Who Cares?

The Mid Staffs scandal has thrown a light on the growing role of untrained healthcare assistants

The Sunday Times 1o February 2013

As she visited her mother, a heart patient on an acute hospital ward, Ann Smith, a nurse trained in the 1980s, was dismayed to discover no one was monitoring whether the 78-year-old was eating or drinking anything.

Because there was a full jug of fresh water by the bed, the assumption was that it must have replaced an empty one. The people who delivered the meals were not the same people who cleared them away, so no one noticed that food was being left untouched day after day. Not only that: one of the carers appeared not to know how to take a patient’s temperature. “Because of my mother’s condition, her hydration level and fluid intake were absolutely critical to maintain her calcium and potassium balance,” says Smith.

“She was meant to be on a soft diet. I lifted the lid on her lunch. It consisted of three ice-cream scoops of brown stuff, green stuff and white stuff.

“A doctor had arrived to examine her, and he glanced at the food and screwed up his face. I said: ‘Would you eat that? I wouldn’t give it to my dog’.”

Smith, 54, from Cookham, Berkshire, and her sister have five children between them and both work full-time. But they also live fairly close to the hospital where their mother was being treated, and so resolved to care for her themselves.

There followed a gruelling 19 months during which they took it upon themselves to relieve their mother’s dying days, organising family rotas of visitors, and taking daily meals to the hospital, where they were sometimes refused access to the ward’s microwave to reheat the food.

“It was completely exhausting but we felt we had to do it,” Smith says. “Nursing seems to have become a technical, academic activity. They can tell you about the Child Protection Act, but we seem to have arrived at a situation where they are too proud to wash people’s faces or wipe their bottoms.

“When you’re doing personal care you are observing skin hydration, colour and texture; working out what treatment a patient needs to make them better or simply make them comfortable.

“Hospitals are now completely dependent on low-paid healthcare assistants to do these basic tasks and they just don’t have the skills. Some of them are very caring indeed, but others are not. They have little or no training, and you can’t help wondering if the cost of proper nursing is being priced out of the NHS.”

The questions of whether the new generation of graduate level nurses are “too proud” for basic tasks, and whether cruelty has triumphed over compassion in the drive to reduce costs, were brought into sharp focus by last week’s report into 1,200 avoidable deaths at Stafford Hospital, run by Mid Staffordshire NHS Trust — most of them the result of failures of nursing care.

Buried on page 1,527 of the third volume of the report compiled by Robert Francis QC is a previously undisclosed statistic: hospitals now employ 332,000 healthcare support workers. Some 62,000 of them do technical jobs, but most of the remainder provide frontline, bedside care of the sort once provided by nurses.


INTERNAL NHS figures indicate the number of untrained frontline care workers is about 160,000, but they also show the number of fully trained nurses meant to supervise healthcare assistants is falling.

Among his 290 recommendations for improvement, Francis has called for mandatory training for assistants, and a register that would allow incompetent ones to be barred from patient care in the same way as substandard doctors or nurses.

The government has hitherto resisted calls for such a formal registration scheme, apparently on cost grounds, but it was announced yesterday that Jeremy Hunt, the health secretary, is planning a review of the role of healthcare assistants. It will be led by the campaigning journalist Camilla Cavendish, who will soon be joining The Sunday Times.

Hunt also called yesterday for a police inquiry into the deaths at Stafford Hospital, saying it was “absolutely disgraceful” that no doctors, nurses or managers had been held to account for the terrible failings at the hospital.

Four doctors employed by the Mid Staffordshire NHS Trust — three of them in senior managerial positions — face hearings over alleged misconduct. A further four medics are still under investigation.

When it comes to preventing a repetition of the failings of Mid Staffordshire, however, better training for healthcare assistants is seen by many as a priority.

At present, assistants’ training involves a one-day crash induction, in which workers are shown how to change beds, wash patients and help them with bedpans, clean their teeth and try to prevent the spread of infection. They are then provided with uniforms that make them indistinguishable from nurses to patients and visitors.

Yet respondents to a survey of 2,500 nurses published by Nursing Standard last month, reported assistants were regularly monitoring intensive care patients; carrying out electrocardiograms, administering powerful drugs, taking blood and putting in catheters.

The nurses said some assistants were taking blood pressure readings “but do not know what is normal or not”. Others failed to notice signs of deterioration in patients’ conditions.

Although patients, families and healthcare commentators emphasise that many in this army of assistants are skilled, competent and caring, there are plenty more who have none of those attributes; some may be actively cruel.

Figures released in December by the Office for National Statistics showed 111 hospital patients died from dehydration in NHS hospitals in 2011 and 43 from malnutrition, all the consequence of a collective failure of care. The Francis report records an assistant calling a patient a “fat bastard” when he asked for food.

The advent of the Francis report unleashed a fresh tide of complaints about poor care in hospitals around the country, with people flooding online forums and radio phone-ins with stories of patients being left unfed, thirsty, lying in excrement, screaming in pain or simply “abandoned to die”.

One 24-year-old assistant in Portsmouth, who gave up training as a nurse because of a shortage of staff to mentor her practical training, said she and her colleagues were terrified of speaking out about anything out of fear of losing their jobs.

“We are doing the bulk of basic nursing care,” she says. “Some [assistants] are very good, but you do see all sorts of things, and it’s fairly obvious that some people are doing the job for the wrong reasons. Regulation and registration would be an enormous benefit. It would bring us professional respect and weed some of them out.”

Last year Lord Willis of Knaresborough, a former Liberal Democrat MP, was commissioned by the Royal College of Nursing to investigate whether nurse training was providing appropriately qualified staff. In his report, Willis said he did not find any shortcomings in “nursing education that could be directly responsible for poor standards of care or a decline in care standards”.

Last week, however, he expressed concern about the number of people delivering frontline care without adequate training.

“We need to have legally agreed ratios for trained and untrained careworkers,” he says. “Leaving it to the Department of Health to monitor hospitals doesn’t work. That’s why we’re in this mess.”

Jane Chappell, 52, from Leicester, is from the old school of nursing. She joined the profession straight from school in the 1970s, when the three-year training was given in blocks of two weeks in the classroom followed by 12 weeks on the ward.

“The uniform showed whether you were in the first, second or third year of training, and you were allowed to do different tasks according to your level of training,” she says.

“People are living to much older ages nowadays, and have much more complex health problems. Skilled nursing care is even more essential.”

The criticism of the quality of care in the NHS that has erupted with the Francis report dismays Claire Hughes, 21, a third-year undergraduate nurse at the University of the West of England in Bristol.

“It is incredibly upsetting and demoralising to hear all these things,” she says. “I have seen nothing but brilliant care on all my work placements, from healthcare assistants as much as from nurses.

“I haven’t asked them about their training, and I can see why people are worried about it, but it’s been obvious the ones I’ve worked with were well-trained and competent.”

One outsider who begs to differ is Malcolm Alexander, a professional patients’ advocate for the past 30 years, and now chairman of the National Association of Local Involvement Networks, which lobbies for greater patient representation in healthcare.

Alexander has spent the past month supervising the hospital care of his frail but independent 98-year-old mother, who was sent home this weekend after recovering from a fall in her east London home.

“The thing that really strikes me as something that has changed, is that the hierarchy in hospitals seems more entrenched than ever,” he says.

“The interaction between nurses and patients seems to have completely broken down; they are strangely distant. You rarely see them touch a patient, and there is no one who has the responsibility to communicate with patients’ families. I don’t see how having a degree can have caused this huge cultural problem.”

Yet Alexander does detect one glimmer of light. “Healthcare assistants may be untrained, but my experience of an elderly care ward was they were the only ones who were pleasant, acknowledged our presence, or tried to offer any information — even if it was a bit vague,” he says.