Home » Staffing (Page 2)
Is it necessary to ‘pierce the corporate veil’ in addressing patient safety in the public interest?
The impact of poor staffing on patient safety in the NHS cannot be underestimated especially now. Paul Sankey, Principal Lawyer (Partner) in Clinical Negligence at the law firm Slater & Gordon LLP, wrote this week as follows:
As hospital services are increasingly outsourced to the private sector, and as NHS Foundation Trusts themselves are financed at a corporate level through mechanisms such as the Private Finance Initiative (PFI), it has become necessary to consider the extent to which such private operations can be scrutinised through freedom of information (FOI) legislation. Generally, private bodies are excluded from FOI across a number of jurisdictions, and there has even be a sectoral approach under scrutiny. It is a well established principle that the company has a separate legal personality from its members. In very limited circumstances, the English courts can ‘pierce the corporate veil’, putting to one side the company’s separate legal personality and holding that its members are subject to the legal consequences of the company’s acts. Obvious examples might include product liability in breast implants (PIP implants), but more subtle is to consider the effect of staffing levels in the operation of private companies or indeed PFI-sourced NHS Foundation Trusts.
The RCN provide that staffing levels for nursing must be adequate:
“Attention is now focussed more sharply than ever on staffing. Public expectation and the quality agenda demand that the disastrous effects of short staffing witnessed at NHS hospitals such as Mid Staffordshire should not be allowed to happen again. Time and again inadequate staffing is identified by coroners’ reports and inquiries as a key factor. The Health Select Committee 2009 report states: ‘inadequate staffing levels have been major factors in undermining patient safety in a number of notorious cases’. In one year the National Patient Safety Agency (NPSA) recorded more than 30,000 patient safety incidents related to staffing problems.”
Indeed, as the RCN go on to say, staffing levels constitute part of the wider “business case”:
“The financial context means we need to ensure services are staffed cost-effectively. Many of the identified high impact actions and efficiency measures proposed rely on reducing costs by minimising the expense of avoidable complications such as DVTs (deep vein thrombosis), pressure ulcers and UTIs (urinary tract infections). But ‘avoidable complications’ are only avoidable if effective nursing care is consistently delivered. This relies on having sufficient nurses with the right skills in place – which depends on robust planning in terms of nursing staff resources.”
The Health and Safety Executive provide the following useful information about staffing levels and safety:
“The term ‘staffing levels’ refers to having the right people in the right place at the right time. It is not just a matter of having enough staff, but also ensuring that they have suitable knowledge, skill and experience to operate safely. Economic pressures to save costs and improve productivity, as well as organisational initiatives to delayer, multi-skill and enhance team working, have had the effect of reducing staffing levels. Reductions in staffing levels do not necessarily pose a direct threat to health and safety. Rather, the impact of changes to staffing arrangements on health and safety performance will depend on the quality of the planning, assessment, implementation and monitoring. Health and safety should be managed in the same planned and informed manner as all other elements of reorganisation.”
The issue of whether NHS Foundation Trusts are open to freedom of information requests is complicated. Public authorities often enter into outsourcing and private finance initiative (PFI) arrangements with the private sector to run services or deliver capital projects. These are often the subject of complex requests for information under the Freedom of Information Act 2000 (FoI). Sometimes the private sector will hold the requested information and the public authority will have access to it but on restricted terms. The question arises: who holds the information for the purposes of FoI? Section 3(2) of the act states: ‘For the purposes of this act, information is held by a public authority if: (a) it is held by the authority, otherwise than on behalf of another person; or (b) it is held by another person on behalf of the authority.’
The guidance of exemptions from the Freedom of Information Act by the Ministry of Justice is extensive (“Guidance”). Section 43 exempts information, disclosure of which would be likely to prejudice the commercial interests of any person. An example of ‘commercially sensitive information might be a “trade secret”. Section 43(1) exempts information if it constitutes a trade secret. The FOI Act does not define a trade secret, nor is there a precise definition in English law. However it is generally agreed that a trade secret must be information used in a trade or business; is information which, if disclosed to a competitor, would be liable to cause real (or significant) harm to the owner of the secret; and the owner must limit the dissemination of the information, or at least, not encourage or permit widespread publication. According to this Guidance, a department’s, or other body’s, commercial interests might, for example, be prejudiced where a disclosure would be likely to: damage its business reputation or the confidence that customers, suppliers or investors; it may have in it have a detrimental impact on its commercial revenue or threaten its ability to obtain supplies or secure finance; or weaken its position in a competitive environment by revealing market-sensitive information or information of potential usefulness to its competitors.
It appears that the research is consistent with the notion that unionised workforces can promote health and safety. For example in “Trade union recognition and the independent health care sector: A literature review for the Royal College of Nursing”, it is proposed that:
“A briefing produced by the TUC (2004) cited a wide range of national and international sources demonstrating the beneficial role played by trade unions in promoting health and safety at work. Workplaces with unions playing a safety role showed injury reduction rates of between 24 and 50 per cent. Observation of health and safety regulations was also shown to be substantially higher in unionised workplaces.”
The answers given by Jeremy Hunt about freedom of information thus far have been extremely unhelpful. See for example the Hansard report of Helen Jones’ question (Helen Jones is the Labour MP for Warrington North) on 11 June 2013 on the subject of “NHS Accountability”:
When the current language has been very much of “parity”, as per the “Fair Playing Field” review of the healthcare economic regulator “Monitor”, it is plainly counterintuitive that freedom of information will apply to some parts of the healthcare sector but not all. Logically, either the whole healthcare sector becomes opaque to freedom of information (as is currently the case), but this does not make sense when only this week Jeremy Hunt was singing the joys of “transparency” in the Commons Health Select Committee. The law generally has been slow to catch up with the formidable challenges in regulating against examples of pathological toxic cultures in the NHS. Clinical negligence can attempt to prove on the balance of probabilities breaches in a duty of care on the law of tort route, and indeed the clinical regulators can in theory encourage Doctors to report other people for a fall in acceptable standards, including adequate resources in hospitals. The law could even prosecute for misuse of public office in theory. However, all of these have proved to be impractical, and the number of sanctions or prosecutions has been relatively low. In this jurisdiction, and elsewhere (particularly the US), there has been a long narrative about whether it is possible to “pierce the corporate veil”, in a fashion of incremental judge-made law, but by far the easiest solution is for Parliament simply to legislate on this. The current Health Select Committee with its formidable membership is well placed to make recommendations to parliament. Certainly, the judiciary would presumably agree that manning a NHS ward with a safe number and quality of nurses is in the public interest, and rather than relying on the judiciary to remedy a suboptimal situation after the event (through intricate consideration of public interest disclosure and whistleblowing and other remedies), it might be more helpful if the legislature could do something before the horse has bolted. The savings in “the Nicholson Challenge” have been described as ‘bureaucratic’ in yesterday’s “Estimates” debate, and there is no sign of this abating (see for example the comment made by Stephen Dorrell MP, head of the Health Select Committee (HSC)):
“It is against that background that the Committee recommends in paragraph 16 of the report on health and social care:
“In our view it would be unwise for the NHS to rely on any significant net increase in annual funding in 2015-16 and beyond. Given trends in cost and demand pressures, the only way to sustain or improve present service levels in the NHS will be to continue the disciplines of the Nicholson Challenge after 2015, focusing on a transformation of care through genuine and sustained service integration.””
As is generally the case in medicine, prevention is better than cure, and it would be most helpful if the law could adopt this approach too. However, the good news is that nurses can participate in the Nursing Times “Speak Out Safely” campaign: “to help bring about an NHS that is not only honest and transparent but also actively encourages staff to raise the alarm and protects them when they do so.” Their Twitter is @NursingTimesSOS.
This inevitably is a complex problem, but requires a solution fast.
A minimum staffing level for nurses – a Marmite issue?
This article is not peer-reviewed. You are advised to read this article in bits, according to which parts interest you. If you would like to engage constructively in some of the issues here, I can easily be reached on my twitter thread @legalaware_coys.
Introduction
The concern is that the NHS hospital setting is fundamentally designed incorrectly. It at face value appears to be running within a budget, imposing ‘efficiency savings’ and hoping that patient safety will be achieved within this budget. It could instead with health care managers sitting down with a big spreadsheet and working out how much money they need to run the health service with an adequate level of patient safety? By this mean, “basic issues” are covered, where the whole of geriatric care is not dependent on one Foundation Year doctor with a bleep covering all geriatric wards, hoping that there won’t be simultaneous emergencies.
Forgetting this general design issue for a moment, more specifically should there be a minimum nursing staffing level for nurses? This seems like a basic enough question, doesn’t it? Most people have a gut feeling for where nurses appear too rushed on a hospital ward or care home, and yet this policy issue generates quite diverse opinions. Is the question one of these?
A Marmite Issue
But don’t worry this article is not intended as an advert for Marmite. It has dawned on many that this policy strand is extremely complicated, and indeed relatively recently King’s College Policy+ of March 2012 asked the question, “Is it time to set minimum nurse staffing levels in English hospitals?” Firm conclusions are necessarily tempered by pooling results from different jurisdictions, different healthcare systems, different mixes of registered nurses/healthcare professionals, different mixes of Trust nurses and “bank nurses”, different mixes of full-time vs. part-time nurses, different geographic demands (different populations, different prevalence and incidence of disease), different service demands (acute, subacute, chronic, or similar), different care settings (care homes, hospitals), different patient demographics (e.g. age), and so it goes on. However, the mere complexity of it perhaps suggests the response should not be one of this:
An emu with its head in the sand
This prestigious King’s College Nursing Unit extremely helpfully concluded:
- International evidence suggests that mandated registered nurse to patient ratio can improve nurse staffing and lead to better recruitment, generate a more stable workforce, and more manageable workloads for staff. The impact on patient outcomes is less clear but there is evidence that the resultant lower caseloads are related to lower levels of patient mortality.
- Ratios and recommendations are specialty specific. Existing recommendations are focussed on clearly defined and delineated settings, where patient need is relatively predictable and consistent. Data about current staffing related to safe and ffective care delivery is needed to determine the appropriate ‘minimum’ or recommendation for a wider range of settings, such as acute care for older people.
- There is a need to clarify how existing ratios are expressed and to explore other measures of staffing, such as nursing hours per patient, or per bed.
[ This report can be accessed here.]
Wind the clock forwards, and policy makers are enmeshed in a narrative – in some quarters = which blames risks in patient safety with efficiency savings and understaffing of nurses. In contrast, Dan Poulter was reported on 6 March 2013 as saying that minimum nursing staffing levels are “not the answer”.
The report in the Health Services Journal goes as follows:
“Health minister Dan Poulter appeared yesterday to reject the Francis Report’s call for nationally recognised minimum nurse staffing levels.
Addressing a conference on the Report of the Mid Staffordshire Foundation Trust Public Inquiry, Dr Poulter also said the Government’s response, due at the end next month, would not address in detail each of the inquiry’s 290 recommendations.
Asked about Robert Francis QC’s proposal that the National Institute for Health and Clinical Excellence develop nationally recognised minimum nurse staffing levels for a range of healthcare settings, Dr Poulter said he had “not seen the evidence that supports that”.
“Sometimes when you put in mandatory standards you can have a drive to the bottom,” he told the conference, organised by think tank the King’s Fund. “I don’t think staffing ratios [are] the answer.””
The wider debate
Goryakin, Griffiths and Maben (2010) found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing can be associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess.
Certainly the overall trends in nursing care across a number of jurisdictions is interesting. For example, Duffield and colleagues (2011) report:
“The longitudinal study results show that although there had been increased investments in nursing over the 5-year period, they were primarily in specialized nursing units, such as critical care and ED, and primarily in metropolitan hospitals. At the same time, there was increased casualiza- tion (rates of part-time hours worked) of the nursing workforce and downward substitution, converting nursing positions to AIN. These findings parallel similar trends in many countries including the United States (Bureau of Labor Statistics, 2008) and may reflect the fact that policy makers believe that ICU/ED nursing work is more difficult than general nursing so more staff are provided.”
Baeyens and Closon (2010) recently observed that important differences are seen in the nurse(+aid)-to-bed ratio between the different EU countries. These differences were documented by a questionnaire send to all EU and EFTA countries. It looks very difficult to find a reason for these important differences, sometimes seen within one country. Unsurprisingly the authors concluded that further research was urgently needed to find out what is the minimum staffing level, adapted to the workload, for the quality of the care, the job satisfaction of the nurses and the satisfaction of the patients and their families.
Regulation
At this point, it certainly is useful to know the rough direction of travel of the healthcare regulators. Professional bodies and associations in the UK have put forward recommendations for nurse staffing levels in different specialities, and this is an important consideration for the Policy+ cited previously. For example, it is recommended that every patient in a critical care unit has access to a registered-nurse with a post registration qualification in the specialty, and that there is a ratio of 1:1 for ventilated patients (British Association of Critical Care Nurses, 2009). Whilst on children’s wards, a daytime registered-nurse to patient ratio of 1:3 is recommended for children under 2 years of age, and 1:4 for other ages (Royal College of Nursing, 1993) On mental health (psychiatric) wards, the Royal College of Psychiatry suggests that a daytime ratio of 1:5 RN’s per patient is likely to be needed for acute wards. However, in general arbitrary minimums (sic) are warned against, in that “the determination of appropriate staffing will involve dialogue between managers, nurses and other clinicians” (Royal College of Psychiatrists, 1998).
In the UK, nurses currently comprise the largest single group in the health care workforce in many countries, and account for a significant proportion of all health expenditure. In the late 1990s it was estimated that spending on nursing and midwifery staff contributed almost half of all spending on healthcare in the UK (Jenkins-Clarke, 1999; Richardson, 1999). In recent years, there has been an increasing interest in demonstrating the impact specifically of this crucial part of the health care workforce. Studies have examined the impact on patient outcomes of variation in the numbers of registered nurses, skill mix changes within the nursing workforce and skill mix changes in the wider clinical team involving substitution between doctors and registered nurses.
It may be stating the blindingly obvious but low staffing levels in intensive care environments have been shown to be associated with a number of adverse outcomes, including increased mortality (Tarnow-Mordi et al., 2000). Nonetheless, not all studies have been totally conclusive by any stretch of the imagination: for example, while an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found by McGahan and colleagues (McGahan et al., 2012), most studies demonstrated a trend between increased nurse staffing levels and decreased adverse patient outcomes in an acute intensive care setting in Australia. Staff morale falls and fatigue increases as a result of frequent changes in off-duty and no opportunity for ‘down time’ (Marquis and Hupson, 2003). It is generally reported that patient care is jeopardised and untoward incidents increase (Giraud et al., 1993). Hospital-acquired infection rates increase (Vicca, 1999) and there is also an increase in needle-stick injuries (Clarke, Sloane and Aitkin, 2002). Human observations reduce and dependence on technology occurs, with a decreased ability to detect incidents (Buckley et al., 1997). This evidence appears to be generally consistent.
A paper by Rafferty et al. (2007) provided useful key evidence on the impact of nurse staffing levels on patient outcomes and nurse-rated quality of care in English hospitals, and confirms the findings of parallel studies in other countries. The research focuses on medical and surgical ward-based registered nurses (“RNs”) holding clinical caseloads. Findings suggest that, had all general surgery patients in the sample been treated in hospitals with optimal staffing levels, a reduction of 246 patient deaths could have been achieved. These findings of a relationship between higher nurse staffing levels and improved patient outcomes through reduced mortality are of importance to policy makers, practitioners and patients. The evidence of a link between nurse-staffing levels and nurse satisfaction, burnout and nurse-rated quality of care, is also significant given current international efforts to improve the retention of RNs (Audit Commission, 2002; Buchan, 2004).
In the real world, according to Massey, Esain and Wallis (2009), managing nurse shortages is a major challenge in Trusts today given the worldwide shortage of nurses.To fill the gap created by a lack of permanent staff UK government agencies have increasingly used bank and agency staff. Managing this type of staffing effectively and efficiently, in the context of shrinking healthcare funds, is a major challenge in providing safe and quality healthcare. They found a predictable bank and agency staffing pattern, wherein bank and agency nursing staff were used with increasing frequency towards the end of the week. Demand for bank and agency nursing staff occurred because of: hospital practices that fund a fixed staff establishment for nursing units, while patient numbers and acuity are variable; poor forward planning; sickness, and absence due to professional development or staff training.
Asking the wrong question?
However, Buerhaus argued the following in 2009:
“The imposition of mandatory hospital nurse staffing ratios is among the more visible public policy initiatives affecting the nursing profession. Although the practice is intended to address problems in hospital nurse staffing and quality of patient care, this commentary argues that staffing ratios will lead to negative consequences for nurses involving the equity, efficiency, and costs of producing nursing care in hospitals. Rather than spend time and effort attempting to regulate nurse staffing, this commentary offers alternatives strategies that are directed at fixing the prob- lems that motivate the advocates of staffing ratios. “
This article, from the US jurisdiction, very much had the perspective of healthcare as a business, with Buerhaus further noting:
“Hospitals, like any other business, must decide how much and what type of capital and labor to purchase and the how to combine these resources so that they can produce the desired quantity and type of patient care services (its output) subject to some level of quality. Hospitals also purchase and combine other capital and labor inputs to produce non-clinical care services required to support the delivery of patient care, such as admitting, environmental services, accounting, human resources, etc. Because they have to pay for capital and labor inputs, hospital decision-makers take into account the purchase price of each input. Further, most acute care hospitals are paid according to fixed rates for a substantial portion of their patient population and thus face strong economic incentives to use the least costly combination of inputs.”
The author concluded with a more “flexible” approach (which in policy terms goes well with ‘autonomy’, ‘choice’ and ‘independence’):
“Imposing nurse staffing ratios reduces the flexibility hospitals need to adjust to changing demands to provide patient care, impedes hospitals’ ability to take full advantage of all of the labor and capital inputs they have purchased, and is counterproductive to building constructive relationships between nurses and hospitals. Rather than focusing on forcing hospitals to staff nursing units according to ratios, which are likely to create new problems for nurses, advocates of nurse staffing ratios should consider redirecting their efforts toward fixing problems currently facing the nursing workforce and addressing longer-term problems asso- ciated with the age and supply of RNs. Maintaining and strengthening a flexible approach to nurse staffing, not imposing mandatory nurse staffing ratios, is the key to the long-term survival, advancement, and prosperity of the nursing profession.”
UNISON
This is an issue of considerable importance to nursing stakeholders as one would expected. This concerning the UNISON staff survey of 2013 is currently on their website:
The purpose of the survey is to find out what staffing levels are like in workplaces across the country on a regular day. Staff are asked to keep track of the nurse-to-patient ratio (the number of patients per nurse, in other words) in their workplace and then answer questions in an online survey.
The survey can be found here
Please note that survey responses must be filled in by 09:00 Monday, 11 March to be counted.
Guidance about the survey & the questions it will ask can be found below, download this today so you collect the correct information tomorrow. Help us to improve your working conditions and patient care. If you are not a member of UNISON it’s not too late to join but you can still take part in the survey.
Please download the guidance for further information.
Instinctively it seems like a marmite issue, “Should there be a minimum staffing issue?” requiring a yes or no ‘binary’ answer. Certainly different stakeholders will have valid opinions on this, and be able to qualify their answers on the basis of their own experiences and mindset. That being the case, the answer may be more one of “yeah, but…” This is ‘work in progress’.
References
Audit Commission (2002) Recruitment and Retention: A Public Service Workforce for the Twenty-First Century. Audit Commission for Local Authorities and the National Health Service in England and Wales, London.
Baeyens, J.P., Closon, M.C. (2010) Differences in nurse (aid) staffing in acute geriatric departments in general hospitals in Europe. European Geriatric Medicine 1: 320–322
British Association of Critical Care Nurses (2009) Standards for nurse staffing in critical care (updated 2010), Newcastle upon Tyne: BACCN.
Buchan, J., (2004) A Certain Ratio: Minimum Staffing Ratios in Nursing. A Report for the Royal College of Nursing. RCN, London.
Buckley TA, Shor TG, Rowbottom YM, Oh TE. (1997) Critical incident reporting in the intensive care unit. Anaesthesia May;52:403e9.
Buerhaus, PI. (2009) Avoiding mandatory hospital nurse staffing ratios: An economic commentary Nurs Outlook 57:107-12. 0029-6554/09/$
Bureau of Labor Statistics. (2008). Occupational outlook handbook, 2008– 09 edition. Retrieved July 18, 2008, from http://www.bls.gov/oco/ ocos083.htm.
Clarke SP, Sloane DM, Aitkin LH. (2002) Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health 92:1115e9.
Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, K., Aisbett, K. (2011) Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research 24: 244–255
Giraud T, Dhainaut J, Vaxelaire J, Joseph T, Journois D, Bleichner G, et al. (1993) Iatrogenic complications in adult intensive care units: a prospective two-centre study. Crit Care Med 21:40e51.
Goryakin, Y., Griffiths, P, Maben, J. (2011) Economic evaluation of nurse staffing and nurse substitution in health care: A scoping review. [Review.] International Journal of Nursing Studies 48: 501–512
Jenkins-Clarke, S., (1999) Does nursing needthe dismal science’? The case for economic evaluations in nursing. Journal of Research in Nursing 4 (6), 448.
Lynn Massey, A., Esain, A., Wallis, M. (2009) Managing the complexity of nurse shortages: A case study of bank and agency staffing in an acute care Trust in Wales, UK. International Journal of Nursing Studies 46: 912–919
Marquis B, Huspon C. (2003) Leadership role and management function in nursing; theory and application. Philadelphia: Lippincott, Williams and Wilkins; p. 305.
McGahan, M., Kucharski, G., Coyer, F. (2012) Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: A literature review. Australian Critical Care 25: 64—77.
National Nursing Research Unit. Policy+. (March, 2012) Is it time to set minimum nurse staffing levels in English hospitals? http://www.kcl.ac.uk/nursing/research/nnru/policy/Policy-Plus-Issues-by-Theme/Whodeliversnursingcare(roles)/PolicyIssue34.pdf
Rafferty, A.M., Clarke, S.P., Coles, J., Ball, J., James, P., McKee, M., Aiken, L.H. (2007) Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies 44 (2), in press, doi:10.1016/ j.ijnurstu.2006.08.003
Richardson, G., 1999. Identifying, evaluating and implementing cost- effective skill mix. Journal of Nursing Management 7 (5), 265–270.
Royal College of Nursing (2003) Defining staffing levels for children’s and young people’s services, London: RCN.
Royal College of Psychiatrists (1998) Not just bricks and mortar: Report of the working group on the size, staffing, structure, siting and security of new acute adult psychiatric inpatient units. London RCP.
Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. (2000) Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 356:185e9.
Vicca AF. Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. (1999) J Hosp Infect 43:109e13.
The need for an evidence-based debate about minimum nursing staffing levels
There is a popular notion which is gathering some momentum against anti-privatisation campaigners that the NHS has been consistently starved of essential funds, to make it ‘leaner and fitter’ for privatisation. Financial responsibility has become a central plank of healthcare, as regulators grapple with the issue of what should trigger a “failure regime”. It has become clear through very recent weeks that there needs to be an evidence-based debate about minimum staffing levels in the NHS, whatever your views about the future of English healthcare policy might be.
Victoria Macdonald, a journalist on the Channel 4 blog, explained in a recent article how a ‘perfect storm’ has come together in NHS surpluses, “efficiency savings” and nursing numbers:
“There is an unhappy juxtaposition of figures swirling around at the moment. The first is that the Department of Health is expected to underspent against its 2012-13 expenditure limit by £2.2bn, and none of that is to be carried over for future use. It will instead go back to the Treasury. The second figure is in the NHS workforce survey which shows that last month the NHS lost 800 more nurses.
When the head of the NHS, Sir David Nicholson, announced the need for £20bn savings over a four year period it was promised that these savings would be reinvested on issues such as integrating services and longer term efficiencies Labour claims that Ministers were so distracted by the reorgansation of the NHS that they failed to keep a firm grip on how the savings were being made.”
Baroness Emerton in a House of Lords debate on 11 March 2013 indeed specifically drew attention to the “minimum staffing ratios of registered nurses to non-registered nursing support workers”:
“High-quality and safe care delivery is dependent on nurses who are well prepared, in theory and in practice, with enough time to deliver holistic care with compassion and respect. This is possible only if the workforce plans are such that there are sufficient numbers of registered nurses to supervise the non-registered support workers, as the report clearly shows. Recognising that workforce planning has to be contained within budgetary constraints, it would nevertheless be helpful if minimum staffing ratios of registered nurses to non-registered nursing support workers could be established, along with, I hope, the recommendation that NICE be charged with the responsibility for assisting in this development. I trust that the Government will agree.”
Nicholson in his evidence for the Commons Select Committee for Health on 5 March 2013 argued that:
“Yes. This is a really important issue, I think, and I do not know whether Liz wants to say anything about it. From my perspective, evidence and transparency are the watchwords here, because what Francis says-and I absolutely agree with him-is that we need to use much better what the evidence shows us about what are the right staffing levels for a particular ward, and we need to set that out. We should set out what the minimum staffing level is for each individual ward by using whichever tool that you use, and then we hold the organisation and everybody to account through that.”
Barbara Keeley and Liz Redfern CBE, Director of Nursing at NHS South of England, indeed later had a point of agreement:
“Q279 Barbara Keeley: Was it in place when the 17 that the CQC reported on slipped into having unsafe levels of care? How did that happen? If you were doing what you are doing-I do not know how long you have been doing that-why did we end up with a number of hospitals, and not one or two?
Liz Redfern: It is because of the limitations of looking at something from a distance versus the limitations of the responsibility of the trust board locally. I am able to look at nurse patient ratios for a trust as a measure. That does not tell me how many nurses there are on any particular ward at any one time because that is the responsibility of the trust board. In that sense, those CQC cases were individual wards, individual services. It was not about the whole trust having a problem. That is the difference.
Q280 Barbara Keeley: But who wants to go into a hospital with the knowledge that there are unsafe levels of care on any of its wards? Frankly, you would not want to go near them.
Liz Redfern: No, absolutely not, which is why the local trust needs to be looking at that all of the time and to be on a day to day basis deploying staff in such a way.”
This indeed sets the context for having an evidence-based discussion about what constitutes an adequate nursing staff levels. This debate is important for any regulatory system, which in addition to having public safety as a primary driver, wishes to maintain confidence in, trust in, and the reputation of the nursing profession. Whether #Francis had occurred or not, this is a discussion which would have been had anyway, but it has become all the more urgent for patients and healthcare professionals alike.
