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Gulf in skill mix between hospital trusts revealed

Figures shared with Nursing Times reveal the gulf in skill mix between different hospital trusts and regions.

Some standard acute trusts employ proportionately nearly twice as many clinical support staff - mainly healthcare assistants - in relation to registered nurses as other trusts.

The figures also show there is a three-fold difference between hospital trusts in the proportion of nursing and clinical support staff they employ who are senior nurses at band seven or above.

In many cases the variation is likely to be due to local differences such as the type of services, the way they are provided, or the jobs market.

However, Nursing Times was told that in some cases the figures reflect potentially dangerously low levels of registered nurses and support the case for compulsory regulation of healthcare assistants.

Regionally, the proportion of support staff varies by about 10 percentage points – although much of the difference may be accounted for by London as an outlier, with many specialist and teaching hospitals, and a competitive job market.

Of individual trusts, Taunton and Somerset NHS Foundation Trust has the lowest proportion of registered nurses (60.7%), followed by Mid Cheshire Hospitals NHS Foundation Trust (61.2%) and United Lincolnshire Hospitals NHS Trust, with 62.7%.

The Care Quality Commission is currently investigating Pilgrim Hospital, run by United Lincolnshire, in response to concerns about care. In the spring it said patients “do not always have their needs met by sufficient numbers of appropriately skilled staff”.

Three London trusts have the highest proportions of registered nurses: Newham University Hospital NHS Trust and West Middlesex University Hospital NHS Trust (both 78.4%) and Homerton University Hospital NHS Foundation Trust with 79.9%.

The figures have been released in the week the House of Lords debates a Health Bill amendments requiring healthcare assistants to be registered and minimum nursing numbers being stipulated in law.

Royal College of Nursing policy director Howard Catton said: “For large hospitals these variations mean a significant difference in the number of nurses.

“They appear to be greater than would be accounted for by purely clinical reasons, or because trusts are teaching or specialist hospitals.

“The reasons may be historic, or reflect regional trends or financial pressure.”

Mr Catton called on the government to investigate and impose appropriate nursing levels and skill mix for different service areas, considering both care quality and cost effectiveness.

He said enforced levels, combined with statutory regulation of healthcare assistants, could end the historic trend of “boom and bust in nursing levels”, with numbers swinging between safe and too few.

He said: “There is an opportunity to break that cycle with these amendments. They are seeking to guarantee safe staffing levels for patients.”

Sheffield University Hospitals Foundation Trust nurse director Hilary Chapman said statutory HCA regulation was unlikely but she supported the development of common education and training standards for HCAs among employers.

She said: “We could have an agreed standard across the country to which we prepare healthcare support workers. That would be a very positive step forward.”

Professor Chapman said the Nursing and Midwifery Council and Care Quality Commission should have a role in checking the voluntary system was being followed.

Southampton University chair of health services research Peter Griffiths said: “There will almost certainly be a very strong need to support some good practices [in nursing workforce] as a response to current calls [for regulation of HCAs].” He said employers this could include employers having to earn a “credential” for their HCA standards, although “it is unclear how it would be enforced”.

Taunton and Somerset Foundation Trust said in a statement its “matrons work clinically to ensure the nursing teams deliver high quality care to every patient and the support workers (band 3) at Musgrove [Park Hospital] receive additional training to enable them to work more closely with registered nurses in delivering safe and appropriate care to patients. This training includes taking observations and changing simple wound dressings, all of which is overseen by registered nurses”.

Its acting director of nursing Greg Dix said: “My priority is to ensure that all of our patients receive the very best quality care and experience. We are leading the way in implementing new initiatives - one of which is Intentional Rounding - which are further improving our already high standards of care. In addition to this Musgrove has recently been rated by the CQC as one of only four hospitals in the south west to be fully compliant against standards of care for elderly people. The results we consistently obtain from our patient surveys show that the care we are giving to our patients is of the highest quality.”

A spokesman for Mid Cheshire Hospitals said it “utilises the Association of UK University Hospitals acuity tool to monitor and assess nurse staffing levels based on acuity and dependency of patients”.

Chesterfield Royal Foundation Trust chief nurse Alfonzo Tramontano said in a statement: “The figures quoted for this trust may not be a like for like comparison.  For example, our matrons are not part of this data - they are recorded as super numerary as they work in a supportive capacity - leading their wards.

“In addition, the roles of housekeeper, ward practitioner and healthcare assistants have seen development and expansion in the past few years - and the productive ward programme we are running has led to many changes.  These staff groups take on some tasks previously undertaken by nurses - leaving nurses with ‘time to care’ and the ability to get ‘back to basics’.

“We are confident that our staffing structures provide quality of service and high-standards of care. This is certainly reflected in our national CQC assessments and in patient surveys.”

Figures provided to Nursing Times by the NHS Information Centre are for full time equivalents and include acute trusts only. They include all nursing staff, with midwives and health visitors excluded. Figures for clinical support staff exclude those supporting midwives and some administrative functions. However, a small number of management staff may be included for both.

Readers' comments (12)

  • "Nursing Times was told that in some cases the figures reflect potentially dangerously low levels of registered nurses and support the case for compulsory regulation of healthcare assistants."

    That is missing the point, surely this supports the case for a legalised QUALIFIED Nurse/patient ratio.

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  • Yes Mike it would.
    "Potentially Dangerously low" sounds non debatable to me

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  • I have to agree with you Mike, for too long patient care has been put at risk because there has been no definate guide to qualified staff / patient ratio.

    More and more being put on healthcare asssistants but accountabililty for their actions rests with the registered nurse, I for one really worry about that, previously i was against HCA being regulated but given the way things are going they should be accountable for their actions and the way to do that is to regulate them..............

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  • I do strongly agree that there needs to be a registered nurse patient ratio 1:4 on acute medical, surgical wards, medical assessment wards, etc. But I do not feel this ratio needs to be everywhere. I am a rehab nurse working in a community hospital where the registered nurse patient ratio is 1:10 at maximum and feel this is manageable.

    My last job however, on an acute medical ward was 1:9 (1:18 at night) and this was impossible to work, especially at night because people don't stop being acutely ill over night. I know this ratio sounds a lot better than some other acute wards in the country but we had high dependency patients and BIPAP patients as well mixed in. As a newly qualified it was so stressful, and I had no proper support (mainly because no one could give it, not because they didn't want to) it was making me ill so I had to leave the job. I was also making silly little drug errors because of the pressure and was scared of making one big error so decided to leave. I've been in my current job for twice as long as my last one and I have never made a drug error so I don't think it can be underestimated how much stress can inflict our work.

    I was warned in my last job that despite having a lovely bedside manner I needed to becareful because they are looking for any excuse to get rid of nurses. That was my band 6 and 7 talking to me! I felt like being threatened and I was in tears in front of them (which was humiliating for me!) I knew I had to get out... but if ever this reg nurse patient ratio of 1:4 came in I would contimplate going back to the acute sector because a part of me misses it, although never to that ward again. I know a lot of my peers manage to get on in a similar place but not everyone is the same and some just need a little more support than others (myself included).

    So I feel, yes we need a safe registered nurse patient ratio but its the whole nhs working environment that just needs an overhaul!

    Sorry to rant but being anonymous this is a good place to let things off your chest without fear of being deemed a trouble maker.

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  • Little One

    United Lincolnshire Hospitals where Students were pulled out of one of the hospitals due to concerns over care, support and learning opportunities? What a surprise that they have a low qualified qualified staff ratio.

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  • Anonymous | 25-Oct-2011 4:59 pm I agree that the fixed ratio of 1:4 isn't necessary everywhere, but this could very easily be incorporated into a 1:4 to 1:6 or 8 dependent on clinical environment for example. The Australian model works very well and could easily be incorporated here. The clinical evidence of how well this works is numerous too. The first thing it will do is stop the unsafe staffing levels now, I have been in the same stressful situation as you, as I am sure many of us have. It HAS to stop.

    The only reason it ISN'T happening is because those in charge, the trust management/execs and the government, are refusing to spend the money on staffing levels. That is what it boils down to. It is THEY who should be blamed for low levels of care, it is THEY who should be held to account.

    And you are right, these working conditions do have a serious effect on our health and stress levels too. The working environment within the NHS DOES need an overhaul, but this is a major part of it.

    Oh, and you weren't ranting. No more than the rest of us!

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  • Mike, you say this has to stop, but until we as a workforce stand together, we will keep on accepting the very stressful conditions in which we work every day. I can say that this very serious issue is rights across the UK. Not just England. "Potentially dangerous" - such serious word need serious action. How must it feel to those staff in wards named and shamed for providing poor standards of care - because they do not have the staffing levels to deliver basic care. So very sad that things have got this bad.

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  • What makes all this so unfair is that when anything untoward has happened and is being investigated, its nearly always the nurses that receive the most scrutiny and the blame.

    This is going to happen more and more as registered nurses are cut back, and replaced by HCA's. The registered nurse can not be everywhere and see absolutely everything. They have to trust that the Hca's tell them if a patient is deteriorating so that they can go and check on them. They don't always do that, mainly due to a lack of knowledge and experience. This is why the registered nurse numbers should not be reduced. In my own trust, a lot of Hca's have been taken on recently, and a significant number of trained nurses have had their posts put 'at risk'. This is such a slippery slope to disaster.

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  • Anonymous | 25-Oct-2011 8:53 pm I absolutely agree, we as a workforce have just as much to blame as anything, because far too many Nurses do roll over and accept it. You are right in that we do have to stand together, and this is something that I have been arguing for for a long time!

    Anonymous | 25-Oct-2011 9:46 pm again, I agree, the issue about skill mix and Nurse/patient ratio HAS to be addressed, now. Regardless of how good a HCA any given individual is, you cannot replace qualified staff Nurses with them without expecting standards of care to drop. Perhaps the trusts and the managers involved need to be legally held to account for the dropping standards of care. I would like to see for example, instead of yet another toothless CQC 'report' that denigrates care in any given place and the Nurses getting the blame, I would LOVE to see the trust management and execs actually up in court to explain why they allowed staffing levels to drop so low that it led to those conditions, with significant punitive action taken too.

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  • michael stone

    mike | 26-Oct-2011 9:14 pm

    'I would LOVE to see the trust management and execs actually up in court to explain'

    Well, so would patients and relatives: but in practice you would only get that explanation, during a court case, and almost invariably any manager who could give that explanation, has suffered from 'a mental breakdown' which allows him/her to avoid attending the hearing.

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  • It is only a matter of time before an NHS managment board are charged under the Corporate Manslaughter Act - legislation which also largely removes Crown Immunity from services such as the NHS.

    I would predict that dangerous ratios such as those described will be amonst one of the first successful prosecutions under this Act.

    As long as the staff just keep documenting their plight - there will be less wriggling room regarding Corporate responsibility (even if the Chief Exec does get signed off as psychologically unfit - s/he not the only one on the 'Board').

    Will patients have to die before ratios are universally vindicated? Sadly, I think this is already happening.

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  • Mike, I knew you would be first to post on this one, and I agree with you 100%

    When I started nurse training they had just stopped the "2 tier system" ie, RGN and SEN and replaced it with RN. It's Interesting that the RCN have agreed to give HCAs membership. Does this mean that they regret the intro of RN only registrants? Or is it simply due to finance? (Nurses being more expensive than HCAs of course). The thing is that eventually HCAs will see that they are acting just like nurses and will demand a payrise! So we will be back to the RGN/SEN scenario except they will be called RN/HCA!
    So what has really changed within nursing?!

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