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Safe staffing and skill mix: a hot topic for the NHS in 2014

Brendan Martin and Roger Kline, 12 December 2013

Tioday's evidence of cuts in mental health services in England make us wonder what, if anything, the government has really learnt from report after report in 2013 highlighting the need for sufficient NHS staffing.

According to Robert Francis QC, who has conducted two public inquiries into the scandalous care failings in Mid Staffs, “the overwhelmingly prevalent factors were a lack of staff, both in terms of absolute numbers and appropriate skills, and a lack of good leadership”. (First Francis Inquiry Report, 2010, no longer available online.)

Recommendation 23 of his 2013 report was that the National Institute for Health and Clinical Excellence (NICE) should produce evidence-based tools for establishing the right staff numbers, skill mix and staff/patient ratios for different services. This should be done, Francis said, in consultation with “professional organisations and patient and public representatives”.

The Keogh and Berwick reviews this year also highlighted staff shortages and their impact on care standards, and yet it wasn’t until November that the government finally got around to a full response to Francis and to instructing NICE to act on Francis’s Recommendation 23.

As a result, NICE has announced a “comprehensive review” of the evidence and promised to  produce “definitive guidance on safe and efficient staffing levels in a range of NHS settings” by next summer.

The focus will be on adult wards in acute in-patient settings to begin with, but by August 2014 guidance on safer staffing levels are promised for accident and emergency units; maternity units; acute in-patient paediatric and neonatal wards; mental health in-patient settings and community units; learning disability in-patient settings and community services; and community nursing care teams.

“The guidance will focus on nursing and midwifery staffing levels, including nursing support staff, to ensure an appropriate balance of skills across the whole team on the wards and in other settings," NICE stated, but “will not cover recommendations on setting minimum staffing levels.”

As the government accepted Recommendation 23 in full, should we assume that NICE will implement it in full? One concern is that the NICE announcement made no reference to a key clause of the Francis recommendation, that the guidance should be “created after appropriate input from specialties, professional organisations, and patient and public representatives”.

Rather, NICE says it “will develop the guidance by reviewing the evidence behind existing products, together with any new or additional relevant evidence”, and that “there is already a lot of information available to help us develop the guidance”.

There is indeed plenty of evidence. According to a Nursing Times report of a study by the National Nursing Research Unit at King’s College, London, for example, more than 80 per cent of hospital nurses had to leave care undone on their last shift because of staffing shortages.

This prevalence of “missed care” is an “early warning” for potential patient safety concerns, said the report, revealing that this happened when the number of patients per registered nurse was more than seven.

In May this year the Safe Staffing Alliance, which includes the Royal College of Nursing, Unison and the Florence Nightingale Foundation, said one nurse should look after an absolute maximum of eight patients.

Yet the government’s healthcare regulator, Monitor, says that nursing numbers fell in the last financial year and forecasts further falls in future years after a brief spike in recruitment following the Francis and Keogh reports this year.

This is in line with research by the Nuffield Trust, which has shown that the funding gap will grow considerably as a result of the government’s austerity programme.

The government has rejected mandatory staffing ratios, even though within six months of his inquiry -- persuaded, apparently, by subsequent evidence, such as the Berwick Report -- Francis himself changed his mind and said he supported the idea.

Without additional staff and appropriate skill mix, patient care and safety will suffer. In 2014 this will be a hot topic in the NHS, and our three questions are:

1. Will the NICE guidelines be genuinely evidence-based?
2. Will professional and patient organisations be consulted?
3. Will the government provide the necessary funding?

Many of us will be watching closely.

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