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Trust plans to count senior HCAs as nurses in cost cutting plans

A hospital trust is planning to bump up its nursing skill mix ratio with assistant practitioners, while using specialist nurses to do tasks normally done by doctors.

Under plans set out by Royal Cornwall Hospitals Trust, the 4,650 strong workforce will be cut by up to 14% over the next five years.

The trust’s “Our People Strategy for 2013-2018” sets out an ambition to achieve a ratio of 60% registered to 40% unregistered nursing staff by the end of this year – up from 55% to 45% currently.

By April 2015 the trust plans to increase the ratio to 65:35. However, the 65% would include assistant practitioners who, although more highly skilled than other HCAs, are not registered with the Nursing and Midwifery Council.

Sue Matthews, Royal College of Nursing regional officer for Plymouth and Cornwall, said she was “extremely concerned” by the proposals. 

“The RCN recommend a ratio of 65% registered nurses to 35% non-registered nursing staff, which the trust say they are working towards. However, assistant practitioners would be non-registered staff and should not be counted in the 65% as they are in this paper. 

“Studies show that where there is a low ratio of registered staff quality care is care is compromised,” she said.

The strategy was approved by the trust’s board on Thursday and a consultation will now begin with staff. Interim nursing director Andrew MacCallum told the meeting he was committed to a 60:40 ratio of registered to unregistered.

The strategy proposes band 3 healthcare assistants step up to train as band 4 assistant practitioners or step down a band to the newly-created roll of “nursing assistant”.

Doctors’ job plans are to be redesigned to allow more work to be done by nurses and other non-medical professionals. For example, advanced nurse practitioners will run clinics currently delivered by doctors.

The trust wants to reduce the proportion of its income spent on pay from 65% to 59%. Its managers claim low staff turnover means a higher proportion of nurses and other staff have reached the top of their Agenda for Change pay band than at comparable trusts – pushing up the overall pay bill.

The trust says the extent of the headcount reduction will depend on the extent to which the pay bill can be reduced.

The strategy also sets out detailed plans to set up a “talent pool” for nurses and other staff who are judged to have the most potential and to improve staff development. Clinical simulation training will be rolled out to at least 70% of staff by 2018.

In addition, an employee reward scheme is to be developed, which could include sharing profits with staff.

But Ms Matthews said: “[While] the trust has made assurances that patient safety and quality care remains their priority… this paper does not convince me that they intend to employ appropriately qualified staff and with the expertise to the deliver safe, quality care that Cornwall residents deserve.”

Readers' comments (90)

  • tinkerbell

    who'd have thought

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  • This is disgraceful !

    I am unsure who the "Director of Nursing " is at the Royal Cornwall Hospitals Trust but I will find out.

    Once I have a name and have verified the truth of this report I will request the NMC to determine if the post holder is fit to practise. I would suggest nurses employed by the Trust make the same request of the NMC

    Superficialy at least someone who is a registered nurse and who wishs to impliment such a mad cap scheme is not fit to practise.

    What next ? unqualified home trained surgeons or maybe they plan to replace physicians with the local herbalist !

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  • What has happened to the NHS? I cant believe that patient safety & Care is even being considered to be compromised. When you or a family memeber goes into hospital you expect that they get treated and cared for appropriatley by the relevant qualified staff members. All i can say if i ever get ill near this trust I will be asking the ambulance driver to continue onto the next hospital! SHOCKING!

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  • unacceptable!

    it seems as if H&S have spent all their budget on trivia and have lost total control of what is vital.

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  • michael stone

    What is the point of having 'officially-recognised categorisations', if locally people can redefine them ?! And it is NEVER helpful to call HCAs nurses, or to call nurses doctors - the NHS is confusing enough, without such nonsense !

    However, I'm pretty sure that anything from the DH 'giving incentives' (i.e. cash) for HCA/nurse/doctor ratios, would be clear that it meant 'counted properly' !

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  • It is fairly obvious to say that HCAs can be used to replace nurses or substitute them in basic care and in exceptional circumstances although this is unacceptable for many nurse-related tasks but without the qualifications and NMC RN registration they can never count as nurses, any more than nurses can be counted as doctors, senior bankers or any other profession for which they are not trained, qualified, registered and regulated!

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  • Think about this as a concept rather than a literal translation at an individual level:


    Every time the RN delegates a duty to the HCA which moves them away from the bedside the closer the HCA gets to registered status. When that happens the whole 70/30-60/40 standard will disappear and will need to be completely rewritten and the economics of the day will dictate what the new levels will be and on that day 65-35 RCN led standard will be a distant memory like Sister Plume.

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  • George Barnes

    Oh dear, oh dear – it beggars belief – how can they stoop so low as to break the Trade Descriptions Act. I thought it was against the law to impersonate a nurse. A Nurse is a Nurse is an RN, not an assistant practitioner, HCA (or even relative of a patient!) The definition of a nurse is someone who has done a recognized RN training and (in order to practise in the UK) is currently registered with the NMC as able to practice in that capacity.

    What next, porters being counted as HCAs? You know that if the Royal Cornwall Hospitals Trust are allowed to get away with this misrepresentation then other trusts will be looking on and rush in to copy it. The government won't care – it makes them look better on paper. Trust managements will love it because it reduces their costs whilst seemingly keeping the level of qualified Nurses.

    God how ridiculous can management get? A lot worse probably!

    Ahem, “the newly-created roll of “nursing assistant?” Sorry but I when I started in 1974, I started off as a nursing assistant... it was one step up from being a ward orderly. Nothing new there at all.

    It's all to do with re-inventing the wheel again. Likewise it seems to me that “assistant practitioners” are merely the State Enrolled Nurse but without the accountability to a professional governing body... and as a Registered Nurse that really grates.

    Time for the Nursing Times to mount a campaign to make sure that the term “nurse” actually refers to someone who is legally entitled to call themselves a “Registered Nurse!”

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  • Why did we bother to train if we can get in by the back door, this just devalues the whole profession just as we are trying to have our role recognized and will undermine us in the eyes of the public even more.

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  • tinkerbell

    soon to be introduced nationwide, as this is what it has all been leading up too sadly.

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  • I just wish there was some standardisation in the healthcare system as their is with the collection of taxes to pay for it (there are few doubts there) with clear indications of any changes so that everybody knows exactly where they stand. All this lack of clarity, uncertainty and spoon fed mini bytes of information via the popular press must detract from nurses' ability to concentrate on their jobs and continue to provide any form of holistic and integrated care to any patient at all. the service patients get seems to be very much a hit and miss affair right across the country!

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  • Having been at conference this week where our CNO Jane Cummings facilitated and spoke I am disappointed this sort of news is in the headlines however, the budgets only stretch so far, what matters is the training we all get & that the patients are cared for safely and all of us have clear boundaries and are accountable for our actions. Why we can't have a national standard for nurse ratio & minimum standard for competences is something Ms Cummings should address urgently to put a stop to all this. We need leadership not headlines at the current time we will all have enough to think about and I know doubt action next week with the Francis report.

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  • What was the point in all that time, money and expertise being spent on the Francis Report if rubbish like this is to be tolerated. This is an insult to patients, relatives, nurses, doctors and anyone else who cares about what is going on in health-care.

    Like someone else has pointed out, this is just a cheap 'can't be bothered to train and pay an SEN' gimmick, no accountability, no recognised qualification, no official training - why not just bring back the EN training.

    It is difficult and unsafe enough already having staff nurses on the wards who are completely out of their depth, who work their backsides off and who are expected to take responsibility for everything.

    This is an absolute disgrace.

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  • Registered Nurse is a protected title and it is illegal to call yourself as such, however neither nurse or doctor have any legal protection. It is illegal to identify yourself as a medical doctor if you are not. Anyone with a PhD, DD or DSc for example can call themselves 'doctor', therefore a nurse with a PhD can legally call themselves Dr.!
    I have suspected for quite a while that in the ED where I work that Band 5s could be replaced at least in part by Band 3s. From a clinical skills point of view there is little difference, Band 3s cannulate, take blood, plaster and soon will be able to do basic suturing. If a patients observations are out of kilter then it is as easy for a Band 3 to talk to a medic as it is for a Band 5. The only real difference is that Band 5s can administer medication, but that could easily be undertaken by an registered nurse or indeed any registered practitioner. I forsee the situation where Band 5s in my department will become a thing of the past, Band 3s fulfilling the role with Band 6 and Band 7 filling any role that Band 3 HCAs cannot for legal reasons.
    Advanced Nurse Practitioners operate at the same level of competency as FY2 medics alongside Physicians Assistants and are part of the medical and not nursing teams.

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  • Christine Rashleigh, Director of Nursing at RCHT,

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  • Susan Markham

    Yes that's all fine and well but Band 5s/HCAs are not qualified Rns. It would be deceitful and being very economical with the truth if you had 2 Rns and 8 HCAs staffing a ward and were then to say “my ward is staffed 100% by nurses and therefore I have no need to recruit any more strained staff.” In fact your ward is staffed by 2 RNs and 8 unregistered HCAs and you need to recruit to balance your skill mix to acceptable levels.

    That is where the illegality of the RCT's plans lies (literally.) It looks good on paper but it is just an academic exercise. The current standardized method of auditing staffing distribution across the whole of the NHS distinguish between qualified and registered NURSES and HCAs. The RCT cannot arbitrarily decide that they will implement a new method of determing their staffing ratios.

    Apples and oranges are irrefutably different types of fruit. HCAs and Rns are also fundamentally different. Be sure you keep the distinction clear in your mind otherwise you may end up putting orange marmalade on your pork chop!!!

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  • George Barnes

    Anonymous | 1-Feb-2013 2:29 pm

    Ah well that's the NHS staffing problems all sorted out then. With the flick of a reality change ALL the hospitals across the country are now 100% fully staffed bu nurses. Makes you wonder why we bothered to train at all. Five years of my life to get an SRN and an RM all wasted in the blink of an eye! I could have just stayed as an HCA then at least I wouldn't have to pay my annual registration fee!

    Hey that's a point – if as “Anonymous | 1-Feb-2013 2:29 pm” said – Grade 5s are to become a thing of the past with unregistered HCAs taking over the role with a few Band 6 and 7s left doing the bits that the HCAs can't legally do then eventually (very quickly) Registered Nurse numbers will dwindle... in other words the NMC's cash cow / source of revenue is going to dramatically diminish and their workload and importance will also decrease.

    I wonder how the NMC feels about that prospect?

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  • George Barnes

    Sorry, that should have read "Five years of my life to get an SRN and an RMN"

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  • why is there a need for all these bands? it just seems to divide people as well as standards of care. in Europe, a registered nurse is a registered nurse, and they all work together with their nursing assistants and other members of the interdisciplinary team for the same aims of focussing on the patient and providing them with higher standards of expert evidence-based care which is what the patients are there for. it is of no interest to them who is on what band or nurses obsessing about it!

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  • George Barnes

    Anonymous | 1-Feb-2013 3:21 pm

    Well actually there is quite a need for these different grades, it's called accountability or “the buck stops here...” I have worked in the UK, Europe, Bermuda, for The Armed Forces and Canada. Trust me in all these countries and organization there exists clear delineation between the different grades/bands of staff that operate as a team on the ward.

    We work all work together as part of an interdisciplinary team and each of the various members know what is expected of them and their position of responsibility in the hierarchy of that particular team or organization to focus “on the patient and providing them with higher standards of expert evidence-based care which is what the patients are there for.”

    The patient may not 100% understand the demarcation or the responsibilities of the various staff but the members of the team are... which is very necessary when it comes to leading the team, planning the shift, organising the workload etc etc.

    The various degrees of responsibilities shouldered by the members of the team are reflected in the remuneration they receive... which is why we have various gradings/bands.

    It is over simplistic to say “well let us all just work together” - like the armed forces, nursing is not a democracy, it doesn't rub along like that... someone has to ultimately be in charge of a ward and that person also takes the responsibilty for making sure it goes right - or vice versa!

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