Risks and benefits: changing the nursing skill mix
Healthcare assistants have taken on more and more core nursing tasks in recent years. Sally Gainsbury investigates the impact of this blurring of professional boundaries in the current economic climate
As the biggest single part of the NHS pay bill it was inevitable that talk of reducing NHS costs would quickly make its way around to discussions of skill mix among the nursing workforce.
Although the confidential McKinsey report on NHS cost saving, seen by Nursing Times earlier this month, did not actually use the term “skill mix” it did suggest the Department of Health urgently “limit or remove” mandatory staffing ratios which stipulate the number of registered nurses to patients a ward should have.
It also included the results of McKinsey’s own research into how nurses divide their time when on a ward. The good news is the biggest single chunks of time are spent in patient-facing care – 25 minutes in the hour in total.
But 10 minutes of those 25 minutes are actually spent doing what the management consultants referred to as “psychosocial care” – defined as hand-holding and talking – which although much valued by patients, does not need to be delivered by qualified nurses.
A further seven minutes in every hour is spent doing paper work and administration, leading to the possible conclusion that up to 28 per cent of a registered hospital nurse’s time could be substituted with a healthcare assistant on a lower wage.
Royal College of Nursing senior employment policy advisor Gerry O’Dwyer told Nursing Times current financial constraints meant it was inevitable that the mix between qualified nurses and healthcare assistants on NHS wards would become a renewed focus over the coming months.
“If we are dealing with £15bn to £20bn [in needed savings] you don’t save that by not providing biscuits at board meetings. It’s length of stay, productivity and skill mix. There has to be a grown up debate about all these things,” he said, referring to the five-year savings target set by NHS chief executive David Nicholson.
The Royal College of Nursing recommends that the ratio of qualified to unqualified nursing staff on hospital wards does not fall below 65 to 35 – a benchmark which was by implication endorsed by the Healthcare Commission when it used it in its 2007 investigation of the healthcare associated infection outbreak at Maidstone and Tunbridge Wells NHS Trust.
The ratio of HCAs to registered nurses was also highlighted in connection with care failings at Mid Staffordshire NHS Foundation Trust – identified in a Healthcare Commission report in March.
In his follow up report on the trust, published in April, national director for emergency access Professor Sir George Alberti said he recommended a 60:40 ratio in favor of qualified staff. But he said it was nearer 50:50 because of sickness absence and unfilled vacancies.
The Department of Health itself has never set an acceptable ratio for HCAs to registered nurses and Nursing Times understands that it has no plans to do so in the near future.
A detailed break down of what actually happens on the NHS wards is not currently available, although individual hospital reports show that it is not rare for wards to reverse the RCN’s favoured ratio, with HCAs out-numbering or at least equalling registered nurses.
For example, a nurse writing in a Daily Mail online debate about improving nursing quality in June, said: “The Royal College of Nursing recommends that a ratio of 65:35 qualified/support staff ratio be implemented on wards, yet I have never worked on a ward with anything approaching this. More usually it is two staff nurses and two HCAs for 28 patients.”
The latest NHS workforce statistics back this trend and show the proportion of HCAs to nurses has risen significantly over recent years.
In 1998 there were 10.5 band five or band six equivalent nurses for every one HCA working in NHS England. By 2008 there were only 6.6 band five or sixes for every HCA – more than a 40 per cent increase in their proportions.
That increase would appear to fit with Sir Derek Wanless’s 2002 work on the future funding needs of the NHS. He argued that NHS services could be more cost efficient if nurses took on around 20 per cent of the patient care which was at that time delivered by doctors. That would leave some traditional nursing duties uncovered, and around 12.5 per cent of those tasks could be taken on by HCAs, Sir Derek said.
But Mr Dwyer warns of the dangers of taking an overly-simplistic approach to nurse-HCA substitution. He said analyses such as McKinsey’s bare resemblance to Taylorism – the late nineteenth century theory and method of scientific management whereby the roles of workers in a factory were broken down into each separate task and analysed to develop the most efficient method to fulfil that task.
He told Nursing Times: “There is a danger that if you look at the care delivered and break it up into chunks you miss what’s being delivered.”
“This isn’t new. There has always been a discussion about the right ratio of registered to non registered nurses. When employers look at that they also need to look at what sort of service they deliver for the patient. If they want a task-based service where people come in and have something whipped out, that is not what the patients want. People want what’s called basic nursing care, not a production line,” he said.
Earlier this year research by Dr Foster and Nursing Times revealed a link between low ratios of nurses to patients and high mortality rates. It underlined nurse fears that changes in skill mix to reduce the number of qualified nurses was affecting patient care.
Mr O’Dwyer said he would not automatically say giving a nursing task to an HCA was “dangerous” and he points out that assistants under go training to complete their NVQ qualifications. But he described the nub of the problem as: “When employers talk about skill mix they don’t mean skill mix, they mean replacing band seven with a band three.”
Lizzie Cunningham, clinical facilitator on the NHS Institutefor Innovation and Improvement’s Productive Ward programme, said the issue of nursing skill mix was likely to form part of the next phase of the Productive Ward programme. “Productive Ward has started to get nurses to think about how they are managing their workload better. But we need to take it the next step to get them to look at skill mix.”
“There is absolutely no reason why skill mix cannot help streamline wards. As a ward leader, I would be looking at that to make sure I am doing things as productively as possible and at the highest quality [possible],” she said.
But she told Nursing Times said she had concerns, like other nurses, that the substitution of nurses with HCAs could go too far and was not blind to concerns about quality and patient safety.
Having worked as a nurse for 25 years she said her own anecdotal experience had taught her that “the fewer senior nurses you have around, the more issues arise. You have a higher level of patient safety incidents with fewer senior nurses”.
She highlighted that although an HCA could be thousands of pounds cheaper than a qualified nurse, simplistic cost cutting would not pay off in the long run if more patients suffered falls, which caused them to have extended stays in hospital.
She also gave the example of a serious post-operative patient. While an experienced nurse will be attuned to the early signs of a transplant rejection or deterioration, an HCA or less experienced qualified nurse may not – with potentially catastrophic consequences for the patient.
But Ms Cunningham said that as long as quality and productivity were not set against each other in a “zero sum game” where only one can win, the use of HCAs to free up qualified nursing time to spend on improved patient care should not be controversial.
She pointed to the introduction of ward housekeepers at the beginning of this decade as a precedent. She said this was hugely beneficial in terms of freeing up nurse time from non clinical tasks, such as managing stores and overseeing cleaning standards.
The next step would be the use of ward personal administrators to take on part of the substantial administration ward leaders have. According to the McKinsey study, the typical nurse spends seven minutes in each hour doing paperwork and administration and a further nine minutes doing administration related to patient medication.
Ms Cunningham said some of that work could potentially be carried out by a ward PA – “someone who is not paid at a band seven but probably a band three”.
The use of PAs is already being piloted in South Central strategic health authority area and the NHS Institute expects there to be increasing interest in the scheme over the coming months, particularly as managers aim to make substantial efficiency savings.
But Ms Cunningham urged managers to not to see the use of PAs and other types of domestic staff as an opportunity to slash nursing numbers. The whole point of the Productive Ward programme has been about freeing up nurse time to be reinvested in doing more high quality nursing. And, according to an evaluation of the scheme in London, the capital has freed up the equivalent of 255 new nursing posts through its use of its methodology so far.
That methodology relies on a “bottom-up” approach whereby nurses – rather than grey suited management consultants – critically examine their own work processes to identify how these can be streamlined to give them more quality time with patients.
The risk with fresh attempts to replace chunks of nurse time with PAs or HCAs is that this will be done in a top-down manner which could translate to a 10 per cent increase in HCAs with an easy 10 per cent reduction in nurse staffing levels.
Ms Cunningham said she was aware some hospital trusts would be tempted to take that approach, but she warned that if trusts do need to reduce nursing staff levels they should at least make each of their changes in a staged and gradual manner – evaluating each change to the workload and division before making the next.
The danger is managers will rush to make “a whole raft of changes which are all dependent on each other,” she said. “That’s the way we’ve always done it in the NHS. But if you do things the way you’ve always done them, you get what you’ve always got.”
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