Health Care Assistants

Set out on the right is a copy of a letter sent on April 11 to Duncan Nichol, the chief executive of the NHS, expressing the PTA Staff Side's concern at his letter to all NHS general managers regarding the introduction of health care assistants (HCAs). Mr Nichol's response was not helpful, but we would refer members to the May 1990 briefing paper on health care assistants which gives guidance to members and predicts implications for physiotherapy services.

A further point of concern is how future salaries will be settled for health care assistants. For the moment, the Department of Health's advice is that any HCAs who are created should be paid on 'existing salary scales'. But which scales? Physiotherapy helper? OT technical instructor grades 111, II or I? Or nursing scales? If they are paid on current physiotherapy helper scales they will receive no increase for additional resp- onsibilities. If they are paid on OT technical instructor scales, a 'variation order' from the Department of Health will be needed. It may also cause some concern among other physiotherapy or OT support staff. If they are paid on nursing auxiliaries' pay scales, they may be marginally better off, but will they end up being managerially accountable to a nurse? (An important question because it could affect the grading of a large number of physiotherapists who supervise or manage the work of helpers.)

It is time this mess was sorted out before problems arise. The PT'A' Staff Side's view is that this should be done by negotiations in the PAM (PT'A') Council with a salary review by the Pay Review Body. The current discussions on a PAM (PT'A') grading review (see next page) could be a means of resolving this questton. However, the Management Side has indicated that it does not wish to include health care assistants in the discussions at this stage. The NHS Management Executive has not yet decided where HCAs should be placed for determin- ing pay. It could involve anything up to 100,000 staff (ie 96,000 nursing auxiliaries and 8,000 PAM helpers and technical instructors). Rumours indicate that HCAs could be either placed in the Administrative and Clerical Council or the Professional and Technical 'B' (PT'B') Council. A further possibility is that HCAs could have their salaries uni-laterally fixed by local rnanage- ment without any negotiation with staff. None of these alternatives would be acceptable to the PAM (PT'A') Staff Side. The Chartered Society wishes to see a continued close association between any HCAs and the physiotherapists who are responsible for their work. This is probably best done by keeping them in PT'A negotiations.

Health Care Assistants DEAR MR NICHOL

I am writing on behalf of the Staff Side of the PAM (PT'A') Whitley Council to express our concern at your letter of January 10, 1990, to all NHS general managers regarding the introduction of health care assistants.

We wish to register our serious concern at the uni-lateral way in which the health care assistant scheme has been introduced. In particular, the fact that there has been no negotiation or consultation whatsoever with the relevant Staff Sides. Such action can only generate an atmosphere of distrust between Staff and Management Sides when decisions of major importance are not the subjects of proper consultation in the spirit of Whitley agreements.

We also wish to express our concern at the way in which you propose that this system should be run. It appears from your letter that there are to be no funds set aside for the purpose of establishing training schemes for helpers. The suggestion that funds for this purpose could be realised by savings in the use of professional staff is totally unacceptable and is hardly conducive to staff co-operation. This is clearly so at a time when it is recognised that there are serious shortages among many of the professions allied to medicine, and it is essential that sufficient funding is set aside to recruit and retain qualified professional staff.

Furthermore, there appears to have been no thought given to the resourcing for the assessment of health care assistants to achieve the NCVQ qualifications. It appears to be assumed (erroneously) that the professionally qualified staff have vast amounts of spare time which can be spent training and assessing the health care assistants. At a time of increase staff shortages, and in the absence of necessary additional staff resources, such a scheme will be very difficult to operate without adversely damaging patient care provided by professional staff.

It would also appear that the role of the health care assistant remains undefined as does their accountability, in particular to the professionally qualified staff whom they would be supporting. Helpers, footcare assistants and technical instructors have a close working relationship with these professions because they are accountable to the professions and work as an integral part of the professionally-led teams. Your circular seems to open up the possibility of health care assistants becoming detached from the professions. This development would be unacceptable.

There has been no negotiation or consultation with the PAM Staff Side about the salaries and terms and conditions of employment of health care assistants. This is a matter central t o the role of the Staff Side and we are very concerned at the implications for the future of this decision to by-pass the nurses and PAMs Staff Sides. Full consultation with the Staff Side should take place on issues of such major significance.

You state that 'Training Agency schemes such as the Youth Training Scheme and Employment Training programmes can play an important role'. The Staff Side is concerned that the use of such schemes will be seen as a replacement for full-time health care assistants or as a method of using cheap labour on short-term contracts. We recognise the need to expand the sources of recruitment but would be concerned if these schemes became a route to insecure, temporary health care assistant appointments.

The Staff Side would have welcomed the opportunity for a detailed discussion about the role, accountability, terms and conditions for health care assistants in relation to the PAMs. Unfortunately your letter was issued without such consultation. If staff are to understand and accept the basis for change in the NHS, it is essential that care is taken in proper discussion and consultation with the relevant Staff Sides. This does not appear to have been the case with either the nurses or PAMs Staff Sides.

I would appreciate your comments on this issue and the pattern of consultation we can expect on other issues in the future.

Yours sincerely

P H GRAY Staff Side Secretary

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Grading Negotiations Negotiations have begun again1 At the

moment, they are still at the exploratory stage but two working parties have been established for the Joint PT'A' Council, one to lopk at helpers and technical instructors (Tls) and the other to consider the grading structure for clinical/ managementheaching members of the professions.

The Management Side's initial proposals suggest the complete abolition of a national grading system. By definition, this would mean that each separate DHA's or self- governing trust's local management would decide upon its own graddsalary level for staff. It would destroy any national career structure. The Staff Side has rejected this approach.

The Management Side wants a single pay spine; more incremental points than on the present scale; with the differential between the points about half those that.currently apply (ie 2% instead of 4%). The incre- mental point would not be an automatic annual increase for increased experience in the grade, but would be dependent upon each individual's performance, ie performance-related pay on the cheap! Pay ranges - probably three increments - would be left to local discretion and there could be between 20 to 25 such ranges within the proposed three pay bands for qualified staff. This would mean there would be one increment and two further discretionary points that would be up to local managers to apply and would be unlikely to be 'appealable' if someone felt they were unjust.

There would be a total of five pay bands; two for helpers/Tls and three for the clinical/ managementlteacher grades together. 'Starters' and those requiring close super- vision would be slotted into the bottom band of the three pay bands for qualified staff. Most clinicians and junior managers would find themselves in the middle pay band; and the 'super' clinicians and the senior managers would be found somewhere in the top band.

Teachers and seniors would be located in the middle pay band and principals in the top band. There would be no national grading definitions, it would be up to local managers to decide where individuals would fit in these pay bands and these decisions would be

made after 'due weighting' and regard had been given to the following list of factors in each job:

0 Degree of supervision or instruction given or received.

0 Level of involvement in direct patient care.

0 Degree of autonomy/initiative.

0 Degree of participation in the estab- lishment and review of patient care programmes.

OComplexity and range of task to be undertaken. . 0 Level of clinical specialists.

0 Spread of clinical responsibilities.

0 Responsibility for training, education or research.

0 Provision of advice or other duties outside the professional discipline.

0 Responsibility for negotiations contracts and/or specifications.

0 Responsibility for quality assurance.

0 Responsibility for marketing.

0 Level of resources managed.

0 Responsibility for planning within or beyond discipline.

0 Involvement in corporate management.

0 Involvement in formulation of policy. The Staff Side informed the Management

Side that it was not prepared to scrap the current grading structure and leave grading decisions entirely in the hands of local management. The Management Side has

,now 'backed off' somewhat and has agreed to discuss grading 'guidance'. However, so far it has not proposed any grading structure or definitions. It appears to wish to achieve the maximum possible devolution to local management discretion.

The Staff Side has confirmed that it is not under major pressure from members for this grading review. The Staff Side would like to see a new grading structure but because qualified staff are very cautious about the effect of the new NHS grading agreements for nurses, speech therapists and MLSOs this must:

0 Improve upon the present career structure - not flatten it.

0 Be readily understandable and fairly applied.

0 Help to overcome the severe recruitment and retention problems there ara among all PAM staff (eg there is currently a 10% vacancy rate in physiotherapy).

0 Lead to substantial increases in salaries.

The Staff Side has suggested that the pharmacists' new grading structure which contains nine grades could be the basis for discussion for PAM staff. We have stressed that under no circumstances are we willing to accept a system that scraps the national grading agreements and replaces them with local management discretion. Nor could we accept a national structure with so few grades that it removes even the present limited career structure.

The Review Body has extended the date for both sides to submit evidence on a new grading agreement from early September until October 23, 1990. Both sides have provisionally agreed to meet in working parties every two weeks until mid-Sept- ember; with weekly meetings between mid- September and mid-October, 1990. Phil Gray, the CSP director of industrial relations and PT'A' Staff Side Secretary, stressed the Staff Side's concern that abolition of a national grading structure and the total devolution to local level for management to make up their own grading system could cause enormous upheaval and destroy any career structure. Two individuals undertaking identical jobs could be placed on different salary ranges with few rights of appeal against unfairness. He believed that such a proposal could make the problems with the nurses' regrading look easy by comparison! Neither the Staff Side nor the Chartered Society would agree to such a proposal. CSP members should be aware that the two sides in the clinical/management/teaching grading working party are still a very long way apart. It is possible that no progress will be made.

Second, Mr Gray was concerned that a system without national grades but simply a pay spine could be a clever way of paving the way to the abolition of the Pay Review Body system. The Pay Review Body would only need to recommend the maximum and minimum of the total pay spine. Points along the scale would be determined by how many 2% increments could be contained within it. There would be no need for a Pay Review Body to operate under such a limited remit.

Conference Representatives Training

The CSP is again organising training for new conference representatives. Four courses have been arranged, and it is still possible to apply for the last three.

London (CSP Headquarters)

York (District Hospital)

London (CSP Headquarters)

Stoke on Trent (Keele University)

Monday, July 16

Tuesday, July 31

Wednesday, August 8

Saturday, August 11

New conference representatives, and those who did not attend a training course last year, are invited to attend the nearest course. Limited overnight accommodation is available at Keele University for the course

on August 11, but will be provided only in approved cases. Creche facilities may also be available for this course.

The course content is designed to help representatives participate fully in the conference and will cover: motions, amend- ments and emergency motions; the agenda, conference procedures and standing orders; and making a speech.

A 'mock Conference' a t the end of the course will provide participants with the opportunity to practise conference skills.

Applications should be made at least two weeks before the date of the course being applied for and longer if accom- modation is required at Keele. Further details are available from Linda Austin, Industrial Relations Department, CSP, 14 Bedford Row, London WC1R 4ED.

PRB to Go? In an article in Personnel Today (May 15,

19901, Eric Caines, the new NHS Director of Personnel, gives himself three years to devolve a personnel policy and negotiations to Unit level. He emphasises the large-scale expansion of plans for local bargaining on pay and conditions. He says he 'does not underestimate the colossal challenge the health service is facing' and 'we are drawing a line through everything that has gone before. There will be no more national systems, the Whitley Councils and review systems will go'.

In another article, in The Guardian (May 23, 19901, Mr Caines is quoted as saying that there was 'nothing sacrosanct' about the Pay Review Bodies in the context of his brief to decentralise responsibility for

384 physiofherapy, July 1990. v d 76, no 7

personnel matters to individual hospitals. 'What we are not going to have is a two-tier system. Local negotiations or consultations on pay determination and personnel matters for some groups but not for others would make nonsense of trying to decentralise', said Mr Caines. He went on to say that while any changes in the role of the Review Body would be a political decision, their continued existence would be illogical once the Whitley Councils were dismantled and pay was increasingly being determined at local level. This process would start next April with the creation of the first opted-out, self- governing hospitals.

Phil Gray says 'The PT'A Staff Side is

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extremely disturbed at this apparent threat to abolish the Review Bodies. There has been no discussion with the Staff Sides or with any of the organisations. We have therefore written to the Prime Minister, who was responsible for setting up the Review Bodies in the first place. The PRBs continue to make their reports to her. It would therefore be the decision of the Prime Minister to abolish the Review Bodies. We have asked whether or not Mr Caines is expressing a new Government policy or is he merely expressing his own personal opinions.'

A reply was received which stated that no changes are envisaged to Government

~~ ~

policies and the Pay Review Bodies will stay (see news pages). However, even if it turns out that Mr Caines has been giving undue emphasis to his own personal opinions, it is very clear from his approach that there will be a major move towards local bargaining and the decentralisation of bargaining of pay and conditions over the next few years. The Society must be aware and prepared to cope with this change.

Mr Caines did, in fact, meet the GWC Staff Side on June 4, when he indicated that he was expressing his own views but did not retreat from the position he had expressed in the articles about the long-term future of Whitley and the PRB.

Chiropractic versus MADAM - With reference to the recently published Medical Research Council trial comparing chiropractic with hospital out- patient treatment for low back pain', may I inform colleagues that efforts were made, before the trial began, by the Manipulation Association of Chartered Physiotherapists (MACPI executive committee, to persuade Dr Meade and his committee to alter aspects of the study.

Mrs Christine O'Donoghue and I attended a meeting at the Medical Research Council at which the design of the trial was discussed. We were disturbed by what we heard and at a private meeting with Dr Meade we expressed our anxiety about the fact that, as planned, the study would compare skilled specialist practitioners (chiropractors) with skilled but non-specialist physiotherapists. Since we believed, as has now been demonstrated, that specialist manipulative treatment of low back pain is highly effective, we felt the result would be a foregone conclusion and would be interpreted by the media as 'chiropractic is effective but physiotherapy isn't'. Distressingly this is what has happened.

No arguments on our part had any influence. Do what we might, the trial went ahead, comparing in effect an apple with an orange, rather than what we had argued for, a comparison of chiropractic management of low back pain with specialist physio- therapy management, involving senior specialist manipulative physiotherapists.

Sadly, those who write news items or conduct interviews in the media do not explore the small print of scientific trials. There is much that is very positive for physiotherapists in this trial and that supports the further development of specialisation within our profession. In particular, why were the results of treatment better in one physiotherapy department than chiropractic and in two centres virtually as good, ie in over 25% of the 11 centres, treatment by physiotherapy was as good as or better than Chiropractic.

It is essential in my view that we take up

Out -patient Treat men t the challenge set by this trial and, at the highest levels of our profession, initiate a well-informed discussion of all i ts implications in order to achieve the following: 1. A recognition that, since those who seek our help deserve only the best we can give, postgraduate specialisation is the natural and essential development which should be further encouraged for the majority of physiotherapists. 2. Rather than introduce another profession into State registration with all the problems that would bring, the current efforts by the MACP to train highly skilled manipulative physiotherapists should be supported by the Department of Health and expanded. 3. Further studies to evaluate the outcomes of treatment should be carried out by physiotherapy specialists in subjects such as the management of low back pain. This should entail the comparison of like with like, which is normal in scientific studies, ie treatment by skilled, specialist physio- therapists as against chiropractors or osteopaths or manipulative doctors, and so forth.

I would urge all physiotherapists to read and ponder this trial, since we all need to be ready to answer the barrage of questions it is raising both from the public and the medical profession. It could become a very positive opportunity for us. PETER WELLS BA MCSP DipTP London SW6

MADAM - The recent publication of the MRC's comparative study of of chiropractic and hospital management of low back pain" has prompted considerable media attention.

Much of this claims chiropractic to be the most, if not the only, effective form of treatment of low back pain. This however, was a 'pragmatic' trial of day-to-day practice in two entirely different settings. It was not a comparison of specific treatments. The chiropractic claims therefore cannot be

made on the basis of its results alone. The trial does, however, show that

chiropractic is more effective than hospital management. There are probably several reasons for this.

One possible factor that should be considered is that few, if any, physio- therapists were involved in the choice of the designated centres. As a result, many of the physiotherapists involved (myself included) were not sufficiently experienced in treating low back pain. The fact that one centre did better than chiropractic (although not statistically significant) shows that the techniques we use can be at least as effective. How many NHS physiotherapists, though, are able to use these techniques to maximum benefit?

I disagree with the MRC's suggestion that as a result of this trial chiropractic should be contracted into the NHS. It estimates that the cost of chiropractic for all patients meeting the trial criteria would be €4 million. The long-term financial gain and benefit to the patient might also be achieved if €4 million were spent on improving the standard and accessibility of postgraduate training for existing State registered physiotherapists. 1 feel that as a professional body we should be pushing forward to achieve this end.

Furthermore, we should accept the results of this trial within the context of its limitations and work towards evaluating the efficacy of our own treatment methods.

In addition we must call for a 'fastidious' trial to compare our techniques against those of the chiropractors. In this case the treatments must be given by practitioners with appropriate qualifications working under the same conditions.

STEPHEN PAINTING MCSP Plymouth

'Meade, T W, Dyer, S, Browne, W et a/ (1990). 'Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital out-patient treatment', British Medical Journal, 300, 6737, 1431-1437.

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