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Trusts interpreted NICE safe staffing guidance in 'wrong way’, MPs told

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NHS costs have been driven up by trusts taking a “mechanistic” approach to nurse to patient ratios in hospitals, which was not the intention of the body that produced the safe staffing guidance, senior health figures have told MPs.

Charlie Massey, the Department of Health’s director general of strategy, and Jim Mackey, chief executive of the new regulator NHS Improvement, said there was a difference in “perception” between national bodies and local providers over how to apply the guidance.

“The biggest driver of cost was the perception of the approach to safe staffing and potentially the perception associated with the inspection regime”

Jim Mackey

They also said there was a difference in “perception” over the staffing levels required by inspectors during visits to trusts by the regulator the Care Quality Commission.

These two factors had caused trusts to bring in more nurses than they originally had planned for, largely contributing to the NHS’s current overspend, they claimed.

Speaking before the Commons public accounts committee last week, as part of a session on managing NHS clinical staff numbers, Mr Massey and Mr Mackey were asked how workforce planning had contributed to the NHS’s deficit, projected to reach £2.3bn this financial year.

“Many providers were interpreting some of the NICE guidance around safe staffing to mean things that NICE didn’t want them to mean”

Charlie Massey

“The biggest driver of cost was the perception of the approach to safe staffing and, potentially, the perception associated with the inspection regime. So most providers felt under pressure, running into an inspection, or post inspection to commit to additional staffing,” said Mr Mackey.

He later added that NHS trusts had taken a “mechanistic” approach to the nurse staffing guidance produced by the National Institute for Health and Care Excellence for general adult wards – the first in a planned set that was controversially cancelled last year by the DH.

The guidance, published in July 2014, recommended staffing levels on hospitals ward day shifts should be checked if each registered nurse was caring for more than eight patients, as it could represent a safety “red flag”.

The guidance was commissioned in response to a recommendation in the Francis inquiry into care failings at the former Mid Staffordshire NHS Foundation Trust, which also sparked a tougher inspection regime from the CQC.

“Since I started this job and talking with national colleagues, there is a view that there wasn’t an intention for there to be a mechanistic 1:8 approach [to safe staffing],” said Mr Mackey.

“In foundation trusts and NHS trusts it felt mechanistic,” he said. ”So there is a disconnect between the local level and the national level.” 

Jim Mackey

Jim Mackey

Jim Mackey

Mr Massey also said many trusts had interpreted staffing guidance in the wrong way, assuming a 1:8 ratio was a requirement, “rather than something that should be triggering conversations and questions around their board tables”.

“It became clear during last year, the way in which providers were addressing some of the quality questions on the back of [the] Francis [report] weren’t aligning well with the financial plans they had put in place,” he said.

“Many providers were interpreting some of the NICE guidance around safe staffing to mean things that NICE didn’t want them to mean and – indeed the perceptions of what CQC inspectors would say, coming into hospitals, about staffing ratios – drove behaviours in a way where many providers felt quality was much more important than managing cost,” he said.

“Safe staffing is not as simple as a set of inputs such as 1:8. We need nurse directors to take judgements based on the acuity tool and so on”

Jim Mackey

Mr Massey noted trust chief executives had since been asked by NHS Improvement – being formed from the merger of Monitor and the NHS Trust Development Authority and currently operating in shadow form ahead of its launch in April – and other national bodies to ensure they “achieve quality in a sustainable way within the resources available”.

A member of the committee, Conservative MP David Mowat, said this suggested trusts were being asked to prioritise cost over quality, which was one of the reasons for care failings at Mid Staffordshire.

In response, Mr Mackey said no trust would need to “cross a safety or quality line”.

“What we are trying to say is, for so long there has been a very strong focus on quality and money hasn’t been considered at all in some cases,” he said.

“Good organisations look at these things in the round and that is what we need people to do,” he said. “Safe staffing is not as simple as a set of inputs such as 1:8.

“We need nurse directors to take judgements based on the acuity tool and so on. There are processes that need to go on that look at things in the round,” said Mr Mackey.

  • 3 Comments

Readers' comments (3)

  • I was not sure whether to laugh or cry when I read this. So now a recommendation that costs more money is not really something that should be complied with, it is just something "that should be triggering conversations and questions around board tables”. Ok, what should the 'conversations and questions' be about? How to pretend there are enough qualified nurses without actually employing any more? Presumably that is why we pay large sums of money to 'the Director of Strategy', so he can find ways to 'cook the books' !

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  • Massey you are such a meachanistic tool head - calling kettle black! Lol - you don't get it do you nobody is fooled by your lean rhetoric and you don't realise there are those of us out here who know more for less doesn't work. Send your American tool heads home were British and we don't want them one-hour betrayal of the NHS. changing the rules so as to blame nurses when they don't measure up to no staffing is obvious. You think we don't know how you are winding the NHS down you are a betrayer and so are the 10 others.

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  • I do intend to write a book about my experience since coming to this country from the West Indies to take up nursing over 28 years ago.
    I will have a lot to write about when I take my early retirement.
    At this chapter in my nursing life I am seeing a type of rogue consultants who put in information on topics they have yet to understand properly and get so much money for, in the meanwhile there are champions who keeps on working with not a hint of any recognision as they are just that grade 5.
    When the ward does good the praises goes to the management, the managenent in turn put up on the staff notice board 'a big thank you for all your hard work ' written so it can be erased after 2 weeks. Yeh we read it on our unpaid break while biting into something to eat.

    Only yesterday the site manager took a HCA away from the ward I was working on to send on to another ward. Why ? you ask --- the answer is she was looking at numbers of staff to patients. The carer came after his shift there to report that he had less work to do as they were not as heavy or busy as we were. It was a killer shift yesterday on my ward, I also left work late again!!!!
    If I go on to tell you how much I had to do and did, you would ask the Queen to give me an OBE or someting like that.

    I strongly feel that all site managers should do some time on an acute ward on the floor as part of their contract.
    I strongly feel that if an intelligent system cannot be in place for staffing levels soon, then at least intelligence data form specific types of wards should collected over a period of time with much emphasis be placed on ground work with garde 5s and HCA having a hugh input in the data.This data be analysed by intelligent persons and a near as possible ratio of nurse to patient be made not as one cap fits all, but as I said before according to specific types of wards.

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