The Cavendish Review Ten Years On: Are Support Workers Still Invisible?

The importance of support workers

BIOS has long recognised the importance of the support staff working in orthoptic and ophthalmic services. Support staff are those members of the orthoptic team not registered with the HCPC who work alongside registered orthoptists, supporting them and service users. Last year BIOS were proud to launch its Orthoptic Support Worker Hub which contains a wide range of information, guidance and resources all aimed at helping to ensure that the contribution of support staff is as safe and effective as possible and, if you are a support worker, that you have a rewarding career and our able to develop yourself.

In developing the Hub, BIOS recognised that support workers in the NHS have not always received the recognition they merit. Indeed, a report published by King’s College London (KCL) in July this year shines a light on the issues this important group of staff can face. The report, called The Cavendish Review Ten Years On: Are Support Workers Still Invisible? is the result of a yearlong study carried out by researchers at KCL and the University of Exeter that sought to see whether findings of a landmark review of health and social care support workers carried out by Camilla Cavendish in 2013 still characterise the experience of the support workforce in the NHS.

The original Cavendish Review was commissioned by then Prime Minister David Cameron, following the tragic events at Mid Staffordshire NHS Foundation Trust that had led to up to 1,200 unnecessary deaths. Over a fourteen-week period through a series of meetings, focus groups, roundtable discussions, hospital visits, a survey, a formal consultation which produced 100 individual and organisational responses, and discussions with key stakeholder, Cavendish sought to understand how support staff in England experienced work, and what the consequence of that experience was for them, other staff, their employers and patients.

Cavendish uncovered a large number of issues, barriers and obstacles that many support workers faced – from a lack of standardisation in the tasks they could or could not perform, to poor supervision, to poor access to training, and limited career opportunities. Moreover, the contribution this group of staff made to care, despite them being the key ‘bedside presence’ in many settings, was rarely recognised. Cavendish went as far as to describe support workers as being frequently “invisible” to patients, employers, and policy makers.

During 2023, with the support of national partners including BIOS and other healthcare professional bodies and trade unions, KCL gathered evidence through a national survey, which was completed by nearly 4,300 support workers, interviews with key stakeholders and a review of wider academic research to see what has and has not changed since 2013. Whilst Cavendish only looked at nursing support staff, King’s considered all clinical roles including AHPs. The study focused on England only.

The study found that for most NHS support staff, very little appears to have changed since 2013. Whilst the survey did find that support staff are enthusiastic and proud of the work that they do and strongly believe it makes a difference to patient care –

• Only half feel their contribution is recognized at work.
• Just 20% feel the NHS values support roles.
• Only 53% would recommend becoming a support worker to their friends and families.
• Over half of survey respondents said they could contribute more if they had access to additional training.
• Over half said they did not have access to the information they require to progress their careers
• Just a third thought their appraisals were ‘helpful’.

One area that does appear to have changed for the better, the study found, is clarity about scope of practice. Asked whether support staff were clear about the tasks that they could and could not perform, 80% said that they were. This result, the researchers suggest, may reflect the national competency frameworks that have been produced for several occupations including AHPs and role guidance, such as that produced by BIOS.

In addition to the survey the KCL researchers also reviewed all academic studies that had investigated healthcare support workers published since 2017. What they found echoed the results of their survey and the original review. The common themes that other researchers had identified were-

• Support workers felt undervalued.
• They were underutilised.
• Experienced inconsistent supervision and delegation.
• Had variable and confusing titles.
• Poor access to training.

The researchers did find that a body of evidence is now emerging about the positive impact support workers make to care, and, indeed, the risk of care being missed if a healthcare service’s support workforce is not appropriately developed.

Camilla Cavendish’s original review included many recommendations to address the issues she found, only one of which, The Care Certificate, was adopted nationally, although even this was not mandated. In the KCL study’s survey support workers were asked whether they thought her proposals were still needed. The results are shown in the table below.

The KCL study is the first comprehensive national analysis of the NHS support workforce in England for over a decade. It is disappointing that across the NHS little progress appears to have been made since 2013. Camilla Cavendish contributes a foreword to the KCL report and writes that at a time when “the NHS faces acute backlogs and staff shortages, it is vital to maximise the potential of all staff. This group are a strategic resource”.

BIOS recognises the importance of this group of staff, as the orthoptic profession does more widely. Initial analysis of the Society’s annual workforce survey suggests that the experience of orthoptic support workers is more positive than support workers in the NHS generally. BIOS is committed to continuing to develop resources for support staff, and also to help services not only utilise the resources on the Hub, but also the national NHS England Allied Health Professions strategy, including its competency framework. There are many reasons why services and support workers should – and are – using these resources, including to create new roles, ensure clear scope of practice and safe and effective delegation of tasks.

The work on the Hub continues, guided again by a profession-led expert group that includes support workers. Key to this work will be a survey planned for the autumn that will seek to find out more about what support workers and managers need to address any issues. A significant number of services that currently do not employ support staff say that they would like too. The BIOS survey will explore what barriers they face and what can be done to address these.

From the undertaking visual acuity tests, to performing Ocular Coherence Tomography and retinal scans, imaging, installation of eye drops (and potentially much more!), appropriately trained and supervised support staff are key members of the orthoptic team. Being a support worker in itself is a rewarding career, but it can also be a step into becoming a registered orthoptist particularly with the imminent introduction of a Degree Apprenticeship route.

Whilst the KCL study suggests that little progress has been made in addressing the long-standing issues that support workers in healthcare can face, the resources and support provided by BIOS and local services across the United Kingdom means that the picture for orthoptic support workers is brighter. That is not to say more couldn’t be done, which is why BIOS continues to develop its resources to support this vital part of the workforce.

If you are interested in being a member of the BIOS project’s expert group (which meets virtually every quarter) or would like to share good practice, please contact [email protected].