NMC will also extend the revalidation period for current registered nurses by an additional 3 months and seek further flexibility for the future (NMC, 2020b).
Perhaps the most significant part of the NMC's action plan is to create a temporary register for final-year undergraduate nursing students, although, at the time of writing, this is not yet in operation. However, existing students in the final 6 months of their programme can, if they wish, opt to undertake their final 6 months as a clinical placement. Up to 18 000 third-year nursing students could be eligible to gain temporary student registration with the NMC, which would allow them to free up more experienced nurses from a range of hospital divisions to help out in more acute COVID-19 clinical environments (NMC, 2020c).
Those third-year students who opt to do this will still need to satisfy regulatory requirements. Therefore the NMC will introduce a range of emergency education standards (NMC, 2020d). These will be developed in the full recognition that it will not be possible for students on clinical placement to be supernumerary in this emergency situation. However, the NMC will continue to expect that students will be supervised and work within an appropriate delegated framework.
The NMC is removing the requirement that nurse education programmes have a 50% split between practice and theory. The regulator understands that this may result in some programmes having a greater than 50% weighting towards practice and will tolerate this, providing all of the learning outcomes continue to be met. Not since the inception of Project 2000 in the late 1980s have students been part of the nursing workforce in this way.
Critical care nurses
Critical care nurses are the most involved in caring for severely ill COVID-19 patients. The sheer numbers of patients needing respiratory support via positive pressure ventilation and extracorporeal life support will outstrip the supply of nurses with the appropriate skill set. It takes significant periods of training and years of experience to become a competent critical care nurse. Many years ago, I undertook training to develop the competencies to acquire a paediatric advanced life support qualification and it was the most difficult and precise qualification I have ever undertaken.
Many non-critical care nurses will now be placed in situations outwith their competency toolkit and the NMC understands that being placed in these caring environments will be personally and professional challenging for many nurses. The demand for critical care nurse capacity during this pandemic will grow exponentially, and there will not be time for nurses to undertake traditional training, and therefore skill mix and capacity will have to be remodelled. The NMC emphasises that it is team effectiveness that will be paramount in this situation, defined by robust and trusting relationships, expertise and the contribution and skills of all its members, including critical care nurses and medical intensivists. The NMC is encouraging critical care nurses to feel confident in using their professional acumen when delegating duties to their non-critical care nurse colleagues and are asking these nurses who are working outside of their comfort zone to carry out delegated care and duties and to work in partnership with their more experienced nursing colleagues and the wider multidisciplinary team during this crisis. (NMC et al, 2020).
Perhaps it is fitting that the new NHS Nightingale hospitals are dedicated to the founder of modern nursing. As she noted:
‘To be “in charge” is certainly not only to carry out the proper measures yourself but to see that everyone else does so too.’
This quotation is very apt for critical care nurses in this time of pandemic.