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Exclusive: Berwick nursing advisor says report was 'specific' on staffing

The Berwick report tacitly backed staffing ratios and the regulation of healthcare assistants in its recommendations, according to the senior nurse involved in the NHS patient safety review.

However, Elaine Inglesby-Burke told Nursing Times these measures alone will not bring about the culture change the NHS needs.

Chaired by Professor Don Berwick, former health advisor to US president Barack Obama, the review was commissioned by the government in the wake of the Francis report into the care scandal at Mid Staffordshire Foundation Trust.

Ms Inglesby-Burke was one of 15 experts in Professor Berwick’s review team. She is executive nurse at Salford Royal Foundation Trust and also a member of the campaign group the Safe Staffing Alliance.

In an exclusive interview with Nursing Times, Ms Inglesby-Burke said she knew some quarters of the profession were “disappointed” by the Berwick report’s recommendations, which did not explicitly call for mandatory minimum staffing levels or HCA regulation.  

But Ms Inglesby-Burke said the report’s call for the government to ensure all HCAs “meet clear codes of practice as is the case with medical, nursing and other professions” could be interpreted as support for regulation of HCAs.  

She added: “It wouldn’t have to be regulation, but we are going to have to find a system that wraps around HCAs to ensure they’re trained and behave appropriately.”

On staffing ratios, Ms Burke pointed to a note in the report that “calls managers’” attention to research on “proper staffing”.

The research in question – by the Florence Nightingale School of Midwifery at King’s College London – found operating a general medical or surgical acute hospital ward with more than eight patients per registered nurse increased the risk of harm.

“We have been specific: staffing levels should not fall below one to eight in an acute medical or surgical ward. It’s not to be interpreted as ideal or sufficient. Trusts are being asked not to ignore the scientific evidence,” she said.

The report’s main recommendation on staffing is that the National Institute for Health and Care Excellence develop tools for predicting staffing needs for all care settings that can be adjusted in real time, depending on the changing needs of patients.

Ms Inglesby-Burke told Nursing Times the NICE work would predict what staffing levels were needed “beyond safe” across the health service, and would need to be continually developed and updated.

She added: “We had to be clear the report was about safety across the NHS not just about acute hospital wards.

“What people were expecting was we were going to mandate one to eight – but if we had, what about everyone working in mental health, community services, A&E?”

The report also highlighted staffing levels as one of 12 indicators trust boards should look to as early warning signs, along with incident reporting levels and the views of staff and patients.

Ms Inglesby-Burke said it was essential that organisation’s leaders looked at ward or departmental level to get a true picture of the safety of care in their organisation.

Launching his team’s report earlier this week, Professor Berwick said the most important of his recommendations was that the NHS develop a learning culture.

Acknowledging that the “vast majority” of NHS staff “try every day to help to the very best of their abilities”, the report called on the government to invest in training the workforce in quality improvement techniques.

Ms Inglesby-Burke said no “single thing” could make that learning culture happen.

“This report is not a quick fix; there is nothing new in here,” she said. “What the report provides is a set of actions to use moving forward. We don’t have to wait for permission from the government.

“It will be hard work changing the culture of the NHS but it’s absolutely doable,” she told Nursing Times.

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Readers' comments (5)

  • Who was expecting a ratio of 1 to 8? isn't this what everyone thinks should be the absolute maximum of patients per RN in any setting, obviously many more nurses are needed in individual settings, that is why we call it individualised care.

    HCAs (and anyone else working in health or social care) should already be working within a code of conduct which should be written into their job description - don't people see the regulation of HCAs as a way forward to ensure they are held accountable and responsible, which of course they already are. No member of staff at whatever grade in whatever role should be carrying out any task without appropriate training in the first place. All staff should have a clear role, have sufficient training and supervision and be supported by each other.

    Does anyone think involving a US 'guru' is paving the way for a US style of health-care, you know how it goes - slowly slowly drip by drip.

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  • Anonymous | 9-Aug-2013 10:36 am

    I agree with everything you say.

    With regard to the regulation of HCA's, I agree wholeheartedly with Inglesby-Burke: I think too many people have been clamouring to put HCA's names on a register in the belief that this act alone would maintain standards and safeguard patients, whereas the real focus must be on training and education - and I don't mean more NVQ's.


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  • Berwick and Inglisby-Burke are saying nothing new. In fact, if you look again, you will see that they have said nothing.

    What early warning can be triggered by staffing levels if each area does not have its own agreed and recorded level? These are just empty words which have no meaning in reality.

    With regard to the regulation of HCAs. This should definitely happen. Standardised knowledge and training is only a starting point . The current status of the hotch potch of roles and the multiple recognised and unrecognised training regimes (or none) is no longer acceptable.Each RN should be able to walk into any ward and at least have an idea of the abilities of those she has to manage.

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  • How many more reports do we need written before the correct action is taken?
    All of us who read and write into these very pages have got so familiar with the same topics regurgitated in different ways under slightly different guises each couple of years to make it sound like new news.

    The wrong decision was made many years ago regarding nurse training. The SEN (RGN 2) should have remained in place with more opportunity to convert to RGN level 1 and degree status if desired. The HCA would have remained as such - a health care assistant undertaking a very valuable job - providing basic care - i.e., ensuring patients were turned, fed etc. The SEN (RGN 2) would remain as the accountable, qualified practical nurse delivering care at the patient's bedside with the appropriate background knowledge to enable her/him to deliver the plethora of additional skills which are now expected from HCAs but without 2 years training and 6 month post training Diploma courses.

    When will things get better? I personally dread any of my family going into hospital. I keep a very close eye on everything and from recent experience - It's just as well I do.

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  • Anonymous | 11-Aug-2013 7:00 pm

    I don't think the demise of the SEN was necessarily a bad thing as we can now have just a rebadged verson such as a Level 3 HCA or a TAP nurse.

    As an ex SEN I received zero support from the hospital I worked in to convert so I did all my conversion at my own expense and in my own time.

    In my opinion I think there is far too much emphasis on who is academically capable and we have slipped backwards introducing a degree based RGN as to me it is clearly evident that those who do high acheive in academia does not guarantee any higher ability to care, have vision, lead or have empathy.

    Unfortunately, because those in high academia make the decisions, we are lacking the input of many who are capable of innovation and vision because they do not run hand in hand.

    (11 plus failure, zero GCEs but reader of philosophy and psychology) :-)

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