Politicians are always telling us
how much we love the NHS, and how we should value the nurses and doctors who
work in it. But the institution we are all supposed to revere has come in for
some bad press lately. This week a Commission on nurse training, chaired by the
former Liberal Democrat MP Lord Willis of Knaresborough, reported that
thousands of untrained and inexperienced “healthcare assistants” are carrying
out tasks that should be in the hands of trained nurses, and this is putting
patients at risk.

The Willis Commission was set up
earlier this year by the Royal College of Nursing, to respond to public
concerns about falling standards of hospital care and to examine the present
system of nurse training. Its conclusions strongly favour the current system of
graduate entry to the profession and ascribe most of the deficiencies in care
to the fact that patient contact is no longer the province of nurses but of
untrained staff. According to evidence submitted to the Commission, for every
four registered nurses the NHS employs six unqualified assistants.
Frighteningly, these auxiliary workers are often unsupervised and can, for
example, be left to carry out jobs in the community that were once the
prerogative of a District Nurse. Patients and their relatives are unable to
distinguish between these assistants and registered nurses, and may rely on
care and advice they are not qualified to provide.

Clearly the reliance of the NHS
on inexperienced and unregistered auxiliaries is a very serious problem. Given
the increased autonomy and responsibility being placed in the hands of GPs as a
result of the new healthcare reforms, we should also be troubled by the possibility
that surgeries will cut corners by employing cheap assistants where nurses
should be. But I think the Department of Health should also probe more deeply
than Lord Willis into the factors that have contributed to this state of
affairs.  One of the background papers
submitted to the Commission acknowledges that complaints about patient neglect
have increased as hospital-based nurse training has been replaced by
university-based courses and higher academic qualifications. Yet the Commission
chose to visit universities, rather than hospitals, when gathering evidence,
and seems to have relied disproportionately on evidence from professionals
rather than patients and their representatives. Its conclusions (PDF) are mired in the kind of jargon which now so often forms
a barrier between users of a public service – in this case the sick and
vulnerable – and the managers who control it. Rather than setting out bold and
direct advice for better, ward-based training and stricter supervision, it
refers to “strategic understanding”, a “collective narrative” and “local and
national partnerships.”

Significantly, the Commission
fails to make any link between the modern system of degree-led nurse training
and the low standard of unqualified staff. Surely it should be questioning the
evolution of a system in which nurses are becoming technocratic, desk-bound
managers who delegate patient care to inexperienced care workers?

Some of the evidence given to the
Commission hinted at the problems endemic in this division of responsibilities.
Rosemary Cook, director of the Queen's Nursing Institute, raised serious
concerns about training methods. In her view, too much time is spent at
computers in virtual reality wards rather than acquiring skills on a real ward,
working with real patients. Supervision is inadequate: nurse mentors are too
reluctant, or too busy, to correct trainees, who may pass on to their next
assignment with their failings unrecorded. Compliance with equality and
diversity creates an additional layer of problems.

Cook defends graduate entry on
the basis that the demands of risk management and complex technology now
inherent in nursing would be beyond the ability of non-graduates. But it's hard
to read her evidence as a ringing endorsement of the present training system.
What comes through strongly is the worry that trainee nurses are not spending
enough time carrying out the basic, repetitive but essential tasks that used to
be the staple of their first year in hospital. “Virtual” patients cannot
substitute for this day-to-day acquisition of knowledge and understanding. The
nurse who has fed and bathed hundreds of patients, made their beds and cleaned
their wounds, not only has a wider range of understanding of the sick, she also
gains the knowledge and confidence to supervise others, and to demand high
standards of them.

Yet we now have a system in which
trainee nurses spend as much time in the classroom as they do on the ward. How
can they possibly acquire the skills they need? The system also surely denies
to the NHS a hugely important source of committed, compassionate workers in the
form of student nurses. We have broken the continuum between the novice who
washes the patient and the ward sister who manages the patient's condition; the
menial task which is accomplished with pride as a step towards greater

The Commission has performed an
important task in drawing attention to the over-use of unqualified staff. In
response, the Department of Health says that “minimum training standards” for
healthcare workers will be drawn up by January. But the Department should not
let the matter rest there. It should take the opportunity to look at the impact
of graduate-based nurse training and the gulf which has opened up between
nurses and those ancillary staff who work with patients. We should pay much
greater attention to nursing as a vocation. 
Let us dump the snobbery that assumes the only jobs worth having are
graduate jobs. The non-graduate path to nursing — where hours on the ward are
valued more highly than hours in the lecture room or at the computer — should
be re-opened. Certainly, healthcare assistants should not be taking the place
of nurses. But nor should nurse trainees be allowed to qualify unless they have
shown themselves as willing and able to wash and feed a patient as to fill in a

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