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Nurses cannot dismiss calls for reform out of hand

22 April 2013

It’s not unusual for a trade union representing its members to resist change, and today the Royal College of Nursing is sticking well and truly to form. Not only has Peter Carter, its chief executive, called the government’s plan to put nurses through a year of work as healthcare assistants ‘stupid’, he has also penned an op-ed for the Guardian in which he appears resistant to the suggestion that the profession needs to consider wholesale reform following the Francis Report. Carter writes:

‘For the million or so people working in the NHS, a number of things come with the job: a boom-and-bust budget, growing demand and a high level of public expectation. What staff don’t always expect, although many have now become attuned to it, is repeated criticism from the government responsible for the health service.’

Carter goes on to call Jeremy Hunt’s remarks about the ‘normalisation of cruelty’ ‘unintentionally misdirected’, adding that ‘the sad reality is his remarks disappointed many in the health world, myself included. Yes, poor care happens and the Royal College of Nursing will never be a refuge for it; however, it is not systemic and if the rhetoric is overblown, people will take comments like these less seriously’.


It must of course be disappointing to hear a hard-working and altruistic profession which you have served for many years being painted in the light that Jeremy Hunt chose to do following the shocking Francis Report. But the RCN must beware appearing resistant to any suggestion that the training and continued development of nurses needs examining to ensure patients’ best interests are the priority. Does the profession believe, for instance, that good nurses should be rewarded for their hard work with a promotion that gives them a clipboard and more time away from the bedside? Can the RCN explain what the boundaries between healthcare assistants’ work and nursing should be? Carter says in his pieces that HCAs must be regulated and trained, as recommended by Francis. He also wants legally enforceable staffing levels on wards. These are all sensible ideas, but there is no suggestion in his response that nursing itself has any questions to answer.

Unsurprisingly, Ann Clwyd, the Labour MP leading a review of the way the health service handles complaints, took a dim view of this argument that no systemic failures exist in nursing. On the Today programme this morning, she told Carter:

‘Two thousand emails can’t be making up a story. Two thousand people have bothered to write to me and are still writing to me and they all mention the same things over and over again. Things like having panic buttons out of reach, not being able to reach their food and water. I had one story about a woman who had two broken wrists, they were up in the air and the food and the water were dumped at her side. That story is repeated over and over again.’

Those who defend the NHS from all criticism often use emotional case studies to shut down valid debate about the service it provides. But Clwyd’s case studies are just as compelling as the success stories. They – and the recommendations of the Francis report – cannot be ignored, and the RCN must beware appearing to dismiss any case for reform out of hand.

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  • Dave KP

    I am one of the new degree trained nurses. I work in intensive care and a
    large part of my job is basic nursing care of my patients. We wash our
    patients every day, feed them if they are well enough to eat, regular
    mouth and eye care and yes we wipe bottoms when our patients soil themselves,
    sometimes many times a day. I do not think any of this is below me. 99% of the time
    this basic care is done by the nurses not the healthcare assistants.

    The nurse bashing currently going on is really getting to me, it is insulting to hear people think you are ‘too posh to wash’ when this is the complete opposite of
    what you do. I love my job and think I am good at it. I used to work in the private sector and took a huge pay cut to go into nursing. In my experience nearly all nurse go into the profession with altruistic intentions.

    The proposal for one year working as a healthcare assistant is stupid for a
    number of reasons. Nurse students already spend half their three year
    course in clinical areas caring for patients. Working as a healthcare
    assistant is no guarantee of ensuring compassion. I came into nursing
    late and I am not sure if I would have been able to finance a four year entry
    into the profession. How many other people would we lose by increasing the
    entry time required to enter nursing. The implication of the government is
    that people coming into nursing don’t care, we do, and that we don’t want to
    get our hands dirty, this is untrue.

    By far the greatest contribution to poor care is insufficient
    staffing and poor management. This was highlighted in the Francis report.
    Management were chasing foundation trust status by cutting corners, costs, personnel and ignoring whistle blowers. The RCN wants minimum safe staffing levels set in law but the government is rejecting this.

    On the subject of degree based training the general public may not be aware
    of what a complex job nursing is these days. Yes basic care is fundamental
    but it is one part of the job. In intensive care when our patients are
    very sick they are at risk of dying if we don’t do our job correctly. It is the
    nurse at the bedside who maintains therapies being delivered. The patient
    might be on half a dozen different intravenous infusions some of which could
    cause a patient to arrest if discontinued abruptly, a ventilator, a
    haemodialysis machine, an intracranial pressure monitor. This is not an
    exhaustive list. All these therapies require hour to hour or minute to
    minute continual adjustments based on the evolving physiology of the patient.
    We also initiate and analyse blood tests and adjust therapies as a result.
    If our patient’s condition deteriorates we are the first to spot it and alert
    Doctors as we are by the bedside and continually assessing our patients.
    If you or a loved one were critically ill would you prefer a nurse who was
    intelligent enough to obtain a degree or not.

  • Big Harry

    But But But. they are angels all. When someone dies on their ward of neglect, malnutrition, infected bedsores it is not their fault, It is the evil Tories, and when Labour have been in power for a decade, its Thatcters fault. How dare you cast any aspersion on the Olympics claim of envy of the world. Shame on you.

  • emiller7

    Any buisness is only as good as the people who run it. Managers today have no interestbeyond asserting their supposed power and making themselves look good at the expense of good workers. Demoralizing!

  • MikeF

    Arguably it is the managers rather than the nurses who should serve the year as a healthcare assistant.

  • anneallan

    In the days when nurse training was more like an apprenticeship, the first year was spent doing basic jobs on the wards, broken only by ‘school’ sessions of one to six weeks. It was very clear that you were there to learn, from the bottom up (often literally). This pattern of placement on a ward – where you were very much part of the team – interspersed with schooling, continued throughout the three years.
    By the third year, you were allowed to take limited responsibility for running the ward and had the heady experience of outranking the SENs.
    Speaking of which, bring them back; they had enough training to understand the reasons for the practical side of the work, but maybe from choice or lack of academic ability had not taken the longer course which included more theory. A good SEN was absolute gold dust.

  • FF42

    It seems both the Union and the Government are spoiling for a fight. There is a policy issue at the heart of this, which is how far you should push clinical and care responsibilty from highly paid doctors to an increasingly professionalised but cheaper nursing corps and from nurses to cheap and unqualified healthcare assistants. I believe one of Francis’ main recommendations is that HCAs should be qualified too, which the Government is resisting.

    • Colonel Mustard

      Yes, everybody wants to be Chiefs rather than native Americans these days – the reason so many salespeople are called sales managers and other ‘enhanced’ titles. Probably a sub-set of growing personal ambition and considerations of status taking precedent over that late and lamented but once very British concept of duty. And probably the reason there are too many Chiefs and not enough native Americans in so many walks of life.

      Once HCAs are qualified watch the standards deteriorate even further as another level of hierarchy is created and those on the bottom rung demand more status and more menials to do the jobs considered beneath them. A meme for Britain in the 21st Century.

      • salieri

        And might I also suggest that this enhanced status has encouraged people, including the author of this piece, to call nursing a profession? Ridiculous. It’s no more a profession than driving a bus – sorry, acting as team leader for general transportation.

      • FF42

        Not sure about this. Unlike the old State Enrolled Nurses, HCAs are neither qualified nor subject to professional standards. The problem I think may lie in the gap between graduate nurses and HCAs that in the old days was occupied by SENs

        NB, salieri, the “nursing profession” has been around since Florence Nightingale:

  • dalai guevara

    You want to save money on the NHS?
    You have cut nursing to do that, every five year old knows you cut nursing.
    Now cut pharmacy.

    • Slim Jim

      No, a surgeon’s scalpel to the many-layered bureaucracy. We need nurses and medicine, less so the pen-pushers.

      • dalai guevara

        of course.
        A quick google reveals that the NHS England employed 1.4m staff in 2010, 41k of which were ‘managers’. 7,800 now earn over £100k.
        I wish our other state asset which is RBS was run this leanly.

        • FF42

          The NHS is under-managed, not over-managed. There are too many of the wrong kind of managers, but more seriously there is lack of the right kind of managers. In fact, the NHS needs more managers and better managers.

          I don’t have any connection with the NHS except as a patient, incidentally. I am just comparing it with a well run private company

  • Their lips are moving so….

    Why is everyone so surprised?

    Narrow interest groups, no matter what their political complexion or raison d’etre, will always fight their corner for their particular group. By implication (and design) their bandwidth is limited. A trade union is there to support its members. It is not there to see the wider view, per se, and will move to protect its own as a natural, reflex action. That is, sort of, as it should be.

    We are all used to seeing bolshy unions protecting people who in a sensible world no-one would defend. We are also used to seeing bolshy bosses who think that their workers are nothing more than serfs. That, I suppose, is the human condition – our laws and rules are intended create the checks and balances which soften the edges of the extreme. Trades unions and trades bodies are the lobby groups which seek to ensure that the checks and balances are a.) reasonable and; b). work. But we shouldn’t be surprised when a trade union defends its members against what it sees as generalistic and largely, in their view, unfounded criticism. Even if, in many other peoples’ opinion that criticism is well founded.

    What doesn’t work here, is that the RCN is on one face a trade union and on the other a standards body. Separate that confliction and you will go a long way to resolving the problem.

  • john_atte_kiln

    I’m 70, and inevitably I’m starting to bother the NHS a bit now,
    as are of course my friends. I keep hearing complaints about nurses
    from them, high heels in the ward at night for example, but last year I
    had an experience of my own that shows me that this article is not far
    off target.

    I had to have a colonoscopy, the camera up the bum thing. I found it
    excruciatingly painful. The reason is that they ask you to starve for a
    couple of days beforehand. In consequence the colon is flat and, in
    order to make room for the camera, they pump air into the colon. It’s
    like the worse case of wind you’ve ever had. Unfortunately I have poor
    resistance to pain, I have been known to faint from leg cramp. After a
    few minutes of inserting and rising levels of pain, I passed out. When
    I came round, I’d lost all semblance of awareness, no idea where I was,
    who I was and what was going on. All I could see were 3 or 4 strange
    faces babbling at me incessantly. I panicked, a deep terror-stricken
    fear. I shut my eyes desperately wishing it to go away, but when I
    reopened my eyes, again the 3 or 4 gibbering, alien faces. Then
    fortunately my brain did finally kick in properly and I got back my

    My point is this. When a patient is in trouble as I was, they don’t
    need everybody and a dog yattering at them, they need a single,
    trained, kind person to give them someone to to hang on, a substitute
    mother actually for a brief period. But these staff had no
    understanding of this at all. None. At the end of a colonoscopy, you
    fart of course, and a lot. It’s all that air. All around the room, the
    staff, now busy getting ready for their next case, chorused “Oh good
    man” “Well done” “Excellent” “You’re doing well”. All of this without
    looking at me, mechanically, thoughtlessly. It was so patronising, I
    can’t tell you. I felt so angry with them.

    Note that – angry with them. Not the NHS. I don’t care how difficult it
    is to work in the NHS currently, that’s no excuse for a simple,
    thoughtless inhumanity.

    Compare all this to an experience I had about 30 years ago. I had a
    local NHS aneasthetic operation to remove a lump on my chest. There
    were 2 people there, the surgeon and a nurse. The nurse’s role, which
    she took up as soon as I was laid on the operating table, was to sit by
    my head, talk to me, occasionally stroke my face, everything to ensure
    that I was calm and felt safe.

    At the bottom of the reasons for NHS staff inability to do decent
    patient care is that they are disconnected, afraid of the patients.
    Yes, of course that problem lies with the NHS itself, but I still say
    that’s no reason for thoughtless unkindness.

    • Slim Jim

      I’m sorry to hear about your bad experiences. I too had a colonoscopy a couple of years ago, and I have to say I was actually very impressed with the way I was treated by the surgeon and the nursing staff. They made me feel calm and assured, and I loved the wee shorts with the velcro opening at the rear! They wouldn’t let me keep them though! I have however, had bad experiences at the same hospital at a different department, but I’m convinced that there is a management problem. Too many managers perhaps? Or an overbearing bureaucracy? I don’t know the answers, but I agree with the thrust of this article. There is indeed something wrong with the NHS, and reform it must.

  • Archimedes

    Out in the real world, people have been complaining about poor care in the NHS for years — back when everyone in Westminster was pretending it was the greatest thing in the world, everyone else knew there were deep rooted cultural issues. The issues are very much systemic.

  • BigAl

    Royal College of Nursing is just a UNION now and not a credible professional body that can be relied upon to promote the nursing profession. On The Today programme, Mr Carter came across as complacent and arrogant and as usual the only solution was more money and nurses.

    Does the union view nursing is “too posh to wash” after all of that university education?

  • Russell

    We have many teachers who think teaching is beneath them and of more importance is their pay, pension, working hours and holidays.
    We have nurses who think nursing (caring) is beneath them and of more importance is their pay, pension, working hours and holidays.
    We have police who think protecting the public is beneath them and of more importance is their pay, pension, working hours and holidays.
    We have civil servants who think serving the public is beneath them and of more importance is their pay, pension, working hours and holidays.

    Taxpayers should be told in no uncertain terms which political party is responsible for all the above…..LABOUR.

  • Colonel Mustard

    I can remember when all nurses were healthcare assistants in the days when there were no healthcare assistants, when they wore smart uniforms and kept the wards spotlessly clean. ‘Carry on Nurse’ and its sequels are no longer funny but a lament for a lost profession.

    Carter’s Ph.D thesis on ‘Understanding reasons why nurses abuse patients in their care’ might offer a clue to his attitude. Modern nursing needs the boot of a Sir Lancelot Spratt rather than the hand wringing of a Peter Carter…

  • Chris lancashire

    The dismissal of this sensible proposal as “stupid” perfectly captures the arrogance of this trade union. The sad fact is that many nurses see themselves as quasi-doctors with true patient care beneath them. This has come about from years of government interference and encouragement to have nuses graduate with degrees, Unfortunately more government interference is now necessary to remind nurses what they are there for.

    • FF42

      Nurses are quasi doctors these days, taking on responsibility for clinical treatment and so on. This isn’t just to bolster their egos – basically it saves money on expensive doctors. That’s no excuse for not caring properly for their patients and the same applies to doctors.

      I think Mr Hunt might be barking up the wrong tree. I think it would be difficult to get through a five year nursing degree without being involved in basic patient care along the way. Perhaps courses need some adjustment but I would be reluctant to make the training even longer. Problems of insufficient patient care are more likely to apply to senior nurses after graduation.

      • Makroon

        The suggested one year of “basic experience”, might serve to weed out the aspirant nurses who have no vocation, and no empathy.

    • Makroon

      Spot on.
      Mind you, the supreme irony was the famously self-regarding, arrogant, impervious to any criticism, BBC, taking this Carter person to task for ‘not listening’ (Today programme).
      I thought Labour MPs with an independent mind and some moral fibre were an extinct species – good for Clywd

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