The Cavendish Review

The inquiry into the deaths of patients at Mid Staffordshire NHS Foundation Trust (the Trust) by Robert Francis QC, published on 6 February 2013, investigated between 400 and 1200 deaths at the Trust from 2005 to 2009. The report catalogued the many failures of the NHS managers and regulators to identify the poor standards of care towards patients at the Trust, and produced a number of recommendations. Thoreya Swage looks at the Cavendish Review, which was set up to address them.

There were four key recommendations that focused on the role of unregistered staff or healthcare assistants, which were to have in place:

  • a consistent description of healthcare support staff

  • a registration system for healthcare support staff

  • a code of conduct for healthcare support staff

  • a common set of national standards for the education and training of healthcare support staff.

In response to these recommendations, the Secretary of State for Health set up a review chaired by Camilla Cavendish to address these areas. The terms of reference included the consideration of any improvements in the way these staff are recruited, trained, supported and supervised, and to reassure patients and users that the care they receive is compassionate and competent.

The review did not cover statutory regulation of healthcare support workers, which the Government considered was adequately managed by the Care Quality Commission (CQC) under the current general assurance processes.

In the 14 weeks available for the review, much of the work was conducted with frontline staff in hospitals and care homes through focus groups, seminars, webinars, online surveys, meetings and informal consultation, and included domiciliary care staff, healthcare assistants, personal assistants, nurses and registered managers. In addition, information on best and innovative practice was sought from some of the best organisations in health and social care.

Although the report addresses the issues relating to more than 13 million healthcare support staff who work in hospitals, care homes and the homes of individuals, the findings apply equally well to the healthcare assistants that work in general practice.

The findings

The staff

There are over 100,000 support staff in health and 1.225 million in social care, who are overwhelmingly female (about 84%), a high proportion of whom come from black and minority ethnic groups (15% health and 29% social care).

There is a profusion of titles ranging from healthcare assistants to auxiliaries to support assistants, which causes confusion with the public, who are not able to tell the difference between these workers and qualified nurses.

Given the multitude of titles that these support staff are called, for ease of reference, those working in the health sector are called healthcare assistants, and those working in the social care setting are referred to as care workers.

The per annum pay levels in healthcare range from £14,294–17,425 for a junior post to £18,838–22,016 for assistant practitioners, and bears no relationship to any national standards of training or performance.

The scope of their work includes tasks such as making beds, helping patients to eat, drink and bathe, monitoring vital signs, undertaking simple dressings and accompanying patients to theatre.

Increasingly, more advanced tasks are being undertaken, such as female catheterisation, insertion of intravenous tubes and venepuncture, applying complex dressings including plastering, giving injections and setting up infusion feeds, taking ECG tracings, liaising with medical staff, and conveying medical information to relatives and writing up care plans.

The difference between a registered nurse and a healthcare assistant is that only the former can administer the full range of prescription-only medication, whereas the latter can do this only under the supervision of a nurse. In addition, the role of the nurse is to assess, plan and implement patient care and delegate appropriate tasks to the healthcare assistant. However, increasingly, healthcare assistants are being asked to undertake tasks that used to be the remit of nurses.

In social care, although these staff carry out “basic” tasks, there is an expectation that these workers should be able to work independently, going into people’s homes and dealing with what they find there without any direct supervision. The pay levels are lower than that for healthcare, equating to £13,974 per year.

The tasks range from helping someone with their shopping, changing dressings, diabetes and pressure sore management, administering medication, venepuncture and catheter insertion. These tasks are again supposed to be under supervision, but this is not always necessarily the case.

Both types of support workers in health and social care tend to have low-level or no qualifications at all.

Feedback from the healthcare assistants, care workers and users

The feedback from the focus groups highlighted the need for employers and commissioners of services to value healthcare assistants more and ensure that their pay more accurately reflects the tasks they do. This group of staff has suggested that there needs to be greater clarity about their roles and a better career path.

The review also sought views from individual patients and users of care services as well as charities and campaign groups. From this, three main areas of need were identified:

  • to build relationships with each individual who is cared for, ie how to act with compassion and respect rather than just focusing on tasks

  • to know that healthcare assistants or care workers have reached certain levels of competence

  • to understand the difference between the support workers and who is in charge.

Training and development

Training for people undertaking support worker roles generally is inconsistent and mostly of a level insufficient to guarantee the safety of patients and users. There is a large range of vocational qualifications available, but there was very little evidence that these resulted in improved outcomes. This causes confusion for employers as to which courses have enough rigour to train their support staff and therefore, in some cases, they provide their own in-house training to meet the standards that they require.

There were, however, some isolated examples of excellent training, demonstrating the commitment some employers had to the development of their unregistered staff. There was an urgent need to have a consistent “Certificate of Fundamental Care”, which would encompass the minimum standards expected of a care support worker across health and social care, building on the National Minimum Training Standards developed by Skills for Health and Skills for Care and linked to the National Occupational Standards.

When nursing was made an all-degree profession over a decade ago and the role of the State Enrolled Nurse was abolished, this removed the possibility of keen and talented healthcare assistants progressing on to nursing.

There are no courses available to bridge the gap between healthcare assistants and nurses and often the former would be expected to fund some of their training themselves.

Supporting care support workers

The review noted it was essential that healthcare assistants felt supported in their work by their immediate managers who, in turn, should be supported in this role further up the organisational hierarchy. Accountability for healthcare assistants should be at board level with the Director of Nursing responsible for their performance. Similarly, this should be the case with employers of social care services.

It noted too that the army treated its healthcare assistants as part of the whole team and set high standards for their performance. This supports growing evidence that outcomes for care are improved when all staff are valued as part of a team.

The employment terms and conditions are not conducive to good-quality care with the advent of zero hours contracts, cuts in fees and lack of payment for travel time, making it difficult for some workers who provide care in the home to continue. This, together with frequent long shifts, results in high attrition rates.


The recommendations cover four key areas.

Recruitment, training and education

The recommendations under this heading propose the following.

  • Health Education England, in conjunction with the Nursing and Midwifery Council (NMC), employers and other key agencies, develop a “Certificate of Fundamental Care” to demonstrate a minimum level of skills attained by support workers, and together also develop a “Higher Certificate of Fundamental Care”, which should be linked to more advanced competences.

  • The CQC should require care workers in health and social sectors to possess the “Certificate of Fundamental Care” before they are permitted to undertake their work unsupervised.

  • Nursing students and healthcare assistants complete the “Certificate of Fundamental Care” together.

Developing a career in caring

These recommendations include the following.

  • The development of new bridging courses by Health Education England and the Local Education and Training Boards, which help healthcare assistants move into pre-registration nursing and to widen the opportunities for such workers to go into NHS-funded programmes.

  • The NMC making caring experience a requirement for beginning a nursing degree and assess the contribution of such experience towards a “fast-track” degree. Similarly, Skills for Care should assess how this experience can enable care workers to go towards other courses, such as social work, therapy and other related programmes.

  • Both health (NHS employers and Health Education England) and social care should establish a clear career framework linked to job roles and core competences.

Encouraging the best from people

These recommendations highlight the need to:

  • permit healthcare assistants to call themselves “Nursing Assistant” on completion of the “Certificate of Fundamental Care”

  • ensure that Directors of Nursing are accountable at board level for the training and performance of healthcare assistants

  • review the proposed Skills for Health code of conduct for staff in social care and, for health, enhance the social care compact or develop a formal code of conduct by June 2014.

Time for caring

These recommendations consider the following.

  • Commissioning for outcomes and not activity should be set up by 2017.

  • The impact of 12-hour shifts undertaken by healthcare assistants should be taken into account when reviewing the effect on patients and staff.

  • There should be statutory guidance for councils to include payment for travel time for care workers undertaking work at people’s home.

Implications for primary care

While all the recommendations apply to healthcare support staff that work in hospitals, care homes and the homes of individuals, the recommendations do have an implication for primary care.

There are healthcare assistants who work in general practice, undertaking many roles including basic health checks and assessments, health advice and phlebotomy. Many of them do not necessarily have the required training or background, and some work unsupervised.

Although some healthcare assistants do have a clear job description, receive appropriate levels of pay and work closely with the practice nurse, this is not the case for all. The level of functioning in primary care requires a high degree of maturity and resilience.

When the “Certificate of Fundamental Care” is developed and staff begin to qualify, patients will be increasingly asking about the level of competence of the healthcare assistant who is taking their blood pressure or doing the ECG. In addition, the CQC may begin to ask about the training and development of healthcare assistants working on their own within the surgery setting.

Furthermore, as their counterparts in hospitals and care settings begin to receive remuneration that is reflective of their skills and qualifications, healthcare assistants in primary care may migrate to those sectors and leave a decreasing pool of potential staff who could fill the void.

Practices may wish to consider the tasks their healthcare assistants are undertaking in light of this report. It will only be a matter of time before the recommendations of the Cavendish Review will start to be applied to primary care.