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Revealed: The hospitals with the worst nurse staffing


Almost every NHS acute hospital in England is failing to meet its own nurse staffing targets, an investigation has revealed.

Analysis of quarterly hospital-level staffing data by Health Service Journal has found that 214 acute hospitals – 96% of those reporting – failed to meet their own planned level for registered nurses working during the day in October 2016.

Meanwhile, 85% – 190 hospitals – missed their target for nurses working at night in the same month.

This is the worst performance for both day and night since Health Service Journal started collecting data in 2014. See the box below for an explanation of the data HSJ used and how it was collected.

safe staffing main graph image

Hospitals failing to meet planned staffing levels graph

Source: NHS Choices and HSJ analysis

The decline in performance comes despite record recruitment of nurses in the acute sector. The deterioration appeared to accelerate last year as tougher caps on agency spending were introduced in April. This could suggest a fall in agency staff on hospital wards, which has made it harder for trusts to meet their planned nurse staffing levels.

Nurses have said their hospitals are delivering substandard care because of staff shortages, with pressures on the NHS leading to practices such as “one upping”. This is where an extra bed is added to a bay of four with no call bell or access to walled oxygen – creating extra work for nurses and an increased risk of infection.

One working in the South West said: “I feel inadequate and ineffective when short staffed. I have an overwhelming feeling of sadness that I cannot provide these vulnerable human beings with the care they need and deserve…

“The most patients I have ever had is 16 on a night shift, I know for a fact that I did not do all the observations and can only hope that I did not cause anyone any real harm,” they said.

More than 150 hospitals have failed to achieve their planned daytime staffing levels for nurses for the whole period that Health Service Journal has monitored staffing levels, from quarter four of 2014-15 to quarter three of 2016-17.

The majority of hospitals below their planned staffing levels for nurses were at or above plan for healthcare assistant staffing, suggesting some sites might be filling gaps in the nursing workforce with less qualified staff. In all eight quarters, the majority of hospitals exceeded their planned HCA staffing levels, with even more exceeding their HCA plans at night.

A national workforce expert warned this could lead to “false reassurance” that hospitals were maintaining safety by focusing on numbers of staff, though research shows that nurses are key to outcomes and substituting HCAs can increase risks.

Other key findings from the data include:

  • 79 hospitals had less than 90% of planned nurse staffing in daytime in October 2016
  • 62 hospitals had less than 95% nurse staffing in the day across all eight quarters, with 15 of those never achieving more than 90%
  • At night 92 hospitals had fewer nurses working than planned across all eight quarters, with 18 trusts below 95%
  • In October 2016, five hospitals, excluding community sites, had less than 80% nurse staffing during the day (see table)

Table: Hospitals with less than 80 per cent planned nurse staffing in daytime (October 2016)

Trust Hospital site Q4 2014-15 Q1 2015-16 Q2 2015-16 Q3 2015-16 Q4 2015-16 Q1 2016-17 Q2 2016-17 Q3 2016-17
Mid Yorkshire Hospitals NHS Trust Dewsbury and District Hospital 87% 86% 87% 87% 89% 88% 78% 75%
Mid Yorkshire Hospitals NHS Trust Pontefract General Infirmary 86% 85% 82% 83% 74% 80% 86% 77%
The Princess Alexandra Hospital NHS Trust Princess Alexandra Hospital 87% 79% 77% 78% 72% 72% 76% 77%
North Tees and Hartlepool NHS Foundation Trust University of Hospital of North Tees 84% 87% 86% 79% 80% 83% 79% 79%
Wrightington, Wigan and Leigh NHS Foundation Trust Royal Albert Edward Infirmary 86% 85% 81% 83% 87% 84% 83% 79%
  • Princess Alexandra Hospital has not achieved above 80% of planned nurse staffing since quarter four of 2014-15. The Princess Alexandra Hospital NHS Trust was rated inadequate and placed in special measures in 2016. The trust did not respond in time for publication.
  • West Cumberland Hospital, part of the North Cumbria University Hospital NHS Trust, and Princess Anne Hospital, run by University Hospital Southampton NHS Trust, had less than 90% of planned nurses working at night in all eight quarters.

Professor Peter Griffiths, from Southampton University and who was a member of the NHS Improvement safe staffing committee for acute wards, said: “This is clearly not a good place for the NHS to be and it isn’t getting any better.”

He said using HCAs to fill gaps in nurse staffing could be a reasonable strategy. However, he added: “If that becomes a long term approach to filling gaps you could very easily delude yourself that you’re maintaining safety because you’re maintaining numbers. But actually all the research shows the key workforce for maintaining the safety of patients is the registered nursing workforce, so there is the risk of a false reassurance.”

Professor Alison Leary, head of workforce modelling at London South Bank University, said: “The overall trend shows organisations bolstering nurse gaps with HCAs. This might seem like the only practical solution at the time and could be seen as someone being better than no one. However, when that becomes the norm, we have to consider the inherent risk given the evidence that registered nurses have direct benefits for patient safety.

“Added to this is how trusts worked out staffing in the first place – 80% staffing might be tolerable in areas that have carefully thought through staffing and the risk, but 80% on much lower establishments is concerning,” she said.

About the data

  • HSJ has collected staffing data, published on NHS Choices, for the first month of every financial quarter since quarter four of 2014-15 (January 2015).
  • Reporting of safe staffing data was made a requirement following the Francis report into poor care at Mid Staffordshire Foundation Trust.
  • 214 out of 232 acute hospitals reported data in October 2016.
  • The data shows an individual hospital’s average performance across all wards for that month against its own planned levels. There will be variation between individual wards and between the quality of each trust’s staffing plan.
  • Trusts with significantly more ambitious staffing levels may appear to perform worse than those with a lower, easier to reach staffing target.

Related files

Readers' comments (6)

  • I recently took early retirement aged 55 after 37 yrs as a theatre nurse. I would have liked to have worked two days a week but would still have had to work a 3 shift system including nights so I opted to leave and I now have a bank contract with a private sector company now where I can choose my shifts.
    If my manager could have been more flexible about my shifts I would still be working for the NHS now, and I have several colleagues in the same position who feel the same.

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  • Nurses have been required to take on roles of other staff who are significantly better paid. They have a much better standard of education that the last generation. Employment conditions are poor. There is little flexibility in their contracted working hours. Many Trusts have imposed Zero hours contracts. The nurses are "blamed" if things go wrong, sacked and cannot afford a defence. It is a toxic atmosphere to work in.
    Why are you surprised that we cannot recruit educated people from this country and will have an even bigger shortage if the nurses from European countries go home. We will have to rely on those nurses draining the resources of the developing countries again.

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  • Anonymous 20/01 4:37pm - I take issue with the assumption that as a member of the 'last generation' I am paid any more than newer nurses who have a 'much better standard of education' (and by the way, attaining a standard of education means nothing unless you are able to translate that into provision of a high standard of care.) I am paid less than £30000 per annum for full time hours, am dual qualified and (despite my apparently pitiful standard of education!!) bring 30 years experience in paediatrics to the table. I have been a well paid manager and elected to return to the bed side to do what I enjoy and am good at. I agree, however, that the atmosphere in which nurses work is toxic; most I know are terrified of being reported to the NMC, despite placing their PIN at risk on an almost daily basis due to being under staffed, under resourced, over worked and exhausted.

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  • I agree with nurse 57 thier is no substitute for experience. I am one of the new generation having qualified with a nursing degree but honestly that degree makes no difference on the floor. The experience gained over years is what conrtibutes to sound decision making and recognising a failing patient quickly. Having been a nurse for 6 years the only real benefit i have from my degree is the research skills, it does not place me higher than a nurse whithout a degree when it comes to real actual nursing.

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  • yes I agree that having a degree does not make you a better nurse, experience counts. To reduce the number of practice hours will be a mistake by the NMC, as you do not learn how to look after a patient by just talking about it in a lecture theatre or in groups. I feel there is more a risk of nurses being reported to the NMC due to not having the skills to deal with basic nursing care, for example assessment of pressure area care and managing the sick patient and general communication. As they say - you start learning when you qualify,

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  • 20/01. 4.37 I was referring to the education and training that the doctors have and the fact that nurses are replacing many hours and tasks previously undertaken by the doctors. The nurses pay does not in any way resemble the doctor's pay even when they are doing the same work.
    I was looking at the wider picture as we work in multidisciplinary teams and many nurses appear flattered to take on doctors work without the value of the work being recognised.

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