We must stop cavalier changes to hospital staffing, says Peter Griffiths
The government says it is maintaining frontline services. Yet it is focusing on nurses in reconfiguring the health workforce, probably because their pay accounts for approximately 35% of the English NHS pay bill. Nursing jobs are being lost.
If better health outcomes can be obtained with fewer resources, it is hard to argue against job cuts. This, combined with an increased emphasis in preventing ill health, in essence, the rationale behind the Quality, Innovation, Productivity and Prevention Programme (QIPP).
But, whenever I hear QIPP, I am reminded of NASA’s Faster, Better, Cheaper management philosophy. In the early 1990s, it seemed to be delivering successful space missions on time and at lower costs. Then came a series of costly debacles, with the failure of four missions that cost hundreds of millions of dollars. The conclusion of many was that it was possible to achieve two of the Faster, Better, Cheaper objectives at the same time but not three.
An independent report criticised a failure to align human resources with strategic goals. This was management speak for a relentless staff cuts with no assessment of what was actually required to deliver projects. The suspicion was that Faster, Better, Cheaper just meant Cheaper.
At least nobody died. But, back on planet earth, the inquiries into Mid Staffordshire Foundation Trust have revealed a situation that is not so different - and people did die. Key issues included dangerously low staffing levels and skill mix. With a little editing, the inquiry into Faster, Better, Cheaper could well be about Mid Staffs. How does “relentless staff cuts with no assessment of what was actually required to deliver safe and effective care” sound?
“Significant changes in hospital staffing are experiments and, because of potential adverse consequences, they should go ahead only after being subjected to the same sort of scrutiny that experimental studies are”
These events have renewed interest in mandated minimum nurse to patient ratios in hospitals, to stop future tragedies.
Chief nursing officer for England Dame Christine Beasley told the Mid Staffs inquiry ward teams with fewer than 60% nurses were not acceptable in any circumstances. However, she rejected mandated staffing levels. She expressed a reasonable fear that minimum levels would become targets, with what should be the floor becoming a ceiling, leading to a decline in standards. However, evidence from California, where mandated nurse ratios have been implemented, suggests this would not happen.
Mandated ratios may also stifle innovation, and managers should be able to innovate with staffing levels and skill mix. I’d like to think evidence that a richer nursing skill mix with more registered nurses is associated with better outcomes would be sufficient to guide managers in making the difficult decisions about priorities, which they will have to make over the coming years. I’d hope the hint in the evidence that it may be more cost effective to have more nurses than support staff would lead them to innovate by upskilling to raise the ward team’s capacity to deliver quality.
But immediate cost savings are tangible and the measurable consequences - good or bad - can take time to become apparent, even when the detrimental effect on care is obvious to nurses and patients alike.
There appears to be no political support for mandated staffing levels. So here is an alternative suggestion. Significant changes in hospital staffing are experiments and, because of potential adverse consequences, they should go ahead only after being subjected to the same sort of scrutiny that experimental studies are.
That way, we may stop some of the more cavalier changes and, at the same time, accumulate an evidence base that may really help to deliver safe and effective care in these challenging times.
Peter Griffiths is chair of health services research at the University of Southampton and executive editor of the International Journal of Nursing Studies