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Safe Staffing: Time to seriously remove the Horlicks Goggles

September 21, 2013

Interesting to read on a BBC blog this week that ex-Conservative-Health-Secretary-turned-chairman-of-Health-Select-Committee Stephen Dorrell is ‘a man who knows a thing or two about the Health Service’. I thought the whole point of Tory Health Secretaries (ex- or otherwise) is that they know absolutely nothing about the Health Service. Whatevs. The Health Committee’s first response to the Francis Report was published last week, and Mr Dorrell took to the airwaves to publicise it.
His overarching message, as he told BBC Breakfast, was that the fostering of a ‘culture of openness and transparency’ should become the focus of the NHS. As an illustration, he spoke approvingly about Salford Royal NHS Trust and its policy of making public the staffing figures for each of its wards on a day-to-day basis. Media reaction was mostly trained on this rather eye-catching initiative, and although Mr Dorrell made no explicit reference to research which shows that patient outcomes decline when trained nurse-patient ratio dips below1:8, inevitably the two issues became intertwined.
OK, so let’s be clear about this: I am not against the Safe Staffing Alliance’s demands for a national minimum general-wards staffing ratio of one Registered Nurse to eight patients, not counting the nurse-in-charge. Neither am I against the idea of displaying daily staffing ratios on boards at the entrance to the ward so that the public can see how well the hospital is responding to the needs of its patients. I think any action in this area is better than none. I just don’t think either of these initiatives represents the panacea some people would have you believe. And here’s why.
1. Modern ward design militates against the operation of a 1:8 ratio. Supposing you have got a thirty-six bedded ward, divided into three twelve-bedded areas with walls and doors physically separating them. If you have five trained staff on duty, this gives a ratio of 7.2 patients per nurse, fractionally below the eight patient-per-nurse ‘minimum acceptable standard’. But how are you going to distribute your staff? If you put two trained nurses in two of the areas, one area will still be left with, in effect, one nurse for twelve patients. Or do you ‘honour in the breach’ and put two nurses in one area and one in each of the other two with the fifth nurse ‘floating’ between them?
2. You think this won’t result in mountains of additional paperwork? What planet are you on? At least once per shift, nurses will be expected to provide a detailed breakdown of available staff and reasons why staff who are notionally available are not actually on the ground – at training, gone home sick, unfilled bank shift etc. But it won’t stop there. It will also be seized upon as a back door opportunity to gather data on  patient dependency levels ‘as a way of determining future staffing requirements’. But if you think you’ll ever get really get any additional help out of it – dream on!
I went through this whole pantomime with a ‘time-and-motion’ system called GRASP in the 1990s. Every day, after struggling to get through the direct care, the doctors’ rounds and the ‘ordinary’ paperwork, we’d then be faced with a nice, crisp pile of Patient Care Hours assessments (as they were called), and if we didn’t get them done by four o’clock in the afternoon we’d be on the receiving end of hectoring phone calls from some jobsworth with their feet up in an office somewhere. And did this exercise in futility ever secure for us a single extra pair of hands? What do you think? Even when the Patient Care Hours scores were off the scale.
3. Parkinson’s Law…as applied to nursing. Parkinson’s Law, first described by Cyril Northcote Parkinson in a humorous essay of 1955, posits that ‘work expands so as to fill the time available for its completion’. Applied to twenty-first century nursing, Parkinson’s Law can be modified thus: ‘drugs, management and paperwork expand so as to fill the number of trained-nurse-hours available for their completion’. In other words, it’s not unusual to enter, say, a twelve-bedded area which is, on paper, adequately staffed – two staff nurses and a health care support worker. But when you look around, you find that the reality is that the two staff nurses are sat at the desk writing notes and the single support worker is rushing around doing all the observations, all the washes, all the toiletting and all the feeds. Anyone who thinks that the adoption of a universal minimum 1:8 trained-nurse-to-patient ratio is going to herald the return of some kind of Golden Age of Nursing where angels of mercy in starched aprons spend all day mopping fevered brows, needs to seriously remove the Horlicks Goggles.
4. The public won’t understand what they’re being told. The public already professes itself to be in a state of permanent bafflement about the meaning of different nursing uniforms, even when the various grades of staff are dressed in contrasting colours and there are large posters on the walls offering explanations. It sometimes seems that our fellow-Britons are perversely determined to cling on to the belief that nursing uniform policy exists solely to furnish them with yet more evidence of some grand NHS-wide conspiracy to confuse them. Given this state of affairs, it’s hard to see how they are going to make much sense of staff:patient ratios.
What passes for ‘outside-the-box’ thinking across much of the NHS dictates that ‘Staff on Duty Today’ boards will inevitably be positioned in the general environs of the sluice – so in future, rushing to grab a commode for some desperate patient will become an exercise in dodging the conversationally-inclined middle-aged bloke who’s mooching around at a loose end in the corridor while he waits for ‘the wife’ to take leave of her mother. After several minutes of quizzical board-gazing, he’ll stop you with an amiable “’Scuse me love, can you explain this?” and then, completely oblivious to your repeated non-verbal ‘on-a-tight-schedule…!’ cues, proceed to probe you with a long list of supplementary questions for the next five-to-ten just to pass the time until ‘the wife’ tracks him down.
5. But…if you have what appears to be an acceptable number of nurses and care is still substandard, it’s going to look really, really bad. On the other hand, supposing the public, in that random, unpredictable way it has, seizes on the idea that the achievement of a one-trained- nurse-to-eight patients ratio must mean that staff will always have time to bestow the highest possible standards of care. You know it won’t, I know it won’t – but what if relatives come on the ward, clock the staffing levels, think “that looks adequate, what a relief” and still find that patients are having to wait an unacceptable length of time for attention – how are they going to react? They may well think “well, they’ve got enough nurses, so those nurses must be either lazy or disorganised or both”.
6. ‘Staff On Duty Today’ boards shift the blame for inadequate staffing away from central government and onto individual Trusts. Devolving to Trusts the responsibility for developing and implementing tools to calculate the numbers of staff required for various care environments encourages the public to blame staff shortages at their local hospital not on central government cuts but on out-of-touch boardroom policies. Which suits the government just fine.
Let’s not forget though, that the point Stephen Dorrell actually went on television to make was, as I stated in my introduction, about the need for ‘openness and transparency’. So it’s worth asking why this debate has focussed so exclusively on numbers of nurses. What about doctors? Isn’t it about time someone started wondering about doctor:patient ratios in hospitals? Especially at nights and weekends?

For Nick Triggle’s blog on Patient Power, which mentions Stephen Dorrell, see: http://www.bbc.co.uk/news/health-24162536
For Stephen Dorrell’s interview with BBC Breakfast, see: http://www.bbc.co.uk/news/health-24141825
For the Health Select Committee’s Report, see: http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/657/65708.htm#a23

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