§ Helen Jones (Warrington, North)
I am grateful for this opportunity to discuss the role of health care assistants in the national health service. I do so confident in the knowledge that the Government are committed to the modernisation of our health service and to making it once again the best in the world.
Part of that modernisation is our commitment to supporting and valuing our staff. In that context, we hear much about doctors and nurses, and rightly so, because no one underestimates their dedication and skill. However, other members of staff are also an important part of the health care team; without them our national health service could not function. Those include the category known as health care assistants or, in some trusts, support workers.
The confusion of names is in itself significant. Over the years, we have failed to value the skills and input of those workers and to provide a clear definition of their roles and career path. Some trusts call them health care assistants, whatever their role. Others distinguish between health care assistants and nursing assistants. Some trusts have incorporated the old nursing auxiliary grades into their health care assistants' schemes, while others have yet to make progress on that.
Even more confusingly, some trusts have a health care assistant grade, but still designate some of the staff within that grade as nursing auxiliaries. We do not know exactly how far that integration has gone. In a parliamentary answer to me on 9 February about the number of trusts that have incorporated nursing auxiliaries into their health care assistant grades, my hon. Friend the Minister said:No figures are kept centrally."—[Official Report, 9 February 1999; Vol. 325, c. 168.]That is confusing enough, but the position becomes even more bizarre when we look at the different pay scales on offer and the often confusing employment contract status of many of those staff. A survey done for Health Service Report a couple of years ago showed wide variations between trusts, and the position has altered little since then. Some trusts have three grades for their health care assistants; some have only two; and some use a single grade to cover a range of roles from housekeeping duties to direct patient care. Some have training grades while others do not. In some trusts, paid progression depends entirely on the length of service, whereas in others it is linked to performance factors. Indeed, it is possible to have staff doing exactly the same job on different rates of pay within the same trust because some staff retain the old Whitley Council contracts while others are on locally negotiated contracts.
That is profoundly damaging to the teamwork that we want to support and encourage within the health service and, ultimately, it is also detrimental to patient care. The problem goes back a number of years: when the grade was introduced, no proper assessment was made of the skills on offer or the way to enhance and use those skills. We did not set down proper qualification levels for the differing roles that health care assistants can perform, or the roles that should be subject to direct nursing supervision.
Although I say "we", this Government were not in power then, and the problems have been inherent from the beginning. That grade of health care worker began to be 364 introduced along with the changes in nurse education in Project 2000 and, as the role of student nurses on the wards diminished, the then Conservative Government promoted the use of that new grade, which they later called health care assistant. However, from the start there was no consensus on how the job should be defined. The nursing "professionalisers", if I may call them that without wishing to be derogatory, wanted the role to be strictly defined and clearly differentiated from nursing.
In their National Health Service and Community Care Act 1990, the previous Government explicitly linked the introduction of health care assistants with the freedom for trusts to set pay locally. They then encouraged the use of that grade through a series of initiatives on re-profiling and skill mix, but without a national agreement on the qualifications that should be attached to the different roles or the proper skill mix that should be used in hospitals. As a result, there is a wide variation between different trusts. Job titles are interchanged and the boundaries of the different roles are becoming increasingly blurred. We do not even know for sure how many health care assistants there are. The Department of Health's statistical bulletins distinguish between health care assistants and support workers on the ground that the latter work mainly in the hotel and property areas. It is almost impossible to maintain that distinction in practice.
The Health Service Report survey to which I referred earlier looked at the roles undertaken by health care assistants in different trusts and found that they varied widely. They range from direct patient care to technical support in radiography and phlebotomy to clerical duties and housekeeping duties on hospital wards. Anecdotal evidence from health care assistants themselves, and a survey done by the public sector union, Unison, shows that that is still the case. The majority of respondents to that survey said that their work involved aspects of patient care and that substantial minorities were engaged in a wide range of other duties such as taking blood, plastering, assisting new mothers with breast feeding—the list could go on endlessly.
The job descriptions that the trusts gave Health Service Report on that occasion are revealing because they show that the role has not been clearly defined. For example, Bolton hospital NHS trust defined the role of an HCA grade 1 as being acombination of direct patient care, technical, clerical and housekeeping duties".It did not help that it then went on to define the role of an HCA grade 2 in exactly the same way. Warrington hospital NHS trust, which is my local hospital, said that the work of what it calls a support carer 1 was "basic carer duties" and the role of a support carer 2 was "extended carer duties". That is as clear as mud to me and, I assume, to everybody else. In practice, it means that workers are switched between different roles, depending on staffing on the wards at any particular time.
There are even wide variations in the number of health care assistants employed by different trusts. I discovered from a parliamentary answer to me on 7 May last year that 13.3 per cent. of the work force of my local hospital—I know that it is concerned about this—are classified as health care assistants, whereas only 9.3 per cent. of the work force of Wirral hospital NHS trust, which is not far away, is so classified. That means either that we are getting the figures wrong or that there is no consensus 365 about the role that those workers should perform or the proper skill mix on hospital wards. It cannot be that one hospital simply needs many more cleaners and housekeeping staff than another.
It is time that we put an end to that confusion and looked clearly at the skills and competencies needed for health care assistants to perform their different roles. The previous Government said that that would be done through national vocational qualifications, but we do not know how far that system has been put into practice. When I asked, the Department of Health told me, as it frequently does, that that information was not available centrally.
Health care assistants themselves report wide variations in training practices. They often feel that the qualifications that they gain are not given the recognition that they deserve.
It would be folly to allow that situation to continue, because those staff have a great deal to contribute to our health service. Many of them are mature women with considerable caring experience to offer us, but if we want a modern and committed NHS work force, we must allow all staff to acquire the skills that they need and to benefit from a sensible pay and career structure.
I hope that I have shown through my remarks that those people are often front-line staff who have a great deal of contact with patients. It is vital that people who are ill and in hospital receive good nursing and medical care, but equally important to patients are the people who keep them clean and comfortable, who help them to eat if they are too weak to do so by themselves and who will even sit and chat and share a joke for a while. Those roles are often and increasingly performed by health care assistants, as well as by nurses, and it is time that we put their job on a proper footing.
We should move forward to arrive at a national framework of pay and employment, after consultation with all the various interested parties. I realise that that cannot be done quickly, but we should be moving in that direction. We should set down clearly the qualifications and the competencies needed for the different roles that health care assistants perform. It simply cannot be right that someone can move from cleaning the ward one minute to direct patient care the next, without us specifying the skills or the qualifications that they have to have to do that. That is not in the interests of patients and is not tenable.
We also must have clarity on training. We should move to a national system linked to NVQs and move away from the system of in-house competencies, which some trusts have been using. That system disadvantages staff and is not fair to patients. Staff have the right to equal treatment, wherever they work in the NHS, and patients have a right to expect the same standard of care, wherever they are being treated.
I am pleased, too, that the Government have introduced proposals to allow health care assistants to train as nurses without any loss of pay. I hope that we will expand that system, because many of those people, most of whom are women, have valuable skills to offer. Many of them could not train as nurses when they were younger for various reasons—often because of family responsibilities. I hope that we will value them and allow them to move forward, but if we are to achieve that we must underpin it with sensible career progression through the various grades of health care assistant grade 2.
366 I want to discuss the question of supervision and regulation. I hope that I have shown that many health care workers switch roles and are often involved in patient care. We need to set clear skill levels and qualifications for those roles and we also need to look carefully at which of those tasks ought to be supervised by qualified nurses and which ought not. Although it is often reported, it is unfair to leave staff working on the ward unsupervised when there are not enough staff on duty—or when the ward is pushed—and then move them back to other duties, and tell them that they cannot work unsupervised, when there are plenty of staff available. That is unfair to staff and to patients.
I strongly believe that we must have some form of regulation. I was pleased that the JM Consulting report on the regulation of nurses, midwives and health visitors mentioned health care assistants. No one wants to introduce a system that is too bureaucratic, but it cannot be right to leave vulnerable people in hospital when there are not proper checks on the staff who are dealing with them. Nor can it be right that, in extreme cases, someone can be struck off the nursing register, but can get a job as a health care assistant dealing with vulnerable people.
We need action to be taken for the benefit of staff and of patients. The previous Government tried to run the NHS on the cheap. They created a dog's breakfast of a system, which was in no one's interest. That system exploits low-paid staff and does not protect patients properly. I do not envy Health Ministers, who have to sort that situation out; it is a bit like the old Irish joke: "We wouldn't have started from here." But that situation has to be sorted out if we are to have a health service that is fit for the 21st century.
We need a system that values the staff, keeps them working and allows them to progress in the NHS—and provides the best possible care for patients. I hope that my hon. Friend the Minister will be able to take those points on board and that we will gradually move forward, to sort out the mess that currently exists and to put into place a much more efficient and fair system. I look forward to hearing his response.
§ The Minister of State, Department of Health (Mr. John Denham)
I congratulate my hon. Friend the Member for Warrington, North (Helen Jones) on obtaining the time for this important debate. It is clear from her speech that she has taken an interest in the subject for a long time and knows a great deal about it. Making the most of the contributions of all staff, including the valuable work carried out by health care assistants, is absolutely integral to our ability to deliver the ambitious programme for modernising the national health service and to meeting the increasing expectations of patients and staff.
We need health care staff to be adaptable and responsive, and able to work effectively within teams where role boundaries are flexible. Health care assistants are an invaluable and important part of the NHS. As my hon. Friend has said, they make an important contribution to the direct care of patients as well as supporting a range of health professionals in a wide variety of ways.
There is no fixed definition of what a health care assistant is or does. The latest figures show that there are almost 18,000 health care assistants and almost 67,000 367 support staff employed in the NHS. The majority of health care assistants work in trusts and many work with the elderly. A significant number work with vulnerable adults, such as those with psychiatric illnesses or learning difficulties. Others work with mothers and babies, with children, or in the community.
Support staff work to provide essentials such as ensuring the cleanliness of the hospital environment, and food and drink for patients. The term "health care assistant" has also developed as an umbrella term for a variety of staff groups. Those include staff whose work is supervised by chiropodists, occupational therapists, physiotherapists, radiographers and speech and language therapists.
For statistical purposes, the guidance on occupation codes used in our census of NHS staff defines health care assistants as support staff who are trained, or who are undertaking training, in job-related competencies through national vocational qualifications or other local training. In the service itself, the term "health care assistant" is often used interchangeably with titles used for other staff who undertake similar roles and provide similar support, for example health care support workers, nursing auxiliaries and nursing assistants.
Ultimately, the responsibility for determining the job role of a health care assistant lies with the employer. Different skills and different levels of skills will be needed in different working and clinical environments. We feel that local managers need to be able to provide the right sort of services for their locality and a rigid definition would restrict their ability to meet local service needs.
Similarly, it is a matter for employers to provide the necessary training and resources to enable staff to undertake their duties. We are aware that many NHS employers use local and national frameworks to train their health care assistants. Many use NVQs, or their component occupational standards, to specify the competence and performance outcomes of health care assistants in the workplace. Those standards provide a measure of quality and enable clear specification of the roles and responsibilities of staff. The attainment of NVQs is supported by on-the-job training and assessment, as well as off-the-job training. The latter is provided either directly by the employer or by an education provider.
The national health service executive has, for some time, supported the use of NVQs and occupational standards. It did so in 1995 and in subsequent education and training guidance issued to the NHS. That approach has been reinforced by the approach taken in the first human resource framework for the NHS, "Working Together", which we published last September. One of the aims of the framework is to make the NHS a better place to work in. Developing the commitment and skills of staff, including health care assistants, will be one way of achieving that. The House should not underestimate our commitment to strengthening the role of human resources in the national health service, ensuring that we are a good employer, and ensuring that we can develop the skills of our staff. That means that NHS employers will increasingly have better human resources planning, and better development plans for individual members of staff.
368 As my hon. Friend said, some health care assistants will wish to make progress in their NHS careers. Recognition of the skills and experience of such staff provides them with increasing opportunities to gain entry to programmes leading to professional qualifications, particularly nursing qualifications. Education consortiums are working with higher education institutions to open up nursing careers to as wide a range of people as possible, including existing NHS staff such as health care assistants. As has been said, we have already opened a route whereby NHS employers can second health care assistants on to pre-registration nursing diploma courses. That allows local education consortiums to fund up to 80 per cent of an employee's salary—up to a certain limit—with the employer funding the remainder.
That new approach has proved to be of considerable interest in the service. Therefore, as part of the £50 million nurse recruitment plan announced in September by my predecessor, my right hon. Friend the Member for Darlington (Mr. Milburn), up to 200 additional secondments have been funded this year, with up to 1,000 additional places being made available over the next three years. The package also includes measures to provide non-means-tested bursaries for enrolled nurses who wish to return to work and convert to first-level registration, and an expansion of part-time and flexible pre-registration nursing and midwifery diploma programmes.
There are also a number of local schemes established by the NHS, which recruit health care assistants, support them in the achievement of level-three national vocational qualifications in care or modern apprenticeships, and, using the funding that I have described, second them to nursing diploma programmes. I understand that in my hon. Friend's constituency such a scheme is operated jointly between Warrington and Halton NHS trusts and the north and mid-Cheshire training and enterprise council.
The scheme has three stages. Young people are employed by the trusts, and, in collaboration with the TEC, undergo a two-year modern apprenticeship course. Provided that students secure an NVQ, they are then placed on a nursing diploma course at Chester college, funded by the local education and training consortium at the college. Placements are undertaken at Warrington and Halton NHS trusts, and, on successful completion of their diploma courses, students are guaranteed employment. The scheme is an example of the way in which the NHS, TECs and education providers can work well together, helping individuals to achieve their potential, addressing nursing shortages and helping patients at the same time. Those developments are supported by the Government's wider approach to lifelong learning, which seeks to enable those capable of progressing to do so through education and training opportunities.
More recently, we have published proposals for the modernisation of the NHS pay system in our paper, "Agenda for Change". Our aim is a modern pay system that will enable staff to do their best for patients, working in new ways and breaking down traditional barriers. We want a system that pays fairly and equitably for work done, with career progression based on responsibility, competence and satisfactory performance: a system that will simplify and modernise conditions of service, providing national core conditions and considerable local flexibility.
369 Our proposals identify people—such as health care assistants—who should have more scope to develop their jobs. Those people will be encouraged to take up training opportunities and secure NVQs. Our proposals for pay reform recognise that, in many cases, employers have created health care assistant posts to provide flexible support for nurses and other staff. Postholders often fulfil a wide variety of different roles. We want to preserve the benefits, while giving staff the security of core terms and pay minimums. "Agenda for Change" sets out the means to do that, recommending a national system with meaningful local flexibility.
We are also committed to working with unions and employers to agree the basis of a national job evaluation framework on which all NHS jobs can be assessed. That will be an essential underpinning to ensure equal pay for work of equal value, and will be relevant to groups performing a wide variety of roles, including health care assistants. Staff should receive equal pay when they are performing the same role; differences should reflect variations in skill, role and responsibility.
The skill mix that an NHS organisation requires locally will depend on a number of factors: the type of services that it delivers, the type of patient who is being treated, and the environment in which patients are treated. NHS organisations must therefore determine the mix of skills, roles and staff that they need at local level. But, although training is available for health care assistants, they cannot be a substitute for professional staff. The current national average ratio between qualified and unqualified staff is more than two to one—about 70:30—although I understand that in my hon. Friend's constituency it is about 60:40, and that the local NHS trust is taking action to define the roles and training needs of its support workers.
It is important for health care assistants to be properly and adequately supervised to ensure the safety of patients in their care, the quality of the care offered, and the accountability of individuals involved in providing care. Support staff should carry out assigned tasks involving direct care in support of, and supervised by, other registered health professionals. Employers also have a role to play: they should ensure that employees are suitably qualified and competent to perform the duties for which they are employed, and that high standards of patient care are maintained at all times.
Concern has been expressed by, among others, my hon. Friend, about the development of the roles undertaken by health care assistants, and it is well known that concern has been expressed in the past about the need for the regulation of support workers. On 9 February, my noble Friend the Under-Secretary of State, Lady Hayman, announced that the Government had accepted most of the recommendations of the body that conducted an independent review of the Nurses, Midwives and Health Visitors Act 1997, whose report was submitted in autumn last year. During extensive consultations, fears were 370 expressed about the threat to public protection that might be posed by unregulated support workers, including health care assistants. The reviewers recommended, and we have accepted, that a short review should be commissioned to explore the scope and need for regulation. It will be a UK-wide review, and UK health Ministers will want to consider its terms of reference carefully.
The Government have already announced plans to regulate social care staff by setting up a statutory general social care council. The driving force behind the council will be the need to increase the protection of service users, their carers and the general public. Any review of health care assistants will have to take account of the Government's proposals for a general social care council, published in the social services White Paper, "Modernising Social Services".
Systems of professional self-regulation and protection of title play a vital role in ensuring public protection, but flexible role boundaries will help to meet changing health care needs and public expectations. Flexibility provides the scope that is necessary to develop health care teams to meet patient's needs. Well-trained health care assistants, working under the supervision of registered and accountable professionals, make an important contribution to care, and provide the ability to tailor skill mix to patient and service need. Cost-effectiveness and efficiency are maximised by appropriate skill mix. It is inefficient, and a misuse of highly and expensively trained professionals, to let them undertake care tasks that others, with the appropriate training and supervision, could undertake to the required standard.
We must ensure that we have enough nurses to support and supervise our health care assistants. Registered professionals are required to delegate appropriately to support staff, and employers are required to ensure that their staff are competent to undertake the tasks required of them. We must also have enough nurses to provide the treatment and care that patients need. The new human resources framework is a major step forward in our drive to meet those aspirations.
§ It being Two o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Sitting suspended, pursuant to Standing Order No. 10 (Wednesday sittings), till half-past Two o'clock.