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The Cavendish Review (Pt 1): Time for a Reality Check RE-WRITTEN!

July 14, 2013

This week hundreds of thousands of people, the overwhelming majority of them women, went to work with an extra spring in their step. Camilla Cavendish’s government-commissioned review of Health Care Support Workers (HCSWs) was finally published and – despite all the eyebrow-raising about how much a posh Times columnist could really relate to an occupational group traditionally dominated by individuals with little formal post-sixteen education – the sympathy and admiration Cavendish feels for her subjects shines through every line. In this landmark submission, there is much for unregistered staff to feel cheerful about.
Cavendish’s achievement is one that will be music to the ears of many HCSWs: the public acknowledgement of the huge contribution they make. Drawing on earlier work by Professor Ian Kessler et al, Cavendish is clear: it is HCSWs – not nurses – ‘who now give the bulk of hands-on care in hospitals, nursing homes, care homes, and in the houses of individuals who need help to live independently’ (para 3.1.1). Additionally, and possibly as a result of carrying out most of the physical care, HSCWs are often the ones who form the most helpful and meaningful relationships with patients – something patients themselves are eager to recognise.
The underlying reason why the Cavendish Review was needed in the first place is that professional regulation and boundary-setting in health and social care have not kept pace with the ever-expanding range and complexity of care-delivery. The speed of change is captured in paragraph 3.8.6 when Cavendish says  ‘A 2005 Royal College of Nursing (RCN) study of 700 nurses found that 60% of nurses were the first to have taken blood from a patient or carried out cannulation. By 2012, only seven years later, nurses were sometimes delegating those tasks to [HCSWs]’. The result, as the report correctly identifies, is a blurring of roles and confusion over what can safely be delegated and to whom. A safety incident waiting to happen, in other words.

According to many commentators, the solution to this problem is crystal clear: HSCW regulation. The specific exclusion from Cavendish’s remit of an examination of the desirability, or otherwise, of formal regulation for HCSWs attracted predictably hostile comment, much of it from the RCN. As the Cavendish Review was released, Dr Peter Carter was again touring the studios with the usual message. Time for a reality check.
The case for HSCW regulation is that it would protect the public by ensuring consistent standards and enabling the removal from the register of unsuitable practitioners. These are reasons enough to press for it to become a reality. So from the moral standpoint, it’s unanswerable and the RCN is totally justified (in ‘The Weaknesses of Voluntary Regulation for Health Care Support Workers‘, its position statement on the subject) in flagging up as absurdity the fact that ‘[unregulated] HCSWs are being asked to undertake tasks previously carried out by registered nurses who are subject to statutory regulations’. The trouble is that when the government rejects regulation on the grounds that it would be a ‘bureaucratic nightmare’, it really is more than just a lame excuse.

Firstly, there’s the issue of who exactly would need to be registered. An unexpected revelation from the Cavendish Review is that the NHS  doesn’t know how many HCSWs it employs; additionally, the review identified over sixty different job titles (para 3.2.2 and 3.3.3); secondly, the low status of many of these jobs, especially in the private care sector, means that people tend to drift in and out of them and don’t see them as a ‘for life’ career –  making it difficult to keep track of individuals and – if a register were implemented – probably creating the conditions for a regulation-related scandal in the future. It’s also unclear who would maintain any register. The NMC? It has enough problems already and the RCN would probably object to the association of HCSWs with ‘nursing’. The Health and Care Professionals Council? A new body? But how would overlap and movement between jobs (e.g. from HCSW to nurse or social worker) be dealt with?  With its clash of moral imperative and bureaucratic challenge, this is a question that might more properly be addressed to the philosophers than the nurses!

But the problems go even deeper. It’s an irony of the Cavendish Review that although submissions made to it ‘suggest that there is enormous variation in what [HCSWs] are doing at different pay bands in different Trusts’ (para 3.7.2), the likelihood is that in general, HCSWs have a much better conceptualisation of their job than  many RNs do of theirs. HCSWs do hands-on care. HCSWs talk to people. Driven in part by what Cavendish calls an ‘audit- and targets-based performance culture, coupled with the drive to discharge patients as quickly as possible’ (para 3.8.7), many qualified staff who thought they were entering a caring profession now spend their days mired in admin. HCSW regulation, with its  implication of independence of decision-making and action, could well accelerate this trend. Is this really what the RCN wants? OK – procedures like catheterisation and venepuncture would be retained within the ‘regulated’ fold, but if they were no longer the preserve of nurses, wouldn’t this be something of a pyrrhic victory?

Because in some ways, it’s difficult to avoid the suspicion that the real reason behind the RCN’s obsession with HCSW regulation is professional insecurity born out of fear that the professional status of nursing is being eroded. In other words, it’s  as much about protecting the RCN as it is about protecting the public. If the College wants to make a more constructive contribution, maybe it’s time to move on from couching the debate solely within the narrow terms of HCSW regulation. The continuing refusal to be honest about the problems inherent in regulation – it would be a journey to an unknown destination which might have profound consequences for registered practitioners – or to work with what we already have, causes unnecessary anxiety to trained nurses. In particular, by failing to separate ‘regulation’ from the word registered practitioners dread above all others – ‘accountability’ –  the RCN risks perpetuating many damaging myths. In this sweltering season, the Cavendish Review is a breath of fresh air. Maybe it’s time for others to open a few windows too.

Camilla Cavendish was banned from talking about HSCW regulation. The RCN will only talk about it in the most black-and-white language. So it looks like it’s down to GA to bring something more nuanced to the table. Here goes:

1. Employers should do more to publicise the HCSW voluntary code of practice, encourage staff to sign up and keep records. For large publicly-funded employers like the NHS and Social Services Departments, this is a no-brainer.

2. We should follow Camilla Cavendish’s lead in looking at ways creating a career pathway in caring. People who stayed in the job for longer would be easier to track.

3.  The advent of the new ‘Assistant Practitioner’ grade of staff and the Certificate of Fundamental Care (if accepted by government) could provide a starting place for some kind of register.

4. Employers should hold training sessions and workshops for ALL grades of staff on changes to HSCW training. The last thing we need is for new ideas to be held back by the same old misconceptions and prejudices. ‘Accountability’ issues should also be addressed separately from regulation – there are far too many myths.

The government will respond to the Cavendish Review in the autumn. Grumbling Appendix will look in more detail at what the review DID say (rather than what it didn’t!) in a future post.

To download the Cavendish Review, go to

For Professor Ian Kessler’s work see

For the RCN’s position statement on HCSW registration, see

For The HCSW voluntary Code of Conduct and National Minimum Training Standards, see

For an outrageous distortion of the Cavendish Review, see
Here’s a taster:
What Camilla Cavendish actually said: According to research undertaken at the Universities of Oxford and York into the NHS, around two thirds of acute trusts are now using numeracy and literacy tests to screen Band 2 candidates across most of their organisations. But a third do not. (Para 6.3.2).
What the Daily Mail told its readers: They [HCSWs] provide fundamental care, but many cannot even read.

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