The healthcare assistant proposal is expensive, will lead to an unstable workforce and it adds risks to patient care, says Trish Morris-Thompson
The Robert Francis QC inquiry explored the role of the entire NHS system in the significant failings in patient care at Mid Staffordshire NHS Foundation Trust, and concluded with 290 recommendations.
Forty of these relate to nurses, nursing, nurse leadership, nurse practice regulations and training of nurses. Twenty-eight relate to the medical profession. Eight-seven relate to the health regulators, and the remaining relate to the other parts of the NHS.
It is incredibly sad that the media and the politicians have focused on the recommendations for nursing. The main headlines and debate are focused on recommendation 187 which is: “There should be a national entry level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of the patients under the supervision of the registered nurse.”
“Such experience shall include direct care of patients, ideally including the elderly, and involve hands-on physical care. Satisfactory completion of this direct care should be a pre-condition to continuation with nurse training. Supervised work of this type as a healthcare support worker should be allowed to count as an equivalent. An alternative would be to require candidates for qualification for registration to undertake a minimum period of work in an approved healthcare support worker post involving the delivery of such care.”
“Given there are 290 recommendations, the focus on recommendation 187 only begs the question: conspiracy or cock-up?”
The government response to Mr Francis’ report focused very much on nursing and misunderstood the above recommendation. With much fanfare, it announced that all potential student nurses, to gain entry to training, would have to work for a year as a healthcare assistant.
This is wrong on so many levels.
It completely misinterprets the content and intent of recommendation 187. The unintended consequences of this are as follows:
- Students and newly qualified nurses make up a very small proportion of the nursing population. There are 660,000 of us on the NMC register. Students and newly registered nurses represent about 15-18% of the workforce.
- It undermines existing healthcare assistants; they are the backbone of clinical services, retain corporate memory of their services and provide much support for nurses and direct care for patients. They are, in the main, the most stable element of the nursing workforce.
- The costs of this proposal could put additional pressure on existing fragile NHS budgets; if existing HCA posts are to be targeted to meet this, demand will require significant orchestration to provide a timely pipeline for nearly 19,000 new students entering nurse training each year from over 44,000 applicants. The council of Deans of Health working paper, Healthcare Assistant Experience for Pre-Registration Nursing Students in England estimated the cost of these 44,000 applicants as £400m–£766m, depending on whether an apprenticeship rate or a band 1 rate was paid. The instability and additional costs this places on services could build additional risk into the services and, as a consequence, into patient care.
- It will also destabilise the existing HCA workforce, not least by turning it into a divided staff group of HCAs (potential student nurses) and HCAs (permanent).
- Supervision of this group of staff would place additional pressure on nurses.
- The sustainability of the proposal is also fragile. Local education and training boards, as commissioners, have the freedom to decide locally on how they commission education. Some may decide not to insist on this, resulting in a postcode lottery over qualification criteria.
A deeper analysis of recommendation 187 identifies it is in four parts:
- “There should be a national entry level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of the patients under the supervision of the registered nurse.”
This exists already; student nurses spend 50% (2,300 hours) of their training on direct patient care under the supervision of a mentor.
- “Satisfactory completion of this direct care experience should be a pre-condition to continuation in training.” Again, this already exists and mentors are required to sign off students as competent in key areas.
If the above processes are found not to meet expectations, contracts with higher education institutions can be altered to address this. Local education and training boards have the tools to identify if this occurs and the power to intervene and address it.
- The opportunity for confusion and misinterpretation lies within the next sentence:
“Supervised work of this type as a healthcare worker should be allowed to count as an equivalent.” The equivalent to what is not clear and the use of the title “healthcare worker” unfortunate. Perhaps this slipped by Mr Francis’ professional advisers.
- “An alternative would require candidates for qualification for registration to undertake a minimum period of work in an approved healthcare support worker post involving the delivery of care.”
In essence, the preceptorship programme was set up to do this and support newly qualified nurses through their first 12 months as a staff nurse.
An alternative would have been to build in a fourth year after training working under the supervision of a senior nurse in a clinically focused programme. This operates in the Republic of Ireland and works very well. Certainly, it would be more palatable to the profession.
In making the announcement, this government has triggered significant negative media headlines, and much public debate and confusion. This has resulted in a very angry response from the profession as witnessed at the Royal College of Nursing Congress last week.
Given there are 290 recommendations, the focus on recommendation 187 only begs the question: conspiracy or cock-up?
Professor Trish Morris-Thompson is visiting professor of nursing, Buckinghamshire University; RCN clinical fellow; trustee Florence Nightingale Foundation; and patron, Britain’s Nurses