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Prime Minister David Cameron has defended plans to get trainee nurses to first work as healthcare assistants to improve patient care.

He acknowledged that the proposals for England were controversial but said the NHS needed to focus on the level of care it provided.

The Royal College of Nursing called the health care assistant idea "stupid".

Delegates at the RCN's annual conference also heard how nurses were over-stretched by low staffing levels.

Unsafe staffing

A total of 71% of 2,000 senior nurses surveyed said they were not confident that staffing levels were always adequate, with more than a third saying they were unsafe on a weekly basis.

The RCN said the findings illustrated the need for minimum staffing levels to be set - echoing a call made by Unison last week.

The idea of setting minimum staffing quotas was put forward as an option by the Francis inquiry when it published its final report in February into the failings at Stafford Hospital - one of the biggest scandals in the history of the NHS.

Mr Cameron said the NHS had to "do better in the level of care" and that ensuring nursing staff got more training in basic skills was part of this.

He said: "We have said that nurses should spend some time when they are training as healthcare assistants in the hospital, really making sure that they are focused on the caring and the quality, and some of the quite mundane tasks that are absolutely vital to get right in hospital.

"It is going to be controversial, but in the end the sort of health service we want is not just about making sure we have the facts and the figures, and the money spent well, it's about the level of care, so when our elderly relatives go in there, we know they are going to get a really good quality of care."

Patients first

The Francis inquiry highlighted appalling neglect, abuse and incompetence in the four years up to 2009. There were between 400 and 1,200 more deaths at the hospital in that period than would have been expected.

The , concluding the failings went from the top to the bottom of the system, and made 290 recommendations for the future.

But when the government published its response in March there was no commitment to set staffing-to-patient ratios.

RCN general secretary Peter Carter said that along with the refusal to introduce other recommendations, including a registration system for healthcare assistants, it was "very disappointing".

"We know that some of the most important recommendations from the Francis inquiry are being ignored, potentially leaving in place the systemic failures which allowed such a tragedy to happen in the first place."

One proposal is to get nurses to work for 12 months as a healthcare assistant before their training.

It was put forward by ministers despite it not featuring on the list of 290 recommendations made by the inquiry. RCN president Andrea Spyropoulos said she was astounded when she heard it.

She also said it would "waste taxpayers money".

"I don't believe it will happen. I believe it is a really stupid idea that will not benefit patients."

Mr Carter said: "Student nurses in their training spend over 50% of their time in clinical areas.

"There seems to be a view out there that somehow they spend all of their time in universities. That simply isn't the case. "

Referring to concerns raised about staffing levels in the RCN's survey, he said: "They [nursing staff] made it clear that they felt, sometimes on a daily basis, sometimes on a weekly basis, the number of staff that were available on wards and other departments were simply inadequate in order to provide the safe and satisfactory level of care patients need.

"And it's a really worrying return and we think the government would be well advised to take this seriously."

He said reports of unsatisfactory care tended to be predominantly "but not exclusively" in relation to elderly care.

"And you will find that often there is one nurse or one healthcare assistant to maybe nine or 10 older people, often requiring full nursing care."

He called for legislation to ensure minimum staffing levels.

Trust responses

Meanwhile, a survey by The Daily Telegraph reveals a rise in hospital managers and consultants paid six-figure sums. Over 7,800 NHS staff were paid more than £100,000 last year. The highest paid executive earned £340,000 - almost 16 times the pay of ward nurses.

Shadow health minister Jamie Reed accused the government of betraying the NHS.

"Hospitals are struggling to cope and patients are paying the price," he added.

A Department of Health spokeswoman said: "As individual trusts respond to the Francis inquiry we expect them to look at the issue of nursing numbers in their hospitals.

"However, if the RCN wants to have credibility in this debate then they must first set out how they are going to respond to the criticism levelled at them in the Francis report."

The RCN was criticised for not doing enough locally to support staff while its dual role of union and professional body was also questioned.