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.
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Apparently the population of Japan passed 100m in the 1960s. As it did so there were 6 workers for every non-worker. In the 2030s the population of Japan will again pass 100m, but on the down escalator, by when there will be 6 non-workers for every worker. We aren’t so far behind.
I just read an article about a chap who runs 20 care homes in Scotland. He emoys 1400 people to care for 700 residents.
Maybe robots will solve the conundrum, or maybe euthanasia, but no matter how you train nurses the fundamentals will keep overrunning nursing provision.
Don’t become old & poor is my advice.
As I understand it, you can gain access to nursing through diploma courses as well as degrees. Having a diploma limits your promotion prospects however.
I have always been unimpressed with degree courses for careers which have a high practical content. I trained as an electronic engineer starting a degree course in the mid sixties (anybody remember thermionic valves?).
I was unimpressed with the teaching and practical experience of the lecturers and left without a degree.
Some friends who stayed on and gained their degrees were unable to understand practical circuitry and in some cases have never soldered a single component, meanwhile I will still tackle board level maintenance, make devices and have designed my own electronic circuitry. Who is a better engineer?
I work in IT, specifically Data Integration, Reporting and Analysis using mainly the SQL Server stack.
With just two exceptions (who were both over 50 when I worked with them and who gained their degrees when one can assume degrees were worth something), the worst of my colleagues have all been computer science graduates, of all ages. The best, however, are self-taught, some of whom are also Microsoft Certified.
One of the best whom I work with currently is apparently self-taught in everything with a great deal of skill and experience gained from just doing it (sometimes professionally). I think he may have been to a polytechnic for a year to study electronic engineering, but that’s it. Definitely no “degree”.
I have had to work with Uni Grads, in engineering, give me a self taught or apprenticed engineer any day. Apprenticeships and self learning give you all the stuff that is not written in a book, how to use your hands and mind first before a computer program. And one thing uni grads invariably do not get is, that there is still far more to learn about your subject once you graduate or complete your modern apprenticeship. Particularly from others.
Anyone remember the phrase, You will never be any good until you are about forty. Because it took that long to be accepted as knowing what you were talking about, let alone getting the colour of the tea right.
I too work in IT – software development. We’ve employed all sorts of people over the years and a Computer Science degree doesn’t appear to offer any guarantee of ability or productivity. We tend to employ people who can demonstrate a decent basic proficiency in a programming language, ascertained by administering an exercise it’s hard to cheat on (unless you get your mate to do it – but then we ask people to present and explain their work). In all cases, people who do well on that exercise have proved they can learn all sorts of other related tools and languages as necessary, on the job.
A nursing degree is easy to get and relatively cheap as the State pays.
Once they have a degree, this is entry to other better paid jobs.
can I also suggest that successive government destruction of the family has allowed the abandonment of the elderly to the state, where once families looked after each other.
Exactly. So many of our current problems boil down to the devaluing of the family particularly in its extended form where individual responsibility and mutual concern can obviate most need for “social care”. But we think nothing of moving to the other end of the country for work then complaining that the council where we left our ageing parents aren’t doing enough for them.
Here’s the fix for social care: families.
The thing that Lefties and feminists have done their best to destroy since the 1960s as being irrelevant because the State will provide cradle-to-the-grave.
“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. “
Don’t we already have these? Nurses. We used to have district nurses when I was young, and now we have community nurses.
Men are not biologically predisposed to be carers, unlike women. That is why only about 5% of nurses are male.
Men tend to breadwinners so would need much “improved” pay. Where will the money come from? Anyway, it’s not a question of money, it’s what people want to do, and men don’t want to be nurses.
These folk really have no contact with the real World or any understanding of Humans.
Ann Bradshaw, I think as a society we would no longer have the will or understanding of life to implement your wise recommendations, but thank you for setting them down, and I hope your voice is heard.
How long would it be before regulations were introduced to require a university degree before becoming a “the enhanced care practitioner”. Not long.
Meanwhile, the answer to social care is to explore more economical means of provision.
Care in their home is the best and most economic but ifresidential care is needed we should not use Victorian detached houses as the locations. Purpose built and not in town centres would be best I expect. Like Premier Inns or Best Westerns.
Use automation to detect falls and monitor the residents by CCTV. Engage with relatives in ways that do not treat them and the resident like children.
Once again, a sensible suggestion that the old ways were much better than the modern crap and the sooner they are returned to the better.
I recently attended a private hospital for a minor op. I’m fine thank you. But I noticed two things. Firstly I was treated well as a ‘customer’, in a private room, and kept cheerfully informed of what would happen next. None of the ‘treated as a dumb work unit in a process’ stuff. Secondly there was a high proportion of ‘nursing assistants’ to ‘nurses’.
Perhaps the private hospital catered for ‘bread and butter’ work and wouldn’t be able to tackle more technical health care work? I don’t know. But I do wonder how my private costs would compare to a proper accounting for the same care in a NHS facility.
Perhaps all ‘bread and butter’ work should be done privately, and only the more complicated stuff by the NHS? We seem to be edging towards that arrangement with the private hospitals being used for ‘overflow’ NHS work – but it would break the NHS taboo to formalise such arrangements as routine.
There are plenty of other countries where the NHS model is not used, and often the general level of service is better (and cheaper). It is a matter of political will.
I doubt any of the ‘geniuses’ commenting here have any idea of what they are writing about. A member of my family works in’social care’ – changing diapers, wiping excrement off walls, stopping dementia-stricken elderly fighting each other and other similar ‘pleasures’. It’s clear no young people want to do this any more. The only solution is to place the elderly in care homes in the Third World where they can get proper care with sufficient staff who are forced by economic circumstances to do the work nobody in the UK would want to do.
Your point is well made. Many of us have been making this same point for 25 years. Sadly I think the arrogant bureaucrats who run the NHS will continue to ignore it until the system collapses and the patients either leave for the private sector or die in squalor, unvisited at home or ignored in the waiting rooms of A&E.
Unfortunately when those with no practical experience of the situation implement ill thought through policies we end up with the dog’s dinner of a mess we now find ourselves in. Let’s hope somebody with real experience and insight is allowed to sort out the issues so well represented in this article.
The grossly inconsidered Covid vaccine mandates were responsible for the loss of 40,000 carers and this mistake was threatened and nearly implemented in the NHS too despite the absolute knowledge that the Covid vaccine neither prevented infection nor transmission.
Add to these unintended consequences the high cost of university training for almost all health care workers and the relatively low pay and poor working conditions and you have the perfect storm.
No wonder the Government are now trying to introduce assisted dying to reduce the problem by culling the number of patients requiring care.
I totally agree that degree status for nurses has been an unnecessary and damaging conceit; student nurses used to be counted as part of the workforce and got excellent hands on learning, – something students and the NHS needs once again. However, I don’t see that the above piece provides any answer to the general shortage of workers, nor would it guarantee to provide those willing to undertake elderly/dementia related care. Perhaps part of the solution is to provide more support for home carers: day care, night sitting service etc, rather than trying to provide inpatient / long care beds in institutions. Anyone who thinks dementia care or indeed care of the frail elderly is easy just as long as you have the right training should try it themselves. See how long you last.
See reply to your question in comment at the top of the list
The article suggests that reintegrating the nursing profession’s medical and social care by returning to the paid apprenticeship mode of training on the wards will remove the alientating requirement for a ‘degree’ and so rekindle the nearly dead recruitment situation. Student nurses, years one to three, would be NHS employees, not university undergrads under the control of the Blob. This extra deployable workforce of the student nurses would have enabled those Covid hospitals to be staffed, the university controllers stopped their deployment. This extra workforce would provide social care of a far higher quality than obtains now.
I agree with most of what you say but there’s no guarantee graduates would want to work in social care. I wouldn’t have touched it with a bargepole when I qualified aged 21; at that age you tend to want the glamour: acute admissions/A&E/surgery… the heroic stuff. And let’s not pretend that the salary would suddenly rise enough to be enticing.