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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)

  • I think that staffing levels really do need to be looked in to in the nhs.

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  • Anonymous | 7-Aug-2013 3:57 pm

    In the first instance, there wouldn't be enough nurses standing in the dining room. Nurses are moved around from ward to ward as it is. In addition, given how complex nursing has become and the requirement for specialised areas, it's probably not practical.

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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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  • Anonymous | 7-Aug-2013 6:00 pm

    In the first instance, there wouldn't be enough nurses standing in the dining room. Nurses are moved around from ward to ward as it is. In addition, given how complex nursing has become and the requirement for specialised areas, it's probably not practical

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  • George Kuchanny

    Having read through the comments I think I will stick with my original notion of starting at a 1:4 ratio. Then add a backup pool as required. We all know a patient can deteriorate for no clear reason but might need 30-60 min of individual attention to get stable hence the need for a backup pool. Backup pool determine by size of hospital. ICU (or ITU) wards stay at 1:1 ratio.

    Backup pool duties to be specified by matron/head honcho nurse e.g. Read up on xyz for lifelong personal development or some such until call comes in about patient in distress on z ward. Any luck nobody in distress...

    In other words very specific very achievable staffing levels that can be implemented by chief execs within their known Trust income. If savings are required then the Exec can find cost benefits elsewhere. Otherwise the easy option of dropping a member of staff here and there to cut £200,000 off the bill becomes an almost irresistible option.

    Patient safety and care plus staff morale take a beating but do not show up on the balance books. Too irresistible, so let's see a report that gets very specific about this pivotal staff level issue.

    The reason that passenger aircraft never take off without a full flight crew despite some idiot passengers having a moan is safety. Same reason for having staffing levels that must be ring fenced for hospitals. We are all hearing 'austerity' and 'skint Britain', now is the time to act to protect staffing levels. So come on RCN get stuck in!

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  • It beggars belief that we are debating this issue. Why do nurses spend 3 years training, plus many more post qualifying, if no-one knew that less nurses on ward = reduced quality of patient care/reduced clinical outcomes/higher patient mortality. The fact is that the govt are trying to ignore the elephant in the room. "Oh no, no, we don't need a minimum staffing level to be mandatory/legal requirement because that would mean that nurses could no longer be blamed for the mess that is the NHS today and we would have to take responsibility for it". The RCN want a minimum staffing level. Why doesn't the govt listen to the RCN? Because the RCN have time and time again given away nurses' rights, that's why.

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  • Anonymous | 9-Aug-2013 11:30 pm

    I agree completely. But nurses themselves have to look at their own lack of action. Without a doubt, the government have eroded nurse staffing levels in large part because they have never been resisted. The response from our unions (and, lets be honest, the members) is usually something along the lines of "expressing concern", which is easily brushed aside. The day we down tools and withdraw services, is the day they will sit up and take notice. Until then, we can expect no let up from this government.

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  • Several comments posted here have been 'bang on'.
    Minimum staffing levels will not be recommended by any advisory body. That would suggest a level of competence and accountability.
    In the meantime, most nurses will work flat out on understaffed wards. And yes, we are all accountable. Let's remember how important we are and that we are nurses to help others and solve problems. Patient's problems that is. Not those created by bed pan shy advisors.

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  • I worked permanent nights on an acute ward. Never seen the dining room and I don't think the night sister did either. Getting the chance to have a break would have been lovely.
    But no qualified nurse to cover me. I made sure everyone else got their break. Might have got a postcard from the dining room?
    But I agree with the above, we need to go forward.

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  • Needs to apply to private/charity sector also- care homes/ hospitals/prisons etc. these sectors are ignored but form a huge part of healthcare. eg 3 staff in total to 30 residents not enough. Also consider what staff- no nurses in residential homes.

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