It is not every day that you get to show a cabinet minister your job, but Layla Rumble, a maternity assistant at Bloomsbury Birthing Centre, part of University College London hospitals trust, did just that last month. The health secretary, Patricia Hewitt, scrubbed up and in NHS uniform, discovered the extent of Rumble's role in caring for women in labour, assisting the midwife with delivery and making postnatal visits.
She notes that Hewitt was "surprised at the diversity of the job". Rumble explains: "I take observations - blood pressure, temperature and pulse rate - and I record those in the notes. Legally, that is the midwife's responsibility."
Rumble is not qualified as a midwife or nurse, but she is one of 220,000 nursing auxiliaries and healthcare assistants (HCAs) who could provide the answer to Britain's shortage of nurses.
They will need to come from somewhere. Since 1997, Britain has relied heavily on overseas recruitment - a third of qualified staff registered by the Nursing and Midwifery Council (NMC) last year came from abroad.
The NMC figures show overseas recruits fell by a fifth last year and could drop further, amid fears that developing countries are being stripped of skilled staff that they can ill afford to lose. At the same time, the worldwide nurses' shortage means competition for recruits is intense, with the US pulling in nurses from the UK and the rest of the world.
The picture is complicated by a recruitment freeze at many NHS hospitals, imposed not because nurses are no longer needed, but because of widespread financial deficits.
Foluke Ajayi, head of recruitment at NHS Employers, says: "In terms of future [nurse recruitment] projections, we need to maintain the momentum. We're looking at significant numbers retiring in the next five to 10 years. We need to build up numbers to accommodate that."
Gail Adams, head of nursing at public services union Unison, argues that HCAs are lining up to fill the gap; at a conference of 400 HCAs, 84% said they wanted to qualify as nurses. The snag is that, as low-paid workers, often women with families to support, "the only realistic route into training is through a secondment. They cannot afford a 50% drop in salary on to a student bursary", Adams says. The bursary is just £5,837.
The Department of Health (DoH) has this year allocated £185m to fund HCAs to train while on paid secondment from their jobs, with about 13,500 places offered through schemes set up on a trust-by-trust basis.
Lyn McIntyre, assistant chief nurse at Addenbrooke's trust, manages the secondment scheme there, and says the more mature HCA secondees bring NHS experience that nursing students usually lack. Once trained, they do particularly well, she says. "They've all moved up. There is one in an F-grade position, a junior sister on a ward."
But around the country there are not enough secondment places for the number of HCAs wanting to take them up. Kim Hazeldine, an HCA at Stockport foundation trust, with 18 years' experience, is one of the lucky ones. Having started her course on a bursary, she was allowed by her trust to apply retrospectively for a secondment. "The trust was very supportive," she says. "I've got a family and it meant me and my family wouldn't have to struggle on a bursary. It's not a big amount extra, but it makes a difference. We can manage."
Hazeldine, who competed with a colleague for the single secondment available between them, says it is "a tragedy" for HCAs who cannot get a secondment, and will put them off entering qualified nursing. "There are a lot of men and women who won't come forward because they won't be able to do it on a bursary," she says.
One who is wrestling with her next move is Michelle Addams, an HCA at west London hospital. She has nine years' NHS service and had no problem securing a training place at university, having worked hard to gain literacy and numeracy qualifications and an NVQ Level 3. But she fell at the second hurdle - trying to get a secondment from her trust.
"There were 24 people, but they said they had money for just 10 places," she says. "I was crying like a baby. If we are that good to go to university, why are we no good for a secondment?"
Addams, a single mother with a four-year-old son, is now in a dilemma. Studying on a bursary will mean taking on part-time work on top of the full-time course. "It means working seven days a week," she says. "Would I be able to concentrate? I would need to do it for three years. And I need to spend time with my boy."
The myriad different rules that trusts have adopted for their schemes also leave some HCAs in difficulties. At Shrewsbury and Telford hospitals trust, Jo Smith found secondees will only receive 80% of their wages. "You either give 20% back or you have to work a [day's] shift a week. If I'm studying, that'd be six days a week. I've got children as well," Smith says.
The reduced pay would bring in only £1,500 more than a bursary and Smith's benefit entitlement. "The HCA door's opened - but they're closing it at the same time," Smith says. "There should be 100% funded secondments across the board."
Lucia McKeever, for 27 years an HCA at Armagh and Dungannon trust, has long sought a place on her trust's scheme, a distance learning course run with the Open University. But she works in the learning disability field and the scheme is restricted to those in mental health. Now she wonders if she will ever go further. "I'm rapidly coming to the stage where I feel I'm too old," she says. "It's a great waste of skills and experiencefor any HCA."
Hewitt told the Unison HCAs' conference that she would ask DoH officials how nurse training could be changed "to tap into this thwarted potential of HCAs".
Adams says: "The secondment scheme is a positive step, but it needs greater funding and an end to the lottery of who gets a place and who doesn't. Every trust seems to do their own thing. There needs to be a fair and transparent system to ensure that everyone is treated on an equal basis."
Aware that finance directors whose trusts are millions of pounds in the red might not be feeling sympathetic, she adds: "You can't let short-term financial deficits affect decisions about the future NHS workforce; 60% of nurses are now over 40, and we need to train enough to cope with their retirement."
Some names have been changed.
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