The new regulator NHS Improvement has been accused of “undermining and dismantling” official safe staffing guidance, after it was revealed that it was revisiting work already completed by the National Institute for Health and Care Excellence.
Senior sources close to the work at the regulator have said it is planning to publish safe staffing guidance for acute inpatient wards and maternity services.
”It is just brushing it all under the carpet”
Nursing Times’ sister title Health Service Journal was told the action risks confusing hospitals and undermining the guidance published by NICE following the Mid Staffordshire NHS Foundation Trust public inquiry.
This time last year NHS England chief nursing officer Jane Cummings said in a letter to providers: “Nothing we are doing changes the NICE guidance that has already been issued… The next phase of the NHS’s role in this area is focusing on new care areas and will not involve going back on the guidance already published.”
However, it has been revealed that NHS Improvement has established eight committees to draw up new staffing guidance under the title of “safe and sustainable staffing” (see box below). The groups have met a handful of times since the start of the year.
In 2014 NICE published its guidance for acute wards, which established the evidence based risk to patient safety when nurses care for eight or more patients, although it avoided recommending a mandated minimum ratio. It published guidance on maternity services in February 2015.
Last year the government and NHS England halted NICE’s safe staffing work, a key recommendation of the Francis inquiry, shortly before it was to publish completed guidance for accident and emergency departments, which did recommend minimum nurse to patient ratios. This report was leaked in January.
Only the acute ward and maternity guidance remained as official documents for NHS hospitals to consider.
One senior source close to the work said: “The goal is no longer to think about safe staffing but safe and sustainable staffing, in other words only what can be done within budget, as if that is acceptable.
“Reviewing adult and maternity surely risks undermining and dismantling the NICE guidance, which was more evidence based than this work could ever be. Not only have we moved backwards, all the goalposts have shifted.”
They said there was “absolute determination” to avoid including any specific staffing numbers in the guidance being developed.
National bodies wrote to NHS trusts in October saying the 1:8 nurse to patient ratio highlighted by NICE should not be “unthinkingly adhered to”, despite evidence showing harm could occur when nurses care for eight or more patients.
Another senior source within NHS Improvement said: “This is about revisiting NICE’s work. The expertise on these committees is primarily around nursing.
“It certainly runs the risk of confusing people and the committees are progressing their work without really having a clearly stated idea of how it articulates with the NICE guidance and there is a significant danger that will affect what the output is,” they said.
“It is deeply ironic and says something about the NHS when the one to eight ratio is seen as such a threat,” they said. ”It was initially intended to mark out the extremes of what is tolerable for safety and if achieving even tolerable staffing creates such alarm it says something about the parlous state we are in.”
Mark Radford, chief nurse at University Hospitals Coventry and Warwickshire NHS Trust, chairs the committee for maternity services and defended its role. He said: “This enhances the NICE work. The maternity work stream is examining all evidence to support safe and effective staffing of maternity care.”
He said his committee had considered NICE’s work and would also include other professions such as doctors, allied health professionals and midwives. “Our work looks to draw upon this holistic view to ensure principles of safe staffing are articulated to the NHS,” he added.
Susan Osborne, chair of the Safe Staffing Alliance and a former nursing directors, said she was worried about the effect of the new guidance. “Instead of recognising what the actual need is for nurse staffing and creating a three to five year plan to meet those needs they just keep fudging it by producing more guidance based on hardly any new evidence. It is just brushing it all under the carpet,” she said.
Refreshed guidance on safe staffing from the National Quality Board was also due to be published in March this year but has been delayed for unknown reasons.
NHS Improvement was approached for comment but had not replied in time for publication.
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Janet Davies, chief executive and general secretary of the Royal College of Nursing, said: “There is abundant research and evidence highlighting the strong link between nurse staffing levels, the quality of nursing care, and patient outcomes so the message to all trusts and managers must be that safe staffing on all wards is the number one priority.
“While there is not one definitive number for all wards and settings, clear guidance and workforce planning tools can help ward managers make the right plans based on the specific needs of their patients,” she said.
She added: “Given the unprecedented pressures on budgets in health and social care the need for clear guidance on patient safety is more critical than ever. There is a danger that some of the key lessons of the Francis Report may be forgotten, and short-term financial targets will again take priority. This can only have a negative impact on staffing levels and patient care.”
NHS Improvement’s safe staffing committees and chairs
- Emergency care – Pauline Philip, chief executive, Luton and Dunstable Hospital FT
- Mental health – Ray Walker, chief nurse, Mersey Care NHS FT
- Learning disability – Oliver Shanley, deputy chief executive, Hertfordshire Partnership FT
- Community services – Crystal Oldman, chief executive, Queen’s Nurse Institute
- Maternity services – Mark Radford, chief nurse, University Hospitals Coventry and Warwickshire Trust
- Children’s services – Michelle McLoughlin, chief nurse, Birmingham Children’s Hospital FT
- Adult acute inpatient wards – Hilary Chapman, chief nurse, Sheffield Teaching Hospital FT
- Care home sector – Trish Morris-Thompson, chief nurse, Barchester Homes