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'Localism is a laudable aim but it may result in care factories'

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‘If we loosen the national grip on planning and professional education, we must ensure nurses and HCA colleagues do not become mere workers’

I have said before that we are reinventing 19th century nurse training in the way we prepare our healthcare assistants. There are different courses in different places, run by a variety of private and public bodies, to varying standards and with no common curriculum. With the proposal in the Health and Social Care Bill to leave regulation of these essential, frontline workers to their employers, there will be no consistent oversight of the resulting practice or standards of conduct.

We have reached approximately 1890 in the history of nursing. Even this is a generous interpretation: by this time, standardised training and regulation for nursing generally was still about 30 years away, but national training and practice standards for district nursing were in place, together with a system for regular supervision of district nurses.

While the bill is debated, the Department of Health is consulting on new proposals for workforce planning and education for healthcare professionals. The key theme is localism: less national planning and more of it undertaken by networks of local employers; less central control, more education planned and overseen by the professions themselves. In many ways, this makes sense and sounds attractive - as does the long-overdue idea of making all organisations that employ nurses contribute to the cost of training the next generation of professionals.

Since its inception, the NHS has paid to train nurses; when staff leave to work for independent companies, charities or other non-public employers, the NHS has to train more people to replace them. The armed forces have always trained their own nursing workforce, but other employers have benefited from the NHS’s investment. Perhaps it is time to get a contribution for this from these other employers.

So networks of local employers may be the logical place to start surveying the needs of the whole healthcare economy in an area and ensuring all partners in care provision share the costs of workforce planning and preparation. But localism has its limits.

The role of the proposed new body, Health Education England, will be crucial to ensure three important tests are met: first, that the combined local commissioning efforts result in enough professionals trained in important but low-volume specialities (education providers will not be able to put on a course locally for just a few people a year); second, that skills and qualifications are transferable across the country and do not diverge into local educational dialects that are incomprehensible to a new employer 50 miles away; and finally, that the competing commercial interests of local providers don’t skew the nature of the workforce in a race for contracts.

This third point already happens in some social care agencies - a large force of inhouse-trained, low-paid care assistants can carry out a high volume of (short, task-focused) visits to patients at a much lower cost than a community nursing service, but can’t offer high-quality assessment and care. Hence the concern about reproducing this model using HCAs.

Meeting local needs by local planning is a laudable aim. But if we loosen the national grip on planning and professional education, we must ensure nursing does not return to being a cottage industry in which nurses and HCA colleagues become mere workers. In addition, professionalism must not be replaced by industrialisation with the cheapest labour producing lowest common denominator services delivered by rote. No fine words about nursing leadership, enterprise, innovation or co-production will make those things a reality in an employer-led care factory.

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