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Francis calls for rethink on minimum nurse staffing

The chair of the Mid Staffordshire Foundation Trust Public Inquiry has called for a rethink on minimum nurse staffing levels – less than six months after deciding not to recommend mandatory ratios in his landmark report.

Last week Robert Francis QC suggested to regulators that a minimum staffing level should act as an “alarm bell” for questions about safety, in the same way as high mortality rates.  

In February, nursing unions and other campaigners had been disappointed Mr Francis did not go further on staffing levels in his high profile report on Mid Staffs.

Although he called for nationally recognised tools for establishing appropriate staffing levels, he stopped short of backing the introduction of mandatory minimum nurse-to-patient ratios. The bulk of his recommendations for nursing instead focused on the culture and values of the profession.

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 alliance – whose members include the Royal College of Nursing, Unison and the Patients Association – said in May that no ward should have more than eight patients to one registered nurse, plus a nurse in charge on acute surgical and medical wards.

Mr Francis was speaking last week at a board meeting of the Care Quality Commission, where the regulator’s response to his report was discussed.

His intervention comes after Sir Mike Richards, the CQC’s new chief inspector of hospitals, confirmed he was not planning to include staffing levels in the new surveillance model that will be used to decide which trusts to inspect – though they will looked at as causes of poor care such as unanswered call bells.

But Mr Francis urged the CQC to consider monitoring staffing levels as a “way to show real support for staff”.

Elaine Inglesby-Burke, director of nursing at Salford Royal Foundation Trust and a leading member of the Safe Staffing Alliance, said she hoped Mr Francis’ comments would influence the government’s final response to the Francis report, due later this year. “We are delighted that we have been heard,” she said.

Sally Brearley, chair of the prime minister’s Forum on Nursing and Care Quality, told Nursing Times a “pivotal moment in the debate on minimum nurse staffing levels” had now been reached.

Explaining his change of view, Mr Francis told the CQC that evidence heard by his inquiry in 2011 had been insufficient at the time to persuade him that a “minimum across the board staffing level” was needed.

“I was… only dealing with the events arising out of a particular hospital so the inquiry, for all its breadth, in the end had limitations,” he said.

An inquiry nursing seminar was told evidence on minimum staffing levels was inconclusive while in her evidence former chief nursing officer for England Dame Christine Beasley said her concern with mandatory ratios was “instead of becoming the floor they become the ceiling”.

RCN director of policy Howard Catton said nursing had been more divided over the issue when Mr Francis was hearing his evidence sessions than it was now.

“We have seen much more of a consensus across the profession that includes not just the ‘usual suspects’, like us, but leading nurse researchers, key nurse executive directors and the Patients Association as well,” he told Nursing Times.

He said Mr Francis’ apparent change of heart could help to “persuade others of the value and credibility of looking at nurse staffing levels as a warning sign”.

In a statement, chief inspector of hospitals Professor Mike Richards said staffing levels would be considered during inspections.

He added: “Over time, we hope that our new inspection model will help to give a clearer picture of the link between staffing levels in hospital wards and the quality of care provided. This should contribute towards an evidence-base for making decisions on minimum staffing levels.”

 

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Readers' comments (30)

  • tinkerbell

    Good on your Robert, it ain't over till it's over.

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  • Shoulda been in the original report, Mr. Francis. Near the top.

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  • michael stone

    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”.

    I've pointed out before that Francis is very clever - he knows the dangers of setting staffing ratios (that minimums will be seen as maximums, and that trusts will also claim 'we met the ratios, so we MUST 'have had enough staff'').

    I doubt that his position has changed - I suspect he is trying to protect patients against the setting of minimum ratios which will then be abused by Trusts ?

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  • Unfortunately, woolly language doesn't have any point here. This isn't about minimum staffing levels. It is about adequate staffing levels for each area. There are a variety of researched based formulas and recommendations for these adequate staffing levels. They are habitually dismissed out of hand and therefore not acted upon.

    I agree with Mags. This should have been at the top of the list of recommendations in the original report and then the debate on how best to achieve decent staffing levels could have been further down the road.

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  • How much evidence does he need. There is so much data out there from countries that have used ratios for years, and it all states the same, SAFE PATIENT RATIOS SAVE LIVES , Not only does it save lives but it has a huge impact on reducing hospital acquired infections ,workplace accidents AND burnout. UK governments and managements have seen all of this for years, but they can only see the dollar sign in this. They need to read and absorb how ratios can also save money. I am fortunate and can write this from working 1:4 ratios. We will no doubt be fighting at some stage soon to have them made mandatory. Its called safe patient care and respecting staff. If this comes in for you, it will be a huge step in the right direction. :)

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  • Yvonne Bates | 6-Aug-2013 11:43 am

    Absolutely. Too many excuses are being made for not even considering any kind of ratios.

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  • This is the sort of debate that stifles action as we are now too busy arguing about other issues rather than the real problem. Should have ben top and acted on and those resisting asked to let those who are willing to try take a turn. High quality care and safety must be expectation for every patient. The data on which to base evidence based practice there but we are deterred by the initial high costs. Its better to solve the problem and reduction in costs will follow

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  • Tiger Girl

    Yvonne Bates | 6-Aug-2013 11:43 am

    mags | 6-Aug-2013 12:49 pm

    And what about if 'an expert committee' doesn't come up with 1:4, but comes up with 1:8 or 1:10? And with overly simplistic descriptors?

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  • Thank you Yvonne Bates, couldn't have said it better myself. I too have experience with 1:4 ratios (thank you victoria, Australia...where I trained, though every government tried to get rid off it as soon as it came in!) & I think it definitely needs to happen over here in the U.K. (admittedly i'm in theatres atm & not wards full time....though i still do it to 'keep my hand in' so to speak).

    But I think all the Unions, senior nurses (yes CNO i'm talking to you) need to start standing up for their profession (strike anyone?) more because the sense of apathy & lack of confidence I see in nurses over here to affect any positive change overall all is quite scary. But I don't know how we can change it :(

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  • Tiger Girl | 6-Aug-2013 3:54 pm

    If it isn't even being discussed, then how will you know? What is the alternative?

    It all boils down to whether or not we leave it to an 'expert committee' or insist on appropriate formulas and not simplistic calculations. Of course, I know that 'we' as a profession will actually do nothing. Why break the habit of a lifetime, eh?

    Yvonne has recounted many times the actions taken by herself and her colleagues in Victoria, Australia. Organised, cohesive and sustained action by a determined and united nursing profession against a hostile government. They gained a 1:4 ratio. Better for the patients, better for the nurses and something we can only dream about.



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  • George Kuchanny

    The 1:4 ratio sounds an achievable target to get to. Low dependency wards may be able to use HCA staff to get there. Most of our ICU (or ITU) wards have a 1:1 ratio and the difference between the care an ICU patient gets and one on say a ward running on low staff levels e.g. a 1:8 ratio is truly something to behold. High nursing staff levels save lives. End of story.

    Somebody will now bang on about cost and sustainability. It can be done. Where there's a will there is a cost saving to be identified and redeployment of funds to where they truly make the biggest difference.

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  • Maybe, if he had spoken to real front line nurses and staff, instead of focussing on producing a report designed to suit his political masters, we might have more respect for what he is saying now. Instead of that, I find myself dismissing his report as sound bite, media pap.

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  • Exactly George. We know from our colleagues in Oz that it is achievable. There is no doubt that managers and government would resist and muddy the waters. I am also sure that the battle for decent skill/mix ratios would also need to be fought as they would seek to replace RNs with HCAs at every opportunity (which they are already doing).
    I don't really care what it is called, whether it's minimum staff ratios, adequate staffing levels or what have you. Nursing staffing levels in any area should be what the nurses, who are the experts, have deemed as safe and neccessary. It would, at the very least, vastly increase the safety and quality of care and certainly would save lives.
    Nurses really do need to take the gloves off, pick up the broken bottles (or is that just here in Glasgow?) and set about the mob who are running the NHS (and any other healthcare system in the UK) into the ground.

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  • George Kuchanny | 7-Aug-2013 2:06 am

    Exactly George. We know from our colleagues in Oz that it is achievable. There is no doubt that managers and government would resist and muddy the waters. I am also sure that the battle for decent skill/mix ratios would also need to be fought as they would seek to replace RNs with HCAs at every opportunity (which they are already doing).
    I don't really care what it is called, whether it's minimum staff ratios, adequate staffing levels or what have you. Nursing staffing levels in any area should be what the nurses, who are the experts, have deemed as safe and neccessary. It would, at the very least, vastly increase the safety and quality of care and certainly would save lives.
    Nurses really do need to take the gloves off, pick up the broken bottles (or is that just here in Glasgow?) and set about the mob who are running the NHS (and any other healthcare system in the UK) into the ground.

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  • Dunno what happened there?

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  • tinkerbell

    mags | 7-Aug-2013 11:11 am

    Exactly Mags and there the matter should end.

    We are not asking for more staff because some of us would like to put our feet up and have a rest now and again, we are asking because patients are being placed in danger but still it drags on ad infinitum like Russian roulette whilst peoples lives are put in jeopardy and the consequences have already been proven.

    I am sick to the back teeth of all the rhetoric now and I think nurses of the land should march en masse to 10 downing street and throw a brick through the window. I have a collection of bricks in my back garden that would do nicely.

    I am hopeful we would be let off with a 'caution'.

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  • Having worked somewhere that had a 'dependency tool' years ago, believe me this isn't the answer to all your problems.

    One would complete said tool then one would often be challenged to explain how 'scores' had been reached.

    Like most tools and risk assessments, it was very subjective and because there isn't a pool of instantly accessible staff - if you had highly dependent patients on a particular shift - it served only to highlight, retrospectively when you were short staffed and became nothing more than an utterly pointless paper exercise.

    A colleague even looked at the data to see if there were any patterns, but other than having an extra nurse on a Friday afternoon for discharges, no patterns emerged.

    I think the only way forward, really, is to have a mandatory qualified nurse/patient ratio e.g. qualified nurses on hospital wards should not be expected to be accountable for more than (insert number) patients.

    Allowing HCA's to be included in nursing skill mix will blur things and allow Trusts to take the mick.

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  • When I worked in the States, each ward and shift had to complete a patient needs form.
    From this form the hospital supervisor calculated the staffing needs (Numbers and skill mix) for each ward.
    This tool worked exceptionally well, and as the charge nurse I rarely felt that we had got the staffing numbers wrong.
    The only time it didnt really work so well, was if we had five emergency admissions during the shift- but it ensured the oncoming shift had enough staff and the correct skill mix for the number of patients on the ward.
    Also the good hospital supervisors would call staff on the oncoming shift to see if they could come in early. All of this was before the minimum staffing ratios that are currently in place in CA.
    I can't see why this system can not be utilised here in this country. Afterall, the US hospitals on the most part are profit making institutions, and they felt the system worked well for them...they were concerned about budget....but also did not want litagation either!

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  • Anonymous | 7-Aug-2013 12:53 pm

    I don't think that dependency tools are the answer to any problems. I don't think that any one formula for staff ratios is going to work (although 1:4 for many areas would at least be acceptable). I only know that current staffing levels are dangerous and doing nothing is no longer an option.

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  • When on permanent nights (a few years ago now) nurses used to report to the Dining Room and the Night Sister decided which ward you worked on, maybe this is the way forward?

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