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This country is for hard-working people. But not hard-working nurses?
When your script is written by a hard-nosed hedgie or private equity fund owner, it can be easy to lose sight of the basic fact that it’d be impossible to run the NHS without nurses.
“Aspiration” has been a powerful slogan for all main political parties in the UK, with a history of its own. Historically, Labour has drifted away over decades from ‘working class people’ to ‘middle class people’, so much so people have asked what Labour really can offer those at the lowest end of the pay scale.
“Hard-working” is not necessarily synonymous with “being very well-paid”. There are hundreds of thousands of healthcare professionals, staff grades or experienced specialist nurses, who are extremely hard-working. Many of them are not well-paid. Professional footballers and employees in the City tend to be well paid. Nurses tend to have their job as their source of income. Some people have various sources of income, naming no names.
Unsurprisingly, the Unions have criticised Government moves to halt a 1% pay rise for all NHS staff in England. The Department of Health said the increase was “unaffordable” alongside the current system which sees many staff automatically receive incremental annual rises. This is, of course, a totally bizarre argument when you consider that around £3 bn was returned into the Treasury only last year.
It was decided that these savings should not be pumped back into frontline care, staggering when you consider the close link between patient safety and safe staffing. Health trusts are currently under pressure to make savings and the NHS wage bill accounts for around 40% of its budget.
The Conservative party conference was plastered with the phrase “hard-working” – “For Hardworking People” beaming from the platform – and a host of frontbench speakers milked the term for every last iota of rhetorical impact. It’s hard to know exactly where this odd meme came from, but it might be something to do with George Osborne decided to tweet #hardworking in his popular tweets.
Of course, “hard-working” – whether it is a predicate of “families” or “people” – is potentially ‘low-hanging fruit’ in political communications. It has various layers of meaning, however.
‘Hard-working’ also relates to the issue of how hard nurses actually work. Whilst nurses work shifts, there is no sense that any professional nurse should wish to leave punctually at the end of the shift, if there is a patient with unmet needs (and who hasn’t been safely ‘handed over’ to nurse colleagues). In previous discussions about rewarding nurses, it has been mooted, for example, that ward managers should be incentivised to stay at the bedside rather than being forced to choose administrative roles if they want to progress their careers. However, it is generally the case that individuals do not enter the nursing profession to make ‘loadsamoney'; there are other income-generating routes which are far easier. That is why people who have had an easier life, through politics, aren’t fooling anyone by dressing up in a nurse’s outfit for a day and for some cameras.
Take for example the issue of ‘hard-working’ in the context of compassion delivered by nurses. It is hard to know what the link between ‘hard-working’ and ‘compassion’ might be, except nurses who are looking after busy wards with not enough time even to go to the toilet report genuine frustrations in having time to deliver ‘compassionate’ care.
The word “hard-working” generally connotes something else: the virtue of the dedicated employee, who is ever available, an asset to company and country, never shirking, never clock-watching. This is particularly case in relation to the work ethic of nurses. Nurses work in teams, and has a strong ethic of collaborative working. If however a nurse agrees on professional grounds that the working environment is unsafe, and needs to ‘speak out safely’ against this, this can be professionally difficult.
There is nonetheless a slight twang from the Right that “hard-working” is linked to the neoliberal conception of the entrepreneurial self. This self never stops working; writing blogs, professional networking, setting up innovative businesses. However, this belief falls down with the fundamental finding that many ‘hard-working’ nurses on the left-of-centre in politics also voluntarily do such activities. A related issue there is that the Right do not have a monopoly on entrepreneurialism or innovation.
The word “collaboration” implies working together for the greater good but actually encompasses far more. Several pre-conditions must be in place for collaboration to be successful. Collaboration must have shared objectives. The value system among the participants must be similar. Communication must be honest, respectful, and purposeful. Nurses are especially good at this aspect of their working hard.
Indeed, most people in the general public acknowledge that nurses are caring and hard working in the face of challenging conditions, research has shown. A poll by YouGov revealed that 76% of those asked think nurses do their best and care about their patients. However, 82% of the 1,968 people surveyed also said nurses should be given the chance to speak more freely, with only 14% believing that this is already the case.This finding implies that nurses have a strong sense of professional ethic for their patients, and not just ‘doing time’ to receive the salary.
Another desirable quality of ‘hard-working’ is the notion of thrift. This boils down to an old notion of second world war pluck. Given the perceived necessity for tightening our belts and knuckling down and applying the old elbow grease in order to dig. It will be ‘hard-working’ people who, in a ‘war-like’ spirit get ‘Blighty’ out of this mess. For this, the alleged ‘profiligate spending of Labour’, which turns out to be £860 billion recapitalising the banks and sufficient public spending to ensure the highest satisfaction ratings of the NHS ever, is the enemy. Austerity is the cause under which we can all unite together?
The NHS is now expected to deliver 65% of its planned efficiency savings by year end, officials have told MPs. However, hard-working nurses, working at demands which far outweigh safe resourcing levels, will be a recipe for a disaster, as Mid-Staffs showed. The Care Quality Commission has issued the hospitals with warning after carrying out inspections, and the Keogh mortality report (and the Francis reports) have given plenty of examples of how even hard-working, well-meaning nurses, can’t cope. Of course it can be demoralising for ‘hard-working nurses’ to come home after their shift to listen to a diatribe of abuse about hospital standardised mortality statistics once they come home from work.
Notably, the term “hard-working” brings with it a status in front of your bosses. You might believe yourself to be “hard-working”, but to really know for sure you’d have to be told it by a rich person. Wealthy health service managers will now be able to pocket salary increases of 4%, which could boost annual pay packets by over £6000. By contrast, it was revealed this week that a 1% rise for NHS staff in England had been scrapped. A manager on £100,000 could be in line for a £4000 salary boost, while an NHS director could get up to over £6000.
In one sense, it evokes a “dignity of labour”, related to a productivist ideology of a historical layer of skilled workers; “Protestant work ethic” or the “Presbyterian work ethic”. Osborne’s decision to visit factories and skilled manual workers in particular may suggest he was aiming to evoke this sense. The problem with this approach, putting enormous emphasis on ‘productivity’, is that it conceptualises healthcare in the same terms as the efficiency of making an iPad. Heavily based in the Frederick Winslow Taylor management school of efficiency and productivity, it tends to ignore the professional ethic of nurses, or the value that they bring in their professional work which is hard to measure.
The “hard-working” theme is thus a populist-right appeal which encodes a series of policies designed to profoundly transform British society. However, it turns out to be a sham when you consider how it gives the appearance of not including ‘hard-working nurses’.
The general secretary and chief executive of the Royal College of Nursing, Dr Peter Carter, said that Chancellor George Osborne said it was “affordable” to give NHS staff a 1% pay rise in this year’s spending review. Dr Carter added that the Government was “emotionally blackmailing hard-working staff”.
All a bit of a shambles. But quid novi?
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.
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.
Remember them?
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.
