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NHS 247 – don’t mention the Staffing!
According to a recent newspaper article, the latest workforce statistics obtained by Nursing Standard magazine from the Health and Social Care Information Centre reveal that there are 348,311 nurses, midwives, school nurses and health visitors working either full-time or part-time in England. That is 2,991 fewer full-time posts than when the coalition government came to power. United Lincolnshire Hospitals NHS Trust, Basildon and Thurrock University Hospitals NHS Foundation Trust and Burton Hospitals NHS Foundation Trust are “plugging gaps” by hiring nurses from abroad. Basildon and Thurrock is looking to recruit 200 nurses from the Philippines and Spain. The international campaigns launched by the trusts reflect a growing trend to search beyond the UK for staff.
According to reports from Whiston, management staff have defended their recruitment policy after it transpired that Whiston Hospital’s A&E was understaffed by around eight per cent. An investigation by the BBC found that 11 of the 131 positions at the hospital’s casualty department remained unfilled. It is believed the shortfall is regularly made up by employing bank and agency staff, in line with other reports from around the country. The revelations about staffing levels, made following a Freedom of Information Act request, have unsurprisingly prompted nursing leaders to criticise current staffing levels. Meanwhile, according to reports from Croydon, a staffing crisis at Croydon University Hospital A&E has left it with the second largest shortfall of permanent employees in the country. That ward has a third fewer permanent workers than its NHS trust believes it needs, with the biggest gap in the supply of nurses. Croydon Health Services NHS Trust employs 151 permanent A&E staff, a shortfall of 48. Only Barking, Havering and Redbridge University Hospitals NHS Trust had a bigger deficit of staff, according to official statistics obtained through Freedom of Information requests. The trust stressed holes were plugged with temporary and agency staff, although these typically cost more than full-time employees. It claimed employing temporary staff did not impact on standards of care, unsurprisingly.
Last week, the Royal College of Physicians published its “Future Hospital Commission” report (“Report”). Generalist and specialist care in the future hospital came under some scrutiny in this report, but not in a way which addresses where there can possibly be more Doctors ‘on the ground’. Generalist care includes acute medicine, internal medicine, enhanced care and intensive care. Specialist components of care will be delivered by a specialist team who may also contribute to generalist care. A critical question is, in the average DGH, which of the ‘specialists’ are going to chip in with the acute general medical take. Currently, it is not uncommon for respiratory, gastroenterology and endocrinology physician consultants to run the acute general medical take, but (generally) neurologists and cardiologists do not take part.
“Patients should receive a single initial assessment and ongoing care by a single team. In order to achieve this, care will be organised so that patients are reviewed by a senior doctor as soon as possible after arriving at hospital. Specialist medical teams will work together with emergency and acute medicine consultants to diagnosis patients swiftly, allow them to leave hospital if they do not need to be admitted, and plan the most appropriate care pathway if they do.”
The “24/7″ aspect of ‘Future Hospitals’ is emphasised in various places in the report, for example:
“Acutely ill medical patients in hospital should have the same access to medical care on the weekend as on a week day. Services should be organised so that clinical staff and diagnostic and support services are readily available on a 7-day basis. The level of care available in hospitals must reflect a patient’s severity of illness. In order to meet the increasingly complex needs of patients – including those who have dementia or are frail – there will be more beds with access to higher intensity care, including nursing numbers that match patient requirements. There will be a consultant presence on wards over 7 days, with ward care prioritised in doctors’ job plans. Where possible, patients will spend their time in hospital under the care of a single consultant-led team. Rotas for staff will be designed on a 7-day basis, and coordinated so that medical teams work together as a team from one day to the next.”
Against this is the backdrop of the Nicholson “efficiency savings”, as reported (for example) here in the Guardian:
“The prime minister, David Cameron, his health secretary, Andrew Lansley, and the NHS’s most senior figures have all stressed that the government’s drive to make £20bn of efficiency savings in England by 2015 should not prompt hospitals and primary care trusts to cut services provided to patients. Instead, they say, the money should be saved through reducing bureaucracy, ending waste, adopting innovative ways of working and restructuring services.
Yet the growing evidence from the NHS is that its frontline is being cut, and that NHS organisations are doing what they were told not to do – interpreting efficiency savings as budget and service cuts. While restricting treatments of limited clinical value – such as operations to remove unsightly skin – is uncontroversial, reducing patients’ access to drugs, district nurses, health visitors or forms of surgery they need to end their pain arouses huge concern.”
Shaun Lintern, in a typically excellent article in the Health Services Journal, threw some light on this in relation to the report by Professor Sir Bruce Keogh, in July 2013:
“The NHS has little idea whether staffing levels at English hospitals are safe, Keogh review panel members have admitted. The report by NHS England medical director Sir Bruce Keogh said data for eight of the 14 hospital trusts examined by the review suggested there was no problem with nursing levels on wards.But when the review teams carried out their inspections they found “frequent examples of inadequate numbers of nursing staff in some ward areas”. In his report Sir Bruce said: “The reported data did not provide a true picture of the numbers of staff actually working on the wards.” The review suggests high level data on workforce levels may present an unrealistic impression of staff available on hospital wards on any given shift. This could lead to NHS trusts drawing false assurances from workforce data while their wards go understaffed. At several of the trusts examined the review team found staff feeling unable to voice their concerns to senior managers.”
Julie Bailey and #CuretheNHS, as well as a number of prominent patient groups such as #PatientsFirstUK, as well as certain regulatory authorities such as the #CQC, have all emphasised the need for ‘safe staffing’ for the NHS to succeed. Prof Sir Brian Jarman has time-and-time-again emphasised the pivotal impact of safe staffing on the hospital standard mortality ratio, as for example in this seminal article from the BMJ in 1999, on page 1517:
“In model A higher hospital standardised mortalityratios were associated with higher percentages of emergency admissions, lower numbers of hospital doctors per hospital bed, and lower numbers of general practitioners per head of population. The numbers ofhospital doctors of different grades were also considered as explanatory variables, but total doctors per bed was found to be the best predictor.”
A symptom of a poorly staffed NHS (in certain autonomous units) would be the system completely falling apart from the strain of increased numbers during the Winter period. A ‘solution’ proposed by NHS England has been some of £2.4 billion surplus will be plugged into a ‘quick fix’ of the situation, and/or hospitals can employ temporary bank staff. This may in the short term attempt to mitigate against a dangerous situation. According to the GMC(UK)’s “Good medical practice” (at point 56):
“56. You must give priority to patients on the basis of their clinical need if these decisions are within your power. If inadequate resources, policies or systems prevent you from doing this, and patient safety, dignity or comfort may be seriously compromised, you must follow the guidance in paragraph 25b.”
Many senior consultants do not wish to speak out safely currently against poor resources. This is reflected in this tweet/comment by Dr Kim Holt:
This further emphasises the need for (all) staff to speak out safely against dangerous clinical care (hence the critical importance of the “Nursing Times Speak Out Safely” campaign.) From the consultant physician front, with the ‘input’ from operations and flow managers, there are currenltly reports of insufficient doctors and nurses being able to see patients in A&E in a timely fashion. It seems that the response to this, while NHS managers have remained consistently immune from materially significant blame for poor clinical care, has been for medical consultants to shunt patients, including vulnerable frail patients, out of A&E into MAU (or even, at worst, medical outlier wards), without patients having ever been clerked. That would be therefore direct evidence of a ‘gaming’ managerial culture directly impacting on how NHS consultants on the ‘shop floor’ have to react in the face of cuts and pressures from clinical demand. Whilst it might be sexy for all politicians and the Royal College of Physicians of London to talk about 24/7, no government minister has gone public to say how they will literally achieve ‘more for less’. Where will the extra money come from? Presumably existing staff will have to do more work for the same pay, and still have to comply with the law governing working (i.e. the Working Time Regulations passporting the European Time Directive).
Whilst their Report is to be welcomed, the Royal College of Physicians have effectively delivered a ‘motherhood and apple pie’ document for Government. It sounds nice and does not even address issues relating to the home patch? One of them will be for the Council of the College to consider whether it wishes for ‘specialist’ Consultants to ‘chip in’ with the acute medical take 24/7. They have after all at some stage passed the Diploma of the Royal Colleges of Physicians (UK)?
Meanwhile, for all the methodological criticisms of Jarman’s work, it can only be assumed that he genuinely wishes to improve the quality of care of NHS hospitals in England, and that he sincerely wishes to prevent the staggering distress of those foci of poor care where evidenced previously in the NHS. His words, on @RoyLilley’s “NHSmanagers.network” blog, could not have been clearer.
Where was the Big Society last week in the parliamentary discussion of the Keogh report?
The Big Society was the flagship policy idea of the 2010 UK Conservative Party general election manifesto. It now forms part of the legislative programme of the Conservative through the Liberal Democrat Coalition Agreement. Its stated aim was to create a climate that empowers local people and communities, building a “Big Society” that will take power away from politicians and give it to people.The idea was launched in the 2010 Conservative manifesto and described by The Times as “an impressive attempt to reframe the role of government and unleash entrepreneurial spirit”. The plans include setting up a Big Society Bank and introducing a national citizen service. The stated priorities were to give communities more powers (localism and devolution), encourage people to take an active role in their communities (volunteerism), transfer power from central to local government, support co-ops, mutuals, charities and social enterprises, and publish government data (open/transparent government).
The Big Society remains as vague now, as it did then. Localism has clearly been a frustration of ‘communities taking action’. Both the ‘Save Trafford A&E’ and ‘Save Lewisham A&E’ have been on the receiving end of an argument which urges the need for responsible reconfiguration of NHS services.Whilst campaigners in both situations have urged the need for recognition of their own services, the constant rebuttal has been that in any policy formulation or consultation there are bound to be dissenting views particularly if the sample size of respondents is high. Many people will share the frustration of those who had been encouraged by mechanisms such as the Localism Act (2011), in wider local issues.
There has been a big drive also to encourage ‘social value’ in public services, manifest in the Public Services (Social Value) Act 2012. The fundamental idea behind ‘social value’ is that it is a way of thinking about how scarce resources are allocated and used. It involves looking beyond the price of each individual contract and looking at what the collective benefit to a community is when a public body chooses to award a contract. Social enterprises are businesses that exist primarily for a social or environmental purpose. They use business to tackle social problems, improve people’s life chances, and protect the environment. Healthwatch England has referred to “The NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012″.
In relation to the section covering political campaigning, their view is that,
“section 36(2) ensures local Healthwatch has the necessary freedom to undertake campaigning and policy work related to its core activities and believe to do otherwise would be distracting. We do however, appreciate how there could be some confusion due to the nature of the wording in the section.”
Another issue is how failing Trusts have been allow to provide poor care for members of the general public. Accusations have been made of a poor ‘culture of care’, and this issue has become political with accusation-and-counteraccusation. Patient groups are vital in representing the views of patients accurately. I know, because I was resuscitated after a cardiac arrest and successfully kept alive for six weeks in a coma at the Royal Free Hampstead. However, more than a decade ago, I studied my basic medical degree at Cambridge and Ph.D. also in early onset dementia there. The concern is that Trusts are not being altogether transparent in their metrics about care. However, I personally think patient groups to do this responsibly should be free to campaign on behalf of patients for poor care, but without turning the public against all hard-working doctors and nurses. My experience was that junior doctors and nurses feel terrible about episodes of poor care, so they definitely wish to work with the patient groups. This is not at all a ‘them against us’ issue, but the language of ‘service user’ and ‘they’re providing a service we pay for’ have not helped in this narrative, perhaps together with a concept that clinicians ‘carry out orders to maintain managerial targets’. This concept is particularly toxic, as it might appear at first blush consistent with a growing trend towards the deprofessionalisation of medical Doctors and nurses. Patient groups do an extremely worthwhile rôle, and I have the highest regard for them.
This is why it is all the more important I feel that these issues about the NHS can be held in future in a dignified and balanced manner, without further talk of Hunt ‘politicising the NHS’ or an ‘active smear campaign against Andy Burnham’. Patient groups need to be carefully about their involvement in the media, otherwise they can easily become politicised. The academic issue of whether HSMRs are reliable has become politicised, although the academic debate about HSMR is safely ringfenced in the academic journals such as the British Medical Journal. The limitations of the claims of ‘excess deaths’ or ‘needless deaths’ always needed to be done carefully, and it was left to Sir Bruce Keogh himself and media sources not particularly known for their Conservative loyalty, such as the Guardian or New Statesman, to defuse the panic which had set in following irresponsible reporting of the Keogh mortality report at the weekend.
Political campaigning is defined by the Charity Commission is as follows:
Campaigning: We use this word to refer to awareness-raising and to efforts to educate or involve the public by mobilising their support on a particular issue, or to influence or change public attitudes. We also use it to refer to campaigning activity which aims to ensure that existing laws are observed. We distinguish this from an activity which involves trying to secure support for, or oppose, a change in the law or in the policy or decisions of central government, local authorities or other public bodies, whether in this country or abroad, and which we refer to in this guidance as ‘political activity’.
Further details are given as follows:
“Political activity, as defined in this guidance, must only be undertaken by a charity in the context of supporting the delivery of its charitable purposes. We use this term to refer to activity by a charity which is aimed at securing, or opposing, any change in the law or in the policy or decisions of central government, local authorities or other public bodies, whether in this country or abroad. It includes activity to preserve an existing piece of legislation, where a charity opposes it being repealed or amended.”
It would seem therefore that the definition of ‘political activity’ is not the same as the “rough and tumble” of politics seen in House of Commons debates, nor even on Twitter. However, it is really hard to know what ‘changes in the law’ might follow from Keogh or the Francis Report. This in part, one must to be admitted, needs clear definition what an appropriate ‘outcome’ might be. If the aspiration is “safe staffing”, serious consideration should be put into how enforceable this is, how it could be measured. and what sanctions might follow from an offence regarding it. A clear problem is that stakeholders will always have different views, particularly if there are more of them, and resolving conflicting views is especially difficult. This is all the more significant if you hope a ‘motherhood and mother pie’ approach in keeping with that ‘flagship policy’ of the Big Society. It is clear that some patient groups, indeed the Government, oppose a flat ‘minimum staffing level’ for perfectly rational reasons:
Christina McAnea, UNISON head of health, said this week:
We are pleased that the Keogh Review, as the Francis Report before it, has recognised the relationship between quality care and safe staffing levels. UNISON has been campaigning for safe staffing levels and the right skills mix on wards for many years. This includes in the evenings and at weekends – there is clear evidence that out of hours cover isn’t safe. It is time for the government to start listening and take action by committing to minimum staffing levels. They must also listen to staff and patients who are the best barometer of an organisation.
Spending pressures mean that health workers are losing their jobs. Financial pressures are building up in the NHS just as the demand for healthcare and its cost is rising – trusts are being asked to make obscene savings. Undoubtedly, this will hit standards of patient care hard, and is the direct consequences of decisions made by the government – not by hardworking NHS staff.”
Whilst one clearly not make everyone happy all of the time, it is fortunate that there are so many brilliant stakeholders who ultimately want the best of patients in the NHS. The purpose of the English law is obviously not to get in the way of all the people participating in English health policy at this particularly sensitive time. Politicians can help too by not turning people against other people, and members of the public can help too by not doing the same.
