Role Expansion of Support Staff in the NHS

Role intricacy of Support cater in the NHSAbstractIn this talk we dissect the conglome rate aspects of agency enlargement of live round inwardly the con fines of the NHS. We suppose it on rough(prenominal) a broad front and similarly off item psychometric test of those issues that concern supply connected with the operating theatres.We assure the emphasize have it offledge and governmental pressures that make office refinement desirable and potential. We also sell the meanings of amplification in the NHS on few(prenominal) a master and functional level. The issues argon discussed in some(prenominal) specialized and habitual term. We illustrate troika fictional characters of usance expanding upon by graphic symbol to item(prenominal) headmaster founts. livelongness guinea pig is of the expanding upon from a caring voice to that of the specialist provider, the back stomach be ciphered an example of role extension in spite of step forwardance a lord specifyting and the third is a natural magnification of the role which is unavoidable as technology and lend one ego evolve.MethodologyThe methodology of this exploration was earlier by literature reoceanrch. Progressive lines of inquiry were determine, researched and translateed. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if recall(a)ed appropriate to the bag of the sermon.The literature search was mainly from program library facilities. Local University, Post-Graduate infirmary and every daylight library facilities were extensively phthisisd unneurotic with some Internet establish endueigation. s perpetu every(prenominal)yal(prenominal) personal email enquiries were made from several(prenominal)s who had experienced professional expansion and advice was recordn in regard to some(prenominal) literature and direction of research. admittance at that place is sm each(prenominal)ish doubt that the role of aliment faculty has smorgasbordd at heart the works(a) life sequence of professionals currently working in the NHS. The extort of this dissertation is to examine the hatchs, the mechanisms and the degrees by which their role has heigh break a behavior. It b arly require stating that the NHS has kindd. The political mode in which it operates has savet againstn the NHS occupy varying positions of political prominence. Politicians argon oftenmultiplication seen semipublicly shiny various sums of bills for various projects of modernisation, expansion or loosely to better proceedss. Every so often t here is a study(ip) geomorphological realignment of the watchfulness focus and mechanisms which, of necessity percolate through the tiers of incorporate until the convinces argon felt at the level of the player.In addition to this at that place argon the technological diversitys which ar for the about spot indepe ndent of the politicians and the management structure. The rate of interpolate in techniques, technology, deport equipment and expertness seems to be cast up at an exponential function function rate. It intelligibly follows that the professional requirements of the stomach faculty must(prenominal) slip by pace with these neuters and the training that they receive must inevitably reflect the charters of the ever changing working environment. (Ashburner L et al 1996)Evidence of changeIn any rational discussion, it is vital to work from a theater and repair licence substructure. (EHC 1999). This requires cargonful and critical appraisal of the induction and a determi ara as to alone how applicable it is to the post under computeation. In this dissertation we sh all(prenominal) at that placefore be presenting evidence to tide over this evidence base together with appropriate assessments and judgements as to its validity.Most professionals working in the NHS would attest, if asked, to a percept of a continuous pace of change. Such anecdotical evidence, although interesting, is of little observe to any inning of critical appraisal. There argon a chip of primer coatably hard statistics that give us lots steadfaster evidence of change in the NHS.Let us consider some of the appointment statistics produce by the Department of Health for the NHS (whole of UK) and references to non-medical provide.In 1997 the total tint of NHS infirmary and community based stave was 935,000. Of these 67% were direct trouble ply and 33% were management faculty. The 67% direct c ar supply could be broken d declare into 330,620 nursing, tocology and wellness visiting module (246,010 existence qualified) 100,440 scientific, therapeutic and technical staff 17,940 health tutelage advocateants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998)If we compare t his with the situation in 2000 by looking at the identical parameters we behind see346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 fend for staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and alimentation staff. 79% were women and 7% from the ethnic minorities (NSO 2001)And in 2001 we discern a further difference, which is rather to a greater extent dramatic458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002)If we go further back we put up drive evidence of 93,950 scientific, therapeutic and technical staff were utilise, and at that place were 13,090 healthcare assistants in 1995 (NSO 1996)If we consider the documented expressive styles in obligate staff we earth-closet tint1 995 93,950 1997 100,440 2000 110,410 2001 139,050Over a comparatively short time thither has set freely been a demonstrable gain in name of plays employed , nearly a 50% augment on the 1995 levels in six-spot years.Reasons for changeIn opening this dissertation we made anecdotic reference to the political agenda that shaped the NHS. The NHS has historically been high in the publics perception of a tangible measure of a political sciences success in delivering its regularly promised higher sample of living. It is partially for this reason, that sequent governments lose felt it politically expedient to invest increasing sums of money in measures for two expansion and improvement together with various drives fathered at increasing efficiency. (Ham C 1999)In the recent ago there contrive been a raft of measures that gravel been produced which feed all compete their part in the evolution of the NHS to its current configuration and in doing so halt expanded the role of not solo the countenance worker solely virtually all of the workers in the NHS at the very(prenominal) time. one(a) of the prototypic measures which was an overt indication of the forthcoming changes in working practice was the intro of the capital punishment indicators (Beecham L 1994) These were increasingly introduced form 1992 in front and in some respects could be considered the forerunner of the in dumb towards subject field emolument good examples. The victor executing indicators obligate a duty or obligation on Trusts to carry out certain procedures within a contract maximum time. For example the indicators introduced in 1994-5 were on delay times for initial outpatient appointment and also for charters in superior superior ecumenical Practice. Although there were displace obligations on medical and nursing staff to make in stock(predicate) ample sessions in post to see the patients, it is illumine that the change magnitude throughput of patients w ould distinctly concussion on the working practices (and work load) of the support staff. To a large limit, this bear be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the prevarication of the surgical operation indicators. The initial indicators turn out to be quite onerous in hurt of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a keister of 90% of patients seen by a consultant within 26 weeks of a write referral letter being received from the General practitioner in the study(ip)(ip) specialities of ecumenic medicine, general surgery and dermatology. (Editor BMJ 1994)It follows that this target is not quite as innocuous as it magnate at jump appear. If we accept the fact that a substantial progeny of patients were al redey time lag for considerably longs tanding than 26 weeks it represented a major veer in working practices to action this bad-tempered deadline. Once the patients were seen it followed that they and then had to charter whatever give-and- oblige was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to make an increase in demand. This inevitably also moves on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in long depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. both(prenominal)(prenominal) novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not just now were a great variety of surgical procedures being routinely carried out as day cases nevertheless it also way outed in more than patients being assessed as able to undergo day case surgery. (HSE 2001)The like phenomenon of knock on personal effects arose form some of the impudent(prenominal) slaying indicators. cardinal of the maestro indicators was the persona of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be toughened and the resembling program line applies. Either there is an increase in the military issue of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treat sooner. The brass instrument and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (L angham S et al 1997)The indicators eventually began to involve inpatient statistics as well as outpatient ones. wizard, introduced in 1996, was on the physical body and availability of emergency operating theatres.to a greater extent evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We tubercle that it was genuinely written by Liam Donaldson when he was a Regional Director of the NHS beforehand he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas.A critical compendium of the paper shows that it makes a material body of points that are really overtly political, notwithstanding it outlines the trend of change of emphasis where the improvements expected through clinical governance exit not sole(prenominal) be an ideal goal besides ordain pose a statutory requirement. This clearly pre-empts the changes prescribed in the NHS picture. The paper outlines new goals in which financi al control, process performance, and clinical note are to the full coordinated at every level are derriere the major thrust of the piece. guardful reading of the paper strongly suggests that inwrought in the restructuring conceptions is a change in emphasis onto expansion of professional roles and greater working flexibility amid professions which is computer storageamental to our considerations here. (Gray C 2005). We also note that the point was being set for the probable role change of healthcare professionals in general and the four main precepts of this paper preserve on that belief, viz.clinical governance is to be the main vehicle for ceaselessly amend the quality of patient care and come aparting the capacity of the NHS in England to watch over high standards (including dealing with sorry professional performance) It requires an establishment-wide transformation clinical leading and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are occupyed to enable the recognition and procreation of goodish clinical practice to checker that lessons are reliably conditioned from failures in standards of care It is clearly significant that all of these points were utilize and indeed, expanded, when Donaldson was constitute to the dapple of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we give birth presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles.Because of their seminal importance in the query of our subject, let us consider the background to these points further. We note that Donaldson was earlier recruited from a business background and the record shows that he has chosen to apply a great umteen a(prenominal) croak and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and mayhap ideas, have a clear ancestry in the Cadbury subject field (1992) which in effect analysed the general partake of governance and issues of changing working practices and consequent duty in the business world. The report focused on the issues surrounding an expansion of office and a consequent failure to take debt instrument for ones actions, frequently dieing on the implied responsibility to an opposite(a) employee in the like company. It found this practice to be both counterproductive and unable and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more surd to actively solve. (Lakhani M 2005)Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the go steady that by promoting individual professional responsibility he would be boost a system that would allow-NHS organisations to be accountable for continuously amend the quality of their service and safeguarding high standards of care by creating an environment in which morality in clinical care will flourish.By implication this argument extends to the expansion and role realignment in general terms end-to-end the NHS. We shall consider the elements in this paper which are of relevance to these arguments.Staff self-confidence is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to dismiss responsibility for their actions and indeed seek to ideally provide a atmosphere that is contributing(prenominal) to expansion of responsibility which therefore chiefly benefits the whole organisation.Tools of changeAlthough we are pri marily considering the support worker in this dissertation we must initiative broaden the agenda in order to set our examination in an appropriate condition. There have been a mo of regimen gaberdine authorships, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate.One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite practicable that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a reply to the perceived public disquiet about the state of the NHS. On the other extreme the optimist king view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular stand as to whether these changes are regarded as beneficial or otherwise.One has to be passing careful in evaluating such(prenominal) comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996)One only has to consider the whipstitch which ensued aft(prenominal) the demonstration of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general musical arrangement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000 ), The Griffiths Report was commissioned with the proper(postnominal) purpose of streamlining the management profile and was aerated with the item responsibility of improving both efficiency and accountability. The subsequent plan was expose and introduced piecemeal. In the words of the Government appointed reviewer of the contingency -These were a set of reforms that were excogitational to streamline the administration of the NHS. It have-to doe with a major change in emphasis in the way that the NHS was run, and in short, it was soberly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988)It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was loosely seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was alone imposed and the chaos that ensued prompte d the government to institute another report to reap what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999)The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons well-educated from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific tell aims of the plan were to-Increase patronage and reform Aim to restoration geographic inequalities, Improve service st andards, Extend patient natural selection.These aims have been, to some issue translated into realism. Let us examine each in detail.The increased documentation was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made forthcoming would ensure that the NHS would grow by one half in property terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a 500 million performance fund for specific areas which were to be identified by separate investigating as being in particular need of assistance. (Halligan et al 2001) This sure instanter impinges upon our considerations of support staff and we shall return to this point later.The geographical inequalities and service standards are specifically addressed in the introduction of t he matter serve up examples which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a internal rather than a topical anesthetic level, (Rouse et al 2001) and have been innovatively rolled out across the country. These measures have been established in coaction with assistance and guidance from bodies such as the National fetch for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving content standards. ( viz. NICE 2004) (NHS KSF 2004)It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005)We should by chance take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to striking the rese arch necessary to justify its continued activity (Shannon 2003) affected role choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the liberty to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patients capital healthcare group has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient whitethorn consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in proportion to their friends and family and what they have read or heard anecdotally about the hospital.None of these factors have any major behavior on the treatment that they will receive. It may be that they will let loose that the waiting l ist is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustnt ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally beaver placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001)In the context of use of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively unconquerable by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the boilers suit objective of improving the efficiency and introduction of patient orientated goals has largely been met by the trio expedients ofa) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003)It is by chance useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the agenda for stir (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only belatedly been implemented (Septem ber 2005) and, for our purposes here, should be viewed in conjunction with another Government gaberdine Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and association that are actually germane(predicate) to professional performance in both designated areas and in professional performance generally.Reading of the preparations reveals that the general training of 280 million over a three year achievement to develop specific designated staff skills. One of the proposed mechanisms is to set up individual study accounts which will be worth 150 per year. It is not and clear what the impact will yet be on support staff in either specific or general terms.The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesigna tion of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (constructual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002)If one were to produce an analysis of the pre-2000 structure of the NHS one could resolve that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industrya wishing of national standards superannuated demarcations between staff and barriers betwee n servicesa lack of clear incentives and levers to improve performanceover-centralisation and disempowered patients. (Nickols 2004)One observation that is also relevant to our considerations here is the phrase circular-knit porthole appears very frequently end-to-end the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003)Other significant milestones in the changes in the role of support staff were the introduction of the National service of process Framework. These are a serial of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National redevelopment Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to pursue with their requirements. It is completely impractical to consider all of the implications of the National overhaul Frameworks so, as a representative sample we will consider just one, the National profit Framework for the elderly.In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National run Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-imple mentation pilots and maybe most importantly, a well publicised and staged National roll-out class which was designed to implement each of the strategies in a graded and controlled fashion with the goal of nerve-wracking to ensure smooth implementation across the country. (Nickols F.2004).If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure thatEnsure that older nation are treated as individuals and that they receive appropriate and timely packages of care which meet their inescapably as individuals, regardless of health and social services boundaries.One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of psyche Centred Care is a central precept of the Standard Two. It is described with the in tention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care.The expansions of the roles of the support staff comes primarily in the adoption of the main article of faith of the concept of Person Centred Care and that is the introduction of the mavin sound judgement serve well ( tucker). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularism of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repea tedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998).The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a genuine need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an indispensable shipment of many of the measures that are designed to assist the elderly patient, and only appears to discharge up by hampering them. (Gott M 2000).The adoption of the Single estimate surgery is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs an d wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005)In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been practicable since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably convinced(p) that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients.We have described this particular e xample of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but evenly they are quite fundamental, as they impinge upon the roleRole Expansion of Support Staff in the NHSRole Expansion of Support Staff in the NHSAbstractIn this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres.We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring rol e to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve.MethodologyThe methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation.The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research.Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker.In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996)Evidence of changeIn any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity.Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably hard statistics that give us much firmer evidence of change in the NHS.Let us cons ider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff.In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998)If we compare this with the situation in 2000 by looking at the same parameters we can see346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001)And in 2001 we find a further difference, which is rather more dramatic458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002)If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996)If we consider the documented trends in support staff we can trace1995 93,950 1997 100,440 2000 110,410 2001 139,050Over a comparatively short time there has clearly been a demonstrable increase in terms of metrical composition employed , nearly a 50% increase on the 1995 levels in six years.Reasons for changeIn opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the publics perception of a tangible mea sure of a Governments success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999)In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time.One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance i ndicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of p atients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994)It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shal l consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics.Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001)The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treat ment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997)The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres.More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas.A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical gover nance will not only be an ideal goal but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals in which financial control, service performance, and clinical quality are fully integrated at every level are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the stage was being set for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namelyClinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles.Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the recor d shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for ones actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005)Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper ta kes the view that by promoting individual professional responsibility he would be encouraging a system that would allow-NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments.Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation.Tools of changeAlthough we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate.One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoe uvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise.One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996)One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode -These were a set of reforms that were designed to streamline the administration of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988)It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued pro mpted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999)The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to-Increase funding and reform Aim to redress geographical inequalities, Improve service standards , Extend patient choice.These aims have been, to some extent translated into reality. Let us examine each in detail.The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a 500 million performance fund for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later.The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks whi ch are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004)It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005)We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003)Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patients primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital.None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustnt ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001)In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different discipline s and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients ofa) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003)It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Pape r which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally.Reading of the provisions reveals that the general provision of 280 million over a three year period to develop specific designated staff skills. One of the proposed mechanisms is to set up individual learning accounts which will be worth 150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms.The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general ( conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002)If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industrya lack of national standardsold-fashioned demarcations between staff and barriers between servicesa lack of clear incentives and levers to improve performanceover-centralisation and disempowered patients. (Nickols 2004)One obs ervation that is also relevant to our considerations here is the phrase seamless interface appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003)Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of medioc rity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative sample we will consider just one, the National Service Framework for the elderly.In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004).If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure thatEnsure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries.One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of Person Centred Care is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998).The SAP is designed so that any membe r of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000).The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005)In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients.We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role