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NICE experts called for minimum staff ratios in cancelled A&E guidance, reveals leak

  • Guidelines for A&E staffing recommended minimum nurse/patient ratios
  • Documents suggest lower nursing numbers linked to poor outcomes
  • Ratio recommendations were made despite government resistance

Suppressed NICE safe staffing guidance for hospital emergency departments called for the NHS to implement minimum nurse ratios to ensure safe care, it has been revealed.

The National Institute for Health and Care Excellence’s unpublished final report on accident and emergency department safe staffing, kept secret for months, has been leaked alongside a number of related reports.

The guidance shows NICE’s safe staffing committee pressed ahead with recommending minimum nurse ratios in English A&E departments, despite opposition to the idea of minimum ratios in government and senior NHS circles.

Shortly after the guideline was completed, last June, NHS England controversially suspended NICE’s safe staffing work, which left areas such as mental health and community nursing without advice.

The guideline, published today by Nursing Times’ sister title Health Service Journal, said all “type 1” A&E departments, which includes most in England, should provide, as a minimum:

  • one registered nurse to one cubicle in triage
  • one registered nurse to four cubicles in majors
  • one registered nurse to two cubicles in resuscitation
  • two registered nurses to one major trauma patient
  • two registered nurses to one cardiac arrest patient
  • one registered nurse to one priority ambulance patient

It also recommended that every A&E shift should have a registered children’s nurse, or at least a nurse trained in caring for children. Each shift should also have a band 7 nurse “to lead, supervise and oversee the shift”. An appendix to the guideline said such a role is “associated with higher levels of safe care”.

In a change from its draft guideline, the safe staffing committee decided against setting a minimum ratio for nurses working in the minors area of A&E.

An external study, carried out for NICE, looked at the effects of different scenarios on a model A&E department.

It found that a “low nursing skill mix and low staff numbers will have a negative impact on outcomes (more patients leaving without being seen, higher average duration in A&E departments and higher occupancy)” and that “moving towards a higher average skill mix of nurses might improve some patient and process outcomes”.

“Minimum ratios for areas of the A&E department and registered nurse-to-patient ratios for particular situations are recommended”

NICE guidance

The guideline said: “Minimum ratios for areas of the A&E department and registered nurse-to-patient ratios for particular situations are recommended in this guideline based on the evidence available and the safe staffing advisory committee’s knowledge and experience.”

It said the document was designed for trusts to “ensure that patients attending A&E departments receive the nursing care they need at all times of the day and night, on weekdays and at weekends”.

While the ratios “should be used as a minimum”, the guidance said these were not fixed and additional staff could be used above the minimum levels based on local professional judgement.

The guidance also recommended a systematic process for senior nurses to calculate staffing levels and suggested a system of “red flag” events to serve as a “warning sign that something may be wrong with nursing staff levels”.

These events include: a crowded department; missing patients; aggression towards staff; falls; and patients leaving the department against advice. Other red flag incidents include delays of more than 30 minutes for giving pain relief or food and drink, and a more than a 10 minute delay in helping patients use the toilet.

The decision to suspend NICE’s safe staffing work was criticised by high profile figures including Sir Robert Francis, who recommended that NICE carry out the work following his public inquiry into failings at the former Mid Staffordshire NHS Foundation Trust.

In 2013, health secretary Jeremy Hunt rejected the suggestion of minimum nurse-to-patient ratios. Then in July 2015 he said at a King’s Fund event he “never wanted” mandatory nurse ratios from NICE’s work on safe staffing.

NHS England chief nursing officer Jane Cummings has also argued against minimum ratios, instead preferring a multidisciplinary staffing focus, though it is unclear how this would look and operate.

“It is concerning that these consequences may have been a factor in the decision to scrap this important work”

Donna Kinnair

NHS Improvement is developing guidance on safe staffing levels that is expected to be published this year. Mr Hunt has said this will be reviewed by Sir Robert, NICE and chief inspector of hospitals Sir Mike Richards.

A spokeswoman for the Department of Health said the document should not be treated as official guidance, adding: “A comprehensive programme of work on safe staffing is being led by NHS Improvement and full guidance will be published later this year.”

Dame Donna Kinnair, director of nursing, policy and practice at the Royal College of Nursing, said: “These guidelines were put together by experts, looking at strong evidence who found a very clear relationship between the number of registered nurses and patient care.

“The evidence for the importance of having the right number of nurses, and the right ratio of nurses to healthcare assistants, would have led to new recommendations and guidance on the safe range of nurse staffing levels,” she said.

Dame Donna added: “These recommendations would have exposed shortages, and this would have had financial consequences. It is concerning that these consequences may have been a factor in the decision to scrap this important work.

Donna Kinnair

Dame Donna Kinnair

Donna Kinnair

“The evidence clearly shows the importance of the registered nurse and their role in patient care,” she said. “Any work on safe staffing that follows must be centred on this fact.”

Unison general secretary Dave Prentis said it came as “no surprise” that NICE had been going to recommend minimum staffing levels for A&E departments.

“We believe NICE should be able to complete and publish its guidance and the NHS should have been afforded the time and resources to implement before any changes being assessed by the Care Quality Commission,” he said.

He added: “It is vital that there are enough nurses on duty to ensure patients get the level of care they need and so staff can concentrate on delivering that care.”


Readers' comments (6)

  • michael stone

    Quickly scanning the above, it looks as if the withheld recommendations, if implemented [in full], would leave 'almost no wriggle-room' for hospitals: which is probably why the goverment did not like them !

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  • when i think of all those nurses working hard on behalf of the nation. the government needs to be ashamed of itself

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  • Pussy

    Cloud Cuckoo Land.

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  • Nice piece of journalism. I suspect its what all of us either working in or in conjunction with A&E already knew/know on a daily basis but its deeply relieving to know that it has been seen and recorded appropriately by NICE. Demonstrates all that we said would happen under a Tory govt.

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  • michael stone

    20 JANUARY, 2016 11:22 AM

    Can you confirm that - I'd quite like to hold a world record.

    My comments are not often pointless - often my comments are very-much 'to the point', such as one I made yesterday:

    If the issue is 'are my comments obvious' then I would point to 3 comments I made in that discussion thread - all 'are obvious to me' but not, it appears, immediately obvious to many clinicians:

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  • NICE should be looking at all areas/wards of the hospital staff ratios to patients,there are many a day that the majority of areas are not safe to start wether it be a shortage of auxillaries or nurses majority of the time staff are looking after nine patients instead of six,due to shortage of staff the management thinks its safe to take staff from other wards to cover another area,although we have all trained as nurses there are the few that do get moved feel out of there depth depending on the area making it more stressful for all the staff compromising patient/staff safety,there also seems to be alot of floor/bed co ordinators which needs to be looked into to see if it is working properly we need more nurses and auxillaries to be able to do or job safely this would hopefully cut down in the sickness levels

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