Later today, a review of patient safety in the NHS by an acclaimed US expert, Don Berwick, is expected to recommend minimum staffing levels for hospitals, a “zero harm culture“, regulation of health care assistants (HCAs), and a “legal duty of candour ” for NHS entities and/or staff within them to admit their mistakes. The Berwick review will be published around 11 am for journalists and ‘interested parties’, and 3.30 pm for everyone else, it is anticipated. A “zero harm culture” is a reasonable policy goal, but there has to be a safe number of pilots and cabin crew to make the plane fly safely, and you have to check there’s enough fuel in the tank.
On the publication of the recent Francis report, David Cameron said:
“The Government has so far resisted calls to introduce mandatory staff ratios for hospitals in the wake of the Mid Staffordshire scandal arguing that it would not necessarily improve patient care and could lead to organisations seeking to achieve staffing levels only at the minimum level.”
One of the most horrific things I have watched in the last few months is the undignified spectacle of campaigners ‘at each other’s throats’, discussing the issue of patient safety. Forgetting for a moment the well known indecency of the Care Quality Commission having given clinical departments a ‘clean bill of health’ before a disaster happened, the way in which some campaigners have avoided the need for a safe nursing staff level has truly offended me. In part, this is due to the fact that some campaigners are blatantly political. However, this has been to conflate an objective discussion of patient safety with a need for party loyalty which has completely not discussed the need for safe nursing levels. Any senior nurse or Sister will tell you about the ‘How many registered experienced nurses do I have on duty for this shift?” test question before nurses start their 2 pm – 9 pm shift, for example. Cutting nursing numbers makes the atmosphere for the nurses who are left turn from providing quality care for which they have trained to do into a method of ‘firefighting’, with an attitude of ‘I hope nothing goes wrong on my watch.” It is all very well for management consultants from outside of the profession to bleat on about ‘compassion’, and indeed this is low hanging fruit given the almost ubiquitous desire for compassion from the caring services, and an under-resourced service will have its consequences. The usual criticism of this argument is ‘there’s no excuse for lack of compassion’, but indeed in a well resourced National Health Service, this should not even be an issue. But it is – particularly as NHS Trusts locally implement ‘McKinsey efficiency savings’. It is easy to demonstrate financial solvency in the balance sheet, but it is possibly easier for Trusts to hide substandard care in both mortality and morbidity, which is why there is such a need for accurate data without the horrific shroud-waving we have seen in recent weeks.
It can’t simply be a question of the “numbers”, “stupid”. It is methodologically tricky to make cross-comparisons between hospitals, especially across a number of different jurisdictions with varying emphasis on private healthcare provision. Differences may be caused not by the staffing level of nurses per se, but by other unmeasured factors associated with higher levels of staffing by registered nurses or other unmeasured characteristics of the hospitals’ nursing workforce, such as proven competence in that particular specialty. The level of staffing by nurses is an incomplete measure of the quality of nursing care in hospitals. Other factors, such as effective communication between nurses and physicians and a positive work environment, have been found to influence patients’ outcomes. For example, the quality of “hand over” in nurses from shift to shift may have a bearing on whether clinical issues are picked up upon, e.g. a particular patient is getting ‘sicker’ and requires more frequent clinical observations; or simply that a patient’s CT scan of the thorax has been postponed for a fourth day in a row?
Politicians generally are not clinicians putting aside for a moment the rather rare cases of Dr Dan Poulter or Lord David Owen, and so can, generally, only be blamed for things which fall under their jurisdiction (or things which do not fall under their jurisdiction, as Justice Silber explained to the Secretary of State last week.) The Government has been criticised for presiding over cuts to nursing posts at a time of increasing concern over patient safety in NHS hospitals. Nearly 5,000 nursing places have been cut since the Coalition took power in 2010, with 800 lost in April this year alone. While NHS England plan to recruit more than 4,100 new nurses next year – a 2 percent increase – the health sector’s own economic regulator, Monitor, said last month that the recruitment drive was a “short-term fix” and will be followed by a further 4 per cent cut to nursing posts over 2014-15 and 2015-16. It has been argued that each ward is different, with a different case mix and layout, and staffing levels should therefore be locally determined. It has also been argued that if authorities set a local staffing levels the “floor” will soon become the “ceiling” and it will not be long before all hospitals plummet towards the bargain basement. This is where who provides the healthcare service does become relevant, in contradistinction to the Tony Blair dictum, which I have previously discussed on this blog. A private healthcare provider, even a NHS Trust which is funded through the PFI initiative, is able to hide staffing employment data on the grounds that this information is “commercially sensitive”.
The Nursing Times “Speak out safely” campaign has also been at the forefront of calling for a culture where the concerns of staff are valued and taken seriously. Also, the “Safe Staffing Alliance“, which includes the Royal College of Nursing, Unison, the Patients’ Association and the directors of nursing at a number of English hospitals, has campaigned for national minimum staffing levels since its foundation last year. The “Safe Staffing Alliance” is made up of NHS directors of nursing, senior healthcare academics, leaders of professional organisations and the Patients Associatiobm and oints to the current variation in staffing levels. Recent research by King’s College London shows that in some NHS hospitals registered nurses will provide care to an average of five named patients during a shift, while in other hospitals nurses have up to 11 patients to care for. Research has found considerable variation between and within hospitals even when specialty and patient dependency are taken into account.
- Registered nurse staffing levels vary considerably in English hospitals. In some National Health Service (NHS) hospitals registered nurses will provide care to an average of five named patients during a shift, whilst in other hospitals nurses have up to 11 patients to care for. Whilst a degree of variation in staffing between units is expected and necessary because of differences in patient needs and the type of care provided, research has found considerable variation between and within hospitals even when speciality and patient dependency are controlled for.
- Some wards can be well-staffed while other wards are dangerously understaffed. When the numbers are added up across a hospital the overall staffing levels can appear to be adequate. Planning safe nurse staffing levels is a recognised problem in many countries, including the US, Belgium, China, Korea and the UK. Care Quality Commission reports consistently warn that quality and staffing vary considerably within NHS hospitals.
- Neglected care (or care not done because of time pressures) is correlated to low registered nurse staffing levels on a ward. There are more errors in care, failure to rescue increases, and care is more likely to be ‘left undone’ when there are fewer registered nurses on a ward.
- Understaffing has cost implications for hospitals. Emergency admissions are higher where there are fewer registered nurses and nurses are likely to suffer more injuries and stress, exacerbating staffing problems and costs.
- Some specialties – such as older people’s care – typically suffer lower staffing levels and more dilute skill-mix. 50% of the nursing workforce caring for older people is made up of care assistants who are not trained nurses.
From “Registered Nurse staffing levels and patient outcomes: Overview of research evidence” published by the NNRU, King’s College London February 2013.
Even Robert Francis QC revisited the explosive issue of staffing levels last week:
However, during a public appearance last week, Mr Francis said he had seen evidence from the Safe Staffing Alliance – a confederation of nursing and patient groups set up earlier this year – that had convinced him the issue should be revisited.
Mr Francis stated: “It’s evidence… [that] ought to be considered with regard to whether there is some sort of benchmark, which at least is a bit like a mortality rates – an alarm bell which should require at least questions to be asked about whether it is possible for a service to be safe.”
He stressed the level should not be viewed as “the adequate level of staffing, but the level below which you cannot be safe”.
The ‘hospital standardised mortality ratio‘ as the warning trigger is for mortality, so clearly pretty distal in the chain of events, very blatantly. Francis has called for simple effective measures which are simple, meaningful, and for breaches against which can be sanctioned. His discussion of this issue of objective findings of poor staffing levels, in this context, is about 55 minutes in when you play this video:
Benchmarking can be a useful tool, but if used at an aggregated trust level it can mask underlying risks. Many directors of nursing have witnessed turnaround teams who suggest staffing can be reduced, on the basis of a comparative overall trust nurse-to-bed ratio. However, the recently published Keogh mortality report identified low nursing levels in many of the trusts they investigated (see my previous blogpost). The tragedy is that minimum safe staffing levels were recommended six months ago by Robert Francis in the report on Mid Staffs. However, the Government is yet to introduce a national standard for nurse to patient ratios, despite constant warnings from medical professionals.
Another campaign has been set up to lobby government to introduce a mandatory minimum staffing ratio of four patients to each registered nurse. It is reported in Nursing Times that:
Members of the 4:1 Campaign said they were “acutely aware of the pressures experienced by staff everyday through understaffing and the negative consequences this has on direct patient care and experience”.
“We believe a mandatory minimum staffing ratio of 4:1 should be introduced by the government to ensure that patients are cared for safely and effectively,” they state in a letter to Nursing Times.
“Research articulating the link between high patient-nurse ratios and poor patient health outcomes is strong and the experience of 1:4 ratios from California and the Australian state of Victoria demonstrate the immense benefits to patients and hospital staff where mandatory staffing ratios have been implemented.”
Further research in this jurisdiction is needed to refine the measurement of the nursing case mix on the basis of discharge data, and to elucidate the factors influencing the staffing levels of nurses and the mix of nursing personnel in hospitals. Given the evidence that such staffing levels are associated with adverse outcomes, as well as the current and projected shortages of hospital-based registered nurses, systems could be developed for the routine monitoring of hospital outcomes that are sensitive to levels of staffing by nurses. Beyond monitoring, hospital administrators, accrediting agencies, insurers, and regulators should take action to ensure that an adequate nursing staff is available to protect patients and to improve the quality of care. The professional regulatory bodies, such as the General Medical Council and the Nursing Midwifery Council, have not found themselves deliberating on wider matters of insufficient resource allocation, unless they happened to be effected by clinicians holding professional registration. Other clinical regulatory bodies might be more effective in regulating this particular domain, which clearly impacts upon the ‘quality’ of clinical care.
Since earlier this year, UNISON, the UK’s largest health union, has been challenging the government over its refusal to implement what is potentially an important recommendation in the Francis Report – the introduction of minimum staff to patient ratios. Most professionals believe that this simple intervention would provide safer, more caring environment for all. That call had been backed by a new survey from the union of more than 1,500 nurses, midwives and healthcare assistants, which shows that 45% of respondents are looking after eight or more patients on their shift. Research shows that looking after this number increases the risk of patient harm. While in political circles, we have heard a lot from the hedge funds and private equity funds about liberalising the economic activity in the NHS, it would be timely to take careful note of the frontline staff regarding what they will help them to deliver safe and compassionate care.
Remember them?
