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Hospitals to replace nursing posts with lower paid assistants


A number of NHS hospitals are planning to replace an increasing number of trained nurses with cheaper, unregistered ‘nurses’ paid at a lower rate.

Leeds Teaching Hospital and East Kent Hospitals University Foundation are among those trusts known to be making or planning such changes.

The chief executive of another hospital trust, who did not want to be named because staff have not yet been informed, said the nurse “swap” was in response to financial pressures and a shortage of experienced band five nurses.

The increased use of electronic monitoring of patients meant it was now possible to replace registered nurses with healthcare assistants, the source added.

A spokesman for Sheffield Teaching Hospitals Foundation Trust told Nursing Times it uses “band four nurses who have reached a higher level of competence and experience who at times fulfil some of the roles previously carried out by band five registered nurses”.

He said: “In these areas we developed the roles primarily as a response to specific recruitment difficulties and the roles are supported by very specific training programmes.”

Foundation chief nurse Hilary Scholefield added: “We have not used band four posts to replace band five registered nurses in order to make financial savings; in fact it is the absolute contrary.

“Band four posts were introduced in our hospitals more than six years ago and this is now a well embedded formal programme of education and training which has enhanced, not detracted from the 70/30 skill mix of our nursing workforce. It has not impacted on the number of registered nurses we have.”

Unison head of nursing Gail Adams said: “This is not like for like work. You can’t swap band four for band five staff. We have seen the effects of these cuts in Mid Staffordshire and Maidstone and Tunbridge Wells. There has been no discussion of this at a national level.”

A spokesman for Leeds Teaching Hospitals said “a major trust-wide organisational development programme with workforce modernisation at its heart” would include “exploring the potential of new roles to support our registered workforce”.

The trust’s Unison branch secretary Sharon Hamilton – herself a band five nurse – said staff had not been informed of any plans to increase the numbers of band four staff. Asked if she agreed electronic patient monitoring meant there was more scope to use lower qualified staff Ms Hamilton said: “It’s OK having a machine that bleeps but if the patient starts changing colour then it’s only a person who can see that.”

Earlier this month a Nursing Times survey revealed many nurses felt the increased use of patient observation technology made it less likely staff would spot signs of patient deterioration (news, page 1, 13 October).

A review of ward staffing levels and skill mix at East Kent, seen by Nursing Times, states nursing’s transition to being an all graduate entry profession by 2012 could mean fewer nurses, but a greater proportion of leadership roles.

It anticipates a “major expansion in the number of people required to work at assistant and associate practitioner role”, which is paid at band four. It describes this role as delivering “protocol-based clinical care that had previously been within the remit of registered professionals”. Meanwhile, a number of band five nurses at the foundation trust will be moved into band six positions, to take on ward management tasks.

Director of NHS Employers Sian Thomas said such changes were “exactly what Agenda for Change” was for and the knowledge and skills framework could be used to measure the skills appropriate for any new role. “The tools are already there to change the career ladder,” she said. “It’s right where we have qualified registered practitioners to have them doing jobs they are qualified to do”

Ms Thomas said responses to the NHS staff survey indicated that up to one in three nurses felt they were doing jobs that were below their knowledge and skill level, suggesting scope for substitution with lower skilled staff.

Royal College of Nursing head of employment relations Josie Irwin said she feared such changes were “financially driven” but she would not object if they were on the basis of a proper evaluation of clinical needs and staff engagement.

Ultimately, the “test” was whether changes to the nursing profession and skill mix made a positive different to patient care, she added.


Readers' comments (70)

  • As a 'long in the tooth' previous EN and now converted RN.... who's main role now is teaching and training HCA's I find some of the comments made above extremley offensive to all HCAs.
    i.e. "I have to point out that by it's very nature i.e. below standard spelling, punctuation and grammar, that it illustrates the difference in levels of intelligence and education needed to fulfill the role of a nurse. Nurses are educated to a very high standard, and for very good reason."
    Trained nurses have to be 'highly educated' to do the job do they? Thats why most of them have forgotten why they became a 'nurse' and spend quite a bit of time delegating tasks to the HCAs, for example basic nursing care and communication; to name but two of the most important things a nurse should be doing on a daily basis for their patients.
    I am very glad that the HCAs I train don't have the 'level of education and intelligence' of whoever wrote that entry! They are obviously in the wrong job.
    As for the accountability issue HCAs are accountable the same as a registered nurse, except if the task is delegated without knowledge of the HCAs competence. So the answer to all the 'stressed out band 5's' is don't delegate if you don't know; do it yourself!
    I fully support the development of the HCA role as there is a huge gap in the nursing workforce, which some HCAs once properly trained, assessed and informed are more than ready to step into. Hopefullly they can also then become regulated to!

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  • There has always been a role there for HCAs. I was what was called a Nursing Auxilliary (NOT nurse!) before I trained as an RN. It gave me a great insight into the role of the RN and taught me so much about the care and comfort needs of patients. However, it not equip me to take over the job of a trained nurse. I was motivated enough to go forward and do my training. We didn't have NVQs as auxilliaries, but the guidance and support from the trained staff on the ward. We were not 'wannabee' nurses. We realised that the two jobs were very distinct. The point I am making is that there is a potential here for HCAs to be used and abused by management who are just looking for cheap labour and not considering the needs of patients or the added burden of responsibility that will be born by the HCAs, and the RNs who have ultimate accountability. RNs are not valued or respected in the UK anymore, they are underpaid and are leaving the NHS in droves. I say to the NHS bosses and Government, 'Stop papering over the cracks and looking for the cheapest way out'. It's the patients who will suffer in the long run.

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  • I am a Professional Development Nurse for the Unregistered Workfroce and I agree in the main with many of the concerns put forward.

    However I see it differently having worked with and still working with many willing and skilled Health Care Support Workers and Assistant Practitioners.

    There still remains a sticking point over delegated responsibility and accountability but i have managed to work through this with trained staff by first providing tools to measure the competence levels of the support worker which can be evidenced both locally and nationally. Then we looked at building the knowledge of accountability for the support workers, reframing their ideas about their role and responsibilities.

    I appreciate it is a lot of work for the registered staff to monitor and assess whether someone is competent to undertake a skill unsupervised, but a robust system which provides evidence of skill acquisition should support this.

    Additionally within our organisation i provide support where possible, by going out with the support staff and working alongside them and assessing competencies.

    Therefore in my opinion i feel it is not beneficial to disregard the above article but to recognise the implications and think of solutions as to how we can be a part of the change.

    Unfortunately whether we like it or not, the need for skill mix is real

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  • I feel that all the nurses out there who feel that HCA's would wish to take on the kind of responsibilities that trained nurses have to deal with are very much mistaken. HCA's are a vital part of any hospital department as we are the ones who do all the minual tasks that nurses feel they are to highly qulified to do. Not all nurses fall into this catigory only the majority. Some trained nurses started off as HCA's and these particular nurses know how hard HCA's work. It is not the HCA's idea to bring in these changes it is the management who are trying to save money.

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  • I was a hca for many years but now a staff nurse although I think the work of a hca is needed in the running of a ward or department it should be kept as a supportive role. If the trust wants to make cuts try looking at the higher grades of nursing staff who attend many meeting and sit behind a computer all day I agree with a matrons role but not as many as we have in our trust too many chiefs not enough shop floor worker why do we need matrons and senior sisters and sisters all in the same department and not just 1 of each but many??? Strange and I agree nurses are the lowest paid profession why can we not have the salary we deserve bring us in line with other professionals. Who else works long hours on the front line gets constant abuse has to go without breaks and leaves late all the time??

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  • I am a staff nurse on the verge of giving up on my career after only 5 years. The increasing demands on myself and all the staff in the trust where i work are dreadful. Patient care is compromised on a daily basis as we are required to work short staffed as the trust is over budget, and they refuse to bring in bank staff. We have two wards lying empty because they cant afford to staff them and the rest of the wards are often asked to justify why patients are in a bed! Its gone beyond ridiculous. My point is the people in charge running these hopitals get huge salaries and bonuses and they will go all out to meet targets and any cost. Stop paying bonuses to these people and give them a salary like the rest of us and maybe patient care will become more of a focus rather than budgets in order to get a bonus! Its not by employing more band 4 staff that will save hosptals money but by reducing the amount of pen pushers there are. All nurses and HCA work hard we deserve better but most of the time its a case of put up and shut up to the detrement of the patient.

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  • I agree completely with 29.10.09 02.11 comment, and the majority of other points. I would add that the article by Sally Gainsbury is misleading. The title replacing nurses with lower paid assistants goes on to call the assistants "unregistered nurses" which is a contradiction in terms. Nurses are registered and HCA's are assistants.
    Solicitors and other professionals have research assistants etc, but we don't call them unregistered solicitors. What is the NMC doing about this? I hope that the Council will comment.
    Good HCA's are excellent in a support role. Those with the desire and ability can & frequently do study for a qualification in health or other professions.
    Kathleen White

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  • I agree that many HCAs are capable of taking on more responsibility. Let's give them the proper training, put proper monitering and accountability systems in place and then give them a proper title; how about Enrolled Nurses?

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  • I feel there are a lot of responses here, dumbing down the role of an HCA/NA. I worked as an NA for some time before starting my nurse training this year. Whilst I agree it is wrong to cut back on registered nurses and ask Band 4's to do their jobs. At band 2 I did do the nurses job. I cared for the patients, spoke to them, listened to them, did activities with them. Whilst the nurse was chained to the office writing care plans or in the clinic doing the meds. There has been a nurse shortage for some time and NA's fill this gap somewhat. However why are so many nurses moaning about no responsibility on the NA's part? Yes if I don't check on a patient and then something happens, I will hold my hands up. But don't we agree to be responsible when we graduate and are nurse in charge on the ward? Do some nurses even know what the standard band 2 wage is? It's not a livable wage that's for sure! I earned more in a call center, and that is shocking.

    I think we all need to work together regardless of banding to get the correct levels of staffing. The trust I worked for regularly under-staffed, and yes it WAS because of the money. I can't possibly understand why you would cut down on C&R training when it is a necessity on some wards. But until these trusts have their statutes reviewed, there will remain cut corners in nursing, when really that is not what the NHS is about or why we come into this profession.

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  • Unfortunately, this has absolutely EVERYTHING to do with cost saving. I attended the BACCN conference in BELFAST this year. One of the themed lectures was on role development, in this was a presentation from Bolton Hospital. The presenter proceeded to describe an HDU that was failing, staff retention, the environment were all factors, including over occupancy of the beds. The presenter continued to point out that they were struggling to recruit band 5 nurses into thier unit. Their solution was to employ 2 band 4 assistant practioners, who replace the band 5 and are supervised by the staff nurse on shift, they carry out all tasks but are unable to sign for medications. They discussed this role as a trail blazing initiative of which there were plans to role out into the ICU !
    They are NOT registered, there is no way of striking them off if they are incompetent ect.. ALso what about the question of banding, band 5's will become more supervisory, and as this element seems to have the most wheighting over clinical skill, surely more 5's will have a case for re-banding to a 6!

    I believe that this is an important moment in the nursing profession, money is being squeezed out of the trusts, savings need to be made, if they get there way the 4 , will be the new 5! We should be asking the unions (unison and rcn), to earn thier money for once, to draw decisive lines in the sand, make a voted on position statement and present to the govt.. other organisations such as BACCN ect.. also have a pivitol role to play in this issue!!!

    It is now for us to decide, sleep walk into the demise of our role, or stand up for patient and profession, look to Hospital scandals such as Mid Staffs and recognise that what went on there, is not totally a shock and we can all recognise at least some of thier issuse in most trust's up and down the country.

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