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Trish Morris-Thompson: 'The plan to make students work as HCAs is wrong on so many levels'


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


Readers' comments (14)

  • Money + support will be thrown at the government's pilot scheme to make it work.
    Why would people choose to take band 1 pay as HCA(student nurse) over band 2 HCA job ? so would everyone start at band 1? Wouldn't HCAs already be eligible with 1+ yr experience if they wish to go to nurse training?
    A 4th year of pre-reg student training + lack of income will not encourage recruitment or retention, people can still choose other career paths post qualifying. After 4 year studies on other courses, students are now more likely to be Masters degree qualified and find better remunerated careers for their knowledge and skills. Wasnt it due to competition between graduates and lack of local employment that students have to complete extra year prior to being registered. Also a lot of employers in UK take newly qualified nurses (NQN) (4 year courses) as they'll gain people with that year of hands on experience that local NQN (3 yr courses) here don't, all for same entry band 5 pay. Then what about fast-tracked post graduate pre-registration courses, someone with a decent degree could be a RN in around 12-24 months. It's more likely their skills will be fast tracked into more strategic roles.
    The removal of the 6 month increment for NQNs on successful completion of supported induction/preceptorship programme also means some nurses will struggle longer for support prior to the 12 month review, also removes recognition of competence and from now on everyone has taken a year's pay cut.

    More emphasis should be explored at implementing all recommendations of the Francis report.

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  • Why not just go back to student nurses spending their first year working on a general medical, general surgery and care of the elderly placement.

    They will need continuous supervision, bring back clinical facilitators and give staff nurses the support and time to actually work with students. At the end of each placement why can't they be assessed so that they meet the standards set. If they continually don't meet the expected standards then they can't carry on with their training.

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  • Anonymous | 16-May-2013 9:41 am

    worked well before, why not now?

    it seems a lot of money and resources are being wasted in all this faffing around and endless enquiries which seem to produce no useful results.

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  • 10;22AM
    Totally agree. Money and resources wasted.

    I think the reason is that the government overall are looking to downgrade nurses as -despite platitudes - they think we are above ourselves and should be hand maidens. Also, if they have HCA's at band 1 (pre student nurses) that will save a fortune as they can then slowly get rid of Band 2&3 HCA's.

    There is no reason why nursing students should waste a year pre training as a HCA as they work unpaid as a HCA for 3 years during training. Plus many HCA's apply for nursing courses anyway. Its about time they re-thought the non degree route, ie SEN's and diploma's. Not all nurses want to be desk bound managers.

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  • Yet another example of people who don't know what happens in real life or at the coal face of nursing making decisions about how we should work.
    Even senior nurses will not have worked on wards for many years now and do not appreiciate (they might say they do but until they walk a mile in our shoes...) what it is like.
    It is get them in, pile them high is the mantra to get the money but if there are any complaints, your on your own.
    No longer are the grass roots nurses listen to. I see it every day when nurses are saying they cannot take another patients (as the dependencies are now so high) but doctors and managers just literally turn their backs on them & ignore them.
    Things that only 10 years ago were uncommon on wards are now everyday. Patients with trachies for example. Wards can have 6/7/8 patients now.
    So qualified nurses have enough to content with without having to supervise an ever changing group of HCA's.
    Who will pay for these transient posts? How much is it going to cost to advertise, interview & screen these staff who are only going to be there for a year? What about the lack of continuity on the wards?
    Whilst I think it is good that people who do have more experience - been a HCA, trained as a nursery nurse, works in the ambulance service etc, get the credit for this when applying for nurse training but lets face it, many of us did not have this when we started.
    It is down to the interview & selection process with people who know what it is all about.
    Just a thought... what about bringing back a scheme similar to the cadets? May as well as give it a few year and the HCA will be the same as our very good reliable SEN's of the past.

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  • PS
    good to hear someone actually and articulatly speaking out & up for a change.
    If this lady knew all this why did the inquiry team not?

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  • staff morale is at an all time low, can you imagine what it would feel like if you were an experienced band 2 or 3 HCA, worse still if you had tried to get into nurse training but weren't considered 'academic' enough.

    student nurses do not need to work as an HCA, they just need to learn the basics in their first year of training.

    perhaps everyone working in health should be on a three month probationary period, it's not just student nurses who may not have the right qualities.

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  • It's been difficult to criticise Robert Francis' report becasue we are all horrified but what happened. The main problem is that neither he nor the people advising him have explained the process by which the recomendations are derived from the evidence. The relevant section of the report simply says things like (23.56) '...the enquiry was told of concerns...' and this evidence-free 'telling' has resulted in this recommendation which would not have prevented what happened in Stafford anyway. We should not be surprised that this has happened - the whole process of investigation and response is a political rather than a clinical or academic one. A political response is needed, and it has not been forthcoming. The RCN was discredited and has not properly responded to the criticism about its performance and structure, and UNISON does not have the numbers to be authoritative. We can't expect anything from the Chief Nurse or Directors of Nursing becasue they are enmeshed in the managerial/political web that was partly the cause of the mess.

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  • if it's fundamentally wrong, isn't likely to work, costs an awful lot of money to implement and reduces staff morale then I am sure it will be implemented.

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  • tinkerbell

    Robert Francis QC is not a fool, he didn't become a QC because he lacks observation skills, in fact he is much more qualified to comment than some of the old lags who haven't worked on the frontline for years, because he can see what a mess it all is but has to remain objective and his recommendations were entirley objective and based on his observations. He just made serious, sensible, recomendations, how they were interpreted or whether they are taken up or not is out of his control.

    He achieved his objective, job done. Sadly this government had no intention it appears of actually listening to or implementing his recommendations.

    Another whitewash.

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