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Steve Ford: 'Will the NHS get mandatory nurse staffing levels?'

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.

 

Steve Ford

News Editor, Nursing Times

Readers' comments (20)

  • No way will we have mandatory staffing. It would get in the way of Cameron and Hunt's plan to privatise the NHS and make it unattractive to Hedgefund companies who are only interested in asset stripping. They don't want to be saddled with having to provide mandatory staffing, there is no profit it that. The health service will be run to provide maximum profit of their shareholders. The parts that are not guaranteed to return a profit, like the care of the elderly and mentally ill, will probably be left under the NHS and become like a poor relation. Welcome to Cameron's NHS.

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  • "So far, so, so, but this year has seen three new names have a significant bearing on the debate – Francis, Keogh, and Berwick".

    You will notice the Chief Nurse for England, Jane Cumming's, has as usual been deathly silent on the debate, Hunt no doubt is keeping her well muzzled.

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  • Francis, Keogh and Berwick. Take time to read between the lines. There is so much fudging going on that nothing is being said. No one wants to commit to anything and that includes the unions. We are no further forward and there certainly is no political appetite for debate. The government has ignored the explicit recommendations made in the Francis Report. There is no reason to expect any response to issues upon which no recommendations were made.
    The most likely outcome will be another silly initiative involving consonants and a numeral.

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  • The upper echelons of Nursing are being very quiet aren't they? But everyone can hear them whisper,
    Minimum staffing, mmmm?
    Maximum saving, great!
    Many patients. (When did I last nurse one)?

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  • Nursing has been a sorry profession since I qualified in 2008, almost every nurse I know, and I know a lot of them have been increasingly miserable these last few years. The NHS is crumbling and rather than spending money on more nurses and HCA's, money is spent on mealy mouth bureaucrats like the CQC. What do they really know or understand about what goes on in any ward? So much money wasted on this foolish witch hunting nonsense!

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  • make everybody in the organisation (if it needs spelling out to some this means from the very top person to the very bottom) fully accountable for their own actions and the work they do (which to spell it out again also includes HR and managers providing enough of the right kind of staff and resources in each and every area) then perhaps there would be no need for this CQC stuff or any other such pearls, twinsets and clipboard brigade.

    Using quality control instead, such as EU standards or ISO norms, makes everybody responsible for the quality of the care they deliver with constant audits and ensures job satisfaction, motivation, pride in the care they give, better interpersonal relations and communications and, above all, patient satisfaction and wellbeing (which if anybody still needs reminding, referring hopefully mainly to non-clinical staff, is the core purpose of the organisation).

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  • Anonymous | 14-Aug-2013 1:05 pm

    The NHS is over-audited. This is one of the problems. Nursing time is taken up with tick box exercises which end up nowhere. They do nothing to improve patient care.

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  • Anonymous | 14-Aug-2013 2:47 pm

    such quality controls would eliminate all this extranous work and leave more time to concentrate on practical patient care. it is an excellent, modern and dedicated system which is self-regulating and would also eliminate all this need for bodies such as the CQC and other external inspections with all and sundry tripping all over everybody else's feet which seems a useless, demeaning and costly exercise.

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  • Providers are already legally required to have the right number of staff - it's just that no one has agreed say what that is for each setting yet.

    At the moment, the law says something like "the provider must ensure there are the appropriate number of trained and qualified staff for delivering the service required" - and this law applies equally to all health and social care providers not just hospitals.

    The reason it is hard to set a ratio in law is because that ratio would have to apply to care homes, domiciliary care provider, GP surgeries etc as well as hospital wards.

    The best approach to my mind is to make the it a legal requirement for each provider to have a safe number of staff, apply this to absolutely all providers, and then set out via other guidance what "appropriate" means in each setting.

    We are already half-way towards this, because the existing law already requires providers to have the sufficient staff.

    If the existing law were supplemented by NICE guidance setting out the details, we'd effectively achieve the aim of having mandatory staffing levels.

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  • A few years ago I left the NHS to work in a nursing home. We were always getting in trouble for not meeting the required staffing levels, not by choice I may add. What was the care standards commissions answer? Why scrap staffing matrix's of course. As has already been said the NHS is being prepared for privatisation. I was recently told that an audit was to take place. My reply was that I didn't have time to update in the time allowed. I was told it had to be done the inference being that it should take presidence over patient care. Oh how nursing has changed and certainly not for the better

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  • Anonymous | 14-Aug-2013 3:03 pm

    Self-regulating? Another problem with the NHS!!!

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  • When I first qualified as a RGN, nursing staff on each ward were able to use their professional judgement and decide the staff to patient ratio on each shift. The amount of nursing care each patient required was taken into consideration and Agency Staff were ordered if some patients had particularly time consuming needs. Now regardless of patients needs staff to patient ratio remain the same...therefore not all patients are getting the care they require and nursing judement is not respected.

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  • Anonymous | 14-Aug-2013 8:12 pm

    we used to also decide if a patient needed to be specialed (one to one) and had enough staff to delegate a staff nurse. I imagine this no longer happens or they go to ICU.

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  • We don't need mandatory staffing levels, we just need the "C", well that is the gospel according to Jane Cummings. How lovely life is in La La land.

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  • We don't need mandatory staffing levels, we just need the 6"C", well that is the gospel according to Jane Cummings. How lovely life is in La La land.

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  • I am always baffled why nurses do not seem to use the Standards of conduct, performance and ethics for nurses and midwives, more often.

    Pass the issues up the line, your code is there to protect both you and the general public. Put the onus on the managers to protect you whilst at the same time protecting yourself and those in your care.

    Its there in the code. In the current climate I would speculate that managers would ignore it at their peril.

    Manage risk
    32. You must act without delay if you believe that you, a colleague or anyone else may be putting someone at risk
    33. You must inform someone in authority if you experience problems that prevent you working within this Code or other nationally agreed standards
    34. You must report your concerns in writing if problems in the environment of care are putting people at risk

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  • Anonymous | 16-Aug-2013 9:15 am

    Why are you baffled? Are you not aware of the culture of bullying which exists in healthcare settings and is widely reported here? Simply quoting the code patently doesn't work without robust systems for protection of staff who report concerns to managers. These don't exist.

    "In the current climate I would speculate that managers would ignore it at their peril."

    There is no evidence to indicate that management behaviour has changed. Why should it? All initiatives and reactions to the Francis Report have completely ignored the recommendations made, and have placed the blame and responsibility for 'fixing' the situation squarely at the feet of the Nursing profession.

    The biggest problem for nurses is that, in this country, they are incapable of acting with any degree of unity or solidarity. That is any government's greatest advantage over us and always will be. That is not baffling. Just very disappointing and very damaging.

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  • Anonymous | 16-Aug-2013 6:41 pm

    So then, what you believe is that the code of professional standards, published by your governing body is not worth the paper it's written on?

    Tell that to the NMC when an act or ommission to protect the public ( yes thats you and I) was ignored because you were in fear of the bullies. It may in some respects be about acting in "unity or solidarity" as you put it but ultimately its about having the courage as an individual to stand up and be counted. Managers are only people like everyone else.

    The NMC will only look at the facts, don't put it in writing, don't make managers aware, then its at your peril, not theirs.

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  • Anonymous | 19-Aug-2013 8:59 am

    Seriously? You value the NMC as a legitimate organisation? And you deny that bullying culture is a serious and damaging issue both within the NMC and NHS? Yes YOU!!
    Pretend that everything in the garden is rosy, but mark well, you don't actually have to act badly through commission or ommission to be hauled up before the NMC. You see, that's what happens in a corrupt culture where the regulatory body has been deemed by its own inspector as unfit for purpose.
    Now slap yourself on the back of the head, open your eyes and stop being a robot apologist for the incompetent!

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  • Anonymous | 19-Aug-2013 8:59 am

    read any CHRE Report in recent years on the performance of the NMC for evidence of serious problems with this organisation. read the francis report for evidence of the appalling consequences, professional and personal, suffered by those who spoke up.

    Anonymous | 19-Aug-2013 5:37 pm

    well said!

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