A new staffing measurement recommended in a major review of how the NHS can become more efficient fails to recognise the complexity of care provided by nurses and could lead to unsafe staffing levels, workforce experts have warned.
They cautioned that the introduction of the metric – which measures how many hours of care are provided collectively by registered nurses and healthcare support workers per patient in a 24 hour period – could begin a “race to the bottom” on what were deemed adequate staffing levels.
“You could have a fabulously staffed ward in the daytime and terribly staffed ward at night time and this measure won’t reveal that”
The metric, called the care hours per patient day (CHPPD), should become the “principal measure of nursing and care support deployment” – from as early as April this year, according to Lord Carter’s efficiency review final report published yesterday.
The review proposed that hospitals be benchmarked against an average CHPPD range, which would be defined by the new regulator NHS Improvement, in collaboration with the chief nursing officer for England, the Royal College of Nursing and other organisations.
In his review, Lord Carter worked with 32 hospitals over 18 months to look at their challenges and how to improve productivity.
Analysis of data from over 1,000 wards found a wide variation in the care hours provided per patient day – ranging from 6.33 to 15.48 hours, with an average of 9.1 hours.
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The report suggested that, in the future, wards with similar speciality, length of stay, layout and patient acuity and dependency could compare their CHPPD figures and “consider if variation is unwarranted, to assist productive ward initiatives”.
The new measurement has been developed from staffing metrics already used internationally in Australia, New Zealand, and the US, which see efficiency reviewed within a CHPPD range by checking variation at ward level on a daily basis.
The metric for the NHS will be calculated by adding the hours of registered nurses to the hours of healthcare support workers and dividing the total by every 24 hours of inpatient admissions.
“This doesn’t take into account any care that is left undone. It gives us an average of hours of care”
The report noted: “Conventional units of measurement – such as reporting staff complements using whole-time equivalents, skill-mix or patient to staff ratios at a point in time – may not reflect varying staff allocation across the day.”
But concerns have been raised about a number of issues with the new metric, including that it does not recognise the different types of care provided by registered nurses and healthcare support workers.
Professor Alison Leary, chair of healthcare and workforce modelling at London’s South Bank University, described the new metric, based on averages, as “a blunt instrument for a complex situation” and warned it could be a “race to the bottom”.
“It’s a complex relationship between staffing and safety… this [metric] isn’t a reflection of that complexity, so it’s hard to see how it would be helpful in ensuring safe staffing,” she told Nursing Times.
“This doesn’t take into account any care that is left undone for one thing. It gives us an average of hours of care,” she added.
Jane Ball, a nursing workforce expert from Southampton University and former deputy director of the National Nursing Research Unit at King’s College London, also raised concerns about making staffing decisions on the basis of the metric.
She said it was a “fatal flaw” to measure hours of care by registered nurses and healthcare support workers together.
“To arrive at a metric that is a merger of registered nurse staffing and healthcare support worker staffing is a fatal flaw in terms of ensuring safety,” she said.
She also said measuring hours of care per day in this way – even if it just focussed on registered nurses – would just provide an average over 24 hours and, therefore, used in isolation could hide shifts with unsafe levels of staff.
“The problem with that is, you could have a fabulously staffed ward in the daytime and terribly staffed ward at night time and this measure won’t reveal that,” she said.
Ms Ball said the use of nurse-to-patient safe staffing ratios alongside the metric would help to avoid this, but warned there was a risk trusts would pay too much attention to the new measurement requirement.
In response, a Department of Health spokeswoman told Nursing Times it expected the CHPPD metric to be one factor trusts took into account when making decisions on safe staffing.
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Lord Carter’s review, which made 15 recommendations in total in a bid to help NHS hospitals save £5bn a year by 2021, also found a “vast” variation in the use of “specialling” across the sample of trusts being analysed.
It pointed to one trust that saved £1m by adopting a “rigorous” policy for managing this type of one -to-one care, which it suggested should in the future be referred to as “enhanced care”.
A good practice guide and national programme for tackling variation in specialling across the service should be developed, with acute trusts implementing changes by October, it added.
Meanwhile, a “significant proportion” of the £5bn saving will not be unlocked unless delays in transfer are managed more effectively, said Lord Carter.
His report found that while official NHS England statistics showed an average of 5,500 patients per day were delayed, information provided by acute trusts revealed a worse problem with up to 8,500 per day unable to leave.
It estimated the cost of these delays to be around £900m to NHS providers.
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To tackle this, the report recommended the Department of Health, NHS England and NHS Improvement work with local government on a strategy to help trusts ensure patients can be moved out of hospital as soon as they are ready.
In addition, the report said motivation and morale among the NHS workforce needed to be addressed in order to improve performance and productivity.
It noted sickness and absence rates varied from 2.7% to 5.8% across the trusts in its sample and highlighted the “alarming” high rates of alleged bullying and harassment reflected in the annual NHS staff survey.
NHS workforce data also suggested poor retention of staff in the service, said the report, with 121,000 new staff joining in the year to August 2015, but the number of employed staff only rising by 18,000 in the same time.
The report’s recommendations included more regular staff reviews, improved management practices to understand attrition rates, and a reduction in bullying and harassment through a campaign led personally by each trust chief executive.