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Minimum Staffing Ratios: The Garden of Mediocrity gets a hefty dose of manure

March 30, 2013

How many nurses does it take to change a bed sheet? Is it a) Four: one to change the sheet, one to do the documentation, one to ‘manage the change process’ and one to conduct an audit; b) Three (The Daily Mail view): one to change the sheet and two to lounge around the Nurses’ Station talking about the ward night out; c) One: haven’t you heard of Supernurse?; or d) Impossible to be specific: the number of nurses required to change a bed sheet depends entirely on local conditions. The government’s answer, as set out in Patients First and Foremost: The Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) is not, you may be startled to learn, c). Actually it’s d).

In his Report of the Mid Staffordshire NHS Foundation Trust Public Public Enquiry (2013), Robert Francis QC recommended that ‘standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards’ (Recommendation 23). Well Hallelujah! Finally, a recognition from someone the government might actually listen to, that we can never achieve the first-class standard of nursing care we all strive for if we don’t have enough staff. For a few short weeks, nursing held its breath: would the government endorse Francis’ advice? The answer, when it came, was a resounding ‘no’.

To anyone who pays careful attention to the utterances of Jeremy Hunt MP, Secretary of State for Health, this decision didn’t come as much of a shock. You might even say it was trailed. Ministerial opposition to minimum staffing ratios has historically rested on the argument that their introduction would create a barrier to achieving the highest standards by legitimising a complacent reliance on the lowest allowable numbers. Viewed in this context, Hunt’s March 8th speech to a conference organised by the Nuffield Trust could have been read as a coded indication that the message hadn’t changed. “We celebrate excellence” he said “we criticise failure, but do we do enough to challenge mediocrity? Because…[t]he weeds of failure grow more quickly in a garden of mediocrity”. It’s no surprise then, that (albeit in less horticultural language) Patients First and Foremost repeats this same familiar mantra as one of its reasons for demurring on Francis’ Recommendation 23: ‘minimum staffing numbers and ratios risk leading to a lack of flexibility or organisations seeking to achieve staffing levels only at the minimum level’ (para 5.3).

So that’s that then. Or is it? Curiously, this an area where different parts of the Department of Health (DoH) seem to be saying different things. In Compassion in Practice. Nursing, Midwifery and Care Staff: Our Vision and Strategy (2012) the DoH said that ‘Directors of Nursing in Trusts should agree staffing levels through the application of evidence based tools and we recommend these are published at least every 6 months’ (p 22). Sir David Nicholson, the embattled NHS Chief Executive, went even further when he appeared before the Commons’ Health Select Committee on March 5th. He said “Every single hospital has to go through a process where they identify ward by ward what their staffing level should be and they should publish it. In my view, as you come into the ward, it should should show what the level of staffing should be, and what it is”.

The key to understanding all this muddle lies, as ever, in the Health and Social Care Act (2012), due to take effect on 1st April. Patients First and Foremost pleads, as a secondary reason for not taking up Francis Recommendation 23, the idea that ‘Local NHS organisations are best placed to take responsibility for the skill mix of their workforce because they are best placed to assess the health needs of their local health community and must have the freedom to deploy staff in ways appropriate for local conditions’ (para 5.4).

To most nurses, the idea that ‘local conditions’ could be a factor in deciding appropriate staffing levels at the ward micro-level seems faintly ludicrous: after all, patients are patients aren’t they? They’re the same wherever you are. A similar degree of incredulity is afforded to the proposition that enforceable minimum staffing ratios would somehow work against the delivery of first-class care. How could we possibly end up with fewer nurses than we have already? Surely any workplace management tool worth its salt would immediately demonstrate that many if not most wards are chronically understaffed and in need of an urgent injection of extra pairs of hands? Unfortunately for nursing, that’s the last thing the paymasters want to hear.

Successive governments have been caught in a cleft-stick over nationally-binding minimum staffing ratios. On the one hand, research shows that they can produce better patient outcomes (1); on the the other, implementing them would have the potential to add millions of pounds a year to the NHS wages bill. For the present administration, this dilemma has been thrown into even sharper focus – partly because of Mid Staffs, but also because of the new Clinical Commissioning Groups (CCGs) that David Cameron’s government has championed as the way forward for the NHS. These will require detailed information on projected staffing ratios and costs in order to make decisions about which services to commission and purchase. The proposed solution, however, is anything but sharply focussed. In fact, it’s pure fudge: forget national standards and leave it to ‘local organisations’ to somehow sort things out amongst themselves.

This and previous governments’ reasons for ducking the issue on minimum staffing ratios are completely understandable: the fact is that there is simply not enough money in the pot to pay for the nursing staff we need. What grates is the dishonesty. In the present case, while Jeremy Hunt is distracting us with meaningless rubbish about ‘gardens of mediocrity’ and ‘weeds of failure’, behind the scenes he is quietly pushing the whole nurse-patient ratio problem into someone else’s in-tray. It’s a strategy that runs the risk of seeing the quality of nursing care around the country become much more uneven – a postcode lottery in other words. Some might counter that this is often the case already – what difference will it make? The answer is that now, for the first time, it appears to be enshrined in policy.

(1) For further discussion of the evidence on minimum staffing ratios, see the RCN Policy Briefing (2012), downloadable at  The National Nursing Research Unit also produced a Policy Plus paper on this subject in 2009. Available to download here:  Recent research has tended to focus more narrowly on the dangers of diluting the skill mix by using increased numbers of Health Care Support Workers.

Department of Health (2012): Compassion in Practice. Nursing Midwifery and Care Staff: Our Vision and Strategy; Published in electronic format only at

Department of Health (2013): Patients First and Foremost: The Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry; London; The Stationary Office. Available to download at

Francis, R (2013): Report of the Mid Staffordshire Foundation Trust Public Enquiry; London; The Stationary Office.

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