Nurse staffing decisions should be based on a “measure and improve” approach to raise care quality rather than the current “guide and comply” method, according to the most senior nurse at the health service’s newest regulator.
Ruth May, executive director of nursing at NHS Improvement, said her favoured approach was characterised by the Care Hours Per Patient Day (CHPPD) metric, a new way of measuring care activity set to be adopted by the health service.
“Just to produce guidance and ask you to comply is a style I don’t think I want to adop”
In her first interview since starting her new role, Ms May discussed ideas across a range of workforce issues, including safe staffing guidance, curbs on the use of agency workers and efforts to retain nursing staff in the NHS.
“It’s a really tough time out there at the moment – tougher being in a [trust] chief nurse role right now than I’ve ever seen before,” said Ms May, who has also been appointed deputy chief nursing officer for England.
She suggested being deputy CNO as well would create an opportunity to work closely with the chief nursing officer’s team to ensure they have “one voice” for nursing and “say the same thing to providers and commissioners”.
In her post at NHS Improvement, she will help oversee the introduction of a new measurement of nursing staffing levels – the CHPPD calculation – which was recommended in a major review of NHS productivity by Lord Carter in February.
It takes into account the average hours of care provided by both registered nurses and healthcare assistants in a 24-hour period. The review recommended the metric should become the “principal measure of nursing and care support deployment”.
But some workforce experts have claimed the metric is a “blunt instrument” that does not recognise the complexity of care provided by registered nurses, and could lead to nurse understaffing.
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However, Ms May said it would be possible to break down the data to separately show numbers of registered nurses and support workers. She stressed that data from the tool should be used at both ward level and in aggregate to ensure care was improved.
“The important bit out of this is how we are moving from ‘guide and comply’ to ‘measure and improve’,” she said. “That’s a philosophy that I’d like nursing to adopt from where I’m standing in NHS Improvement,” added Ms May.
“Obviously you will need to [carry out measurement] with clinicians and make sure they are engaged in order to get clinical buy-in and make the changes to services. But for me, just to produce guidance and ask you to comply is a style I don’t think I want to adopt – it’s much more of a measurement and improve approach,” she said.
When asked if the new metric should supersede guidance on safe staffing produced by the National Institute for Health and Care Excellence, Ms May said: “CHPPD is one metric that will be used to measure and improve [staffing]. It is vital we balance that with what outcomes there are for patients.”
“We made sure there was the facility for them to break the glass”
In addition, Ms May said a new programme of work at NHS Improvement looking at how to improve nurse retention would look at a range of areas around safe staffing. “We know it’s important for nurses and midwives and care givers to be doing the roles they were paid and trained to do,” she said.
“We know in some areas where they have got sufficient ward clerks, sufficient people doing housekeeping, a sufficient mix of staff so that the registered nurses are able to do what they want to do, which is provide nursing care to their patients, and we know those nurses are happier,” she said.
Meanwhile, she said it was “too early” to review whether changes should be made to the agency caps policy introduced at the end of last year and which she helped develop while at NHS Improvement’s forerunner Monitor.
A Nursing Times investigation revealed trusts were struggling to comply with the rules for hourly rates of pay and were breached more than 60,000 times in the first few months. Ms May said she was “pleased” trusts were using a “break glass” provision within the rules, which allowed them to pay more for an agency nurse on exceptional safety grounds.
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“We made sure there was the facility for them to break the glass and make sure their services are safe. That’s right and proper that people do that,” she said.
Ms May said the rules had resulted in both a reduction in total agency nurse spending in the NHS, as well as the price paid per shift. “It’s not without its challenges though,” she said. “Chief nurses up and down England and across it are working hard to make sure that safety is maintained.”
“I believe passionately its right that the agency controls came in,” said Ms May. “What I think now we need to do is to help chief nurses learn from the best, so we are spreading the best practice around a whole range of things – not just agency control.”