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Leading nurse staffing expert warns that Francis report lessons are being 'forgotten'


A leading nurse staffing expert has warned that the “lessons of Francis” are starting to be “forgotten”, due to NHS trusts increasingly being expected to focus on finances over safe nurse staffing levels.

Professor Peter Griffiths, chair of health services research at the University of Southampton, said recent comments by regulators had wrongly indicated a ratio of one nurse to eight patients in hospitals was “generous”.

“That attention [on nurse staffing] has not yet completely gone but it is remarkable how quickly the lessons of Francis are being forgotten”

Peter Griffiths

The body that produced staffing guidance following the Francis inquiry into the former Mid Staffordshire NHS Foundation Trust had in fact found that when a hospital nurse had more than this number of patients there was an increased risk of harm, he said, meaning problems were occurring before that point.

Professor Griffiths, who is also the former director of the National Nursing Research Unit at King’s College London, said: “Our starting point should not be ‘can we afford enough nurses’, but ‘can we afford not to have them?’.

“It was one of the key lessons from the Francis inquiry and, when the inquiry [report] came out, there was a moment where attention was focussed on nurse staffing,” he told delegates at a safe staffing conference in Birmingham yesterday.

“That attention has not yet completely gone, but it is remarkable how quickly the lessons of Francis are being forgotten,” he said to the group of chief nurses and workforce experts.

“It now feels as though we are heading back to a situation where we have to justify the expense of nursing. But you should not have to justify a good staffing level”

Peter Griffiths

He later reiterated to Nursing Times that the review of evidence for nurse staffing in adult inpatient wards in acute hospitals – by the National Institute of Health and Care Excellence in 2014 – found there was an increased risk of harm during day shifts if the nurse-to-patient ratio went beyond 1:8.

“More recently comments from some at [regulator] NHS Improvement suggest that ratio is generous,” said Professor Griffiths.

He warned that “plausible” arguments had been made to reduce staffing levels at Mid Staffordshire – but without considering the risk to patient care.

“It now feels as though we are heading back to a situation where we have to justify the expense of nursing. But you should not have to justify a good staffing level,” he stressed to Nursing Times.

During his presentation, Professor Griffiths also highlighted that harm may be occurring before the 1:8 ratio was reached.

“A ratio of 1:8 is not a target threshold. It is not the magic number. It is a bare minimum. Starting at that level may already be inadequate”

Peter Griffiths

Following another review of the evidence that he helped lead for new staffing guidelines being produced by NHS Improvement, Professor Griffiths said he believed 1:8 should not be viewed as a “target” safe level, as many NHS organisations had done.

“A ratio of 1:8 is not a target threshold. It is not the magic number. It is a bare minimum. Starting at that level may already be inadequate. Patients are probably already at risk,” he said at the Healthcare Conferences UK event.

He said evidence showed that, across a number of patient and staff outcomes, once a nurse had more than eight patients to care for “bad outcomes are happening with substantially significantly increased frequency”.

“By 1:8 and beyond, the bad stuff is already happening, which is why 1:8 should start setting alarm bells going,” he said, adding that he believed a safe staffing ratio was at a lower level than this.

Earlier this month, Sir Robert Francis himself warned that financial and demand pressures on the NHS had created an environment in which a care scandal equal to that at Mid Staffordshire is “inevitable”.

In an in-depth interview to mark the fourth anniversary of the publication of his landmark report, Sir Robert said the NHS was facing an “existential crisis”, and was “manifestly failing” to keep pace with demand.

More on the Francis report


Readers' comments (22)

  • This is why the NMC exists. No matter what the conditions report nurses to the NMC which deflects attention from the real issues. It happened to me. The result , I now despise the NMC and I despise my own profession. There are some positives. I have talked a number of people out of applying for nurse training.

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  • I agree totally with Peter Griffiths and of course Robert Francis,
    The Nursing profession is literally on its knees, but so it would appear are the nursing leaders. Action by all is required it is the duty of senior nurses to speak out,it is a duty of senior staff to inform the public as to what is happening. I say to nurses who still say they are "afraid to speak"
    think and act clinically, The Prime Minister quoted Mid Staffs at the weekly farce of Prime Ministers Questions,Stating she will not take lessons from the Labour Party on standards of care, Well Please Nurses let us all give her a much needed lesson help her to realise that NHS in general will be one big enquiry, The lessons of failure has not been learnt, the Market has failed, I call all nurses to unite now and speak, i will support you and speak with you. This is a call for the Seniors to Lead.

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  • Midstaffs was a behavioral failure, not resources
    Getting folk a glass of water every so often is not hard
    How Francis let himself be hijacked by the unions was another tragedy for patients & our NHS

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  • We all know people are living longer.Less sick patients are in theory nursed at home.So sicker older patients with multiple illnesses and co-morbidity come to hospital.To summarise 1:8 is no longer safe,given the average age of patients being admitted and the severity of their illnesses.In order to be professional and get paperwork completed nurses rarely take breaks stay on late, in order to keep their registrations.
    It is near impossible to get everything completed in your shift.The stress levels in trying to do so are extremely high.
    No one listens when we say we need more staff instead we are accused of poor time management .

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  • I totally agree with Peter . Public and patient protection is without doubt the most important element of nursing responsibility. Nurses make patient memories every day-please make sure they are good ones. Nurses see hundreds of patients-however patients remember that one nurse who made their memory a positive one- make sure its you!! I was a patient recently and I will never forget the nurse who cared for me and my family- she was awesome.

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  • About time that nurse academics and leaders started to speak up. of course so many of them wouldn't know one end of a patient from another - so many trained in the 1970s and 1980s when the patients in the wards were so different! - less sick, less obese, less ready to sue and god help them if they had to do the jobs, take bloods & fill in all the paperwork we now have to in the course of a single shift as well as actually nurse them!
    I am glad Peter is here. For once someone is saying it like it is for us on the front line. If 1:4 is right for our Australian colleagues why is that not so for us? You can bet to Aussies have research to support their figure.

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  • Lets be honest it arguably doesn't take an academic to recognise big safety issues with the NHS. And to rely on an academic to do so may ask the question how attached are we to everyday reality?

    The idea of issues always looming and never arisen is also obvious in that the problem is here and now. There is a constant barrage of alleged warnings without the responsibilty of being the one to say its happened. The notion of Brexit also being a factor is possible but also lets be honest it is a distraction from poor senior management not willing to put themselves on the line for truth.

    Most nurses likely do not know who nurse leaders are and many may refuse to recognise the authority of Ruth May, Jane cummings or Lisa Bayliss. Each one of them in my view should stand down or stand up in what is arguably no time for ambiguity. The question is now whether the frontline profession and patients have been betrayed?

    Many suspect NHS DoH, CQC, Improvement & England have failed and so the debate has moved on to what form should the right protest take?

    And how many whistleblowers have the unions failed in telling hard truth?

    What inevitable could the government or CQC already be wary of?.........

    For one I don't have the answers but I do know that a just society of better answers is different from a manufactured PR just culture that protects blameworthy senior management/ leaders and gov. Role on the truth

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  • Ann ask why many have not spoken out. What you ask although is right can result in potential homeless of those and families that would, retaliation by senior management is a cruel reality including social media propaganda and gov that could hide it. The ultimate sacrifice is an incredible feat. A grass route movement of frontline mass protest is what is needed with group views not inline with corporate management, weak unions or gov. start that then we may stand a chance. Show us whaf you can do Ann.....

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  • I so agree with Debra Butler - cost cutting, poor management and bullying are at the coal face of nursing these days. Graham Pink tried to make a stand on behalf of his elderly patients in the 1990`s, in Manchester - was it Stepping Hill - and was immediately suspended, "offered" a lesser responsibilty post elsewhere in the community away from the issues so he could not continue to fight for his vulnerable patients, and subsequently sacked. Obscene.In 1987, I too, had cause to take up issues similar to his - in my first trained post, I was determined to uphold patient dignity - and was subsequently not renewed in my "temporary contract", because I "wasn`t getting on with the staff" - absolute crap - it was to silence me as my concerns were real. At the age of 22, first trained post, I was appalled. The NHS and indeed any care facility, eg the profit led care homes, so inappropriately named, are to blame for a lot of issues - poor management that uses bullying and threats as basic control tactics....and yes, I am to a degree a hypocrite as I work in one - needs must - but having heard from a mental health nurse today that the bullying she has encountered and indeed others have in the NHS, is endemic, I fail to see where the NHS will be as it will be creating its own monsters by virtue of bullying and poor management - the monster of serious depletion long term of staff on the sick, staff with stress, depression, and potentially strokes and maladaptive desperate coping strategies to meet the stress caused by it all.....I dropped my own hours at work and when asked why - said it was to prevent burnout and stress in myself as the job was relentless. Simple as - cash is not worth that....

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  • Same old, same old when they can't attack the truth they attack the person and then ignore the truth altogether. In my experience what they are prepared to go to in order to hide truth some would argue in my view as criminal retaliation. I definately believe retaliation is rife and the system can be used to full effect in this regard. A concern is certainly now to whether the CQC is a big part of the problem? And as for national guardians what is the point in having internal managers? An external guardian movement made up of nurses is definately needed.

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