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Too NICE to talk to

June 9, 2015

This is where it starts then, the Tory onslaught. Despite Jeremy Hunt’s protestations that transferring work on safe staffing from the National Institute of Care Excellence (NICE) to NHS England will result in ‘a better way of measuring safe staffing, which is more subtle than simply numbers of bodies per shift’, most nursing commentators furiously – and in my view correctly – interpreted it as nothing more than a highly unsubtle strategy to reduce NHS spending on agency staff.

The background, for those of you who have recently been residing on Mars, is that early last week a gung-ho Mr Hunt announced that he was going to put a stop to nursing agencies ‘ripping the NHS off’. From now own, the rates they can charge NHS trusts will be capped. Wrapping himself in his favoured ‘patients’ champion’ flag, he proudly informed the Today Programme on June 2nd that “we will stop paying these exorbitant prices, and the money can go on patient care”. But with most hospitals heavily reliant on agency nurses to maintain staffing at levels demanded post-Francis, how on earth, wondered the nursing world, could the circle be squared?

The shocking answer was revealed later the same week, courtesy of an email leaked to the Health Service Journal (HSJ) . The NICE safe staffing committee was to be suspended with immediate effect, and its work taken over by NHS England. Nurses were incandescent; Twitter was on ablaze; Sir Robert pronounced himself ‘surprised and concerned’; and the HSJ website, in a spooky twist, promptly crashed. But were these reactions justified?

At its most basic, the argument over the decision to relieve NICE of its duties and hand them to NHSE turns on a single word. And that word is ‘evidence’. Much of the criticism, including that voiced by Robert Francis himself, has centred on the idea that NICE is ‘independent’; NHSE, on the other hand, is a quango, and therefore any ‘evidence’ it comes up with is likely to be strangely congruent with prevailing political dogma.

But perhaps what we should really be asking is ‘where is the evidence that the NICE safe staffing committee has made any difference?’ In some ways, it’s not a fair question. Although the last government outwardly embraced the idea of safe staffing, scratch beneath the surface, and its commitment always seemed a bit half-hearted. It remains notoriously difficult, for example, to locate and then to interpret published statistics on the subject. And has anyone ever started a phone call with the words ‘I want to report a red flag incident’?

In fact, it should have been obvious to anyone who read the safe staffing guidelines produced by NICE that there were real problems. Many of these stemmed from the fact that when it came to setting staffing levels, the evidence base was almost embarrassingly slight (something I discussed in an earlier post), even for acute settings. For the upcoming guidance on community nursing and mental health, there was even less to go on. Can you really claim that guidance produced in these circumstances is credible?

So is it sensible to oppose the government’s new stance for no other reason than because it represents a departure from a key recommendation of the Francis Report? I don’t think it is. However good Sir Robert’s intentions in proposing that binding guidance on staffing levels was needed, and that NICE should given responsibility for producing it, I think it’s entirely possible that he had little idea of the true state of research in this area. If he had, perhaps he would have suggested something different.

So – before I’m pecked to death on Twitter for the crime of insufficient outrage – let me be clear: I don’t doubt for a minute that the decision to strip NICE of its role in safe staffing is politically-motivated; I don’t doubt for a minute that it’s a blatant attempt to downplay the importance of staffing numbers to the delivery of safe nursing care; I don’t doubt that it may jeopardise patient safety; and when Jeremy Hunt talks about a ‘more subtle’ way of measuring safe staffing, I’m not fooled for one minute that it’s anything other than an obvious euphemism for ‘cheaper’.

And yet – in a funny way, maybe Jezzer spoke more truth than he knows. We need A LOT more evidence about how nurses spend their time at work, and about the specific (and specifically) nursing interventions that influence patient outcomes. NICE was not tasked to look at any of this. It was not tasked to look at anything that was not wholly about crude staff numbers. But important though they are, crude staff numbers give little insight into nursing’s transformative potential. To capture that does indeed require subtlety.

The problem is that, reliant a thin evidence-base, and therefore a weak self-conceptualisation, nursing does not have the weapons to fight political meddling. It is only through self-knowledge that nursing will have any chance of standing up to what smacks of knee-jerk triumphalism by an exultant new administration. I admit the auspices aren’t good. Speaking to the Nursing Times, Jane Cummings admitted that ‘her office does not, as yet, have any plans to increase resources to manage this [new] work, and that it was yet to work out the detail of how to implement the plan’.

  1. Basket Press permalink

    Your point about evidence is an interesting one. However, having watched nursing colleagues try to gain organisational support for time and resources to conduct research into areas related to clinical practice and staffing and that support not materialising, I have grave doubts about the likely availability of any such evidence any time soon.

    One might expect that nursing academics would be helpful here, but my experience of having a professor of psychiatric nursing practice attached to our trust was that said person discouraged nurses from carrying out any research (they put my team leader off pursuing a PhD related to the work of our team, which had been established because said team leader conducted some research to show we were needed and how we should work).

    Personally, I was discouraged by my management and nursing structure from pursuing some epidemiological research into prevalence of disorders in our area, which would have informed staffing levels needed.

    I do not think there is the will in “the system” to allow nurses to carry out such work.

  2. Hi Basket Press, thanks for commenting. It was interesting to read on that in the wake of the NICE Safe Staffing decision, a member of the Advisory Committee called on nurses in ED to start carrying out their own research into staffing ( It’s a sweet idea, but I can’t help thinking that publishing ‘self-collected’ evidence that contradicted ‘official’ figures would be too close to whistleblowing for many nervous nurses to feel comfortable with it.

    Much of the outrage about the abolition of the NICE committee is based on the idea that NICE at least produces a robust benchmark that Trusts can be held to. I take the point about providing a benchmark, but given its flimsy evidence-base, I would seriously question whether that benchmark is indeed robust or even fit for purpose. The security it provides may well have turned out to be completely illusory when things started to go wrong even at Trusts that complied with it most of the time.

    I do have concerns that NHSE seems completely unprepared to produce anything better however. The change is almost indecently rushed, with no designated ‘handover period’, and Jane Cummings’ pronouncements on the subject so far seem vague and far from reassuring.

    I do think nurse academics have a role to play here though, both as advocates for nursing and as purveyors of information. Perhaps we should press for a formal national nursing research programme that prioritises research into staffing and outcome measures. Unfortunately, this will take time to get off the ground, and time may be exactly what we don’t have.

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