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Should health care assistants be less regulated than vets?

Roger Kline, 20 August 2013

Health care assistants (HCAs) now do the majority of direct care for the elderly in hospitals, care homes and at home. Yet they are less well regulated than the vets who look after their cats.

Robert Francis recommended (209 to 212 of his Mid Staffs report) that HCAs providing personal care in any healthcare setting should be registered, but the government rejected that idea (as had the previous government, despite having promised it).

Instead the government asked Camilla Cavendish to conduct a review into the other Francis recommendations about HCAs, that there should be a national code of conduct and national standards of training.

In healthcare, Cavendish estimates there are 332,000 HCAs of whom 270,000 provide support for doctors and nurses, and it is these I want to consider here.

The HCA role is not new. Many frontline HCAs undertake work similar to that previously undertaken by state enrolled nurses. Across the entire healthcare system role boundaries change over time as healthcare and technology change. The involvement of HCAs in direct bedside care means that they spend more time with patients than registered nurses do.

Done conscientiously, even basic care such as feeding and bathing require skill, care and considerable humanity. In nursing, Cavendish reports that HCAs on wards do far more than that, and that they undertake female catheterisation, cannulation (the insertion of an IV drip or tracheotomy tube), application of complex dressings, monitoring of diagnostic machines, setting up infusion feeds, giving injections, preparing medication and administering it to patients, making ECG tracings, taking blood samples, liaising with medical staff, relating medical information to relatives, and developing and updating care plans.

As the funding pressures on NHS providers increase alongside rising demand, there is a limited number of ways in which employers can cut costs. They can cut real staff pay. They can make staff do more. They can get staff to work more productively. Or they can cut unit labour costs by skill mix, delegating work from more highly paid staff to less well paid staff.

There is nothing wrong with changing skill mix if it is driven by what is best for patients and if those to whom the work is delegated are competent to undertake the new tasks effectively, and are properly supervised and supported using the framework for delegation set out by the Nursing and Midwifery Council. Done properly it can also be way of developing staff who have less formal qualifications.

Yet that will not be the main driver of skill mix in coming years. The majority of HCAs are paid less than £17,425 pa (£335 per week) before tax with just 4% earning up to £22,016 for work often indistinguishable from that undertaken by registered staff in the very recent past (or even now). Since Band 5 nurses earn £27,625 and Band 6 nurses £34,189, the temptation to delegate for the wrong reasons is strong.

Both Francis and Cavendish highlight the shortcomings in current practice. Cavendish makes three recommendations for HCAs which are welcome. She calls for:

  • a “Certificate of Fundamental Care” and a “‘Higher Certificate of Fundamental Care” to systematise training and standards;
  • the training and development of HCAs to be part of the whole healthcare team as it is already in some trusts; and
  • strengthening of the Skills for Health and Skills for Care codes of conduct for support workers.

Elaborating on the latter point, she recommends the strengthened code should:

  • include a right to refuse to do things for which a worker has not been trained or does not know how to do safely;
  • include a right to mandatory training paid for by the employer; and
  • correspond, for NHS employees, with the values and pledges set out simply and intelligibly in the NHS Constitution.

These steps are an improvement on what we have now, but fall well short of the support and protection needed for patients and staff.

Within her terms of reference Cavendish did a reasonable job. But the tidal wave of cost pressures on the NHS will inevitably mean immense pressures to substitute cheaper for more expensive staff across professions.

Ministers are adamant that regulation of HCAs is not needed to help prevent the predictable adverse consequences for both patients and staff. Opposition to further regulation – of HCAs or senior managers – has become a matter of principle in Downing Street.

But they have failed to demonstrate that their alternative – in part set out by Cavendish – will safeguard patients.

Meanwhile, the vet who looks after patients’ cats continues to be regulated.

  • The issue of delegation in healthcare is one of the many issues addressed in Public World’s Duty of Care handbook.
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