Staffing levels, staffing ratios, staffing skill mix – we’ve been writing a lot about these topics over the past few years but even more so over the last few months it seems.
But could it be that we are finally heading for a conclusion of sorts on this thorniest of issues? There has been a noticeable change of pace in the debate, sparked by several key developments.
On one hand, the government and its new health quango NHS England have been resolute for some time now in rejecting the idea of mandating minimum staffing levels for hospital wards.
Dictating from the centre goes against the grain in terms of key health policies like more local decision making by clinical commissioning groups and greater autonomy for foundation trusts.
In addition, trusts under pressure to make savings have viewed reducing headcount as a favourite way of trimming budgets. Ministers have noted no doubt that setting mandatory minimums could see them dragged into a politically toxic situation every time a struggling trust got caught out on staffing levels.
There’s also the well-used argument that mandatory levels would reduce the staffing flexibility that those running trusts and wards need at different times, depending on demand.
Unions, as one would expect, have been pushing the other way. More power to their arm has come in recent months from patient groups and nursing academics.
The Safe Staffing Alliance confederation includes not only usual suspects like the RCN and Unison, but also the Patients Association and members of the National Nursing Research Unit at King’s College London.
In May they argued that evidence from the seminal nursing study RN4CAST showed there was a risk of harm when the ratio fell below one registered nurse to eight patients on general acute wards. And, as reported by Nursing Times, NNRU researchers published a study last month showing general wards needed seven patients or fewer per RN to avoid vital care being missed during shifts.
So far, so, so, but this year has seen three new names have a significant bearing on the debate – Francis, Keogh, and Berwick.
In February we had the public inquiry report into Mid Staffs, published by Robert Francis QC.
Despite initial excitement by supporters of minimum staffing levels, his report avoided mandatory ratios and instead called for the National Institute for Care and Excellence to draw up nationally recognised tools for establishing appropriate staffing levels.
But it seems Mr Francis has had a change of heart. At the start of this month, he told a Care Quality Commission meeting he had now seen the evidence from the Safe Staffing Alliance, which had convinced him the subject should be revisited.
He suggested minimum staffing levels should act as an “alarm bell” for questions about safety, in the same way as high mortality rates.
US patient safety expert Professor Don Berwick got involved in the debate with his report for the government last week.
However, like Francis, it was not initially clear where he stood on staffing – as a result, early headlines said he was in favour of mandatory staffing ratios and later ones said he was against.
Like the Francis report, Professor Berwick said he backed the use of “evidence-based acuity tools and scientific principles” to determine safe staffing needs, and called for NICE to develop guidance “as soon as possible”.
However, his report also included a foot-note on staffing that directly cited the Staff Staffing Alliance’s evidence that “operating a general medical-surgical hospital ward with less than one registered nurse per eight patients, plus the nurse in charge, may increase safety risks substantially”.
The unions responded warmly to this, but some nurses noted their disappointment at the report’s lack of an outright recommendation for a mandatory minimum ratio.
What did it mean – had he rejected mandatory minimum ratios by not specifically recommending them or was he tacitly backing them by discussing the evidence for them?
In my view, although subtle, the language used in Professor Berwick’s report can surely only be interpreted as strong endorsement of setting safe staffing levels – a point subsequently confirmed to Nursing Times by his top nursing advisor Elaine Inglesby-Burke.
Perhaps the strongest evidence came from NHS England medical director Sir Bruce Keogh’s July report into 14 hospital trusts with higher than expected mortality levels. Frequent examples of inadequate nurse staffing numbers were found on wards and all 14 were given actions to improve workforce issues including urgent reviews of safe staffing levels.
So the ball is back in the government’s court – or has it been there all along. It must respond in full to each of the reports later this year and decide the recommendations, if any, they intend to implement.
Giving the job to NICE to come up with a set of scientifically backed safe staffing levels would be the compromise that looks most likely to me.
First, the idea has the support of both reports by Francis and Berwick.
Second, NICE creating guidance on staffing allows ministers to stay at arms’ length, in the same way they have done over the institute’s oft-unpopular rulings on drug treatments.
Third, although not mandated from the centre, it would take a brave or foolhardy trust manager to want to explain why NICE guidance on staffing was not being followed when the new chief inspector of hospitals comes knocking.
While for the unions, they would represent something significantly better than the current situation and would give their local branches and members something tangible to monitor themselves.
Thus we get semi-mandatory, evidence-based safe staffing levels through the back door. No one has to be a political winner or loser – but patients and nurses get what they need.
Are the government and NHS England heading the right direction? We may know come the autumn.
News Editor, Nursing Times