'Critical gap' blights new rules on NHS staffing levels
New measures to make trusts publish ward staffing information do not go far enough and risk burdening nurses with gathering “utterly meaningless data”, it has been claimed.
The warning follows the launch of joint guidance from NHS England and Care Quality Commission setting out how trusts should publish information on levels of nursing, midwifery and care staff.
As revealed by Nursing Times last year, trusts were told in November they would have to start publish staffing data as part of the government’s response to the Francis report into care failings at Mid Staffordshire Foundation Trust.
The number of staff on each shift must be displayed outside all inpatient wards, monthly updates on staffing given to the trust’s board and published online. There will also be an establishment review every six months (see box, below).
Trusts have until the end of June this year to put these systems in place and progress will be checked at the end of this month and again towards the end of May.
“I’m disappointed this does not go as far as we were hoping or expecting it to”
While nurses have welcomed the focus on staffing levels and more honesty about numbers, they worry it may not actually lead to much-needed improvements in staffing on the ground.
“This is a level of scrutiny of the nursing workforce and an openness about what we have got that we haven’t had before,” said Royal College Nursing head of policy Howard Catton. “The transparency is good, but it is only a small step forward and I’m disappointed this does not go as far as we were hoping or expecting it to.”
The guidelines say information about the number of nurses actually working on each shift and the number that were supposed to be there must be displayed for each ward. Information boards should include the full range of support staff on duty – including healthcare assistants and band 4 staff – state who is in charge of each shift and describe the role of each team member.
“Daily reviews of the actual staff available on a shift-by-shift basis versus planned staffing levels should be undertaken and discussed between sisters, charge nurses, matrons and heads of nursing,” the guidance states. “Where shortages are identified they work together to seek a solution, such as the pooling of staff from other clinical areas or the deployment of bank or agency staff.”
Meanwhile, the trust board will get monthly reports on staffing that show planned and actual staffing per shift on each ward for the previous month. These reports will also be published on the trust’s website for the public and patients to see, and uploaded to the NHS Choices website.
The guidance makes it clear these reports must be easy to find and “not embedded within hundreds of pages of other board papers”.
But Mr Catton said this system was a far cry from what was promised in an early version of the guidance published in November, which said that staffing data would be “collated alongside an integrated safety dataset” and “displayed via a single website”.
“My expectation was we’d have some clarity around the staffing metrics or indicators to be used and the presentation of the information would allow for comparison and benchmarking,” he said.
“If there is no consistency and standardisation in those reports, with different metric being used and if it’s being presented in different ways, then how can patients and the public come to a meaningful view about numbers of staff and safety.”
He said consistent, comparable staffing data would also be “hugely helpful” to those involved in workforce planning.
The guidance said the ultimate aim was to develop a “consistent national indicator around staffing”. But Mr Catton said there was no clear timetable to reach that point.
“My concern is people won’t be able to make sense of the data that’s put out there”
Jane Ball, deputy director of the National Nursing Research Unit at King’s College London, said the guidance was “a good starting point”.
But she added: “The critical gap for me is that in a post-Francis world we should not just be assessing numbers of staff in relation to planned staffing levels but also relative to the number of patients.
“My concern is people won’t be able to make sense of the data that’s put out there. It would be really simple to at least say on these boards how many beds there are to give people some means of assessing it,” she said.
The guidance also requires detailed six-monthly reviews of “staffing capacity and capability” that should involve the use of an evidence-based tool. However, Ms Ball said there was a lack of systematic research into the effectiveness of tools used to work out optimum staffing levels.
Susan Osborne, chair of the Safe Staffing Alliance campaign group, described the new guidance as “a bit of a bureaucratic nightmare”. Without clear guidelines on what safe staffing actually meant, there was “a risk of gathering utterly meaningless data”, she said.
“All this is a bit of a smokescreen because it’s not addressing the issue. We know that up and down the country there are trusts that are poorly staffed, yet we don’t have a comprehensive database that says what the staffing levels are in each organisation.
“All this is a bit of a smokescreen because it’s not addressing the issue”
“Until that is properly compiled you just end up benchmarking with the worst,” she said. “We have examples of excellent organisations and I can’t understand why we don’t look at those, find out what their ratios are and use that evidence to say ‘this is a safe staffing level’.”
The guidance, which was sent out to trusts in the form of a joint letter from NHS England chief nursing officer Jane Cummings and Professor Sir Mike Richards, chief inspector of hospitals at the Care Quality Commission, says the first phase will focus on all inpatient areas including acute, community, mental health, learning disability wards and critical care wards.
A further stage will look at requirements for outpatients, theatres and accident and emergency, with future work covering private settings treating NHS patients.
By end of June, all trusts in England must:
- Display information about nurses, midwives and care staff deployed for each shift at ward level. The information must be accurate and clearly on show to patients and their families. It should include the planned staffing level and the number of staff actually on duty plus a breakdown of registered and non-registered staff. Display boards should also say who is in charge of a shift and describe the role of each member of the team. They can include useful information such as the significance of different uniforms and job titles.
- Compile a monthly report on staffing to be presented to the trust board each month. These reports should contain details of planned and actual staffing on a shift-by-shift basis for each ward for the previous month. Where staff shortfalls are identified, the report should include the reason for that shortfall, the impact and action taken to address it.
- Publish the monthly report on the trust’s website and upload it to the relevant hospital webpage on NHS Choices. These reports must be accessible and understandable.
- Put together a six-monthly report on staffing capacity and capability following an establishment review. The reports will be presented to the trust board and discussed at public board meetings. The review should use an evidenced-based tool and the report must set out a “realistic expectation of the impact of staffing” drawing on expert professional opinion. The report should cover points including allowances for planned and unplanned leave, skill mix, staffing shortfalls, supervision arrangements, vacancies, sickness rates and plans to finance additional staff. It should also present staffing data alongside key measures of quality and safety. The paper should make clear recommendations to the board.