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’ (NHS trusts and foundation trusts) expenditure.


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, which rose by 6.2% in 2014/15. Of this, agency staff represents a substantial cost for NHS providers, rising by 27% (£0.7bn) in 2014/15. 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 as they cost less than highly-skilled workers.

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). The Carter Review proposed a new metric to determine correct staffing levels based on “care hours per patient day,” however critics have noted that this metric does not take into account the level of skill of the worker delivering the “care hour”. Research published in the BMJ Open in February 2016 on staffing levels in 137 NHS acute trusts 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, any report that gives  “nurse numbers” or “contacts” or “care hours” without regard to professional status is ignoring a vital difference between the roles and capabilities of different workers on the wards.”

The new nursing associate role

The research reported in the BMJ Open is timely due to the Government’s intention to create a new non-registered nursing associate role that is intended to bridge the gap between HCA and nurse. The Royal College of Nursing and Unison have warned that the new nursing associate role must not be used as a substitute for registered nurses and are concerned that this focus on the new role is diverting attention away from the serious problem of a shortage of registered nurses. A consultation on the role was launched in April 2016.

In March 2016, Nursing Times reported on public board minutes from the Gloucestershire Hospitals NHS Foundation Trust board that suggested that the trust intends to recruit HCAs to cover gaps in its nursing rotas: the trust has said that the minutes are “open to interpretation”.

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 area of 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 detailing 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 “advance 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.”