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In July 2018, the then Minister of State for Health, Stephen Barclay MP, commissioned Tom Kark QC to write a report and to make recommendations in relation to the fit and proper person test (FPPT) as it applied under Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Tom Kark QC review of the fit and proper person test (the Kark review) was published in February 2019 and made seven recommendations on how to improve the operation and effectiveness of Regulation 5. 2022 update The approved proposals which now form the basis of the current implementation work overseen by the newly established Kark Implementation Steering Group (the 2022/2023 Steering Group), are as follows: All Directors (executive, non-executive and interim) should meet specified standards of competence to sit on the board of any health providing organisation. Where necessary, training should be available. That a central database of directors should be created to hold relevant information about qualifications and history. A mandatory reference requirement for each director should be introduced. The FPPT should be extended to all commissioners and other appropriate arms-length bodies. The ministerial position is that Kark recommendation 5 (‘the power to disbar for serious misconduct’) is not being progressed at this time. Ministerial support was received for recommendation 6, and this will be taken forward as an action by the Department of Health Social Care (DHSC) and the Care Quality Commission (CQC): Remove the words “been privy to” from regulation 5. The final Kark recommendation related to extending the FPPT to social services. This is outwith the scope of the current NHS England work and will not progress as part of this programme of work.

An independent review of how effectively the test prevents unsuitable staff from being redeployed or re-employed in health and social care settings. The review was led by Tom Kark QC. It sets out 7 recommendations, including: developing competencies for directors making a central database of directors’ qualifications, training and appraisals expanding the definition of serious misconduct. The current fit and proper persons test is designed to ensure that senior staff who are responsible for quality and safety of care are fit and proper to be in their roles. The test applies to directors in the NHS, the independent healthcare sector and the adult social care sector.

This month sees the call from the Nursing Midwifery Council in the UK to ex nurses and students to join the emergency register in response to COVID-19. In this Episode of the 'This Is Nursing' podcast series, Gavin Portier reflects on his return to critical care and what he learnt about going from a corporate nursing role back into the direct care setting.r

Can we now create a space for interprofessional learning, where trust and respect are born and where clinical skills and clinical reasoning is shared between our professional tribes, asks Lucy Brock in this HSJ article. Lucy works at UCLPartners as the lead for education and simulation. She is also a respiratory physiotherapist and returned to clinical practice to support colleagues on intensive care in March 2020. Regulatory bodies and education systems exist to ensure that patients are surrounded by competent professionals, but the potential of our workforce is unduly limited by their territorial nature and siloed funding. The urgency of a pandemic offered almost no time for creative thinking but we now have a relative reprieve and so a chance to reconsider the limits of professional scope. Can we now create a space for interprofessional learning, where trust and respect are born and where clinical skills and clinical reasoning is shared between our brilliant professional tribes? Might this be key in mobilising a more efficient and agile workforce, better prepared for the next wave?

In her latest blog, Claire reflects on the last few months working as a critical care outreach nurse during the pandemic and looks to the future and how we can transition into the new 'normal'. She urges us all to work together to redesign our health and social care services, building a service that meets all our needs. It's been a busy few months to say the least. Preparing for the pandemic, sourcing correct personal protective equipment (PPE), redeploying staff, acquiring new staff, making ventilators, redesigning how we work around the constraints, writing new policies, new guidance, surge plans, and then the complex part… caring for patients. If I am honest, when this all started it felt exciting. Adrenaline was high, motivation was high, we felt somewhat ready. There was a sense of real comradeship. It felt like we were all working for one purpose; to safely care for any patient that presented to us in hospital. We were a little behind London by about 2–3 weeks, so we could watch from afar on how they were coping, what they were seeing and adapting our plans as they changed theirs. Communication through the ITU networks was crucial. Clinical work has been difficult at times. The initial confusion on what the right PPE to wear for each area added to the stress of hearing that our colleagues in other places were dying through lack of PPE. The early days for me were emotionally draining. However, this new way of dressing and level of precaution is now a way of life for us. I have come to terms that I am working in a high-risk area and I may become unwell, but following guidance and being fastidious with donning and doffing helps with ‘controlling’ my anxieties in catching the virus. Some parts of the hospital remained quiet. Staff had been redeployed, elective surgery cancelled and the flow of patients in the emergency department (ED) almost stopped. I remember walking through ED and thinking: where are the people who have had strokes? Have people stopped having heart attacks? Are perforated bowels not happening anymore? The corridor in ED is usually full. Ambulances queuing up outside, but for a good few weeks the ambulance bays were deserted. The news says over and over again "we must not overwhelm the NHS". I always have a chuckle to myself as the NHS has been overwhelmed for years, and each year it gets more overwhelmed but little is done to prevent winter surges, although it's not just winter. The surge is like a huge tidal wave that we almost meet the crest of, but never get there, and emerge out the other side. I sit in the early morning ITU meeting. We discuss any problems overnight, clinical issues, staffing and beds. We have seen a steady decline in the number of ITU patients with COVID over the last week or so. The number of beds free for COVID patients were plentiful. We have enough ventilators and staff for them. This is encouraging news. I take a sigh, thinking we may have overcome the peak. In the next breath, the consultant states that we don’t have any non COVID ITU beds. We have already spread over four different areas and are utilising over 50 staff to man these beds (usually we have 25 staff). So that’s where the perforated bowels, heart attacks and strokes are. The patients we are caring for had stayed at home too long. So long, that they now have poorer outcomes and complications from their initial complaint. These patients are sick. Some of the nurses who are looking after them are redeployed from other areas; these nurses have ITU experience, but have moved to other roles within the hospital. This wasn’t what they had signed up for. They were signed up for the surge of COVID positive patients. I’m not sure how they feel about this. As the hospital is ‘quiet’ and surgical beds are left empty, there is a mention of starting some elective surgery. This would be great. It would improve patient outcomes, patients wouldn’t have to wait too long, so long that they might die as a consequence. However, we don’t have the capacity. We have no high dependency/ITU beds or nurses to recover them. We would also have to give back the nurses and the doctors we have borrowed from the surgical wards and outpatients to staff ‘work as normal’, depleting our staff numbers further. Add to the fact that lockdown has been lifted ever so slightly, the public are confused, I’m confused. With confusion will come complacency, with complacency will come transmission of the virus and we will end up with a second peak. If we end up with a second peak on top of an already stretched ITU and reduced staffing due to the secondary impact on non COVID care, the NHS will be overwhelmed. This time we will topple off that tidal wave. It’s a viscious cycle that I’m not sure how we can reverse. My plea, however, is to ensure we transition out of this weird world we have found ourselves in together. We usually look for guidance from NHS England/Improvement, but no one knows how best to do this. The people who will figure this out is you. If your Trust is doing something that is working to get out of this difficult situation, please tell others. We are all riding the same storm but in different boats. I would say that I am looking forward to ‘business as usual’ – but I can’t bare that expression. Now would be a great time to redesign our services to meet demand, to involve patients and families in the redesign – to suit their needs. We have closer relationships now with community care, social care and primary care, we have an engaged public all wanting to play their part. Surely now is the time we can plan for what the future could look like together? The Government has announced that Ministers are to set up a ‘dedicated team’ to aid NHS recovery. We need to ensure that patient and staff safety is a core purpose of that team’s remit and the redesign of health and social care. Would you be interested in being on our panel for our next Patient Safety Learning webinar on transitioning into the new normal? If so, please leave a comment below.

London clinicians have shared their top 10 tips to help prepare NHS staff in other parts of the country facing the COVID-19 crisis. UCLPartners asked clinicians working in a range of specialties across its region, the first in the UK to deal with a major escalation in COVID-19, to share their practical advice to support NHS staff elsewhere in the country preparing for a large number of COVID-19 cases.

Partners across the NHS and social care are mobilising at scale in response to the developing COVID-19 pandemic. The AHSN Network's role, along with England’s 15 Academic Health Science Networks (AHSNs), is to support them by helping them take full advantage of the most relevant innovations and technologies that can improve care for patients and support our services in this challenging context. Nationally, the AHSN Network is part of a coordinated NHS response to identify and enable the implementation of technologies that respond to areas of highest priority action, in particular solutions for remote consultation and patient monitoring, diagnostics and point-of-care testing. This web page sets out the AHSN's response to Coronavirus including their programmes; Industry and Innovation Medicines Optimisation Primary Care Innovations Patient Safety Collaborative Healthy Ageing National Programmes.

This webpage written by the Royal College of Nursing, is designed for nurses and offers answers to frequently asked questions on coronavirus and the affect it has on their working life. Find out how to protect yourself, what you should expect from your employer and what to do if you have concerns.

In her latest blog, Claire, a critical care outreach nurse, reflects on how the 'ad hoc' team has to adapt to the new challenges the coronavirus pandemic brings. She offers insights into the challenges she and her team face and gives examples of potential solutions. What is an ad hoc team? An ‘ad hoc’ team is a team that is made up of various healthcare workers that have never met before. An example of this is the medical emergency team or the cardiac arrest team – doctors, anaesthetists, nurses and other allied health professionals scrambled from around the hospital expected to assess and treat a patient in crisis. Often, we don’t know each other’s names, roles or what skills we each have. What we did in Brighton is to get to know each other… We had a MET meeting every morning. We all got together and introduced ourselves, found out what skills we all had and made full use of any learning opportunities that arose. The ad hoc team worked well. We all knew what to expect, even when a complex situation arose – we all knew who to contact and how we could get the best for our patient. Then in comes a pandemic... Staff have been redeployed; rotas have been changed; the usual rhythm of the hospital has disappeared. Our regular meeting doesn’t happen. This causes problems: Who is who? What skills do people have? Has everyone been fit tested? Where do we get the PPE from during a MET call? How do we communicate to each other? What is the guidance to take blood, do an ECG, defibrillate, order an X-ray during the pandemic? All these questions and anxieties could be discussed at this meeting, but due to a change in working patterns, the change in doctors seeing different patients (Green and Red – COVID + or COVID –), its not possible to meet up. Our technical skills are not a problem – the team have great skills in advanced life support, using life saving equipment. What we are finding difficult is the non-technical skills: communicating, tone of voice, body language. It was hard enough to communicate in a high stress situation before all this pandemic… now its even harder and so much more important! Simulation Simulation has been a large part of how we train in low volume, high risk scenarios in hospital. Cardiac arrests, medical emergencies, emergency intubation, transfer, pacing… you name it we have probably simulated it here at Brighton. I have been on the medical emergency team for 9 years now. I like to think I have experience in most emergencies and know what to do and who to call. All of a sudden, I feel a novice. I don’t even know how to go into the room correctly, I don’t know what I should take in to the room, I don’t know what I should wear; every action, every protocol I would normally do can't happen due to current constraints. I am worrying so much that I feel paralysed to do anything for fear I’m doing it wrong. We have simulations every day at 3 pm at our hospital. These simulations are very low fidelity and include how a medical emergency or cardiac arrest in the COVID-19 patient should run. Simulation can never replace what a real-life scenario will feel like. What simulation can do is allow you to understand what needs to happen, in what order and lets you make mistakes in order for you to learn. Most adults learn from ‘doing’ and from experiences – I am so glad we had this simulation as I was about to attend my first MET call a few days later. My experience attending an airway medical emergency The call went out. "Medical emergency XXX ward – COVID positive". Shortly followed by "Anaesthetic emergency XXX ward- COVID positive". I ran faster knowing that as a team we all had to get there and put full PPE on before we could attend to the patient. If the patient has an airway problem, they will not be able to breathe properly and be at high risk of stopping breathing. I remembered at the simulation exercise that one person needs to be the ‘gate keeper’. I decided to take on this role as I wasn’t sure who had attended the simulation before and knew about this role. My role as gate keeper is to make a note of who is in the room, what role they have and to take messages in and out of the room from the doorway. The notes are not able to be taken into the room, so it would be the gate keeper's role to get the information across to the team inside. I was opening and closing the door and trying to hear muffled voices; I was equally trying to convey important medical information, but they couldn’t hear me well enough. It didn’t help that for many of the team English is not their first language; this made it even more difficult. Our anaesthetic team simulate situations on a regular basis as part of normal work. They turned up at the call already kitted up in PPE and wheeling a trolley with everything they needed on it; all their drugs and equipment were there. One of them – the lead anaesthetist – had a headset on which was connected to a walkie talkie. This made conversing with the team so much easier. We could ask questions from outside the room into the room and vice versa without having to open the door. Clearly, they had rehearsed this scenario before – they too couldn’t hear well so had solved the problem by obtaining walkie talkie devices. They asked for equipment, called for X-ray or asked for more information and I could either relay information, pass equipment or order tests for them – so much easier and safer. The patient had a complex airway and needed to be seen by a specialist. A consultant arrived; one I had not met before. He arrived anxious. He was worried about donning the PPE in the correct order and in swift time. I helped him donn and, while I did that, I reassured him on who was in the room, what had happened and what treatment the patient had had. He entered the room knowing he had the right gear on and what he was facing. This enabled him to think clearly and treat the patient. When it was time to transfer the patient to intensive care, we came across a problem. We had two differing protocols. One was from yesterday, the other was rewritten this morning… which was correct? This was quickly cleared up by calling the author of the protocol, but what would happen at 3 am if this was to happen again? Reflections It was my first time as gate keeper. To be honest, I didn’t know what I should be doing… some of the information from the simulation flew from my mind. Looking back, I should have asked for the name and role of who walked into the room and wrote it on their PPE or used stickers. People were in such a rush to get in and save the patient's life that it didn’t feel like a priority at the time. The walkie talkies were a genius idea from the anaesthetists – this is something that I will take back and see if we can implement the same for all MET calls (anaesthetists do not attend MET calls normally). It reduced the opening and closing of the door, which reduced the amount of aerosoled particles to come out from the room that may increase risk of infection to others. Flattened hierarchy – the moment I had with the consultant outside that room was something I hadn’t experienced before. I noticed his vulnerability, he looked for me – a nurse – for reassurance and guidance which was given with no judgement. At that moment we knew we were one team. Protocols keep changing. We are working where national guidance and local policy changes daily. Without robust ways of disseminating this information we run the risk of doing the wrong thing. As clinicians we are not at our desks monitoring for changes in guidance – we need ways of getting this information to us. We use the ‘workplace’ app – we have a ‘microguide’ for all our up to date policies. This is great to use in normal circumstances but when dressed in PPE we are not always able to access our mobile phones. I wasn’t inside the room. I could see the patient. I could see that he was scared. He couldn’t breathe, he was unable to talk anyway due to his altered airway. How were the team communicating with him? How was he being reassured? Our facial expressions say a thousand words – behind a mask the patient sees nothing. I have heard of the CARDMEDIC flash cards, but can we use them in an emergency? Perhaps we could add them on to the cardiac arrest trolley? The patient is doing well on intensive care now. It would have been ideal for us to debrief; however, half the team go with the patient the other half of the team need to get back to other sick patients, so this can't happen. So much learning comes from these calls; we haven’t got this bit right yet.

You can now watch the recording of the Nuffield Trust event: 'Does the rush for new types NHS staff have a dark side?' Changes in the way staff work, including staff taking on new roles and responsibilities, is a well-known policy solution in the NHS, and there are some really good instances where skill mix works well and has real benefits. But are there downsides to the drive to employ new types of staff to help doctors and nurses? What are the implications for continuity of care, staff experience and outcomes? Is the idea of ‘top of the licence’ working a reason for concern in terms of burnout, the fragmentation of care or is it an unavoidable response to the workforce crisis? Chair: Nigel Edwards, Chief Executive, Nuffield Trust Prof Alison Leary, Chair of Healthcare and Workforce Modelling, London South Bank University Dr Louella Vaughan, Senior Clinical Fellow, Nuffield Trust

We know that NHS organisations may sometimes need to reorganise their services to consider how they can best deliver care to patients. This can mean there is a need to repurpose existing environments, for example hospital wards or clinical areas. Staff may also be redeployed to deal with surges in demand when the pressure on the system is at its greatest. We commonly see this during winter, with ‘winter pressures’ wards, but we have also seen this become more common during other times of the year as the NHS deals with the lasting impact of coronavirus (COVID-19) and staff shortages in some key areas. It’s important that the NHS has this ability to adapt to try and make sure it can deliver the best and safest care to as many patients as possible. The ability to flex in this way helps to keep the NHS operating when it is at its busiest and makes sure that patients can still access appropriate care. Scott Hislop, the Healthcare Safety Investigation Branch (HSIB) Principal National Investigator, looks at the challenges faced by the NHS when flexing to meet demands and how to mitigate potential risks to patient safety.

To match the increasing demands that the coronavirus pandemic will place on critical care, new and flexible models of care are required. This document: states principles for deploying and redeploying staff to match the needs of a critical care department, independent of where this care is delivered sets out indicative staffing ratios and competencies suggests professional groups that could potentially form part of this new workforce during times of surge and super-surge. This guidance is correct at the time of publishing. However, as it is subject to updates, please use the hyperlinks within the document to confirm the information is accurate.

The press has all been full of headlines about staffing levels in the NHS, but this is probably a problem across healthcare around the country. What this does is provide the perfect patient safety quandary, how do we keep all the areas safe. This often results in the redeployment of nursing staff to different areas, but does this provide the required levels of safety. It appears that having several areas in an “amber” staffing level is preferable than one red area. It is simple logic, but does this create an unrealistic expectation on staff that means the safety is better but only at a barely satisfactory level? Do we think that any of these decisions influences the efficiency of a ward? Is the ward safe and effective? In this blog, Chris Elston explores these issues and uses a Safety Engineering Initiative for Patient Safety (SEIPS) to show some of the lesser appreciated risks to redeploying staff and consider some ways to reduce the risks.