Safety compromised

We all want an NHS that has safety at the heart of its service to the public. There is now evidence, however, that lack of funding has already led to compromises in safety due to issues of staffing levels, rationing and delays in treatment. The Francis report in 2013 on one of the major scandals in the NHS, that of the Mid Staffordshire Foundation Trust, highlighted the issue of safe staffing levels – it found that the ratio between staff and patient was of fundamental importance to safety and quality of care for the patient as well as important for the staff themselves to be able to do their job to the best of their ability.

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There were great hopes that the recommendations in the Francis report would be applied in practice and the National Institute for Clinical Excellence (NICE) was tasked with determining the patient to staff ratio for various ward types based on good evidence.

Safe staffing guidance produced

It all started so well with NICE producing guidance on patient to staff ratio for acute wards and maternity in 2014/2015. The recommendations for acute wards stated that there is an increased risk of harm when registered nurses are expected to care for more than eight patients during the daytime on a regular basis so this ratio was considered to be the highest ratio that should be used in practice. In February 2016 Wales became the first country in the UK to sign into law a bill that ensures that hospitals in Wales have sufficient nurses on duty at all times. Scotland is set to follow with a law ensuring safe staffing levels.

In contrast, in England, the safe staffing levels guidance has become inextricably bound up with the government’s efforts to control costs. In 2015 NICE’s work on safe staffing levels was halted by the government and NHS England just before NICE was to publish completed guidance for accident and emergency departments; this guidance, which was leaked in January 2016, did recommend a minimum nurse to patient ratio.

Trusts ignore safe staffing levels

Despite NICE’s published guidance, in April 2016 a staff survey by UNISON found that there was little evidence it was actually being adhered to by trusts. The survey was a snapshot of staffing on the 9 February 2016  and found that 71% of respondents were worried that staffing levels would get worse and patient safety would suffer as a result of the NICE work being stopped. The survey also found that the guidance for A&E that was never published, but leaked in January 2016, was not being met in the majority of cases.

On 9 February 2016, the survey found that 75% of A&E nurses said their shift did not meet the NICE-recommended ratio of at least two registered nurses to one trauma patient and the same proportion said they did not meet the recommendation of at least one registered nurse to one priority ambulance patient.  Across all ward types, 55% of respondents said they had cared for eight or more patients on the day of the survey, increasing to 70% of staff who worked the night shift.

NICE’s work on safe staffing has been taken over by NHS Improvement, which was reported in June 2016 to have set up its own committees to look at safe staffing levels. According to the Nursing Times one senior source close to the work said: “The goal is no longer to think about safe staffing but safe and sustainable staffing, in other words only what can be done within budget, as if that is acceptable.”

In June 2016, Janet Davies, chief executive and general secretary of the Royal College of Nursing, said to the Nursing Times: “Given the unprecedented pressures on budgets in health and social care the need for clear guidance on patient safety is more critical than ever. There is a danger that some of the key lessons of the Francis Report may be forgotten, and short-term financial targets will again take priority. This can only have a negative impact on staffing levels and patient care.”

Patient safety is now considered unaffordable

Janet Davies predictions certainly seem to be coming true as in July 2016 Jim Mackey, head of NHS Improvement, said in an interview with the HSJ that in the coming weeks several trusts could find themselves with less clinical staff as the regulators stepped in to dictate ways the trusts can reduce their deficits, with the major target being staffing levels.

Mackey noted in the interview that trusts that exceed the 1:8 ratio will be told that they can not afford to do this. Evidence from the National Nursing Research Unit at Kings College used by NICE shows that “poor staffing levels (more than 8 patients per registered nurses) is associated with a significantly greater risk of harm.”

What Mackey is advocating is an approach where the staffing levels are balanced on a very very fine line between a patient being safe in hospital and a very real possibility of a patient coming to harm.