The end of the world as we know it (and I feel fine)

In the last two weeks, at two separate events, I was asked whether I think the growing attention being given to support workers creates a risk that a government seeking to keep a lid on public spending might be tempted to substitute registered staff for unregistered ones and/or dilute core registered staff skills. The short answer is an emphatic ‘no’. It is actually very hard to find any policy over the last 40-years where this aim was explicitly articulated. It was certainly a concern in nursing, post-Project 2000, when the Healthcare Assistant (HCAs) role was first introduced. Dire predictions that HCAs would mean the end of registered nursing as we know it did not, though, materialise. The same in maternity, where the development of Maternity Support Workers (MSWs) was first seen as a threat to midwives. Far from undermining midwifery, MSWs are now celebrated by the profession. Some argued against Nursing Associates (NAs), but as a registered role any growth in NAs strengthens the registered workforce rather than erodes it. The NHS Long Term Workforce Plan forecasts, in fact, a small fall in the proportion of unregistered staff compared to registered. This hardly points to wholesale substitution and cost cutting as my questioners implied.

I am not sure what the root cause of this, sadly enduring, ‘threat’ and ‘dilution’ narrative is. It does though seem odd that it only seems to focus on support staff. Throughout the history of the NHS tasks have shifted between roles including from doctors to nurses. That is likely to continue, particularly at higher levels of practice, as advance practice grows. Optimising the contribution of support staff is in fact necessary to create capacity for registered staff to develop their careers [1]. This is not about ‘dilution’ but rather about ensuring that the right staff, with the right skills and education perform appropriate tasks. In all the developments going on with the healthcare workforce it is hard to see any threat to registered staff (and would it not be nice if we just talked about the workforce as a single entity?)

For what it is worth I do not know whether the NHS has got the proportion of registered and unregistered clinical staff right. The proportion we currently have has emerged historically often as a consequence of political factors (funding concerns, professional body lobbying) rather than thoughtful workforce planning. I do know, though, that we cannot have a sensible discussion about skill mix until every support worker’s job description is up to date, mapped against a competency framework and they have access to occupationally relevant education [2].

History shows, in the NHS, recurring themes of not only neglect of support roles but also occasional periods of fear of them [3]. I think, though, most people have moved on from these concerns. I now spend the majority of my time working on demonstrating the return on investment of optimising the contribution of support staff. It is rare that I have to go back to basics and justify the role. That was not true twenty years ago (yes, I have been doing this for that long). Twice recently though I found myself defending support roles. In the past the REM song [4] I have used as the title for this piece would pop into my head every time this issue raised itself. I felt fine defending the support workforce then as I do now. I just hope there won't be any need to do so in the future.

Note

[1] There are two interesting, related additional arguments I occasionally hear. The first is – ‘all tasks are registered staff’s tasks including washing patients.’ The second is – ‘support workers are taking away the more interesting part of registered staff’s work’. There are answers to both and I will address them separately in future articles.

[2] More is needed to assure safety not just governance systems and processes but also acceptance of support staff in teams so that they have a voice that is listened too.

[3] The fact that both narratives exist at the same time is interesting. In the same week when I was first asked about dilution, I heard at another event about the great work Unison are doing getting band 2 HCAs upgraded because they are doing band 3 jobs.

[4] Whilst a great song, the lyrics are frankly nonsense. Back in the 1980s a respected commentor predicted that by now there would be more HCAs than registered nursing.