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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)

  • tinkerbell

    Good on your Robert, it ain't over till it's over.

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  • Shoulda been in the original report, Mr. Francis. Near the top.

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  • michael stone

    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”.

    I've pointed out before that Francis is very clever - he knows the dangers of setting staffing ratios (that minimums will be seen as maximums, and that trusts will also claim 'we met the ratios, so we MUST 'have had enough staff'').

    I doubt that his position has changed - I suspect he is trying to protect patients against the setting of minimum ratios which will then be abused by Trusts ?

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  • Unfortunately, woolly language doesn't have any point here. This isn't about minimum staffing levels. It is about adequate staffing levels for each area. There are a variety of researched based formulas and recommendations for these adequate staffing levels. They are habitually dismissed out of hand and therefore not acted upon.

    I agree with Mags. This should have been at the top of the list of recommendations in the original report and then the debate on how best to achieve decent staffing levels could have been further down the road.

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  • How much evidence does he need. There is so much data out there from countries that have used ratios for years, and it all states the same, SAFE PATIENT RATIOS SAVE LIVES , Not only does it save lives but it has a huge impact on reducing hospital acquired infections ,workplace accidents AND burnout. UK governments and managements have seen all of this for years, but they can only see the dollar sign in this. They need to read and absorb how ratios can also save money. I am fortunate and can write this from working 1:4 ratios. We will no doubt be fighting at some stage soon to have them made mandatory. Its called safe patient care and respecting staff. If this comes in for you, it will be a huge step in the right direction. :)

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  • Yvonne Bates | 6-Aug-2013 11:43 am

    Absolutely. Too many excuses are being made for not even considering any kind of ratios.

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  • This is the sort of debate that stifles action as we are now too busy arguing about other issues rather than the real problem. Should have ben top and acted on and those resisting asked to let those who are willing to try take a turn. High quality care and safety must be expectation for every patient. The data on which to base evidence based practice there but we are deterred by the initial high costs. Its better to solve the problem and reduction in costs will follow

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  • Tiger Girl

    Yvonne Bates | 6-Aug-2013 11:43 am

    mags | 6-Aug-2013 12:49 pm

    And what about if 'an expert committee' doesn't come up with 1:4, but comes up with 1:8 or 1:10? And with overly simplistic descriptors?

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  • Thank you Yvonne Bates, couldn't have said it better myself. I too have experience with 1:4 ratios (thank you victoria, Australia...where I trained, though every government tried to get rid off it as soon as it came in!) & I think it definitely needs to happen over here in the U.K. (admittedly i'm in theatres atm & not wards full time....though i still do it to 'keep my hand in' so to speak).

    But I think all the Unions, senior nurses (yes CNO i'm talking to you) need to start standing up for their profession (strike anyone?) more because the sense of apathy & lack of confidence I see in nurses over here to affect any positive change overall all is quite scary. But I don't know how we can change it :(

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  • Tiger Girl | 6-Aug-2013 3:54 pm

    If it isn't even being discussed, then how will you know? What is the alternative?

    It all boils down to whether or not we leave it to an 'expert committee' or insist on appropriate formulas and not simplistic calculations. Of course, I know that 'we' as a profession will actually do nothing. Why break the habit of a lifetime, eh?

    Yvonne has recounted many times the actions taken by herself and her colleagues in Victoria, Australia. Organised, cohesive and sustained action by a determined and united nursing profession against a hostile government. They gained a 1:4 ratio. Better for the patients, better for the nurses and something we can only dream about.

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