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On NHS patient safety: the silence of the lambs is coming to an end
Defamatory comments about any of these whistleblowers will from now be on reported to the Police. The Socialist Health Association is keeping a careful record of the IP addresses of these comments which have been made thus far.
Look at what happened in the biggest financial scandal ever to hit the United States. Driven by profit, company directors in ENRON turned a complete blind-eye to criminal fraudulent activity. They had a healthy relationship with the US government, which they wanted to impress. The shock waves from the ENRON scandal are felt still all around the world, and in the end the US had to legislate the Sarbanes-Oxley Act which does indeed contain provisions on ‘whistleblowing’. The NHS situation is quite different, in that there is much wonderful, safe, work done by brilliant clinicians. Not all managers deserve their demonisation by any stretch of the imagination. The report by Prof Don Berwick is the latest in the long line of reports on Mid Staffs, but this one has yet further emphasised the critical need for patient engagement. Berwick’s committee specifically say that this should not simply be seen as a ‘seen-to-be-engaging’ sop for patients – it is real involvement by patients in guiding policy. For those who wish to ‘cure’ the NHS, there is a real sense that patients are not being listened to, and at worst mistakes are being ‘covered up’. I feel there is now emerging a dual duty of the NHS – one of safety for the patient, and one of safety for its staff. I have long urged the NHS to deal with the mental welfare of its workforce, and to acknowledge the soul-destroying effects of making to work in an environment of fewer staff for greater ‘productivity’. But the two are linked. That’s why the “Nursing Times Speak Out Safely” [@NursingTimesSOS] campaign has a very important part to play now.
[They] want:
- The government to introduce a statutory duty of candour compelling health professionals and managers to be open about care failings
- Trusts to add specific protection for staff raising concerns to their whistleblowing policies
- The government to undertake a wholesale review of the Public Interest Disclosure Act, to ensure whistleblowers are fully protected.
It is all too easy to denigrate the entire workforce of the NHS including frontline staff and managers, but, across a number of different sectors, toxic cultures have bred a hostile, pessimistic workforce, driven away top talent and prevented organisations from reaching their full potential. While toxic work cultures are the end result of many factors, poor leadership has a big part to play. The fuel for toxic work environments is typically a combination of conflict, ego, gossip, and career ladder climbing, A banking consultant recently advised that establishing a solid operating culture starts at the very top of the organisation. He advised that, for banks, values need to be integrated with shared beliefs and a powerful business mission into an energising narrative that uniquely positions the bank for growth and profitability. The corollary for the NHS is a culture driven by patient safety not financial profitability (though increasingly many decisions about the NHS are being taken from a financial not clinical perspective.) If any organisational culture is managed incorrectly or (worse) left un-managed, it can become dysfunctional or toxic. In these situations the organisational culture of an organisation can become a liability, not an asset. It can even lead to the outright failure of that organisation.
“Speaking out safely” is a much less dramatic term than “whistleblowing“, but a whistleblower (whistle-blower or whistle blower)] is simply a person who exposes misconduct, alleged dishonest or illegal activity occurring in an organisation. The alleged misconduct may be classified in many ways; for example, a violation of a law, rule, regulation and/or a direct threat to public interest, such as fraud, health and safety violations, and corruption. Whistleblowers may make their allegations internally (for example, to other people within the accused organisation) or externally (to regulators, law enforcement agencies, to the media or to groups concerned with the issues). The term whistle-blower itself comes from the whistle a referee uses to indicate an illegal or foul play. Most whistleblowers are internal whistleblowers, who report misconduct on a fellow employee or superior within their organisation.
There is no doubt that whistleblowers have suffered in the past, and continue to do so, and that’s why the proof of the Berwick pudding is in the eating. The treatment of Dr. David Drew [@NHSWhistleblowr], a respected paediatrician with an unblemished 37-year career in the NHS, who was sacked in December 2010 for “gross misconduct and insubordination”, is shocking. Dr. Drew is a practising Christian, though far from a fundamentalist: indeed, he describes himself as “a Christian with questions” who has “coexisted peacefully with colleagues of all faiths and none for many years”. He told a tribunal that, when he was a senior paediatric consultant at Walsall Manor Hospital, he had emailed a well-known prayer by St. Ignatius Loyola, “To Give and Not to Count the Cost”, as an incentive to his staff. Later, when ordered to “refrain from using religious references in his professional communications, verbal or written”, Dr Drew asked the trust to provide examples of when such behaviour had been problematic: the only solid thing it came up with, he said, was the prayer. Dr. Drew has described the culture of the health service as one of “fear and oppression” that is “driven by the top”.
Gary Walker [@modernleader] has also spoken out against his horrific situation. Lawyers representing the United Lincolnshire Hospitals NHS Trust, where he used to be chief executive, had written to him threatening that if he went ahead with the interview, he would be in breach of a compromise agreement and that he might be forced to repay the settlement he had received as well as the Trust’s legal costs. The former head of an NHS trust last week also described the culture of the health service as one of “fear and oppression” that is “driven by the top”. Mr. Walker had been sacked the previous year on grounds of gross professional misconduct, the reason given that he swore in meetings. However, Gary Walker alleges that the reason behind his departure was far more complex – that because he made the decision to ignore government targets for non-emergency operations as there were more urgent cases to attend to, he was cornered into resigning from his post.
Patient safety should be the ever-present concern of every person working working under the NHS’ name. Berwick emphasised that the quality of patient care should come before all other considerations in the leadership and conduct of the NHS, and patient safety is the keystone dimension of quality. Berwick further argued that the most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. Collaborative learning through safety and quality improvement networks can be extremely effective and should be encouraged across the NHS. Critical to understanding this approach is that the most effective networks tend to be those which are owned by their members, who determine priorities for their own learning. However, back to reality. According to Roger Kline, one quarter of the staff in the largest employer in Europe report that they were bullied at some point in the previous 12 months. The rate of reported bullying has doubled in just four years. This summer, the British Medical Association annual conference heard how a proper system of regulation needed to be introduced for managers so they could be held to account.
In Summer 2009, psychologists at the Occupational Psychology Centre (OPC) at the Open University undertook a safety culture review of 30 PCTs. Each PCT was questioned about how their NHS trust measured up against nine key building blocks that make up a safe culture. One of those safety culture building blocks was being a learning organisation. The OPC specialise in safety with particular emphasis within the healthcare and transportation sector. Their work has shown that safety critical organisations that embrace and work at being a learning organisation are more likely to have a strong safety culture. A NHS organisation that has a learning culture learns from its mistakes. It has a problem solving approach to safety issues, is responsive to change and adapts to change effectively overtime improving its systems, processes and procedures. It is argued that a learning organisation promotes and lives out a ‘just’ culture. Many frontline clinical staff will readily report the real sense of ‘firefighting’ which they have in any acute shift in the emergency room, and this will be the case even in the most well resourced departments in England. However, it is felt that employees must feel safe to raise safety issues in an open manner including those issues that they are personally responsible for. Their raised issues are then acted upon. This chimes very well with the ‘Nursing Times Speak Out Safely Campaign’.Some of the employees in organisations which have worked with the OPC inform the OPC hat they have a “blame culture” in their organisation. As a result they are reluctant or even worse are afraid to raise safety issues. This can be further toxic to any NHS entity in terms of its safety culture and safety performance. If these safety issues are not dealt with then they can be precursors to more serious safety critical safety incidents and accidents. One often hears of NHS staff saying that, ‘It was an accident waiting to happen. We have raised the issue before but no-one listens’.
Constructive steps can be taken against toxic cultures though.The first step is to identify the major problems by gathering information, This is easier said than done, as perpetuators of toxic environments are less than forthcoming with feedback. This makes it very difficult for managers to discover the root causes of problems and also to deliver solutions to improve the workplace, yet an anonymous employee survey can go a long way to uncovering what people really think about the workplace. However, it’s also really important for the leadership team to identify an ideal culture and values for their business, so that they can use that shared vision as their compass to guide them towards a more positive culture. Asking the question “What does an ideal day look like?” and getting very specific about capturing that ideal culture will be really useful to the leadership team in the coming months (and years) as the organisation begins to change its direction.Once an understanding of the major issues has been formulated, the HR team can develop the action plan. Ultimately, guiding an organisation through cultural change is a long-term strategy, and it takes a “do what it takes” mentality from all stakeholders to really turn a corner. If HR communicates the strategy positively, honestly and continuously many of the team will jump on board very enthusiastically.
According to the Nursing Times, speaking after the publication of Prof. Don Berwick report into NHS patient safety, Ms. Cumming, the Chief Nursing Officer, said it was important trusts had the appropriate staffing level on their wards but called on staff to raise concerns where it was not.She said staffing would be monitored by the Care Quality Commissions new chief hospital inspector Sir Mike Richards. As previously reported by Nursing Times, staffing levels will not be used routinely to trigger inspections but CQC inspectors will check them during visits.She further highlighted the importance of the Speak Out Safely campaign, which is calling for nurses to be able to raise legitimate concerns without fear of reprisal or blame. So, bit-by-bit the pieces of jigsaw are falling into place. There is no doubt that the ‘Public Interest Disclosure Act’ has been a damp squib in terms of protecting whistleblowers’ interests. Likewise, it appears the NHS has gone “power mad” in getting out the cheque books to pay for compromise and confidentiality agreements, rather than listening to the views of the stakeholders.
But the silence of lambs is perhaps coming to an end at last. By this I mean, the lambs are not going to quit bleating. Quite the reverse. Instead, “the quiet man is here to stay, and he’s turning up the volume”, as someone quite famous used to say… Many would, further, add this does just not apply to the whistleblowers and staff who have been ‘silenced'; but the views of some patients have been massively ignored too. And on top of that a complaints system which doesn’t seem to work, and an overly complex regulatory system which appears to be struggling. A briefest look at all the NHS reconfiguration consultations with Trust special administrators might confirm problems with the ‘patient engagement’ process, but hopefully the NHS will move ‘excelsior’ before the law intervenes.
The Brave New Berwick World
In this gloomy world for socialists and the ‘reforms’ of the NHS led by the market (or, rather, McKinsey’s), there was much to welcome in the report by Don Berwick into patient safety and lessons from Mid Staffs. The beauty of the Berwick report was it attempted to take a measured, proportionate response, but Berwick advised in a subsequent interview with Victoria Derbyshire on #BBCNewsnight that it was not a time to be “fuelled up by anger, remorse or hatred about what happened”. There are people who are truly hurt by their experiences at Mid Staffs, and their pain will never go away, but at some stage the Kubler-Ross grieving process will have to progress from anger to acceptance in its natural time-course . It is not as if Mid Staffs ‘never happened’, but the Berwick report places Mid Staffs into a context which makes general, almost quite philosophical, conclusions about what happened, and, more importantly, how one might progress.
The starting point is that Don Berwick has not been drafted in as a Republican to spit bullets at ‘our National Health Service’ as the Medical Director, Sir Bruce Keogh, is fond of saying. In an almost trance-like state, Berwick was saying the NHS deserves to be the ‘best system in the world for patient safety’, and as a country we should rather pat ourselves on the back for a ‘comprehensive, equitable, free-at-the-point-of-use’ system almost spoken like a true socialist. These are, after all, words you only hear from mostly neoliberal politicians here in this jurisdiction through gritted teeth, while policy is geared up for back-door rationing of care in all of its market-led fairly subtle guises.
Berwick’s philosophy poses problems for those experienced in medicine and management. He seems to advocate a ‘learning from mistakes’ culture while promoting ‘zero fault’. Yet elsewhere in the document he does talk about patient safety in terms of realistic risk mitigation. Berwick also talks about ‘wilful neglect’, and appears to offer criminal sanctions in the most extreme cases of misconduct rather than incompetence. This is not so for the lay person to understand, unless you understand two things.
Firstly, it is very hard to take a prosecution for ‘wilful neglect’ under section 44 of the Mental Capacity Act against managers, quite distal in the ‘chain of command’, compared to individuals who provide frontline care. The implementation of ‘wilful neglect’ in practice is complicated further by the capacity issues of elderly patients; physicians will be guided by their own professional guidelines on the withdrawal of food and nutrition in palliative care, but will not wish to be at risk of committing a criminal offence under the new proposals. Berwick indeed refers to ‘criminal’ and other ‘legal sanctions’, meaning it is uncertain whether Berwick, who is not a lawyer, is contemplating a civil (on the balance of probabilities) or criminal (beyond reasonable doubt) burden of proof.
Secondly, it could be that Don Berwick has really at the back of his mind ‘wilful blindness’, a concept popularised by Margaret Heffernan in relation to senior people in management turning a blind eye to misfeasance lower down in the organisation. Extreme misconduct was a feature of senior mangers in ENRON, and, in the end, the US had to legislate the Sarbanes-Oxley Act, to counter this toxic culture. Berwick is able to complete his analysis by indicating where this toxic culture has come from. Berwick clearly posits it is some managers who have ‘gamed the system’, working with national politicians who have not given frontline staff adequate resources. He feels that frontline clinical staff have ‘copped the blame’ for this, and they should in future not be frightened to speak out if they feel they have been given inadequate tools to do the job in hand.
An issue at the forefront of Berwick’s mind is not adding to the overwhelming bureaucratic and legal demands of the NHS. He feels the regulatory system is overly complex anyway, and clearly alludes to the potential that, with the regulatory bodies having duplication of duties, there could be a lot of ‘buck passing’ going on. This has been a problem with clinical staff whistleblowing about inadequate resources, or indeed a ‘duty of candour’, which theoretically are already part of the code of conduct of professional bodies. A clear solution to this would be to encourage sharing of information between the regulators, and Berwick sensibly proposes this. One does wonder though whether his idea of a ‘superregulator’, as also proposed for the legal services sector, has ‘any legs’. Berwick completes his analysis that people have been much more concerned about impressing the regulators and politicians, than the main focus: they should be more concerned about patient safety, then delivering shoddy care through depleted, exhausted frontline clinicians on the cheap, but which is personally very rewarding for them.
Berwick’s overall solution actually could have been suggested in the US jurisdiction, and indeed there is a lot of evidence both here and in the US to support it. That is, to listen to patients first, and to be open about a NHS driven by a real culture of organisational learning. How we get from what we have now to this Brave New Berwick world, requires us to do textbook change management, e.g. “unfreeze”, “change”, “freeze” as described originally by Kurt Lewin, and later elaborated on by Kotler and others. This is possible if done properly, but given the cack-handed way in which the entire NHS reforms were implemented, this could go dreadfully wrong. Whilst the headline media accounts emphasised that “Berwick does not call for a minimum staffing level”, Berwick clearly sees a link between safe staffing and patient safety, which in all fairness is impossible to deny.
The “Brave New Berwick World” is surprisingly apolitical, but it does put the patient and the frontline staff first. It will be ultimately for those in the legal and medical professions, their regulators, and management as a professional body, to work out their responses. Berwick has often highlighted the ‘waste and inefficiency’ of the US system, which is ironically exactly where we are heading with our newly outsourced, marketised and privatised NHS. Berwick, despite media taunting, has tried not to state the size of the NHS as a weakness, in that he feels that one of the beauties of the NHS is that if a part of the NHS runs into problems it can call on the skill and expertise of another part.
The philosophical difficulty that Berwick will have, in giving some prominence to organisational learning, will be fully to embrace the heterogeneity of the NHS. The ‘zero fault’ methodology in patient safety was first popularised in anaesthetics, parking aside its history in the aviation industry. It may therefore be harder to apply in areas of general medicine where risk is a more pervasive theme such as oncology. All anti-cancer drugs have risks, for example, and not treating cancer (whatever type) has a risk of its own. Secondly, ‘learning from mistakes’ means one thing to experts in patient safety, but means something totally different in other areas of NHS management, such as innovation. The NHS has even toyed with rewarding managers who make mistakes in innovation to reward the process of experimenting.
But Berwick should be congratulated in introducing us to his “Brave New Berwick World“. Whilst it may have left scalp-hunters somewhat disappointed, there is a lot of substance in this very brief report that can be constructively discussed.
Letter to the people from England by Don Berwick
Source: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
Your government and the leaders of the English National Health Service did me the honor earlier this year of asking me to assemble and chair an Advisory Group to recommend some important actions that leaders, clinicians, professional bodies, government agencies and others could take to improve the quality and safety of care in the NHS.
I took that assignment with hesitation and humility. I am an American, not English, and cannot claim the detailed knowledge and cultural sensibility that would lead to the best advice. But I was given a chance to recruit a wonderful group of people as the Advisory Group – most of whom have direct experience of your NHS while the rest admire it from afar – and who worked hard together to understand the problems and craft good suggestions. These included scholars whose careers have been devoted to studying safety and the conditions for excellence, clinicians and managers who know the NHS well, and, most important, patient representatives who could draw on their own experiences and their families’, some tragic and hopefully never-to-be-repeated. This group gave me confidence that we would stay on the right track.
Of course, as you know, one of the main motivations for this assignment was the notorious “Mid Staffordshire” tragedy, in which serious problems in a hospital developed that led to avoidable patient deaths and injuries. That event spawned over two years of inquiry by Robert Francis, and, in early, 2013, the “Francis Report,” with over 1700 pages and 290 recommendations. Your Government and NHS leaders turned to our Advisory Group for ideas on how to accelerate improvement of care in the wake of Mid Staffs. Ours was not the only group at all; lots of teams and leaders were tackling the same concerns while we did our work.
Our full report is now here for you and anyone else to see. It contains some technical material regarding regulation, improvement science, and management, but I hope that lay readers will find it comprehensible and sensible. Toward that end, I would like to share a few personal reflections for you possibly to ponder, as follows:
You will have read much in the public press that may alarm you about the patient care in the English NHS. After all, things did go quite wrong at Mid Staffs, and, like others, we believe that problems in care often occur throughout the NHS. In that, however, I assure you that the same can be said of every health care system in the world. Health care is complicated, and, even when the staff and clinicians are doing their very best (which is most of the time), errors occur and problems arise for patients that no one intends.
What you do have in the NHS is something that most other nations in the world don’t have: a unified system of care that is completely capable of identifying its problems, admitting them, and acting to correct them. That is the process now underway; that is the process that led your leaders to convene our Advisory Group; and that is the process that can and, I believe, will help the English NHS to emerge over time as one of the safest health care systems in the world.
That is not easy. And it gets even harder if the staff of the NHS experience a culture of fear, blame, recrimination, and demoralization. I hope that you resist such general negativity, in yourself and anyone else, and instead clearly point the way with energy and optimism toward the care that you and I want, and that the vast majority of people who work in the NHS want to offer.
In the Mid Staffs story and elsewhere, there are occasional cases of people who willfully or recklessly did some harm. That, of course, cannot be tolerated, and occasionally strong measures of enforcement are needed. There are also clearly occasional organizations for which early warning signals suggest that serious problems may exist. In such cases, your government and NHS leaders can and should promptly investigate, reach conclusions, and act.
But enforcement, even though needed, is not really the route to an overall ever better NHS – the NHS you want. Instead, our report says, bet on “learning.” The English NHS is capable of vast and continual improvement of safety, quality, patient-centeredness, and even cost, if, and maybe only if, everyone involved engages in learning every day. The questions that come up in such a culture are ones like this:
Whom do we serve, and what do they really want and need?
How are we doing at meeting those needs?
How do we know?
What could we do differently that would do that better?
Who knows something – a better model, maybe – that we could put to work here?
Imagine an NHS where everyone, all the time, was part of that journey, and has the respect and tools to improve. That’s what our Group recommends, in part, as you will see in this report.
We are recommending four main principles to guide everyone in trying to build an even better “learning NHS.” Here they are:
Place the quality and safety of patient care above all other aims for the NHS. (This, by the way, is your safest and best route to lower cost.)
Engage, empower, and hear patients and carers throughout the entire system, and at all times
Foster wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work.
Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge.
In all of that you – patients, carers, and citizens – have a vital and exciting role to play. Your voice is key to the future. I hope that this report will give you more confidence in speaking up everywhere and all the time in a vital NHS, and will give those who care for you and want to help you the confidence and skills to invite you, hear you, and welcome you into authentic partnership.
Don Berwick
To deny the need for safe nursing staffing levels is to defend the indefensible
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.
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