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Not waving but drowning: is new guidance on staffing the life raft we need?

December 17, 2013

A guest blog by @MsNaughtyCheese

Earlier this year, Robert Francis QC criticised nursing leadership for perceived inaction following his Inquiry Report. He was clear from his own experiences that “many nurses get the point” but, compared to the responses of other professional groups, nurses’ leaders and representatives had failed to respond adequately to the care concerns laid at our door. In the new nursing, midwifery and care staffing guidance How to ensure the right people, with the right skills, are in the right place at the right time Jane Cummings, Chief Nursing Officer for England, says “we must do all we can to support our staff to provide high quality, compassionate care” – but is what follows in this document really “all we can do”?

Let’s take a moment to consider the delegation of responsibility on offer here. Monitor, NHS England and commissioning groups are all tasked with the oversight of ensuring safe staffing, yet the document seems to place the most of the real responsibility on Trust Boards under the “Ward to Board” rhetoric we hear so much about. But how accountable are Trust Boards really? Monthly reviews of past ward staffing to inform a six monthly review Funded Establishments? This does not speak of real-time data and action. It’s a reactive, not a proactive response. A board simply cannot be held responsible for daily staffing. This guidance only advocates a review of staffing levels on a monthly basis – and a month of unsafe staffing before any action is taken is far too long for patients, families and nurses who have already suffered poor care from terrible shortages.

The guide contains some other interesting wording: “not mandatory” for example, and “encourage”. This is imprecise language and certainly doesn’t speak of a firm response to our ongoing staffing crisis. The very fact that this is guidance only gravely worries me – what assurance do we have that it can and will be enforced? The truly telling language however is reserved for the division of responsibility between frontline staff and Boards: while frontline staff must “measure” “develop” “report” “produce” “complete” etc., Trust Boards should merely “seek assurance”. I have no issue with the real, day-to-day responsibility lying with the frontline; what I take issue with is that this guidance, in focussing so much on the so-called Board’s responsibility, fails to recognise or truly support the frontline’s role in safely staffing the Health Service. Throughout the document nurses and midwives are given neither the respect or the power to ensure patient safety through proper staffing.

The combined NHS England and National Quality Board document makes much reference to a review of the Funded Establishment of nurses. Put simply, this is the number of nurses, midwives and care staff which a Trust claims it is willing to employ. In the face of supply issues and funding cuts, it may bear little relationship to the number of nurses a Trust actually has in employment. A Trust can claim they will employ more nurses through raising their Funded Establishment while at the same time being unable or even unwilling to employ more nurses in reality. Troubling, isn’t it?

Another telling quote is that Boards must consider “the impact of wider initiatives (such as cost improvement plans) and staffing, and are accountable for decisions made”. As a nurse who will have to suffer any potentially poor Board level nursing staffing decisions, it concerns me that Boards are given the loophole of considering staffing levels against their financial savings. And as for accountability, this quote indicates to me that as long as a Trust can attempt to explain away their decisions to have poor nurse/patient ratios or cut nursing and midwifery posts they are absolved of any punishment for risking patient safety as a result.

Let’s hear some more from our Chief Nursing Officer. “There have been examples of care in recent times” she says “which have been unacceptable. These have been as a result of individual and organisational failings”. Yet it is exactly these organisations which she tasks with ensuring safe staffing. There is constant repetition throughout the guidance that ultimate decisions remain with individual Trusts. Fine – as long as your Trust is financially secure and can be trusted not to slash nursing and midwifery numbers to make the savings demanded of them. But only this week, Chris Hopson, Chief Executive of the Foundation Trust Network, told the World at One (BBC Radio 4) that at the half-way stage this year, 28% and rising of all Trusts and Foundation Trusts were either in deficit or expected to be in deficit.

The only slight reassurance comes in the form of a warning to Trusts that the Care Quality Commission will use nursing and midwifery staffing data to inform their monitoring and rating of NHS Trusts. But a CQC inspection is too late. In order for it to act, there must already have been potential harm or even worse, actual harm to patients as a result of inadequate staffing. And what action will the CQC take? Give a Trust a poor rating?

It is true that there is no single ratio or formula that can be applied to all areas to ensure good care. However there is a body of evidence that a single ratio – more than one nurse to eight patients – can cause harm (Safe Staffing Alliance). It is true that there is no one-size-fits-all approach, but we know that there is a wrong way: a nurse caring for eight patients or more cannot provide safe care. And yes, 1:8 ratios are not appropriate in all cases (despite our Health Secretary’s uninformed comments that 1:8 may be an acceptable ratio for “geriatric wards”).

The classic argument against the 1:8 ratio is that this figure becomes the ceiling and not the floor. But if safe staffing guidance were strictly enforced this would not be an issue – Trusts would be too fearful not to provide individualised and evidenced-based staffing. And right now there are nurses and midwives wishing that a maximum of eight patients was their ceiling. Coping with way more patients than this every single shift is pushing them to breaking point.

Between the publication of his Inquiry into Mid Staffs and the government’s response to his recommendations, Robert Francis (who has – rather interestingly – accepted the position of President of the Patients’ Association, a supporter of the Safe Staffing Alliance) performed a commendable U-turn on his original comments around the setting minimum staffing levels. He eventually came to the conclusion that having a minimum acceptable staffing ratio could act as a benchmark and an alarm bell, in the same way mortality rates do. He also urged a U-turn from the CQC’s original decision not to use staffing levels when monitoring Trusts’ safety.

I believe that this nursing, midwifery ad care staffing guidance is a poor response to serious issues. I can see very little, if anything, that will give nurses what they need in their workplace to do their job effectively for patients. I’d be thrilled to be wrong. I’d like nothing more then to find in a year’s time that NICE’s staffing guidance has been implemented in full by all NHS organisations with resounding success, that there has been an increase in nursing numbers and that patients finally have greater safety and the care they deserve and need.

Unfortunately, I’m extremely cynical and I don’t believe this guidance is sufficiently robust to advocate and ensure staffing levels that are good enough. Above all, and amid all the talk of processes and boards, commissioners, providers and pathways, are real people – actual patients being cared for nurses, midwives and care assistants who are drowning in unsafely staffed wards. Is this guidance really the life raft they need?

How to ensure the right people, with the right skills, are in the right place at the right time

http://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf

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