David Goodhart suggests in the Sunday Times that the current social care recruitment crisis would be ameliorated if men became “carers”, pay for carers was improved and a new kind of worker, “the enhanced care practitioner”, created who would perform wound care, deliver diabetic injections and check vital signs.
In his article, which is an excerpt from his recently published book The Care Dilemma: Caring enough in the Age of Sex Equality, Goodhart identifies the crisis in social care, and he also recognises that the move to degree status for many professions was “especially regrettable, nowhere more so than in nursing”.
What is alarming is that it is arguable that this ‘graduatisation’ of the nursing profession, which started in the 1990s with Project 2000, created the problem of ‘social caring’ in the first place. And it is arguable that it is the nursing profession itself which can and should reform to meet the needs of the U.K. population for ‘social care’.
Politicians admit that the NHS and the social care system are both broken. Indeed, Wes Streeting, the Health Secretary, has proposed a public consultation to try to fix the NHS. Meanwhile the social care system in England has not been fixed by successive politicians for decades, despite the 2011 Dilnot Report. The recent Labour Budget will add more pressures to employers of care workers as National Insurance costs rise.
According to an Age U.K. report in 2023, ‘The State of Health and Care of Older People in England‘, the broken social care system has dire consequences for older people:
A broken care system means that a shocking 12% of people aged 50-plus in England (2.6 million) have an unmet need for care and the older you are the more likely it is that you will have needs that are not being met. People are struggling to even go the toilet, eat, get dressed or washed, because they can’t do these things unaided and the support isn’t there for them. There is something deeply wrong with a care system when even people’s critical needs aren’t being met. And it’s getting worse.
The NHS depends on social care. The two are deeply interlinked. Indeed, one of Streeting’s priorities is to move patients from hospital into the community. The Royal College of Nursing considers nurses to be at the heart of this. The problem, as the RCN states, is the shortage of community nurses, as numbers have “collapsed”. This reflects more general nursing shortages, with over 31,000 posts currently unfilled.
But what do community nurses (and nurses in hospitals) do, and what don’t they do? And why have community and hospital nursing numbers collapsed? The answer to this, which many people may not know, lies in the U.K.’s separation of ‘nursing care’ i.e. (what qualified nurses do) from ‘social care’ or ‘personal care’ (what unqualified care staff do). And this in turn is relates to the role of a nurse.
First, how is health care different from social care?
In Great Britain, nursing, medical and health care is provided by the NHS and social care is provided separately by local authority social services departments (SSDs). This separation developed in 1974 when local authority public and community health functions were transferred to new Health Authorities.
Health care is related to the treatment, control or prevention of a disease, illness or disability, and the care or aftercare of a person with those needs. It is provided by doctors, nurses and allied professionals aided by unqualified supervised staff, and is free at the point of delivery.
Social care is to maintain the basic activities of daily living and is the responsibility of the local authority. This may be provided in profit-making private care homes or in the person’s own home, often with private agency workers who are minimally trained. Social care is means tested so may be paid in full or in part by the vulnerable person.
Second, what do nurses do?
Leaders of the nursing profession in the 1980s sought to raise the status of the profession, moving training into universities and undermining what were the fundamentals of nursing – that is, washing, dressing, feeding and toileting. Trained nurses now, for example, observe and assess patients’ needs, use care plans and carry out procedures, such as wound care, medication management, setting up intravenous infusions and monitoring vital signs. As registered nurses became more expensive, and as student nurses are unpaid and supernumerary in practice placements, cheaper, less well trained paid health care assistants have taken over what were once ‘basic’ nursing tasks, that is personal care, washing, dressing, feeding, moving about and toileting, both in hospitals and in the community. And, indeed, Goodhart affirms these distinctions by suggesting the new Enhanced Care Worker should replace nursing tasks even further.
The nursing degree is an expensive deterrent to U.K. nurse recruitment, so that currently the U.K. needs to rob other nations of their trained nurses to fill the massive shortfall here.
The cost of implementing Project 2000 according to the National Audit Office was £580 million, primarily to cover the work previously undertaken by student nurses. Also according to the National Audit Office’s 2020 report ‘The NHS Nursing Workforce‘, the cost of employing one overseas nurse in 2020 was £12,000, that is in addition to salary. Student nurses do not receive a salary but need to pay university fees, like any other student, although they do receive a bursary of £5,000 per year and maybe can claim some extras depending on circumstances.
The U.K. nursing degree cannot be assumed to produce highly competent nurses. As the Telegraph reported recently: ‘Pensioner died of sepsis “after nurse did not wipe skin before injection”‘. The quality of the nursing degree itself is very questionable, as I have written elsewhere.
In fact, one look at the papers published in the Journal of Advanced Nursing, the major nursing journal, by so-called nursing academics will reveal how unscientific nursing and its ‘body of knowledge’ has become.
The solution to the problem of both the broken health service and the broken system of social care lies in uniting both systems through a reformed nursing system. Firstly the separation of health and social care needs to be healed. Secondly, and to promote this healing, the nursing profession needs to recover its purpose, understood by Florence Nightingale as its science and art, that does not differentiate ‘higher tasks’ from more ‘lowly’ tasks. As she wrote in her Notes on Nursing (1859): “If a nurse declines to do these kinds of things for her patient, ‘because it is not her business’, I should say that nursing was not her calling.”
In fact, dedication and vocation “require nurses to care for all aspects of patients, especially the messy, dirty, non-technical bits. Not to do so is not to care or be a good nurse“.
The nursing profession needs to reclaim its purpose and principle, appreciating that assisting the patient with his or her activities of daily living – getting dressed, getting washed, cleaning teeth, going to the toilet, eating and drinking – are as important as dressings and medications and more ‘advanced’ skills in what was once called ‘total patient care’. They cannot and should not be separated because they are a unity in the person.
This is illustrated in the memory of a District Nurse working in 1943, quoted in a student doctoral thesis:
It was all barbed wire along the sea front, not a lot of traffic, of course. We were on bikes. One or two walked. But, oh, it was wonderful. You started the day with a prayer. … You would do lots of diabetic injections. Blanket baths, dressings, how the dressings were done. We used to have to boil everything, in those days – we used to have to take everything home. You’d have a biscuit tin, and in that biscuit tin, you’d have your dressings, you’d cut your gauze, your swabs and so forth, and you’d put it in the oven for 20 minutes, with the lid off. That was for your sterile dressings. And you took your bag with you, with your receivers, bowls and forceps, and the bags contained a certain amount of disinfectant as well, and you had to be very particular about everything you did. You put newspaper on the table, newspaper on the floor, everything had to be meticulously done, and you boiled all your things, you took them out, you didn’t have gloves, in those days. But it all had to be done, absolutely, as sterile as it was possible to do in those days; of course you had glass syringes, so you had to be careful in those days.
In 1943 the District Nurse did blanket baths alongside dressings and injections. Her care was unified, as Nightingale emphasised. And this was what I also did, working as a district nurse in Oxford in 1972, although by then we did not need to boil our dressings as we had sterile packs.
The solution to fixing both the NHS and social care lies in a return to Nightingale’s first principles that unified nursing as a science and an art, and to Nightingale’s model of nursing and nurse training which persisted in the U.K. until the 1980s (and gave the model of nursing to the rest of the world). If her method of apprenticeship training (rather than supernumerary placements) could be returned to as the main method for nurse training, then there would be an immediate paid workforce of student nurses in training who could assist district nurses in the community (as well as in hospital) caring for patients. Indeed, this would have produced a workforce during the Covid pandemic.
If student nurses were paid as they trained to become registered nurses, U.K. nurse recruitment might well be improved, and it would no longer be necessary to plunder the rest of the world for nurses and care assistants, and pay heavily for them. Moreover social care would be part of the NHS and vulnerable people needing help with their most personal needs would no longer be shut away in care homes, out of public sight, and inevitably at the mercy of profit making businesses – and at the hands of many carers for whom care work is a poorly paid job and not a vocation..
This matters to us all as we face old age and disability. Who will care for you?
Dr. Ann Bradshaw SRN is a retired Senior Lecturer in Adult Nursing at Oxford Brookes University. Her previous books include The Nurse Apprentice and The Project 2000 Nurse.
To join in with the discussion please make a donation to The Daily Sceptic.
Profanity and abuse will be removed and may lead to a permanent ban.