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Cavendish Review (Part 2): Are you there, Nurse?

July 28, 2013

What ever happened to Cath Jackson? Older readers might remember her wise and wonderful cartoons as one of the greatest glories of the Nursing Times of yesteryear. A personal favourite was entitled ‘Who will wipe the bottoms after Project 2000?’* In successive frames doctor, matron, sister, staff nurse and student all give reasons why it can’t be them. In the last frame, a dishevelled but determined figure, dwarfed by the tottering pile of bedpans in her hands, gamely tries to answer three call bells at once. The person who would wipe the bottoms after Project 2000 is thus unveiled as…’Thingy’. That was in the late 1980s. According to the Cavendish Review, not much has changed.
Half-way down the otherwise unremarkable page 66 lurks one of the Review‘s most revealing comments. Repeating words that will be wearily familiar to many, Camilla Cavendish, the Review‘s author, quotes a health educator who said “I often hear at the beginning of a shift: ‘Right, there are three of us…’ when in fact there are seven people standing there. It’s as if the four [Health Care Support Workers] didn’t exist – only the registered staff…get counted as ‘being there.’” (para 8.2.1).
It takes an outsider to point out the outrageousness of these words; on wards, they’re bandied about so often no one hears them any more. Ironically (and echoing earlier work by Professor Ian Kessler et al), Cavendish makes it clear that it is HCSWs – not nurses – who now perform most of the hands-on patient care and – arguably – also form the closest relationships with patients. In this context, the confirmation that HSCWs are often invisible even to their own colleagues is doubly shocking – not just because it devalues HSCWs as human beings (although that’s bad enough and would be totally unacceptable if directed at patients), but because it implies that the contribution they make – care – is similarly devalued even by those who are themselves professional carers. Luckily, the Daily Mail overlooked this gem when it reported on the Cavendish Review, possibly because it was too busy regaling us with the (dis)information that many HCSWs ‘can’t even read’.
The news that care goes unrecognised is hardly a novel insight. For many years, feminist commentators have described caring as ‘invisible’ because as a characteristically female activity, it cannot easily be fitted into male-dominated social discourse. For nursing, the result has been a well-documented struggle to resolve the tensions between its ‘behind-the-scenes’ origins and its more recent striving for top-billing professional status. Whether by design or not, nursing has increasingly resolved this dilemma by delegating more and more of the physical and even emotional care to HCSWs whilst retaining for itself the management, co-ordination and administrative tasks.
By rescuing them from anonymity and showcasing the complexity and skill of their work, Camilla Cavendish has done all HCSWs an enormous service. But she has – perhaps inadvertently – highlighted yet again just how uncomfortably caring work sits within the professional pantheon. Despite hearing that HCSWs so greatly value the opportunities they have to develop relationships with patients that ‘some told us that they no longer want to become nurses now they have seen how much time nurses are spending on paperwork’ (para 3.6.2), the Review still insists that the most obvious career pathway for HCSWs is nurse training.
A whole chapter (Chapter 7 – Making Caring a Career) is devoted to outlining a future route into nursing degrees for candidates with lesser academic qualifications but positive employment experiences in the care sector. That’s good news for those who want it and could benefit from it, but contrary to the chapter’s title, and taking into account the already-acknowledged division of labour between nurses and HCSWs, the message it sends out is the exact opposite: you can’t make caring a career.
To be fair to the Review, it does have a couple of other suggestions for capitalising on HCSW expertise. Firstly, it talks about using the proposed new nationwide ‘Certificate of Fundamental Care’ as a platform for studying towards a ‘Higher Certificate of Fundamental Care’ (para 6.18.2). The Review is vague about what the possession of this certificate would entitle the holder to do; the suggestion is that it could be based on various modules, each one applicable to different settings.
Secondly, the proposed new HCSW training regime incorporates a period of preceptorship. This, and the expectation that aspiring nursing students will have to work for a year as an HCSW before beginning their training, creates opportunities for appropriately trained HCSWs to take on the role of mentor alongside qualified staff. Given the the Francis Review identified the poisonous effects of poor ward culture as a major factor in the Mid-Staffs scandal, it is heartening that Cavendish is sufficiently impressed with HCSWs to suggest that ‘[senior practitioners] could take on a lead role as ‘formal coaches in the preceptorship year, which research demonstrates is a vital socialisation period for the values that nurses carry throughout their career’ (para 8.6.6).
But could HCSWs go further? Here we begin to run into a problem that this blog has highlighted many times before: any new HSCW knowledge-base will have to be carved out of a knowledge-base that is already occupied by nursing. The issue then becomes one of professional boundaries and how much nurses are prepared to cede to another occupational group. I don’t propose to revisit this subject here; instead, I want to draw attention to an unloved and neglected corner of health care that has been searching for a champion, at least inside hospitals, for the last thirty years or moret: health education. Could this be another opportunity for HCSWs?
Early last year the NHS Future Forum published a document called The NHS’s Role in the Public’s Health, which said (to summarise extremely) ‘every healthcare professional should “make every contact count”: use every contact with an individual to maintain or improve their mental and physical health and wellbeing where possible, whatever their speciality or the purpose of the contact’ (p6). We’ve already established that HCSWs are the group who have the greatest contact with patients and often form the closest relationships with them. Why not drill into their expertise to create an NHS-wide corps of health educators? If nurses wanted to take on this role, they would have done it by now. It’s up for grabs. Give it to the people who are best equipped to do it!
Because even if HCSWs are invisible to nurses, are not invisible to patients. Kessler et al quote a patient who said ‘…the [HCSWs]…they’re one of us. You know, they’re just a person like us…I mean they come along and they say,“You’re alright?” You know, you’re sitting there or, “Are you alright?” You know, “Do you need anything?… They’re one of you, you can talk to them’ (p118). Ladies and gentlemen, this is gold dust! Why aren’t we making more use of it?
The overwhelming impression one takes away from the Cavendish Review is that the HCSW workforce is a slumbering giant, a huge untapped resource just waiting to invited to show the rest of the world what it can do. The least we can do is start talking about them as if they are paid-up members of the human race. In this, as in so many things, it’s the patients who seem to be showing the way.

*Project 2000, for anyone who doesn’t know, was a late-twentieth century ‘revolution’ in nurse education whereby all students became supernumerary.

For The Cavendish Review, see

For Professor Ian Kessler’s work, see

For The NHS’s Role in the Public’s Health, see

For the Daily Mail‘s view of the Cavendish Report, see (if you must)

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