Registration of healthcare support workers
A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are dependent on such care by reason of disability and/or infirmity) in a hospital or care home setting. The system should apply to healthcare support workers, whether they are working for the NHS or independent healthcare providers, in the community, for agencies or as independent agents. (Exemptions should be made for persons caring for members of their own family or those with whom they have a genuine social relationship.)
- Instead of statutory registration, the government adopted a package of alternative measures: a voluntary Code of Conduct for Healthcare Support Workers (published March 2013 by Skills for Care and Skills for Health), the Care Certificate (launched April 2015), and reliance on existing CQC provider registration and DBS barring mechanisms.
- The Cavendish Review (July 2013), commissioned by the Secretary of State, had its terms of reference expressly exclude consideration of statutory regulation, and its training-focused recommendations were adopted as the government's alternative approach (Review of Healthcare Assistants and Support Workers in NHS and Social Care, Camilla Cavendish, July 2013).
- Robert Francis publicly criticised the rejection, stating: "Without any registration system or its equivalent, I believe the public will be at risk." He noted that taxi drivers and security guards face stricter registration requirements than healthcare assistants caring for vulnerable patients.
- The Professional Standards Authority accredits approximately 28 voluntary registers for unregulated health practitioners, but there is no PSA-accredited register for healthcare support workers or healthcare assistants specifically (Professional Standards Authority, Accredited Registers programme).
- Healthcare support workers in England remain unregistered as of March 2026. The Nursing Associate role (NMC-regulated from January 2019) creates a separate registered role but does not constitute registration of HCAs themselves.
How was this evidence gathered?
Response
Not Accepted
Response
Not AcceptedThe government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Francis recommended registration of healthcare support workers (healthcare assistants). This was one of the 9 recommendations the government rejected. Instead, the Care Certificate was introduced (April 2015) as a minimum training standard for new HCAs. Francis publicly criticised this: 'Without any registration system or its equivalent, I believe the public will be at risk.' The RCN continues to call for statutory regulation. As of 2026, healthcare assistants in England remain unregistered and unregulated.
View detailed findings
Rejected. Healthcare assistants remain unregistered and unregulated. Francis described this as leaving the public at risk.
Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.
NMC Revalidation launched 1 April 2016 in direct response to Francis Report. All nurses and midwives must revalidate every three years. Replaced the Post-Registration Education and Practice system. Updated NMC Code published March 2015 strengthened requirements around candour and raising concerns.
Care Certificate launched 1 April 2015 as standardised induction training for all new healthcare assistants and social care support workers. Covers 15 standards (updated to 16). Implements recommendations from Cavendish Review (July 2013) and Francis Report on healthcare support worker training.
NMC published updated Code of Professional Standards for nurses and midwives (March 2015). Standard 14 specifically requires nurses and midwives to be open and candid with all service users about all aspects of care, including when mistakes or harm have occurred.
Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.
Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.