A happy ending?

There is a story that can be told about the healthcare clinical support workforce, one that predates the creation of the NHS. It is one of a workforce that has constantly faced constraints to its full development. These constraints have endured over time, place and occupation and include poorly defined scope of practice, lack of access to occupationally relevant education and truncated career pathways. Talking about maternity support workers (MSWs) back in 2007, for example, Sandall and colleagues noted that the role had the potential to enhance the quality of maternity care but was being held back due to lack of clarity about appropriate education and, consequently, role design. In 2018 I found those issues, along with a load of others, stills characterised the MSW workforce when I researched the role. Other recent research has found with almost boring repetition the same story amongst AHPs, nursing HCAs and others. From support staff working in orthoptic services to those in cancer services or working in mental health, the story is depressingly familiar.

These constraints have had negative consequences for support staff, who feel undervalued by the NHS and also frustrated that they are unable to develop their careers, busy registered staff who can be reluctant to delegate tasks, organisations who experience poorer outcomes than they need too (such as high turnover) and patients who do not fully benefit from the contribution support staff can make despite them often being, as my colleague Professor Ian Kessler described over a decade ago, the key ‘bedside presence’.?

The narrative is shifting though. The story may be heading to a happy ending. There are a growing number of resources being development to address the constraints. These include profession-specific competency and role and responsibility guidance and a growing number of apprenticeship standards. Career portfolios are being produced, alongside career development advice and assistance. New career opportunities are developing, not least the creation of ‘Band 5’ support roles which frequently support practice education.?

The last few years have also seen leaders nationally and locally advocate for support roles in a way I have not seen before. I would go as far as to say that the pivot we have seen owes as much to these leaders, including those working in professional bodies and trade unions, and their promotion of support roles and the development of the resources and interventions needed.?

Back in 2010 I wrote, with colleagues, an article in the British Journal of Midwifery about the possible evolution of the MSW role. We argued the role could go through four distinct stages (the first two of which had probably happened by then):

·??????An Initial stage where social, service, workforce and other enablers or pressures create the rationale for the role which is picked up by a handful of innovators and pathfinders.

·??????A Development stage during which the experiences of those early adopters along with emerging research builds a wider case for the role but also identifies barriers and issues. Some resistance to the role remains.

·??????A Consolidation stage during which hearts and minds are won over and the role is accepted, although all the issues it faces have not been fully addressed. For MSWs this came, I think, shortly after we published when they were allowed to join the Royal College of Midwives, and a little later we saw dedicated events celebrating the role.

·??????Finally, there is an Establishment stage where the role has been deployed in a consistent and coherent way and has access to all the resources needed to flourish.

Movement from one stage to the next is not guaranteed but I think it is fair to say, and not just for MSWs but support workers more generally, that the NHS is now firmly in the Consolidation stage. Are we, though, moving to Establishment? I hope so. The signs are good. Most of the resources, as I have said, are there for most occupations. Three things are now needed:

1.?????Change needs to take place locally. Real change, as Myron Rogers observes, happens where real work does and needs to be owned by those affected. National resources need to be used locally and across the whole NHS.?

2.?????Change cannot be piecemeal. A pick ‘n’ mix approach will not deliver the goods. A holistic approach is needed one that considers tasks, scope of practice along with competences. Appraisals need to be effective and education available including CPD available. Good working conditions need to be delivered. Career pathways designed and so on.?

3.?????Resources should be provided to support the above. The good news is that not much resource is needed and the return on investment will be substantial.

I am writing this on the eve of the publication of the long-awaited NHS Workforce Plan. The Plan is an opportunity to address once and for all the constraints support workers have faced. If it does everyone, most importantly patients will benefit. Let’s hope the story has a happy ending.