Southampton University Hospitals trust this week offered a new pay deal to qualified healthcare assistants which would raise some salaries to £11,600 a year.

Those eligible for such a salary will have done up to two years' training, they will hold nationally recognised qualifications, and their role will encompass a great deal of work previously done by nurses.

It is a far cry from the early 1990s, when the government saw the creation of the HCA role as a way of smashing through national pay structures while, according to its critics, driving down wages and deskilling the work previously done by second and even first-level nurses. Southampton's HCAs are clearly by no means the shock troops of casual labour some feared.

Yet, as we report this week (see pages 24-27), it is also a far cry from what is happening in many other hospitals: one survey found salaries as low as£6,000 a year, with many HCAs lacking training or qualifications of any kind. In some cases, this means that staff with no formal accountability or regulation are carrying out clinical interventions of a relatively high order.

How many patients would willingly allow staff to administer their drugs or take blood if they knew that this was the case? For all the criticisms made of regulatory bodies such as the UK Central Council for Nursing, Midwifery and Health Visiting or the General Medical Council, it is their job to protect the public by holding incompetent nurses or doctors to account.

No one performs that role in relation to healthcare assistants; no one has responsibility for setting, raising or maintaining national standards. Beyond the sanction of ending their employment, HCAs are not accountable. That is neither desirable nor sustainable.

There is no easy way to address this. HCAs are a fragmented workforce. Any attempt at regulation will need to recognise that the level at which HCAs work varies enormously. Creating a new breed of rigidly defined professional would be as backward a step as resuming enrolled nurse training, and would prove immensely unattractive to employers.

But the NHS wants and needs staff with a sound knowledge to underpin what they do and a high level of skill as well as a degree of flexibility in their work. Patients, too, have a right to expect that of the people increasingly providing hands-on care in the health service.

They won't get it if HCAs are regarded largely as a ready source of easily dispensable cheap labour.