Jill Kirby: Nurses should be carers not managers — the Willis report raises serious questions about NHS neglect

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the Commission acknowledges that complaints about patient neglect have increased as hospital-based nurse training has been replaced by university-based courses and higher academic qualifications.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 responsibilities.

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 questionnaire.