The phasing out of state enrolled nurses that began in the 1980s should have given a boost to the professionalism of state registered nurses. But into the space they occupied have come hundreds of thousands of healthcare assistants not subject to any regulation…
When receiving health care at home or in hospital there is every chance that you will have a healthcare assistant to provide the hands-on care – one of the estimated 700,000 who are now employed by the NHS and the private sector.
The number of workers in these roles has more than doubled since 1997, with the majority working as part of what the government now describes as “the nursing workforce”, but others acting as assistants to physiotherapists, occupational therapists and other professionals. Their actual title might be healthcare support worker but they could also be called healthcare assistant, nursing assistant, care assistant etc. The focus of this article will be those workers who provide direct clinical care in hospital or community settings.
Historically Britain had two levels of nurse: state registered nurse (SRN) who did three-year training; state enrolled nurse (SEN) who did two-year training; another smaller group of staff known as nursing auxiliaries. In the 1980s the SEN role was phased out with many converting to SRN status but others leaving the profession altogether. Re-maining as an SEN was deemed to be restrictive to the individual’s career development, as they were not allowed to progress to Ward Sister or Charge Nurse.
No national standards
But into the “space” left by the SEN role we now have a large workforce of support workers who, unlike the SEN, have no agreed national standards of training, and are not regulated by a professional body.
Just like the SEN their career progression is limited, and while some of them may be undertaking roles which directly correspond to the former SEN role their pay may be considerably less. When the health trade unions negotiated the new pay framework known as Agenda for Change it was accompanied by a Knowledge and Skills Framework for the whole NHS, which clearly outlined how staff knowledge and skills should be reflected in their pay band.
But many employers chance their arm by placing the support workers on the lowest pay band and whether they move up the banding tends to reflect local union organisation rather than their skill level.
Many registered nurses have “kept their distance” from this process. Many expressed concern about the rapid expansion in health care assistant roles but did not act on this concern.
Some registered nurses pointed out that they were now doing roles previously done by doctors and realised that they could not do it all. Some registered nurses fondly thought that there would be legal constraints on the endless expansion of the healthcare assistant role.
Now that registered nurses have finally asked the question about how far this process can extend, they have realised that in law there are only three things a healthcare assistant cannot do: deliver a baby, prescribe medicines and certify a death.
Waking up
Registered nurses finally woke up to the fact that the legal onus is not on the employer; rather it is on themselves to delegate to the healthcare assistant only those aspects of the work that the registered practitioner deems to be within the competence of the assistant. If the registered nurse delegates inappro-priately their registration may be on the line. Paradoxically this situation that frightens many nurses is also the key to taking charge of the situation.
All the time employers are seeking to evolve the job descriptions of the healthcare assistants and to reduce the ratio of qualified to unqualified staff, but the registered practitioners have to assert their right to delegate safely. From that requirement to delegate safely, many things can follow. Registered practitioners can use this as a lever to demand the appropriate training and regulation of support staff.
In addition, the key to safe delegation must rest on the registered nurse’s ability to supervise the assistant. If the ratio of registered nurses to support workers is too low then clearly the registered nurse cannot delegate safely. The argument of the registered nurse with the employer must centre on the fundamental legal requirement for the employer to provide safe conditions of work.
For some reason registered nurses seem to shy away from talking about staffing ratios with the people who will really benefit – namely the patients. Maybe they are worried about frightening them.
But the consequence of not talking about the issue is pretty frightening too. It is clear that many aspects of care can be delegated to an assistant but the crucial question of how much can be delegated safely has been carefully researched in the United States.
The practice of charging patients more depending on the type of staff who deliver care has the useful incidental by-product of providing researchers with clear data to examine the link between patient outcomes and staffing levels. A major study published in the New England Journal of Medicine by Jan Needleman et al in 2002 reported on data gleaned from nearly 6 million patients who were in-patients in 799 hospitals across 11 states.
Health outcomes
This study showed conclusively that those patients who had a higher proportion of their care delivered by a registered nurse had shorter hospital stays and fewer urinary tract infections and respiratory infections.
Many members of the public would also be shocked to know that the 700,000 healthcare support workers are not subject to any national regulation. Of course, like other public servants they are vetted by the criminal records bureau, but it is perfectly possible for those who are unfit to practise (but who do not have a criminal record) to be dismissed from one post and then apply for another. They cannot be “struck off” as they are not registered.
Back in 2004 a Department of Health consultation into Health Care Assistant regulation recommended that they be registered with the Healthcare Professions Council (HPC), the body that currently regulates pharmacists and many therapists. Despite the personal cost implications of paying a regulation fee, repeated surveys of healthcare support workers themselves have shown the vast majority of them wish to be regulated.
Despite the 2004 consultation no progress has been made on the issue.
Costs
A recent pilot in Scotland has concluded that statutory regulation would be too costly to implement and maintain. The Scottish pilot recommended something called “employer led regulation” which seemed to entail even more responsibilities for the registered practitioners in monitoring and supervising the assistants.
Registered practitioners who participated in the Scottish pilot described the impact on themselves as “burdensome” and “resource intensive”. Unless they take charge of this situation they could find themselves in the bizarre position of not having any time to nurse because they would be so tied up in the supervision of their assistants – a sort of nursing by one degree removed. It is also unclear how an employer-led scheme would offer the public protection of a statutory register.
As Workers goes to press we await the English Department of Health’s response to the Scottish pilot. We also await a general election in 2010. It now seems unlikely that any regulatory framework will be in place before a general election. The health professions and the public should keep to the demand for statutory regulation before and after any general election.