C-0 Competencies for generic capabilities
Generic capabilities are attributes that all experienced professionals should have, irrespective of their clinical expertise. I have discussed them in detail on other pages. Applying these capabilities within rehabilitation requires a few specific competencies because the patients seen in rehabilitation provide additional areas of challenge; for example, many patients lack the mental capacity to make health and welfare decisions about their rehabilitation. I was surprised that only the regulator of doctors, the General Medical Council, has specified the generic attributes required by all members of their profession. Research in 2010 by the UK Health and Care Professions Council found little research into professionalism. In 2019, the UK Department of Health and Social Care published the results of a public consultation about professionalism in healthcare, an inquiry precipitated by the lack of any agreed framework.
Table of Contents
Healthcare professional standards.
For centuries, healthcare was centred on single, self-proclaimed and culturally accepted practitioners (doctors and surgeons, medicine men, wise women etc.) who were responsible for diagnosis, prognosis, and giving advice or specific treatment. In the sixteenth century, Thomas Linacre persuaded King Henry VIII to allow doctors to form a college to authorise and regulate medical practice.
Over the last 500 years, healthcare has grown exponentially in complexity. For example, doctors specialised, broadly breaking into different groups such as surgeons, physicians, psychiatrists, and family doctors. The General Medical Council recognises that doctors fall into 65 medical specialities, with an additional 31 subspecialties. At the same time, many new professions emerged. The NHS has defined a group of 14 Allied Health Professions, but this group excludes many vital healthcare professions such as nurses, social workers and clinical psychologists.
The total number of healthcare professions is unknown and unknowable. In 2015 Clyde Jensen published “The Continuum of Health Professions“, outlining how professions emerged and suggesting they developed on two axes. The first was the scope of practice, the second was the philosophy of care, and he illustrates how you can use the classification.
He drew two primary conclusions:
- There were, in 2015, more than 250 healthcare professions.
- The scopes of practice of different professions often overlapped.
When a profession identifies itself, it will set up a professional organisation to set and monitor standards. For many significant disciplines, this role transfers to a legal-defined body, such as the General Medical Council for doctors and the Health and Care Professions Council for fifteen other healthcare professions.
The Health and Care Professions Council has set the standards it expects from the regulated professions. Notably, these are restricted to reasonably practical matters about daily activities when contrasted with the much broader areas covered by the General Medical Council.
In its Generic professional capabilities framework, the General Medical Council expects independent medical practitioners (consultants and general practitioners) to
- professional values and behaviours
- professional skills
- practical skills
- communication and interpersonal skills
- dealing with complexity and uncertainty
- clinical skills (giving five specific examples)
- professional knowledge
- professional requirements
- national legislative requirements
- the health service and healthcare system in the four countries
- capabilities in health promotion and illness prevention
- capabilities in leadership and team working
- capabilities in patient safety and quality improvement
- capabilities in safeguarding vulnerable groups
- capabilities in education and training
- capabilities in research and scholarship”
The GMC has translated them into six generic capabilities in practice:
- Able to function successfully within NHS organisational and management systems
- Able to deal with ethical and legal issues related to clinical practice
- Communicates effectively and is able to share decision-making while maintaining appropriate situational awareness, professional behaviour and professional judgement
- Is focused on patient safety and delivers effective quality improvement in patient care
- Carrying out research and managing data appropriately
- Acting as a clinical teacher and clinical supervisor
The Royal College of Physicians has also investigated professionalism, suggesting seven roles. Although all are prefaced by the words “Doctor as …”, there is no reason why the roles could not apply to any healthcare profession. The roles are to be:
- A healer, alleviating suffering, listening, and being compassionate
- A patient partner based on values such as integrity, respect, and compassion
- A team worker because only teams can manage the increasingly complex problems seen in healthcare
- A manager and leader using clinical knowledge to improve the management of teams, departments, or larger organisational units
- An advocate for a patient and groups of patients not yet seen.
- A learner and teacher, always learning but also always teaching
- An innovator, always seeking better ways to help patients
The nine domains within the Generic Professional Capabilities Framework and the six Capabilities in Practice should be fulfilled by any healthcare professional acting independently. Recognised experts (specialists) in rehabilitation should have these attributes.
I have discussed these on another page, and the section of that page outlining the capabilities is reproduced below.
The seven generic capabilities
The capabilities outlined on this page derive from these characteristics of the healthcare system. They are also based on some evidence. The General Medical Council, and others, have investigated the nature and causes of complaints against doctors, other healthcare professionals, and the healthcare system in general. In part, the generic capabilities (high-level training outcomes) required of all doctors were based on these analyses. They are intended to reduce the frequency of poor patient experiences and complaints.
Capability 1: to work in healthcare and other systems.
This capability concerns identifying other necessary organisations and working within the complex network of systems that may be involved with any patient needing rehabilitation.
The capability in practice is that the rehabilitation professional is “able to identify and work collaboratively with all people and teams from Health, Social Services, and the many other organisations that a patient within a rehabilitation service may need.” It is important to note that the professional must be proactive in finding teams and organisations to help the patient. You can go to the page here.
This capability is more critical in rehabilitation than in most other health services. Three notable exceptions are psychiatry, paediatrics and geriatrics, where the range of problems needing to be resolved extends well outside health services. This is illustrated in some posts on this site: here and here.
Capability 2: to understand and adapt to societal contexts.
Health services are a part of Society, “the community of people living in a particular country or region and having shared customs, laws, and organisations.” [OED] and the rehabilitation professional must be aware of many socially-determined factors influencing choices and actions. These include national factors such as laws and ethical considerations and more local factors, especially personally-determined factors, often termed culture: “the ideas, customs, and social behaviour of a particular people or society.” [OED] The page can be visited here.
Thus, the capability in practice is that the rehabilitation professional is “able to identify the relevant legal, ethical, and cultural frameworks that appertain to a patient’s situation, to consider them when making decisions, and to adapt plans in the light of these factors.”
Though these factors are relevant throughout healthcare, they have a more significant influence and impact on rehabilitation because rehabilitation is always person-centred. In addition, in rehabilitation situations frequently pose difficult legal and ethical questions – which are not always recognised and acted on.
Capability 3: to maintain good communication with all parties
Rehabilitation is no different from all other areas of healthcare as far as the central importance of good communication is concerned, not only between the professional and the patient but between professionals. It is essential both in collecting data and in planning and delivering treatments.
The capability is that the rehabilitation professional is “able to establish and maintain effective communication with all patients, and their families, and with all other people, teams, and organisations involved with the patient’s rehabilitation.”
Rehabilitation professionals face more significant problems in communication than most other healthcare professionals for several reasons. Many patients have issues that significantly alter their ability to communicate, such as diminished or absent ability to use language (aphasia), altered ability to speak clearly (dysarthria), reduced cognition, altered ability to pick up on non-verbal aspects of communication, and altered emotional state (to name a few). Families can be challenging to communicate with if they have radically different expectations, for example.
There is also a much more extensive range of other professionals and teams to communicate with, who may have very different knowledge and culture from a rehabilitation team.
Capability 4: to monitor and improve quality and safety
All healthcare services, and probably all teams and organisations, have increasing the safety and the quality of their service as a goal. Rehabilitation faces a specific challenge because, from the patient’s perspective, they are concerned about their overall service, not the standard of individual services. Even if all services were, individually, excellent, the patient might still suffer and experience poor quality through lack of collaboration and cooperation. Patients ‘fall through the gaps’.
The capability is that the rehabilitation professional is “able to monitor and improve the whole network of services involved with a patient, considering safety and quality of their service, each other service individually, and all inter-service transferring and/or sharing of responsibility.”
In other words, the professional has two additional responsibilities: ensuring that services interact and work together so that patients receive a safe, effective service and, if an example of risk or poor quality is identified within another service, drawing it to the attention of that service.
Capability 5: to understand and support research
Research is essential to service development and the setting and maintenance of service quality standards. An expert in rehabilitation needs to understand how to assess and interpret research to increase their expertise; they should also support it wherever possible to improve the quality of rehabilitation.
The capability is that the rehabilitation professional “is able to assess critically, and interpret clinically published research, is able to use findings in their clinical practice, and is able to encourage and support any research undertaken in their service.”
It is unrealistic to expect most healthcare professionals to be researching actively as leaders or significant contributors to a specific research project. On the other hand, research is a vital activity within healthcare services – witness the success of trials of treatments for Covid-19 – and all healthcare professionals need to use research to improve their practice. One way to better understand research is through involvement with researchers, discussing what they are doing and why. The best way to do this is to participate as a helper in research in the service.
More details are on this page. (here)
Capability 6: to teach and train others
All healthcare professionals have a responsibility to teach and train both students entering the profession and, with increasing experience, postgraduates. Rehabilitation differs from other areas of practice in being centred on multi-professional teams. Rehabilitation professionals, therefore, have an additional responsibility to teach other disciplines at undergraduate and, more importantly, at a post-graduate level about their work. They also need to teach and train all professionals about rehabilitation.
The capability is that the rehabilitation professional is “able to teach and to train both undergraduates and post-graduates, in two different spheres: about their own professional practice; and about rehabilitation as an activity.”
Much of this teaching is or should be part of day-to-day work within the team; some will be at team training and local teaching events, and a relatively small proportion will be at formally organised extensive group teaching or training events.
Capability 7: to maintain and use professional expertise
One of the fears felt by professionals entering or training in rehabilitation is that they will lose or not use their professional expertise (or, more simply, be afraid of loss of status); a concomitant risk is a failure to maintain and use their professional expertise. In reality, within a rehabilitation team, it is essential to have a high level of knowledge both to know when it is reasonable to adapt or alter the accepted assessment or treatment and to know when it is inappropriate to do so and to have evidence to support this.
The capability is that the rehabilitation professional is “able to maintain their professional expertise and to use it effectively within the context of a multi-professional team, contributing o team decisions and actions, adapting practice to the patient’s benefit.” The capability is expanded upon and can be seen on this page. (here)
The critical aspect of this capability is that the professional has sufficient and well-founded self-confidence that they can ‘wear their expertise lightly’, using it without difficulty and being complicated.
Competencies for generic capabilities.
The expected behaviours, knowledge and skills are set out in the Generic professional capabilities framework, in the Rehabilitation Medicine Curriculum (pages 13-16), and on this site. Most of the competencies are gained during education and training. However, given the nature of the patients seen commonly with rehabilitation services, four specific competencies may help, which are covered in this section.
Responsibility for funding interventions needed by disabled patients is often disseminated among organisations, each having its priorities, forms, processes etc. Further, some patients have exceptional needs which require special funding, which is often difficult to get. While no one can learn about all sources and their processes, being competent in negotiating complex funding systems and knowing how to present the patient’s needs will help.
Ensuring the best interests process is used.
Many patients seen have reduced cognitive ability and may lack the mental capacity to make serious health and welfare decisions. Although learning about the Mental Capacity Act 2005 is required of all healthcare workers within the NHS, it must be used or understood. It may be used to comply with the Deprivation of Liberty Safeguarding process, but it is rarely used for making medical decisions. Significant decisions are commonly needed for people who lack capacity, such as transferring to a care home, having an operation for contractures, or starting or continuing treatment.
Undertaking quality improvement.
The quality of rehabilitation services depends upon good communication and coordination between many professionals and organisations. From a patient’s perspective, the system is complex and often breaks down. Improving the quality of the patient’s rehabilitation requires improvement within teams and broader networks. The expert rehabilitationist should be competent at recognising the problems and initiating or participating in system-wide improvements. They also need to know how to manage and analyse the data.
Delivering a teaching programme.
A profession is defined, in part, by teaching the next generation of the profession. Rehabilitation is a team activity, but there is no acknowledged body of rehabilitation professional knowledge and skill to teach. Most professional teaching focuses on professional knowledge and skills unique to the teacher’s profession. In rehabilitation, the expert needs to be confident and competent to teach people from other disciplines about their profession’s expertise and to teach about working in a team.