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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)

  • I am one of the "highly trained academic nurses" being described by some here and never shirked from my duty, including getting "down and dirty" and basic nursing tasks - I also never felt above these roles because of my academic qualifications, these were part of my reason for entering the nursing profession! I have also worked with a number of excellent HCA's but they did not undertake a three year programme where they were assessed constantly to fulfill their role, and also are not accountable for their actions in the way we are as registered nurses, in many ways we are more accountable that doctors!! I agree with a previous sentiment whereby someone has suggested they get a cashier (perhaps from Asda as I was informed there are lots of ex-nurses working in our local Asda, and they feel more appreciated) to undertake the roles in finance and management with a vast saving in budget. I think they should bite the bullet and train and employ more registered nurses.

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  • I agree so much with comments 'bring back student nurses to the wards and out of Universities'-I have nursed all over the world and the training I was fortunate to have based in the Schools of Nursing stood me in good stead to work in a wide variety of fields.I am always flabbergasted at the lack of insight as to why there are staffing problems,-for goodness sake train nurses from day one in HOSPITALS,so after 3 years they are confident and competent-bring back Hospital Social Clubs,Dr's parties,nurses the hospital where they are training,and with all those happy students back on the wards,guess what? no more staff shortages,better patient care and dare I mention it,fun?

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  • While I feel that punctuation and grammar are not always a sign of 'unintelligence or competence' and we do have appalling record keeping from trained nurses, this should still be a basic requirement for good, professional nursing. This is nothing to do with whether someone is an HCA as there will be many HCA's who are academically qualified and choose to do the job. However, nursing should be a whole patient system and without a competent and appropriate level of training one should not be deemed a Nurse. We have lost a great deal of professionalism with Agenda for Change - lumped in with every other worker in the healthcare system. Sadly, nurse training now lacks the core experiences which did start to come into play in the late 1970's and early 1980's with the modular training. This could have been easily adapted to become diploma and degree level and provide a good clinical basis for nursing. Instead we have opened ourselves up to poor standards and understanding of real illness, health and caring with a paper based and theoretical training provided by theorist tutors who are also out of touch with the reality of bedside/ community nursing. It is not surprising that we have comments such as band 5 nurses are less competent than band 4 HCA's.

    As most managers do not have any real experience of what an ill, frightened and vulnerable patient needs this still reeks of it being a money saving exercise. I would welcome the Trusts involved, to provide evidence as to why they feel that a band 4 HCA will be better than a band 5 trained nurse.
    Perhaps then we can look at how to address this both for competent band 4 HCA's and to support the skills of band 5 trained nurses.

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  • I have read the above statements and felt the need to write a comment; the role of the HCA is just that, they are staff who are happy assisting RN's with patient care, from my experience I have worked with some fantastic HCA's and some dangerous/unmotivated HCA's, but equally I have worked with some fantastic RN's and some dangerous RN's who I would not let look after my dog!
    My point is that I think people are missing the important point that caring for people takes a certain type of person, at the end of the day the reason we are there is to look after the patient, that takes team effort, which comprises of RN's who can do the extra bits like drug administration and HCA's who, in my opinion, tend to have more experience with dealing with people in such circumstances like being ill.
    We must not forget the patient in all of this, we need to be concerned with higher management, the UK is turning the Healthcare system into a business, this is, unfortunately the world we live in!
    As for the person who said that HCA's can't read or write, and that nurses are better then them, have you missed your calling as a uni lecturer? or author? get over yourself, at the end of the day, nursing is just that, no matter what extra roles you think you are superior in doing, it comes down to maintaining and helping those in need with the daily activities of living! No matter what uni's try to make nursing out to be today, it will always come back to the basics, any other role turns into assisting another profession be it medical, dietician, physio, oh, wait, that's what HCA's do! assist a role! ..... now fancy nurses being so similiar to HCA's eh?
    We need them, they are invaluable, no classroom can teach you about life, you have to life it.

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  • Any and every avenue is seemingly being explored as a cost cutting exercise .... except the most obvious one. The administrative drones and their surfeit of IT equipment, these areas would make a good starting point.
    Hands on knowledge, common sense, observational skills, care and compassion can never be replaced by computers, calculators, clip boards and accountants.

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  • A year ago I presented the Matron of my department with a letter from eight colleagues and myself opposing replacing a qualified nurse with an HCA in an already hard pressed Theatre Admissions/Day Surgery Recovery Bay on patient and staff welfare and safety grounds.

    At the meeting where I presented this letter to my managers, I asked Matron how this measure would improve patient care. A long silence was followed by a nonsensical answer.

    The HCA's in question were both, in my assessment, not capable of doing the job safely, yet I was expected to put patient's safety and my registration on the line on the order of administrators, in accepting responsibility for their actions.

    This I refused to do under the provisions of the NMC COC. Ructions followed but I stuck to my guns!

    I urge others to take a stand on this as it is a worrying trend spreading throughout public services that affects public safety and welfare. For example, the use of Community Support Officers patrolling with or in place of a fully warranted Police Officer.

    No sane person can believe that a reduction in skilled/qualified personnel can improve services can they?

    A two week induction programme and the odd day course is no substitute for the three years spent in nurse training. I used to be an HCA, I know full well.

    The RCN stance on this is typically weak, indeed, by allowing HCA's Associate Membership they validate the penny pinching of Trusts and demean our status.

    Doctors laugh at us for being the minions that we are as the RCP would never allow non-medics a comparative status. Oh, but little nursey is so helpful and accomodating and is a complete doormat!

    Look at it this way, you or your loved one will at some point be a patient at your local hospital. How do you feel about it now?

    Do something about it people, go to your Trust Patient Safety Officer or MP and blow the whistle!

    I did, it was terrible to go through but it was the right thing to do as if anyone had died on my watch I would never sleep fitfully again! How about you?

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  • Can no one see the answer ?????
    Go back to hospital training and the multi layered approach to staffing that we had.
    Matron,[who visited each ward daily& chatted to patients]Charge nurse[who ran the ward & the DR's]senior nurse each shift,then 3rd 2nd & 1yr nurse, cleaner for every ward & they took pride in the work,they owned their ward. Ward assistant to help out where required linen etc, and lastly a porter shared between the wards. Everyone was happy, gained experience and the patients received better care than they do now. Talk to the older patients and they remember what it was like. We also had ward clarks who ORGANISED charts paperwork and the doctors. We can't be worse off than the new system, I could certainly think of ways to save costs and improve the system but I'm ONLY a nurse and worker what would I know.

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  • In my opinion the main issue is registration for support workers. There are some very good experienced HCA staff out there. Set a national test and register them then they will be accountable for their actions.

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  • Please can we stop blaming the academic approach to nurse training for all nursing 'ills'. I am one of those nurses, university trained in the early 90s, who went on to be a good, motivated, caring nurse. We got so much 'stick' from some of the traditionally trained RGNs. Looking back, I think some were concerned that we were going to begin at higher grades when we graduated. Of course, this was nonsense, but goes to show that some nurses will 'eat their own young' so the HCAs don't stand much of a chance. I don't belive that HCAs should take over jobs that are really only suitable for trained staff, but I also think we should appreciate the work they do. Some will want to go on to be RNs.

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  • As a band 2 HCA having undertaken an NVQ 3 I was frequently allocated my own patient in the ICU as the unit could not get enough full time or agency registered nurses. I untertook all observations and patient care for the patient with the responsible registered nurse giving drugs and writing up the paperwork. The nurses appreciated this as prior to me achieving my NVQ they would instead have been allocated two patients and would have needed to complete all care for both of them. These were very stable patients and the RN was always next door to me so if I noticed any issues I could alert them immediately. Contrary to what has been stated about NVQs in the level 3 health award an understanding of A&P is required as is an understanding of what is beyond your role requiring you to call for assistance.
    I believe that this article is advocating the use of band 4 and they undertake a 2 year foundation degree.
    See this link to the course at Southampton uni
    Surely this is similar to a diploma which can also be completed in 2 years?

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