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”
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”
“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.”
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”
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.