Time to change the narrative
Professor Richard Griffin MBE
Workforce, skills, productivity, employment and management
There is a common story told about the expansion of the NHS support workforce. Here is a recent example from a 2021 article by Shore and colleagues, published in the International Journal of Nursing Studies –?
“Healthcare workforces are currently facing multiple challenges, including aging populations; increasing prevalence of long-term conditions; and shortfall of registered nurses. Employing non- registered support workers is common across many countries to expand service capacity of nursing teams”.
The equation –?
Rising demand for healthcare + Shortage of registered staff = More and/or expanded roles for support staff
has been the prevalent narrative for over three decades. It has always troubled me, partly as I am not sure it is right but also because it negates the value of support workers. It says, essentially, ‘we are in a mess because we need to deal with a bigger, ageing and sicker population, but we don’t have enough nurses, midwives or AHPs so we better get some support workers”. Surely, though, the narrative should be – ‘we have a workforce that is able to provide different types of care. Some are support workers, some of registered staff. We will ensure patients get care from the right people and that includes, where appropriate, support staff’. Consider support staff performing medication administration, the subject of Shore’s article. This responsibility should not be delegated because there are no registered staff available but because it is the right thing to do (with the right training and support). As an aside, Shore and colleagues’ literature review found “many benefits were reported as an outcome of delegation, including service efficiency and improved patient care” suggesting, in this case, this is the right thing to do.
Behind the prevailing narrative of demand and shortage is a long history of theorising the development of support workers as being driven by either the professions or a managerial agenda. See, for example, Saks’ (editor) 2020 collection Support Workers and the Health Professions in International Perspective (Bristol University Press) for a recent example. In this volume Susan Nancarrow writing from the perspective of the Allied Health Professions describes the professions driven model as follows-
“The early introduction of discipline specific allied health support workers was primarily promoted to increase the capacity of already stretched allied health professions and to allow existing practitioners to focus on more highly skilled areas of practice, while delegating unwanted or more routine tasks.”
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Under this model support roles are encouraged in order to not only define professional boundaries but also to consolidate them through the shedding of certain “unwanted or more routine tasks”, - often described as ‘dirty work’. In contrast through the managerial model, support roles are not determined by the professions but rather through non-medical managers, often within the context of restrained costs and the need for ‘efficiency’. This approach was associated with so-called New Public Management policies.
Both these approaches frame support workers as almost bystanders in their own development which derives from someone else’s efforts to either close the professions or implement public sector reform. Nothing again is said about the merits of the roles in and of themselves; they are simple “adjuncts” [1].
Whether the profession and managerial-driven models adequately explain the development of NHS support workers since 1979 is, in my view, debatable [2]. ?Even if they did hold explanatory merit in the past, I do not think they do now. Recent developments in the support workforce have been driven directly by the needs of the workforce, not agendas external to it. Competency Frameworks, for example, have been designed for support roles in a number of areas including in cancer care. They reflect the full range of knowledge, skills and attitudes needed by support staff in domains including leadership and research. The frameworks have been developed in partnership with employers, trade unions, professional bodies, Arm’s Length Bodies and support staff themselves. This is a model of collaboration rather than the conflict which is implied by the professions and managerial models.
Whilst the prevailing narrative remains and is recycled uncritically, a new reality is emerging; one that places support roles themselves front and centre; considering the formal qualifications needed for a skilled workforce (largely now embedded in apprenticeships) and their scope of practice. This seems to me to be the beginning of the ‘professionalisation’ of this part of the nursing or maternity or AHP workforce that is not formally regulated by a statutory body. This is a welcome step. The narrative needs to change.
NOTES
[1] Mike Dent in his chapter in Saks’ collection called - The management and leadership of support workers.
[2] Dent, as others have done, uses the introduction of the nursing Healthcare Assistant (HCA) role as an example of the managerial-driven model where nursing tasks are undertaken by “less qualified and lower paid workers…more directly under the control of management than nursing”. Whilst there is no doubt that the HCA role was subject to far little central guidance; the rationale for introducing it was, in fact, changes to nurse undergraduate training which meant services lost capacity as the profession became all graduate and students spent more time at university rather on the ward. Registered Nurses did not suffer as a result of the role being introduced, in fact it was the old Nursing Auxiliary support role that disappeared. I have also found no evidence that HCAs are ‘under the control’ of managers rather than clinicians.
Experienced trade union officer,who has worked at local, regional,national and International levels. All views expressed here,are my own personal views.
1 年Thanks Richard a really important post.
Project Lead at Dawn Grant Limited
1 年Wholeheartedly agree with “responsibility should not be delegated because there are no registered staff available but because it is the right thing to do (with the right training and support)” I’m thinking of many Support Workers with extended roles such as theatres/ recovery etc along with appropriate training & Banding to reflect their knowledge & skills as part of an effective & efficient MDT.
Head of Nursing & Health Professions at Bridgwater & Taunton College
1 年I totally agree! L2 and L3 apprenticeships are in decline in the sector however. Apprenticeships were developed for the wider workforce by employers for good reason, but sadly they are increasingly turning their back on them. ??