Ambulance, Ancillary, Professional, Scientific and Technical, Works and Maintenance Staff
15.1 In this chapter we deal with the professions supplementary to medicine, and scientific and technical staff. We also look at ambulance, ancillary, and works and maintenance staff about whom we heard in evidence relatively little. We dealt with matters common to health workers in Chapter 12.
Professions Supplementary to Medicine
15.2 The eight professions covered by the Professions Supplementary to Medicine Act, 1960 (the PSM Act) are chiropodists, dietitians, medical laboratory technicians (now designated in Whitley Council agreements as medical laboratory scientific officers), occupational therapists, orthoptists, physiotherapists, radiographers and remedial gymnasts. Speech therapists are usually included in this group though they are not covered by the Act. Table 1 shows how many staff have been employed in the NHS during the period 1974-1977. Chiropodists most of whom work in private practice, were discussed in Chapter 8 and we do not deal with them in detail here. The other professions fall into two broad groups – the remedial group consisting of occupational therapists, orthoptists, physiotherapists, remedial gymnasts and speech therapists; and the scientific group consisting of dietitians, medical laboratory scientific officers and radiographers.
15.3 Our evidence concentrated on two linked problems common to these professions, arrangements for regulating them, and shortages.
TABLE 15.1
Members of Professions Supplementary to Medicine, Speech Therapists, and Helpers Employed in the NHS: UK 1974-1977
Whole-time equivalents
| Profession | 1974 | 7975 | 1976 | 7977 |
| Chiropodists | 1,511 | 1,660 | 2,121 | 2,484 |
| Dietitians | 572 | 627 | 707 | 755 |
| Occupational Therapists | 1,988 | 2,340 | 2,561 | 2,774 |
| Orthoptists | 385 | 403 | 441 | 457 |
| Physiotherapists | 5,737 | 6,222 | 6,866 | 7,073 |
| Radiographers | 6,204 | 6,890 | 7,154 | 7,754 |
| Remedial Gymnasts and Trainees | 252 | 277 | 295 | 351 |
| Speech Therapists | 1,180 | 1,156 | 1,481 | 1,539 |
| Helpers in: | ||||
| chiropody | — | 36 | 23 | 21 |
| industrial therapy and occupational therapy | 2,400 | 2,638 | 2,885 | 2,979 |
| physiotherapy | 1,217 | 1,411 | 1,530 | 1,659 |
| radiography | 94 | 88 | 96 | 91 |
| remedial gymnastics | — | 31 | 34 | 48 |
| speech therapy | 3 | 18 | 24 | 28 |
Source: health departments’ statistics
Notes: Medical Laboratory Scientific Officers are covered in Table 15.2.
Regulating the professions
15.4 The PSM Act established for each of the eight professions supplementary to medicine registration boards with the general function of promoting high standards of professional education and conduct. The boards cover the UK and are responsible for maintaining registers, and for approving courses of training, qualifications and training institutions. Each registration board has a majority of elected members of the profession concerned. In practice one professional body dominates each of the boards and can normally secure the election of all its professional members. The boards operate under the general supervision of the Council for Professions Supplementary to Medicine (CPSM) whose membership is composed of representatives of the eight professions, plus eight medical and seven lay members. On major matters the boards require the approval of the CPSM and the CPSM requires the approval of the Privy Council.
15.5 The Act itself does not prevent unregistered members of the professions practising, though it does limit the use of the titles “state registered”, “registered”, and “state”. However, when the Act became fully operative in 1964 regulations were made which prevent the employment of unregistered members of the professions in the NHS, though not outside it. Comparable regulations apply to speech therapists. The effect of the registration machinery was to give control of standards and qualifications to the professions themselves.
15.6 These arrangements have been criticised on the grounds that they place too much power in the hands of the professional bodies who have an interest in limiting entry to the professions. Developing longer and more thorough training may be perfectly consistent with the duties of the registration boards but may not be necessary to meet the needs of the NHS. However, with the possible exception of chiropodists, which we comment on in Chapter 8, there has been little sign that the professions have tried to limit entry to their ranks, and numbers in the NHS have been increasing in most groups, as can be seen from Table 15.1.
15.7 Another criticism of the registration arrangements is that while they confer status and recognition on the professions they could induce rigidity rather than flexibility in staffing. In discussing the need for flexibility in Chapter 12 we noted the difficulties of integrating the two professions of remedial gymnastics and physiotherapy, and we comment below on the limited progress made in developing a common core training for some of the PSMs. Changes in training arrangements are the key to greater flexibility in the role of these professions, but the relationship between registration boards and CPSM could mean that desirable reforms are blocked. We consider that it is now time for an independent review of the operation of the machinery set up under the PSM Act and we recommend accordingly. The review should include manpower and training needs of the professions.
Shortages
15.8 As with other professional staff groups the potential demand for the services provided by the PSMs is very large. We have already noted that there have been increases in most of the professions in recent years, but despite this COHSE told us in evidence that there “are tremendous shortages of the various grades of staff who constitute the PSMs”. The 1975 Halsbury Committee of Enquiry into the pay of PSMs and speech therapists, while accepting that there “are no nationally recognised standards of staffing” and that “the figures must be treated with caution, as staffing standards vary and the scale of need is bound to some extent to be impressionistic”, recorded NHS shortages in some of the professions in Great Britain, for example 25% in the case of radiographers and 55% in the case of occupational therapists. While the Halsbury figures are clearly not to be regarded as accurate assessments of shortages, they suggest that the demand for staff in these groups markedly outstripped supply. With the exception of radiographers, where one recent study suggests a surplus, the position has probably not altered since The shortages occur mainly, but not exclusively, in hospitals where the great bulk of these professions are employed, speech therapists excepted.
15.9 Our evidence indicated widespread concern about shortages in these professions, although to some extent the shortfall has been taken up by the appointment of helpers, particularly in occupational therapy and physiotherapy departments, where, as Table 15.1 shows, numbers have increased considerably since 1974. The growing number of the elderly and pressure on the rehabilitation services will increase demand for most of the PSMs.
15.10 There are evidently difficulties in increasing markedly the number of trainees in the PSMs. Training arrangements vary: most orthoptists, physiotherapists, radiographers and remedial gymnasts are trained at NHS based schools; but most occupational therapy (and speech therapy) schools are outside the NHS, though making use of the NHS for practical work; while dietitians take a polytechnic or university course. There are three NHS chiropody schools, the rest of those training to registration standard being in colleges of further education. The main difficulty in increasing training places is a shortage of teachers, which has been long-standing in the case of the chiropody and physiotherapy schools, and was commented on by the Halsbury Committee. It is clearly essential to have an adequate supply of teachers if the numbers in these professions are to be increased.
15.11 Several of those giving evidence commented on the extent to which the training of the PSMs overlaps, and suggested that more could be done to integrate training. Dietitians apart, standards at entry are broadly similar; a minimum of five “O” levels is required, though most of the professions now seek an additional one or two “A” levels. Most training courses last for three Attempts have been made to establish integrated training schools, for example in Cardiff and London, but although those taking part were enthusiastic, problems arose between the professions and the courses ran into difficulties. A small step in the right direction is the recent decision to set up joint courses for remedial helpers. It seems to us that if there is to be an expansion in training facilities, it should take place at schools which provide for several of the PSMs. Prime candidates for integrated training are occupational therapists, physiotherapists and remedial gymnasts.
15.12 Our evidence about speech therapists, occupational therapists, physiotherapists and remedial gymnasts stressed the importance of evaluating techniques and the effects of treatment. This is recognised by the health departments, and indeed by the Chartered Society of Physiotherapy who emphasised to us the need for research. Proper evaluation of the work of these professions should influence decisions on the content of training courses and the number of staff required. This seems to us to be as urgent as increasing training places. We recommend that the health departments should continue their efforts to generate more research into the work of these four professions.
15.13 The Council for Professions Supplementary to Medicine put to us the desirability of the Council taking on a manpower planning role in addition to its existing functions. It is true that at present the registration boards and CPSM operate without firm guidance on the numbers needed in the professions for which they are responsible, but our view is that manpower planning at national level is a matter for the health departments and we do not support the Council’s proposal. Since the NHS employs the great majority of members of the professions, its needs should be made clearly known to the CPSM and the There is an obvious lack of an agreed and coherent manpower policy for the PSMs and we hope this will be developed. The remarks we made in Chapter 12 about manpower planning are relevant here.
Scientific and Technical Staff
15.14 There are over 20 separate staff groups in the scientific and technical services of the NHS. They range in size from the whole-time equivalent of 11 medical artists to nearly 16,000 medical laboratory scientific officers. They include university trained biochemists, physicists and psychologists and grades for which there are no specific educational requirements above “O” level. Numbers have grown rapidly (see Table 15.2) and new groups have emerged.
15.15 In the last ten years the dominant influence over the organisational development of this group of workers has been the Report of the Zuckerman Most of our evidence has revolved around the implementation or otherwise of the recommendations of this Committee. The other main problem put to us is the responsibility for management of laboratories.
TABLE 15.2 Growth in Certain Scientific and Technical Staff Groups in the NHS: Great Britain 1957-1977
Whole-time equivalents
| Grade | 1957 | 1967 | 1977 | % increase 1957-77 |
| Biochemists and Physicists | 337 | 753 | 1,627 | 383 |
| Psychologists | 153 | 336 | 965 | 531 |
| Dark Room Technicians | 877 | 1,204 | 1,428 | 63 |
| Medical Laboratory Scientific Officers | 2,942 | 9,657 | 15,878 | 440 |
| Medical Physics Technicians | 125 | 410 | 1,767 | 1,314 |
| Physiological Measurement Technicians | 579 | 1,172 | 2,149 | 271 |
Source: compiled from health departments’ statistics.
Implementation of the Zuckerman proposals
15.16 The Zuckerman Committee Report was published at the end of 1968. Its principal recommendations were the setting up of a scientific service to ensure the orderly development of scientific and technical services in support of medicine, and the creation of a new staffing structure which would provide a broader training and better career opportunities for the specialised groups involved in the service. The government accepted the report in principle in 1970 and a certain amount of progress has been made in implementing its recommendations, but it has proved impossible to implement the important staffing structure recommendations, or to introduce the organisation proposed for the hospital scientific service. There seem to have been two main difficulties: some groups of staff did not favour integration into a scientific service (and the negotiations were made much more difficult by pay policy); while the broader structural proposals were overtaken by NHS reorganisation which undermined the centralised, regional hospital board based pattern proposed by the Committee. Responsibility for providing scientific services at present rests with the area medical officers and equivalents.
15.17 In view of these difficulties the Secretary of State for Social Services set up a departmental team in 1977 to review the position. Their report and a draft circular were widely distributed last year. Their main conclusion was:
“a single scientific service – in terms of organisation, management and staff structure and grading – is not practicable nor acceptable; rather we should recognise the present development of three main scientific services – medical laboratory services, radiological services, and clinical engineering and physical sciences services”.
The team excluded from the three main services a number of specialties which had been mentioned in the Zuckerman Report, amongst them pharmacy, psychology, dietetics, orthoptics, and medical illustration and photography. They also recommended that dental and maxillo-facial technology should be excluded.
15.18 The Zuckerman Committee had envisaged that unification of scientific services would enhance the career prospects of the non-medical staff involved. The DHSS team acknowledged that their own proposals did not advance this strategy, but pointed out that while career prospects were extremely important the linking of grading to numbers of staff supervised was not necessarily appropriate to workers in the scientific services. In other words, it was not necessary to bring the scientific and technical classes together into one grading structure to improve their prospects. However, they recognised the “attractions of a single non-medical grade system”, for the scientific services if this could be introduced in the future.
15.19 The report of the DHSS team and subsequent actions were directed specifically at the scientific and technical services in England, and future development of the services in the rest of the UK will be considered in light of developments in England. At the time of writing, the team’s proposals are still being considered. Subject to what we say in paragraph 15.29 below, we think that the DHSS approach is on the right lines and hope it will be developed.
15.20 Our evidence does not suggest that present staffing arrangements are giving rise to serious problems generally: we discuss the particular question of managing laboratories below. The introduction of a common grading “spine” which has been supported, particularly by medical laboratory scientific officers, should probably be postponed until the future pattern of the services is clearer. It is important that high standards for appointment to senior posts in the scientific services are maintained, and it is our emphatic opinion that staff in these posts should normally be graduates in a scientific discipline and we recommend accordingly. We consider that the effective development of these services which underpin the delivery of patient care requires honours graduates who hold a PhD and have had a rigorous scientific training.
15.21 In the main, the laboratory services have developed in an ad hoc manner, based on individual hospitals, in close support of physicians and in response to local demands. However, technological developments, particularly in rapid means of communication, may make it unnecessary for them to be so closely linked to the delivery of patient care. Our own view is that the long term planning of these services should be considered on a regional basis if there is not to be overlapping and even duplication of provision, and if the rationalisation of services is to be promoted. It has been put to us that there has been a loss of impetus in planning since reorganisation and this needs to be We recommend that pilot experiments should be carried out to see whether a regional service for one or more specialties (for example, clinical chemistry and microbiology) might not be both more economical and more efficient, and give a better basis for training. In any event the Public Health Laboratory Service and the Supra-regional Assay Services should continue to fulfil their present, very valuable role in the provision of the scientific services.
15.22 At the national level there is no body similar to those for dentistry, medicine, nursing and the professions supplementary to medicine, to look after education and professional standards. Some of those who gave evidence to us considered that the Zuckerman proposal for a National Scientific Council should be implemented. It seems logical that there should be such a body and moves to establish one should be encouraged.
Laboratory management
15.23 NHS laboratories are usually based on hospitals. A laboratory may provide a number of pathology services depending on the local organisation of services, and may cover chemical pathology or clinical chemistry, haematology, histopathology, microbiology and immunology. Some, but not all, microbiology laboratories are linked to the Public Health Laboratory Service which deals with the control of communicable disease in England and Wales. The specialist services are provided by medical, scientific, and technical staffs. The head of a laboratory is usually a consultant pathologist or occasionally a non-medical graduate scientist. There was dispute in our evidence about how responsibility for the management of laboratories should be allocated.
15.24 In the past the policy on this matter has been quite clear. For example, the guidance issued by the DHSS following NHS reorganisation said:
“The fundamental unit is the department, comprising a body of people associated in a single discipline (eg chemical pathology or clinical chemistry, microbiology, radiodiagnosis), managed by a medical consultant or a non-medical scientist of equivalent standing who is the head of the department.”
It was envisaged that in some places disciplines might be linked in a combined department. Management arrangements were defined as follows:
“The head of department will be responsible for the proper functioning of the department. This does not mean that he must undertake all the management duties himself. There are some aspects of management which are commonly undertaken by a suitable member of his department (eg chief technician, superintendent radiographer). Particular examples of such delegated management functions are the organisation of technical training, the maintenance of proper technical standards, the deployment of technical staff and quality control procedures.”
1 5.25 In their evidence to us the Institute of Medical Laboratory Sciences, disputed these arrangements. Commenting on the DHSS guidance, they said it:
“failed to confirm and consolidate the changes in laboratory management that had taken place over the previous 30 years. Indeed it appeared to be trying to remove management responsibilities from technicians who were in charge of laboratories and to resurrect an obsolete laboratory management structure in which they exercise only those functions delegated to them”.
They said that “medical laboratory scientists do not seek medical responsibility, which properly belongs to pathologists”, but argued that they “have a responsibility to pathologists and the district management team . . . for the technical competence of the laboratory”. They proposed that “separate departments of the laboratory should be organised under one medical laboratory scientist who would be managerial head of the whole laboratory” and “managerially responsible for all medical laboratory work carried out within a district”.
15.26 The Institute went on to propose a staff structure which would integrate medical laboratory scientific officers and NHS scientists (biochemists and physicists). Pointing to increasing numbers of graduate entrants to the technician grades they said:
“Frequently it is a matter of chance or opportunity whether a graduate enters the career structure for medical laboratory technicians or that for biochemists and other scientific officers. Thereafter the graduate is likely to remain within the same career structure regardless of his abilities, interests or job performance.”
15.27 The evidence we received on behalf of the scientists recognised that it should be possible for the technical grades to achieve promotion, though the Association of Clinical Biochemists argued that transfer from technical officer to clinical biochemist grade would require an honours science degree or equivalent qualification at least. The Institute of Biology said that “the merging of the classes of technician and graduate scientist would lower standards of professional competence to the detriment of patient care within the NHS”.
15.28 Evidence from the pathologists emphasised the medical aspects of laboratory management and the importance of a pathologist being in charge. The Royal College of Pathologists said that:
“all laboratories should have a senior medical pathologist on the staff to be responsible for the medical aspects of their work. The heads of the departments in hospital diagnostic laboratories should ordinarily be medically qualified pathologists, but there are laboratories where the head could be a non-medical graduate scientist with appropriate training and experience.”
Other points made on behalf of the pathologists were that it was essential that “the pathologist should be the budget holder of his department”, and that the head of the department would “usually delegate some of his managerial duties and decisions to technicians”.
15.29 The management of laboratories was considered by the DHSS team referred to in paragraph 15.17. They proposed as a compromise that there should be both a head (or director) and a manager. We cannot support this It seems to us that a responsible head of department must manage, and that the proposal would lead to conflict.
15.30 It is unlikely that there is a solution to this problem which will be acceptable to all parties at present. The NHS needs now, and will increasingly need in future, the most able scientists it can get. On the one hand NHS scientists have recently felt threatened by the ambitions of the medical laboratory scientific officers; on the other, they feel that their scientific ability has not been adequately recognised by their medically qualified colleagues. There is a risk that unless the position of the scientists is secured by, for example, facilities for further training and research, and good prospects of getting to the top of their specialty, the NHS will not be able to recruit high quality staff.
15.31 It was put to us that the head of the laboratory should always be medically qualified because a doctor would be better able to collaborate with clinicians, judge the relevance of the laboratory’s work to clinical practice, and persuade clinicians not to make excess demands on laboratory services. We are not convinced. The weight of argument concerning the desirability of a medical qualification varies with the clinical responsibility of the department; it is stronger, for example, in the case of pathology than in medical physics or clinical chemistry. In our view possession of a medical qualification should not outweigh an individual’s capacity as a scientist, though where there are two candidates of equal scientific ability it is reasonable, given that there is nothing to choose between them on other grounds that preference should be given to the one who is medically qualified. Accordingly we recommend that the head of a laboratory should be the most able scientist available.
15.32 The head of the laboratory, whether medically or non-medically qualified, should of course be concerned about possible excessive demands on its services. Examples were brought to our attention of what appeared to be unnecessary investigations being carried out on patients, particularly the elderly. Hospital clinicians have a clear personal responsibility here towards their patients, and so have the clinical divisions, which should be monitoring the quality and effectiveness of services. Laboratory heads have a responsibility to inform clinicians not only about advances in laboratory techniques but also about the costs of procedures. Automation should be encouraged, as should the use of aides for simple tasks. Greater cost consciousness is required.
Ambulance Staff
15.33 In England and Wales the ambulance service was transferred from the control of local authorities to the NHS at the time of NHS reorganisation. The Regional Ambulance Officers’ Committee told us that before reorganisation:
“there was considerable local variation in the quality of the service provided, particularly in relation to vehicles, staff and equipment. Most Services were administered by Local Authorities through their Medical Officer of Health and his Ambulance Officer, a few were under the aegis of the Fire Service, whilst others relied upon agency methods for the provision of part or all of their services.”
15.34 An effect of reorganisation was a reduction from 142 separate services to 53 in England and Wales. Outside the metropolitan counties and London the ambulance service is the responsibility of area health authorities. In the metropolitan counties it is run by the appropriate RHA, while the South West Thames RHA runs the ambulance service for London. One of the disputes in the evidence was whether all services would be better run on a regional or an area basis.
15.35 In Scotland the service was operated before reorganisation by the St Andrews’ Ambulance Association under contract to the Secretary of State. In 1974 it was transferred to the NHS and the service is one of the functions of the Common Services Agency. The Director of the service is at the headquarters in Glasgow and there are eight local operational centres. In Northern Ireland the service was the responsibility of the Northern Ireland Hospitals Authority before reorganisation, and is now run by the four health and social services boards.
15.36 The work of the ambulance service, which in the UK in 1977/78 cost about £138m, falls into two distinct parts. First, it provides transport for emergency and urgent cases, which requires sophisticated equipment, trained staff, and vehicles able to take stretchers. Second, there is a non-emergency service which the health departments told us accounts for about 90% of the work: it takes to and from hospitals, out-patients and day patients who are not able to get there by other means. In Great Britain the ambulance service includes the hospital car service which is usually manned by volunteers and deals with some 14% of the non-emergency work. We have been told that the trend towards shorter in-patient stay, day surgery, and the concentration of resources on large hospitals are placing demands on the ambulance service which will be difficult to meet from existing resources.
15.37 Including workshop staff, there are the equivalent of over 20,000 ambulance staff in the UK. They divide into ambulance officers who are responsible for managing and controlling the service, for example directing ambulances to emergencies and drawing-up “runs” for out-patient clinics; and ambulancemen who man the vehicles. Ambulance officers are generally recruited from the qualified ambulancemen. Ambulancemen are locally recruited and trained. Training consists of a six weeks’ course in ambulance aid at a regional centre followed by 12 months’ practical experience, and refresher courses thereafter. About 80% of staff are qualified. One of the issues raised in evidence was whether, bearing in mind that the great majority of patients transported make little demand on the skill of the ambulancemen beyond the ability to drive the vehicle, less training was required. Staff interests argued that there should be more rather than less training of ambulance staff.
15.38 In Great Britain the pay of ambulancemen has since 1973 been negotiated on the Ambulancemen’s Whitley Council. The pay of ambulance officers, on the other hand, is dealt with by the Administrative and Clerical Staffs Whitley Council. It was put to us that this separation was based on a “false military analogy” and made for divisions in the ambulance service. A similar division exists in Northern Ireland.
15.39 We received evidence from the Director of the Scottish Ambulance Service, the Regional Ambulance Officers’ Committee, and from four ambulance organisations about the management of the service. The regional officers argued that the opportunity to create an integrated and standardised service provided by NHS reorganisation had not been realised. They complained that:
“Regional Ambulance Officers, except in Metropolitan Services, have no line management, their monitoring and co-ordinating role over Areas being restricted because no executive power exists at Region.”
They disliked the “corporate management system which is incapable of making rapid decisions” required by the ambulance service and proposed that in England the service should be run by regions.
15.40 The four ambulance organisations argued for the “tiering” of the They suggested to us that the “role of the Ambulance Service of the future should be divided into two distinct functions, ie Accident and Emergency Service and Community Transport Service”. They pointed out that it was uneconomical to use skilled staff and expensive ambulances for what was little more than a taxi service. The use of “tiering” is not new but there are different views on its value. The advantages are evidently greatest in large conurbations, and we understand that this arrangement is being tried out in some places. The DHSS told us, however, that experience had shown that in rural areas a more efficient cover for emergency and non-emergency work could be provided by a unified service.
15.41 It seems to us that the way ahead is to encourage experiment in ways of providing an ambulance service, for example by linking it with local authority transport services. In particular we recommend that in one or two instances the accident and emergency service should be organised experimentally on a regional basis with “community transport services” being provided by the lower tier NHS authorities; and the results closely monitored. When the structure is right then related manpower and training problems will need to be
Ancillary Staff
15.42 In the UK the NHS employs the equivalent of over 200,000 ancillary staff; only nurses form a larger group. Nearly half of them work as domestics or ward orderlies, but there are many catering staff and porters. Other ancillary workers include laundry workers, telephonists, vehicle drivers, stokers, storekeepers and workers in central sterile supply departments and gardens. Over 70% of ancillary workers are women, and over half work part-time. This is an important group of staff providing important services for patients such as cooking and laundry, and assisting in wards and theatres. They work closely with other staff groups and what we say in Chapter 12 on roles and relationships is relevant here.
15.43 The DHSS told us that “there is no evidence of shortage of ancillary workers” in England, and this is also true for other parts of the UK. Local shortages of particular groups of staff occur from time to time, as might be expected with locally recruited staff paid on national rates which have to compete with local industry. This is a particular problem in the London area. There seem to be two main reasons for the generally satisfactory recruitment The first is the UK’s high rate of unemployment, and the second is that the rates paid to women, which have been the same as those paid to men since 1974, are seen to be competitive for the kind of work undertaken. The DHSS told us:
“While the basic rate does not compare so favourably for men, there are incentive bonus schemes of “lead-in” payments applying to some 40% of staff and overtime is a significant feature in the pay packets of many”.
15.44 There has been little investigation of roles and expectations of ancillary staff in the NHS. One study undertaken of catering, domestic and portering staff in a number of London hospitals in 1975 by the City University Business School, supported by the DHSS, showed that most of the staff interviewed liked the hospital at which they were working and the job they did. Most of them, too, were satisfied with their pay, hours of work and working relationships. However, four major problem areas were identified:
- Induction and training Frequently when staff began work they were not made familiar with the hospital, the people with whom they would be working, or the correct way to do their job. This often led to initial difficulties and may have encouraged the less confident newcomers to leave their job . . . Lack of induction and training was a particular problem for staff who were not fluent in English.
- Conditions of work It has been commonly reported that working conditions for ancillary staff lag behind those provided for other hospital Conditions of work described by some respondents were undoubtedly poor and contributed to low morale. Particular criticisms were made of changing, washing and rest room facilities, and of uniforms.
- Status Many ancillary staff considered that their status in the hospital was low and that they were treated with thoughtlessness and a lack of consideration, in particular by some members of the nursing staff.
- Promotion Most ancillary staff felt that chances for promotion were poor, although almost half of those interviewed said they would not accept a more responsible job if they were offered one. Predictably, people who would have liked promotion but who felt that they did not have any opportunities for advancement, had lower levels of job satisfaction than “
The study concluded that the “most fundamental needs are for systematic induction and training schemes and an improvement in working conditions.”
15.45 Our evidence showed that some of the problems identified in the study referred to above are still with us. For example, the Community Relations Commission told us that it is particularly important for staff who were born overseas that language courses and induction training should be A radiologist in London referred to one of the consequences of the low status of this staff group as “the increasingly aggressive attitude on the part of the “forgotten” members of the Health Service – porters, cleaners, etc.” He went on: “Having for a long time been taken for granted they have realised that their contribution is an essential one and have ‘flexed their muscles’ on many occasions of late.”
15.46 The development of policies for the recruitment, training and role development of most ancillary staff in England and Wales has been undertaken by the National Staff Committee for Accommodation, Catering and Other Support Services since 1975. Training is considered to be a function of local management and is mainly on-the-job. The National Staff Committee has produced training kits for stores staff and is currently studying the training needs of other staff such as porters and telephonists.
15.47 The Confederation of Health Service Employees described ancillary staff as:
“A forgotten army where training and role development is concerned. There is a large reservoir of talent to be tapped here.”
They are a critically important group and the NHS has an obligation to see that they are given at least as much consideration as other NHS staff. We welcome the efforts of the National Staff Committee, but recommend that health authorities should ensure that adequate induction training (including access to language courses where appropriate) is available.
Works and Maintenance Staff
15.48 This group of staff includes architects, surveyors and engineers employed mainly at regional, area and district level; and craftsmen employed on building and engineering maintenance mainly at unit level. There are about 6,000 in the first group and about 25,000 in the second in the UK. Between them these staff plan and maintain the stock of NHS property. As we said in Chapter 10, a considerable part of the hospital stock which comprises the bulk of this property is old and its maintenance problems are considerable.
15.49 Most of the evidence we received from or about this group of staff was submitted by works officers. This is not surprising because one of the effects of NHS reorganisation was to create the works officer. His responsibilities, at various management levels, comprise:
“the organisation and execution of (a) capital building and engineering works and (b) estate management ie the economic use of assets, maintenance of buildings, engineering plant, equipment and services and grounds and gardens . . . and operation of engineering plant and services; it also includes the professional (surveying) and technical aspects of property management – advice on land and property transactions.”
15.50 The works officers were concerned about their position. Whereas in England the regional works officer is a member of the regional team of officers, this is not the case at area or district levels. We were told that some area works officers had difficulties in gaining access to their health authority. Several of those giving evidence emphasised the importance of protecting the maintenance budget from the depredations of other functional departments. The National Association of District Works Officers told us:
“It is apparent that any budget which can be readily diverted as problems arise will always be at risk but in a Service, where the average age of buildings is 70 years, it is clear that such actions can only have a long term and cumulative detrimental effect on the Service.”
They went on to say:
“In our view these reductions in allocations for work, which is essential for the safe operation of the Health Service, is entirely due to inadequate representation of Works Departments at the management levels where revenue allocations are determined.”
15.51 Another cause of complaint was of staff shortages. The South Western Region Works Officers said:
“It should not be overlooked that generally speaking, there are no more managers in the Works field than pre-Reorganisation in the hospital service, but responsibilities taken over in April 1974 from Local Authorities have increased the workload by about 10%.”
We were also told of shortages of craftsmen at unit level which may have given rise to many complaints in our evidence about delays in carrying out minor repairs and other maintenance work.
15.52 There were several criticisms of the lack of a career structure for It was put to us that the change in the type of work since the introduction of the NHS has meant a change “from labour intensive tasks to those requiring less manual but more intellectual input”. This means that in future a younger, more highly qualified workforce may be needed. If it is, it will need to be matched by improvements in career prospects and training. The basic training of most craftsmen has been carried out before they join the NHS. This has been satisfactory in the past, but we are given to understand that there may now be a need to develop apprenticeship schemes within the NHS.
15.53 The Merseyside Branch of the NHS Works Officers Association concluded their evidence with the cheering words:
“it should not be thought that Works Officers are critical of the reorganisation [of the NHS]. This is not the case, for from it have derived many improvements . . . the concept of ‘Works Officer’ . .. has brought together what were two largely separate disciplines – building and engineering into one team with very much improved credibility. This has in turn created good working relationships with medical and administrative officers both at District and Area levels.”
This was not the universal view, however. The Royal Institute of British Architects considered that reorganisation had substituted for previous arrangements “a cumbersome and expensive works structure which has little chance of allowing sensible design and estate management policies to evolve”. It is perhaps too early to gauge the success of the new category of works officer and we recommend that the works staffing structure should be kept under review by the health departments, as should the numbers and training of craftsmen. As has been said, many of our buildings are exceptionally old and a programme for their replacement and upgrading is required. It will be essential to ensure that the works and maintenance staff group has the necessary expertise for such a programme.
Conclusions and Recommendations
15.54 The Professions Supplementary to Medicine Act 1960 established elaborate registration machinery for eight professions, the vast majority of whose members are employed in the NHS. It has been criticised as leaving too much power in the hands of professional bodies so that desirable developments, such as integrated training for some of the professions, have been blocked. It is time that the machinery set up by the Act was reviewed.
15.55 Scientific and technical staff were considered by the Zuckerman Committee who published their report in 1968. Its main recommendations, though accepted in principle by the government, have not been implemented, partly because NHS reorganisation interfered with the structural proposals and partly because of the difficulties in negotiating the necessary staffing The health departments are considering the best way forward and we support their general strategy. Much of our evidence on these services was about who should head and manage laboratories. We do not think that the solution suggested by the DHSS of dividing the managerial responsibilities is realistic. The best available scientist should be appointed as head; the possession of a medical qualification will be an advantage when there are two candidates of equal ability. Moves towards the establishment of a National Scientific Council proposed by the Zuckerman Committee, should be encouraged.
15.56 We received comparatively little evidence about the other groups of staff considered here and we do not feel justified in proposing major changes. We suggest experimenting with ways of providing an ambulance service and we think it important that more effort should be put into providing induction training for ancillary Works officers are a new group, formed at reorganisation, and it will be important to keep the framework within which they operate under review. They are essential to the success of the accelerated building programme we proposed in Chapter 10.
15.57 We recommend that:
- there should be an independent review of the machinery set up by the Professions Supplementary to Medicine Act It should include manpower and training needs of the professions (paragraph 15.7);
- the health departments should continue their efforts to generate more research into the work of speech therapists, occupational therapists, physiotherapists and remedial gymnasts (paragraph 15.12);
- staff in senior posts in the scientific and technical services should normally be science graduates (paragraph 15.20);
- pilot experiments should be carried out in providing a regional scientific service for one or more laboratory specialties (paragraph 15.21);
- the head of a laboratory should be the most able scientist available (paragraph 15.31);
- in one or two instances the accident and emergency ambulance service should be organised experimentally on a regional basis with “community transport services” being provided by the lower tier NHS authorities; and the results closely monitored (paragraph 15.41);
- health authorities should ensure that adequate induction training (including access to language courses where appropriate) is available for ancillary staff (paragraph 15.47);
- the works staffing structure should be kept under review by the health departments, as should the numbers and training of craftsmen (paragraph 15.53).