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HCSW Regulation: an unsuitable aspiration for a bunch of middle-aged women?

April 2, 2013

Did anybody like the government’s proposal (in Patients First and Foremost: The Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry) that would-be nurses should spend ‘up to a year’ in a Health Care Support Worker (HCSW) role as a prerequisite to starting their degrees? Patients’ groups were underwhelmed: interviewed by Martha Kearney on BBC Radio 4 on 26th March, Julie Bailey of Cure the NHS said she thought the changes would ‘achieve very little’. Academics were unimpressed: speaking on the same programme, Dr Jan Quallington, Head of the Institute of Health and Society at Worcester University, called them ‘a knee-jerk reaction’ and observed that ‘if you put a whole host of untrained people into the wards, you run the risk of adding to the burden, not solving it’. Student nurses themselves were predictably indignant. Only the Daily Mail seemed exultant: ‘Nurses told: You’re not too posh to wash a patient’ crowed its front page on the day the plans were unveiled.

Amidst all this hand-wringing (or jubilation – take your pick), the views of one group were completely absent. What did Health Care Support Workers make of the news that in the not-too-distant future, their job may be seen not so much as a career in itself, but as merely a stepping stone to full-scale nurse training? No one thought to ask. It’s an omission that speaks volumes about the public perception of this poorly-researched and much-misunderstood section of the workforce.

Challenge any random passer-by to describe a typical HCSW, and (assuming they come up with anything at all) they will probably talk about a middle-aged woman, possibly born outside the UK, not educated beyond school-leaving age, whose main interests outside work are family life and home-making. In the eyes of the media, these attributes together apparently add up to a person who is unlikely to have anything very worthwhile to contribute even to a debate about the nature of their own work. And yet these are the same people who provide the bulk of hands-on care to patients, not just in hospital but also in the home and in social care settings. The fact that they have been totally excluded from recent debate goes to the heart of society’s two-faced attitude to care work: we say we value it, but how can we when we don’t even want to listen to the individuals who do it for a living?

The government’s initial response to the Francis report did nothing to alleviate this situation. On the contrary, it hit HCSWs with a double whammy. The first blow was that Patients First and Foremost came out against mandatory regulation. The official reason for this was that ‘Robert Francis’ report demonstrates that regulation does not prevent poor care…putting people on a centrally held register does not guarantee public protection‘ (Patients First and Foremost, para 5.22). David Cameron also went on record as saying that HCSW regulation would be a ‘bureaucratic nightmare.

All this is no doubt true, but it also raises a question: why, if regulation achieves so little, do we bother with it for anyone? Why is it thought necessary, as pointed out by Robert Francis himself, for ‘[c]ertain categories of security guards, nightclub security staff and key holders’ (Francis Report, 2013, para 23.132) to be licensed by the relevant authority, but not HCSWs? One answer is that as well as (theoretically) acting as a safeguard for the public, regulation bestows a professional identity and the basis for a professional knowledge-base and a professional voice. In denying this chance for HCSWs to start building themselves a publicly-acknowledged credibility, are we to understand that the government believes the that stereotypical HCSW demographic a bunch of middle-aged women wouldn’t be interested in it?

Hard on the heels of the revelation that there was to be no compulsory regulation of HCSWs came the news that the profile of the job might be about to undergo a minor revolution: in order to promote frontline caring experience and values’ and ‘provide helpful experience for managing healthcare assistants(Patients First and Foremost, para 5.14), student nurses will be expected to spend an extended period working as HCSWs before commencing their training. What? Essentially, this is a very grandiose solution to a complete non-problem: the overwhelming majority of nursing students already have experience of working as HCSWs, if not before their training then certainly during it. It’s an obvious way of earning extra income to supplement your bursary.

You also have to wonder how, if the problem (as has been repeatedly stated by both the Francis Report and Patients First and Foremost) is NHS culture, a deeper immersion in that culture (earlier, for longer) is going to produce a solution. And of course you have to roll your eyes in despair at the sight of nursing, yet again, rushing (or being pushed) headlong in a direction which has no solid research evidence to recommend it. Do people who have prior experience of working as HCSWs really make more compassionate nurses once they have qualified? Nobody knows. In the end, it’s hard to escape the suspicion that the main thing this idea had in its favour was cheapness. To quote Patients First and Foremost (para 5.14), it should be neutral in terms of costs. So it’s nothing more than a simple way for the government to look as if it’s doing something to address public concerns about nursing without actually spending any money.

The question that no one seems to have asked is – what will be the impact of all this on people who already work as HCSWs and have no thoughts of training to be nurses? The message Patients First and Foremost sends out to them is twofold. Firstly, society does not place sufficient value on you to justify spending money on extending to you the benefits that professional regulation would bring; and secondly, yours is not a real career. If the pilot studies are successful and the scheme to force student nurses to complete a preparatory year as HCSWs is rolled out nationwide, your job will eventually become little more than a staging post for individuals perusing the real career that is nursing. And if this is what we as a society are saying to the people who care for a living, then, by extension, this is what we are saying about care itself.

By emphasising the hierarchical and progressive nature of nursing tasks (HCSWs do the care, nurses do the supervision; the higher up the tree you get, the further away from patients you get), Patients First and Foremost re-enforces the split between the nursing and HCSW roles. Unfortunately, it does nothing to empower the latter; you could even say it weakens their position. Proponents of the plans will argue that they open the door to a national Code of Conduct for HCSWs and a mandatory national training programme – but these are nothing more than the standard employment contracts and training that good employers should be providing anyway. Safeguards will also need to be put in place to ensure that applicants in their forties and fifties who want to make a contribution through paid caring work are not discriminated against in the recruitment process just because they do not wish to undertake full nurse training at a later date.

We keep hearing that the the biggest barrier to the delivery of compassionate care in the NHS is the faulty culture. But at the same time, we appear to be promoting and sustaining a culture that ignores and devalues not just care, not just those who deliver care, but that whole section of society from which many of those who deliver care are drawn – older women. Are these really the lessons that we want the nurses of the future to absorb?

Camilla Cavendish, commissioned by the government to conduct an investigation into Health Care Support Workers, is due to report back in May.

Department of Health (2013): Patients First and Foremost: The Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London; The Stationary Office.

Francis, R (2013): Report of the Mid Staffordshire Foundation Trust Public Enquiry; London; The Stationary Office.

  1. I’m not sure I agree with much you’re saying here. I think the fact that HCSWs do the job that nurses used to do, and an understanding of these duties and responsibilities is required to supervise them, makes the suggestion sensible (not sure if a year in advance is necessary). I also think that doctors should have a mandatory period doing HCSW functions. It’s about care of patients and each needs to properly understand the other roles, especially when in a supervisory capacity.

    I also find nothing wrong with someone choosing to be a HCSW for life and moving up the gradings within that through training and study if they wish; or choosing a clear career path to nursing from HCSW, and being able to move from nursing to medicine if they wish. I have no sense that these careers need to be intellectually and financially separated, and I don’t see how making links between the professions would devalue older women.

    • Thank you for your comments. I’m glad to have promoted debate. My starting point here was that although two of the main elements of the gvt’s response to the Francis Report had a direct bearing on HCSWs, no one in the media thought to seek out the views of HCSWs on what the prosposed changes would mean for them. I wondered if this omission had something to do with the fact that the public profile of this occupational group corresponds to a demographic that society as a whole tends to overlook. In the aftermath of the Francis Report, there has been much breast-beating about the high value we place on care and compassion, but this is somewhat undermined by our tendency to denigrate and ignore the social group who are most closely associated with caring activities – middle aged women. If nursing wants to achieve a full understanding of its professional identity, it needs to undertake a much greater intellectual engagement with exactly this type of question.

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