Deskilling the workforce

A large proportion of the NHS's budget is spent on its workforce, indeed this cost is three-fifths of total NHS providers' expenditure. With so many NHS organisations in deficit and seeking ways to save money, there are concerns that they may opt to employ lower skilled healthcare workers to cut costs.


The cost of staff has risen in recent years, due to increasing numbers and rising average cost per staff member employed. The major driver for this increased cost is spending on non-permanent staff, with the NHS spending nearly £1.5 billion a year on temporary nurses to fill the shortfall.

HCAs versus nurses

There are serious concerns that there is a move to replace registered nurses with less skilled and cheaper healthcare support workers (HCSWs), such as healthcare assistants (HCAs). BMJ Open research of 137 NHS acute trusts from February 2016 suggested a link between a higher proportion of HCSWs per patient and a rise in mortality.

Peter Griffiths, lead researcher on the study and Chair of Health Services Research at the University of Southampton, noted in an editorial in the Nursing Times that the study “does clearly show that any policy that regards registered nurses and support workers as interchangeable [...] is ignoring a vital difference between the roles and capabilities of different workers on the wards.”

A survey of healthcare assistants in 2018 revealed that two thirds of HCAs are performing tasks usually carried out by nurses, such as giving patients drugs or dressing wounds. 63% of HCA respondents also reported that they were providing patient care with worryingly little help from doctors or nurses.

These results have sparked further concern that patients may be receiving inferior care that could potentially be unsafe. Last winter, 57% of HCAs said that they had to perform extra tasks, as the service was under the most pressure ever. Additionally, 41% said they were asked to act beyond the limits of their normal roles without the adequate training to do so. More prevalently HCAs are filling rota gaps due to the 40,000 shortfall of nurses. The RCN comment that this risks leading to "nursing on the cheap".

The new nursing associate role

In 2016, plans to create a new non-registered nursing associate role launched. The aim was to bridge the gap between HCAs and nurses. The RCN and Unison warned that this was diverting attention away from the serious problem of a shortage of registered nurses. This role should not be a substitue for registered nurses.

In 2018, the first set of 2000 Nursing Associates are preparing to start their new role, with the first 1000 set to complete their training by the end of this year. However, there are not yet any agreed standards of education, training, conduct and performance as there is no agreed legislation with that allow the new NAs to be regulated by the Nursing and Midwifery Council.

Other areas of concern

In other areas of the NHS, there are concerns about a lack of skilled staff and the use of untrained or lower skilled staff. In particular, NHS 111 services have been criticised for their use of staff that are not medically trained who are relying on computer tick-box systems to assess callers. In the ambulance service, there have been concerns over the increased use of emergency crews consisting of only emergency medical technicians or other staff with a lower skill level than paramedics.

In May 2016 The Nuffield Trust published a report entitled Reshaping the Workforce commissioned by NHS Employers. It detailed the potential for training nurses and other support staff to take the pressure off doctors as a way to tackle the hospital staffing crisis. The extra training would be to give nurses and others "advanced practice roles" or "physician associate status" as a relatively quick solution to the current shortage of doctors.

The publication of the report has caused alarm among doctors and patient groups.  Katherine Murphy, the chief executive of the Patients Association, said: “The proposed new roles and extra responsibilities for existing staff should not be adopted as a ‘quick fix’ solution to the complex staffing problems within the NHS, nor be seen as a cheaper alternative to highly qualified staff."

The BMA gave a cautious response to the report noting that the report was "a sensible assessment of the current situation that the NHS workforce is in....however, while we support the upskilling of the existing workforce and the introduction of new roles to assist with patient need, this should not be done at the expense of good quality training for doctors or, indeed, doctors themselves."