The NHS's expanding workforce of healthcare assistants needs to be better valued and better regulated, says Janet Snell

When the government gave the go-ahead in 1990 for a new grade of staff that came to be known as healthcare assistants or support workers, there were predictions of an explosion in their numbers. It did not happen immediately, but there are signs that numbers are starting to grow rapidly.

Up to 80 per cent of trusts now employ HCAs, and they average 8 per cent of the workforce - though in some trusts that figure is as high as 25 per cent.1 According to latest figures from the Department of Health, in September 1996 there were 20,220 HCAs employed in the NHS - a 28 per cent increase on the previous year. But this figure is almost certainly an underestimate; the true number is probably more like 50,000.

Reliable data is hard to come by, partly because a large number of HCAs are on local contracts, and partly because of the variety of job titles for people working at this grade. More trusts use the term 'healthcare assistant' than 'support worker', while some have opted for titles such as 'healthcare support workers', 'hotel services assistant' and 'generic support worker'. Some units, such as Northern General Hospital, Sheffield, have staff attached to specific roles such as 'support workers to junior doctors', whose tasks may include recording ECGs, taking blood and siting intravenous cannulas.

The picture is further complicated because some trusts have transferred their nursing assistants and auxiliaries to the HCA grade.

Rates of pay vary considerably, and a survey by Incomes Data Services, published in February, found annual salaries as high as£11,440 at Lifecare trust in Surrey and as low as£6,737 for trainee HCAs at Wirral Hospital.

2Even lower rates were found by Carole Thornley, lecturer in industrial relations at Keele University, who was commissioned by Unison to survey all trusts employing HCAs.

3She received responses from 70 personnel managers and over 1,000 HCAs. Some HCAs were on starting salaries of£6,000, and her research revealed that a typical HCA is a female in her 30s or 40s, probably with domestic commitments, and usually with healthcare experience. About 30 per cent had acquired IHALASTN national vocational qualifications, and at 40 per cent of trusts training was not explicitly linked to NVQs.

The survey, published last year, found increasingly blurred boundaries between what HCAs and nursing staff were expected to do. HCAs reported that they engaged in a whole range of activities including administering drugs, venepuncture and restraining aggressive patients, and counselling. Some said they were left in charge of a shift. And more than half (53 per cent) reported that 'little' or 'none' of their work was supervised.

'I think the study opened the lid on the fact that many nursing assistants have been working above their grade for years, ' says Ms Thornley. Almost three-quarters of managers said they planned to expand the role of HCAs, and when asked to rank their reasons for introducing the grade, most referred to 'cost-effectiveness'.

A number of HCAs voiced concern about attitudes of other staff and said they were made to feel like second-class citizens.

One commented: 'I feel that sometimes we are ignored, taken for granted and used to do certain tasks when the time is convenient - in other words, when nobody else is available you can do it, but when others are around you are not good enough.'

Another said: 'I now find myself doing 90 per cent of the work of a registered general nurse in the theatre, but other staff look down on us.'

The extension of the role and the amount of direct patient contact has prompted calls for HCAs to be regulated. There have been suggestions that this could be tackled as part of the current review of legislation on nursing regulation. But the consultation document on nursing regulation rather sidesteps this issue and suggests leaving it to employers, as happens at the moment.

4Regulation might be by the nurses' governing body, the UK Central Council for Nursing, Midwifery and Health Visiting, or by a new social care council, or by the National Register for Carers (see box above), or another body altogether. The UKCC has expressed concern at the current situation and the lack of protection it provides for the public.

'There is confusion between who is registered and accountable for their practice and who is not. We do not feel it's in the interest of the public, ' says UKCC spokesman John Knape.

The Royal College of Nursing is also unhappy with the current situation, in which regulation is left to individual employers.

Pippa Gough, the RCN's assistant director of nursing policy, says: 'Employment practice in the NHS is not up to scratch. It is essential some form of statutory regulation is set up. People move from job to job and managers are not always good at taking up references.

'As things stand, if a nurse is removed from the register they could get a job as a healthcare assistant the next day and have access to the same group of patients. That can't be right.'

Unison national officer Paul Chapman agrees: 'The big problem with regulation is defining the population, as this group works across the boundaries of various disciplines. No one is responsible for HCAs nationally.

'What they do is what local trusts want them to do. Extending their role is not a problem providing the training criteria are met and those working with them are happy about what is happening.

'Job descriptions for HCAs in some trusts amount to a paragraph along the lines of 'the employee will do whatever we ask them to do'. Other contracts are pages long and detail everything from emptying vases of dead flowers to washing patients.'

Ann Eaton, the RCN's NVQ adviser, says this lack of definition causes problems for nurses. 'If a care assistant's responsibilities are properly defined in a job description, then that enables a registered nurse to be clear on what her role is.'

Ms Eaton believes the revised NVQ standards that come into effect from 1 May will give employers a chance to look more closely at who does what. 'It will enable managers to pick and mix the skills they want their care assistants to have.

Some are even suggesting it will enable them to have skill mix within the healthcare assistant role.'

But a survey of trusts by the Institute of Employment Studies found that the effect of changes in staff levels or staffing mix on nursing quality was rarely evaluated.

5The report called for more work using models applied in studies at York University in the early 1990s which suggested that qualified nursing care is more cost-effective than employing lower-grade staff.

But in the short term, rising nursing shortages mean managers face pressing decisions on how to staff the wards. Dr Thornley believes this must mean increasing reliance on healthcare assistants. But unless issues of pay and training are addressed, she foresees problems.

'I think managers would be unwise to assume this grade is always going to be there, prepared to work on poverty pay rates. I was quite taken aback by the strength of feeling among those I spoke to in my survey. I think most share a sense of outrage that women in their 40s and 50s with huge experience in the field of healthcare are earning less than an A-grade nursing assistant.

'These people are joining unions in increasing numbers and there is a likelihood of industrial unrest if they continue to be treated unfairly. They want to be viewed as part of the team and not just seen as cheap labour. It's time managers began to value them and started thinking about how to develop them.'

A day in the life

Sheryl Kendell works on the day surgery unit at St Mary's Hospital, Portsmouth. She is 34 and married with two children aged 14 and 16.

The working day starts at 8am, when Ms Kendell puts out the theatre instruments and other equipment needed for the day's operations. 'I've been trained by a qualified nurse to scrub up and lay out the instruments. I check the patients' details as they arrive for surgery and help move them on and off the table.

'During operations I help out fetching things. We swap around, so I'll go up on the ward and ask patients to get ready and then walk them down to the anaesthetic room. I put the ECG dots on and the blood pressure cuff, pulse oxymeter and squeeze their hand ready for cannulation. I stay with them while they are asleep. If there's any adverse reaction you're on hand to help.

'After the op I go to recovery and I and the qualified nurse bring the patient back on a trolley to the ward. Then I help transfer them to the bed and make sure they're comfortable. They wake up quite quickly and I take their blood pressure and pulse and compare it with the level on admission. Once when I was doing that, a patient had a vagal attack and stopped breathing. It was a bit frightening, but I called the qualified nurse.

There's always someone on hand and we're trained to look out for problems after surgery.

'I write up people's notes and I've learned how to take their Venflons out. I give out painkillers, but they're always checked by the staff nurse.

'When people are ready to go home I'll answer any questions and if I don't know something I'll go and find out. I escort people down in a wheelchair to the car. I've never been asked to do anything I've felt uncomfortable about doing, and you're told during training that if you have a problem you speak up.'

Sheryl left school at 16 without qualifications and took a job in a nursing home. 'Then I had kids and gave up work. I went back when my little girl was three and took a job as a cleaner in a factory as the hours suited.

'Then I worked evenings in the local Co-Op and that's when I decided that, if I was going to have some sort of nursing career, I needed qualifications. I took a job on nights in a nursing home so I could study when it was quiet and also be around during the day for my children.

'Over the next few years I did GCSEs in English, maths, sociology, human biology and law, and A-level psychology.

'I got the job here and I've done NVQ level 3 clinical and outpatient care and level 2 theatre care. I don't want to be a nurse any more as the pay is so bad for the level of responsibility. I want to train as an operating department practitioner. I love working in theatre - I just wish the pay was better. I'm on about£4 an hour. My neighbour is a cleaner in a supermarket - mopping up spilt pickle - and she earns more than I do.'

Checks and balances

Set up in Liverpool in 1989 by qualified nurse Susan Brooks, the National Register for Carers now has 32,000 registrations, and has refused 3,000 applicants. Junior health minister Paul Boateng and Department of Health officials have visited the initiative.

Ms Brooks points out that only 26 of those refused had a criminal record and that offences by people working as healthcare assistants often go unreported.

'We find when someone is caught stealing, or abusing a patient, employers are reluctant to prosecute because of the adverse media coverage and general hassle. So they give them a reference to go elsewhere, and it becomes someone else's problem. We carry out a huge range of checks to verify an applicant's identify and build up a profile of their character and work history. And in cases where we are doubtful we request a police check.

Once we are satisfied we issue one of our 'tamper-proof' ID cards, which took two years to develop.'

When staff at the register were checking out one applicant, who informed them he was having psychiatric treatment, they found a series of unexplained deaths in places where he had worked. 'These were patients in their 20s and 30s and the matter was placed in the hands of the police, ' says Ms Brooks. 'So far there is still insufficient evidence to prosecute, but when we contacted the applicant's GP he said under no circumstance should the man work with vulnerable people. But he has two friends who will give him good references and he's out there somewhere now, ' she warns.

Goodbye to all that

Sandra Potter, clinical manager for the day surgery unit, St Mary's Hospital, Portsmouth, is a former nursing auxiliary who trained as a nurse before securing her management job.

'I think healthcare assistants would make excellent future nursing recruits. They are more likely to stay and they have come to know what they want to do and they have a good idea what the job really involves.

'I'm very disappointed that now our nurse education is transferring to Southampton University they will no longer accept NVQ level 3 as a gateway to a Project 2000 course. It means we are losing the sort of people we were very keen to have.

'I'm never going to be able to employ the number of qualified staff I would like to have, and if I'm going to be using unqualified staff I want them to have the best training we can give them. If you delegate a task you want it carried out to the right standard.

'When I'm recruiting healthcare support workers I look for someone who has a bit of spark and who shows an interest.

'I'm aware that some units will hardly allow their support workers to do anything while we allow ours an extended role. I get very angry when I hear people taking about them as if they haven't a brain.

'In my experience, the fact that you have shown you value them and that you are going to provide the appropriate training and allow them to develop means they will take on that role with relish and take pride in what they do.

'Our healthcare support workers are a product of the trust that we've placed in them.'

Unfit to nurse but suitable to care?

There have been a number of high-profile cases in which struck-off qualified nurses have taken jobs as healthcare assistants. Yuen How Choy was removed from the register in 1984 following a conviction for rape. Despite the nature of his offence - he posed as a community psychiatric nurse to enter a woman's home and then forced her to have sex with him - he was later able to get a job as a care assistant. A decision by the UKCC to restore him to the register led to an outcry, and the High Court later reversed the decision. In another case, Ian Bury was removed by the UKCC conduct committee for verbal and physical abuse of elderly patients in a nursing home. After the hearing he returned to work in the same home as a care assistant.


1 Incomes Data Services. Report 751, 1997.

2 Incomes Data Services. Pay for Healthcare Assistants , report 754. Feb 1998.

3Thornley C. The Invisible Workers . Unison, 1997.

4 The Review of the Nurses Midwives and Health Visitors' Act 1979 . JM Consulting, 1998.

5 IES. Caring Costs Revisited . 1996.