There is an unhelpful battle raging in the NHS that is pitting the support workforce against the trained workforce – particularly in nursing.
There is vocal opposition from some in the nursing profession to growth in the support workforce, including the new nursing associate role.
Appropriate concerns are being raised about the risks to quality and outcomes if we dilute skilled nursing cover on hospital wards, as the evidence grows about the links between levels of qualified nurse staffing levels and outcomes. The point is also well made that apparently routine tasks when undertaken by skilled staff can become valuable diagnostic or therapeutic work.
But my guess is that the elephant in the room is money. A support worker is paid considerably less than a qualified member of staff, and the nursing profession’s fear is that, without challenge, we will see a progressive dilution of skill mix to bridge growing budgetary gaps. It is a fear that is well grounded. Staff have reported to me that dilution of skill mix is not infrequently a part of a trust's savings programme, and also features in a number of STP plans.
The challenge of nursing shortages
But as well as budgetary gaps, there are quality gaps and there are workforce gaps. At the last count there were over 40,000 nursing vacancies in England and more nurses are leaving the nursing register than joining it. The previous buoyant supply of EU nurses is now a trickle and many current NHS staff from the EU are leaving to return home. The promised growth in nursing numbers as restrictions to university training places were removed, along with the supporting bursaries, seems wishful thinking in the light of the latest UCAS data.
The nursing shortages won't be addressed quickly, and as a GP from Health Education England reflected on the challenges he faced recruiting GPs: "Unless I am going to deliver care from an empty chair, I've got to deliver care from a chair with somebody different in it.”
But the bigger issue for me is one of quality, of delivering care that is truly patient centred. While, as I argue above, quality is linked to the numbers of professional staff, support staff can also deliver high-quality, patient-focused care.
Working together well
At a recent round table organised by Macmillan, we heard about a care coordinator role developed to support the head and neck cancer pathway in the north east. One of the best ways to describe the role is that it "reaches the parts that other roles don't".
It supports and is accountable to clinical nurse specialists and includes a mix of administration and some clinical work. Induction included following the patient's pathway and attending clinics to get a deeper understanding of the experience of head and neck cancer patients.
Having streamlined documentation and processes, the post-holder went on to be trained, including in motivational interviewing, so that they could support the clinical nurse specialists with post-treatment needs assessments and helping patients to self-care. The care coordinator also ensures all elements of a patient's care is coordinated – chasing up test results and arranging outpatient appointments.
The role has been hugely rewarding for the post-holder – "the satisfaction and sense of achievement I get when I have helped a head and neck cancer patient in their recovery is immeasurable" – and a great success with patients.
Perhaps most telling of all, the clinical nurse specialists who were originally resistant to employing non-clinical staff now say they think the band 4 has been more helpful to them than a qualified nurse.
When we think about skill mix it is not helpful to think about either/or, it is both/and. This example shows that a highly skilled senior nurse alongside someone skilled but not professionally qualified can be a powerful combination.
Imison, C. (2017) "The professional and support workforce: one needs the other" Nuffield Trust comment www.nuffieldtrust.org.uk/news-item/the-professional-and-support-workforce-one-needs-the-other