Net worth

There is no evidence that the 80 NHS cadet schemes operating in England are succeeding in widening access to the professional healthcare workforce.

Ian Norman explains

Evaluation of NHS cadet schemes suggests that the chief aim of widening the pool of potential nurses and allied health professionals will be achieved only through a loose national framework.

In May 2002, the Department of Health commissioned a two-year independent evaluation of NHS cadet schemes. It hoped to inform national development of a programme designed to widen recruitment to nursing and the allied health professions, particularly from those without traditional education qualifications.

The crucial question is: are they effective in widening access to preregistration programmes in the health professions? The work also seeks to establish whether they equip students with the necessary balance of academic and clinical skills to enter pre-registration healthcare education and progress successfully into the workforce.

Finally, it assesses whether cadet schemes are cost effective compared with alternative paths into pre-registration training.

The first year of our evaluation was designed to provide a comprehensive picture of the range of the 80 cadet schemes operating in England and how they differ; provide an insight into the social composition of cadets; discover if the schemes are actually widening access; and to ascertain cadets' perceptions and experiences of existing schemes, including their job satisfaction and expressed commitment to their host trust and the wider NHS. The research was based primarily on surveys of cadet scheme leads at the workforce confederations, 63 scheme leaders and senior cadets.

Our findings suggest that structural variations between schemes, such as their length and entry requirements, are significant enough to have an impact on the main aims of the schemes. In terms of range, the majority prepared cadets for entry to nurse education, with only 12 offering courses that groomed candidates for entry to allied health professions education.

Crucially, while just over half of schemes run for the recommended two years, some are much shorter. This could mean that although they are 'badged' as NHS cadet schemes, they are in fact serving a different purpose, such as improving skills of the existing healthcare assistants rather than providing a new pathway to pre-registration training for those currently outside the healthcare professions.

Many schemes were also found to be inflexible - almost threequarters offered full-time employment only, four offered part-time only and just five offered a choice of full or parttime study. Only one scheme was available through distance learning.

Applications for most schemes are buoyant, which suggests they are meeting a demand for people wanting to enter the health and social care professions. But entry requirements vary widely.

Nineteen asked for one to four GCSE qualifications, but six required five GCSEs, which is the same entry level as most preregistration nursing programmes. Entry criteria for the remaining 26 that responded included age-related criteria, minimum scores on entry tests (including literacy and numeracy) and satisfactory performance at interview. Forty schemes (65 per cent) reported being open to disabled applicants.

Just over half offered cadets a guaranteed interview for a place on a pre-registration programme for nursing or allied health professions, though only 20 schemes (32 per cent) guaranteed successful cadets a place.

The important discovery is that after comparing profiles of cadets with students on pre-registration nursing programmes, no evidence has been found that cadet schemes are achieving their central goal of widening access to the professional healthcare workforce.

Cadets were very similar in terms of ethnic background to a sample of mental health nursing diploma students surveyed by nursing research unit at King's College London. The cadets were on average 20 years old, 83 per cent were single and the majority (90 per cent) were women.

Around 16 per cent had children.

Just over a quarter (26 per cent) had been employed before starting the scheme and just over half of those had worked in health or social care. Thirteen per cent described themselves as being from an ethnic minority community.

Although there are no national statistics on numbers of disabled nursing students, comparison with one large university revealed that it admitted eight times more nursing students with a disability compared to the average across cadet schemes.

On a more positive note, cadets on existing schemes report low levels of role stress and high job satisfaction. They have an extremely positive view of the quality of teaching and learning offered and feel well prepared for preregistration education in the health professions.

They also report reasonably high levels of commitment to working in the NHS and in their local trust. It remains to be seen whether cadets' levels of satisfaction and commitment is maintained among those who enter preregistration training (almost three-quarters planned to enter nursing), to promote their retention within the healthcare workforce.

Cadet schemes need to be flexible if they are to meet the needs of their local trust and attract local applicants.However, many of our respondents believed that schemes need to be much more consistent, based around a loose but accommodating national framework to inform their proper future expansion.

We found that a framework of this type would need to consider a number of requirements:

National entry qualifications set at a standard level, promoting widened access and ensuring the great majority can progress though the scheme and preregistration healthcare training.

Coherent links with other flexible training and wideningaccess initiatives.

Standard course length (two years or less) but with fast and slow tracks, and possibly a generic first year and professionspecific second year.

An increased proportion of part-time and flexible training modes, which should encourage a greater variety of applicants.

Targeting an increased proportion of schemes to attract applicants from ethnic minorities.

A standard theory-practice split that would be flexible to local demands, but would normally be 60 per cent practice and 40 per cent classroom based.

A set of quality standards assured by a suitable body (possibly the NHS University), which would permit transfer of cadets from one scheme to another.

Nationally recognised end and exit point qualifications that are competency based and linked with the 'skills escalator'.

Engagement of schemes with local universities to ensure progression opportunities for completing cadets into preregistration training programmes, including those for AHPs, which may often have higher entry qualifications than nursing programmes.

Much work is needed to develop a framework to guide the future development of the schemes and we invite stakeholders to begin work on this.Over the next year, of our evaluation we will be seeking good-practice examples to illustrate some of these requirements.

Professor Ian Norman is based at the School of Nursing and Midwifery, King's College London.

The project also involves the Royal College of Nursing Institute, the University of East Anglia, Luton University, and London School of Hygiene and Tropical Medicine.