Safety of patients is being compromised
In late 2016, The NHS Support Federation and the TUC published “Patient Safety - A Warning From All Sides” an overview of reports and articles published by the Royal Colleges, such as the RCN and RCM, unions, charities and think-tanks spanning all areas of the NHS - nurses, midwives, hospital doctors, GPs, and mental health professionals.
Now two years later even more evidence has been presented by those same organisations and others that little has changed with patient safety still being compromised and the NHS continuing to be stretched almost to breaking point by lack of funds and lack of staff.
There is clearly a consensus that underfunding and understaffing leads to issues of patient safety; however, despite the “warnings from all sides” the underfunding and understaffing of the NHS continues and has worsened since our report.
In September 2018, a BMA survey found the majority of doctors (93%) said that pressures on the system have a negative impact on their ability to deliver safe patient care. In addition, most doctors believe that patient services have worsened and around three-quarters of doctors said that national targets and directives are prioritised over the quality of care.
Nurses - stretched to the limit
The key issues for nurses is recruitment and retention in the NHS. Figures from NHS Digital released in July 2018 showed that vacancies for nurses are running at the highest level since records began three years before. In the six month period between October 2017 and March 2018, the vacancy level for nurses and midwives reached 69,408, up from 64,127 for the same six-month period in 2016-17 and a big increase on the 57,964 in the same six months in 2015-16.
In October 2017, an analysis by The King’s Fund showed that the number of nurses employed by the NHS has fallen for the first time on a year-on-year basis since April 2013. The key factors in the fall were a significant reduction in EU nurses and increasing number of EU staff leaving the NHS. Earlier in the year, NHS Digital said 38% of the vacancies in March 2017 were for nurses and midwives, up 17% up on the same month in 2016. For the first time, more midwives and nurses are leaving the profession in the UK than joining; the number departing has risen by 51% in just four years.
The RCN had already called for urgent action on the crisis in nurse recruitment in September 2017. The RCN’s report “Safe and Effective Staffing: Nursing Against the Odds”, based on the experiences of more than 30,000 nurses, had found “a perturbing picture of staff stretched to the limit and compromised patient care.”
Over half of responders to the survey said there were less nursing staff on shift than planned and that care quality suffered as a result. Over a third of nurses said they had to leave some parts of patient care undone due to a lack of time, while two-thirds said they worked at least an hour over shift unpaid. Almost half of respondents said no action was taken when they raised concerns about staffing levels.
Prior to this report, in August 2017, an analysis by the RCN found that the majority of England’s 50 largest hospitals are not staffed to planned levels and they are putting more unregistered support staff on wards to cope with a lack of registered nurses. The substitution of support staff for skilled nurses was particularly prevalent on night shifts; two-thirds of the hospital trusts put more health care assistants on wards than planned. Janet Davies, RCN Chief Executive said: “These startling figures show that, despite the Government’s rhetoric, our largest hospitals still do not have enough nurses and that is putting patients at risk.”
Despite, recommendations from the Francis report in 2013, that the ratio between staff and patient was of fundamental importance to safety and quality of care, the government has consistently drawn back from producing adequate guidance in this area. Some guidance was published in 2014/15, on staffing in acute wards, but soon after this NICE was told to halt the work on safe staffing levels in A&E and urgent care. NHS Improvement took over and but in November 2017, its guidance for A&E and urgent care set no staffing ratios and states there is “no evidence base to support a specific ratio”. This is in contrast to the guidance produced by NICE by experts working in A&E leaked to the press in January 2016, which did set minimum nurse to patient ratios and staffing levels for areas of A&E departments.
Midwives - unit closures and staff shortages
There is a serious issue in the NHS with the shortage of midwives that is affecting patient safety. According to the October 2017 survey of Heads of Midwivery (HoMs) carried out by the Royal College of Midwives (RCM), almost 50% of maternity units have had to close at some point in the previous year because they could not cope with the demand and had serious concerns for safety; one maternity unit had to close its doors due to understaffing and fears for safety 33 times during twelve months. In total units closed 209 times (between April 2016-April 2017).The average was six times and six units closed on ten or more occasions.
The shortage of midwives in England remains critical with the country still short of 3500 full-time midwives. 76% of HoMs reported that they had to redeploy staff to cover essential services either very or fairly often; staff were overwhelmingly redeployed from the antenatal service, the midwife led unit, community and the postnatal service to cover the labour and delivery suite.
As a result of cuts and staff shortages 19% had to reduce services in 2017 compared to 18% in 2016; the most common were parenting classes and midwife led units..
Hospital doctors - safe care compromised
In July 2017 the Royal College of Emergency Medicine urged hospitals to more than double the number of consultants on duty in A&E units in order to ensure that patients receive safe care. The Royal College said that NHS England must recruit 2,200 extra A&E consultants in the next five years, in order to avoid a winter crisis and prevent A&E consultants leaving due to overwork and stress.
Dr Taj Hassan, the college’s president, said: “Each emergency medicine consultant in England is responsible for around 10,000 patients a year. Our staff are working to the very limits of their abilities to provide safe, compassionate care. This is leading to burnout and doctors leaving the profession, creating a vicious circle.”
The closure of A&E departments, particularly overnight, due to difficulties getting staff is now a regular occurrence across England. This means patients have to travel further, increasing the risks of their condition deteriorating. Examples include Weston General Hospital, Grantham Hospital, Chorley Hospital and most recently in Telford.
In March 2018, the Royal College of Physicians' survey of 1,500 NHS consultant physicians found that nearly two-thirds of doctors believe patient safety has deteriorated over the past year and nine out of 10 have experienced staff shortages. According to the study, 80% of those asked said they were worried about the ability of their service to deliver safe patient care in the next 12 months and 84% believed the workforce was demoralised by the increasing pressures on the NHS
GPs - surgery closures and unmanageable workload
There are widespread problems with both the training and recruitment of new GPs and the retention of current GPs. In 2014 the Government promised 5,000 extra GPs by 2020, however it is highly unlikely that anywhere near this number will be added to the workforce.
An investigation by Pulse reported in May 2018 found that since 2013 over a million patients have had to move surgeries due to practice closures. In this time, nearly 450 GP surgeries have closed. Closures have been due to problems with recruitment and funding, as some practices had huge cuts due to Government reforms. Patients often have to travel further to a new surgery and lose continuity of care.
NHS Digital figures for the year to June 2017 show that 202 practices in England closed or merged: 64 in the north of England, 54 in the south of England, 46 in the Midlands and east of England and 38 in London.
In October 2018, the interim findings from a review of the partnership model of GP practice found that the workload for a GP is rising to the point where it ‘verging on unmanageable’ and in some regions of the country may be putting patients at risk.
Just one of several examples of the state of the crisis in GP recruitment and funding, is the closure of a surgery in Folkestone, Kent, which has 4,500 patients registered to it. The closure was due to severe funding and recruitment problems; this left the surgery unable to meet demand. The patients now face severe disruption to their care, made far worse by the fact that seven in eight GP practices in the area have applied to close their lists to new patients owing to safety concerns.
Mental health - a serious and worsening crisis
Within the past few months numerous studies have been produced showing the dire situation for patients with mental health conditions. The safety of patients with mental health conditions is compromised both by a lack of staff and a lack of beds. In March 2018, the Guardian reported that coroners had identified 45 cases in the last six years where a lack of beds, staff and specialist services affected the care of dozens of mental health patients who later died. The Guardian's own investigation found that at least 271 highly vulnerable mental health patients have died over the last six years after failings in NHS care.
In July 2017, the Government promised to increase the mental health workforce by 21,000 staff by 2021 as part of an ambitious plan to treat an extra million patients a year and provide 24/7 care. However, by March 2018 the workforce had only increased by 915 extra people, or 0.5%.
Then in September 2018, figures from the Department of Health and Social Care (DHSC), showed that two thousand mental health staff a month are leaving their posts in the NHS in England. A total of 23,686 mental health staff left the NHS between June 2017 and the end of May 2018. One in 10 mental health posts were unfilled at the end of June, while 187,215 whole-time-equivalent staff work in the sector; the total should be 209,233. The lack of staff results is long waiting times.
In October 2018, a shocking report by the Royal College of Psychiatrists reported that some adult patients had waited up to 13 years to get the treatment they needed; the survey looked at the experience of 500 diagnosed adult mental health patients. In addition, more than a third (37%) of those who had to wait to access specialist treatment saw their mental health deteriorate over this time. The waiting time is not surprising in light of the lack of staff.
A report by the Association of Child Psychiatrists released in June 2018 spoke of the treatment of mental health in children and adolescents as a “silent catastrophe.” The "serious and worsening crisis" within the NHS is due to chronic underfunding and serious structural issues. The report based on a survey of those working in child and adolescent mental health services (Camhs), says specialist services are disappearing owing to underfunding and the transformation and redesign of services in recent years and the result is rising levels of suicide, self-referral to A&E departments and pressure on in-patient units.
In October 2017, the CQC reported on child mental health services, saying they were a "postcode lottery" with some children having to wait up to 18 months for treatment. Four in 10 psychiatric services for young people are failing with crisis care for suicidal young people or those with severe mental health problems sometimes available only between 9am and 5pm. Night-time care was often by adult psychiatrists not trained in children’s mental health.
In September 2017, The Royal College of Psychiatrists, found that the number of NHS psychiatrists dealing with troubled children and young people in England is falling despite the growing demand for care. The Royal College is deeply concerned about the drop in psychiatrists, with the total number of psychiatrists working in Camhs falling from 1,015 full-time equivalent posts in May 2013 to 948 in May 2017.
Despite evidence that the safety and recovery of mental health patients is compromised by sending patients miles away from home for treatment, reports in August and September 2018, looking at child/adolescent and adult mental health patients, found that patients with serious mental health conditions are still being sent hundreds of miles from home for treatment due to the lack of beds.
Earlier in the year in April 2017, research by the charity MIND found that guidelines on the treatment of patients that have recently been discharged from inpatient wards are not being followed, which is leaving thousands of vulnerable people at increased risk of suicide. The guidelines state that patients that have been discharged from mental health inpatient care should be followed up within a week, and those at highest risk within 48 hours; MIND's research found at least 11,000 a year that had not been checked up on within a week.
The CQC - safety remains a real concern
The Government's own annual assessment of the health of the NHS itself, the Care Quality Commission's (CQC) State of Care report published in October 2018 is not gentle reading. The CQC reports that safety is a major concern:
“Safety remains a real concern: 40% of NHS acute hospitals’ core services and 37% of NHS mental health trusts’ core services were rated as requires improvement on safety at the end of July 2018.”
The CQC also highlighted the geographical differences in the care people receive:
“It is clear that people’s experience of care varies depending on where they live…..Some people can easily access good care, while others cannot access the services they need, experience ‘disjointed’ care, or only have access to providers with poor services.”
This report is the most comprehensive the watchdog produces, compiled from inspection reports of 30,000 services plus over 20 reviews of local systems. The report looks at the pressures on all services in the NHS from increased demand, inadequate funding and workforce recruitment and retention issues. The report noted the effects on safety of all these issues, for example the CQC noted that hospital's experiencing increased demand for beds have had an emphasis on reducing patient stays in hospitals (Delayed Transfers of Care/DTOC) however this has been found in some cases to compromise the safety of people moving through services. The report also noted that the CQC had key concerns on safety in the area of maternity and mental health.
The report noted that the impact of workforce shortages were being felt across health and social care:
"Workforce problems have a direct impact on people’s care.....Each sector has its own workforce challenges, and many are struggling to recruit, retain and develop their staff to meet the needs of the people they care for."
A good example given is community healthcare services where from 2009 to 2017, there has been a 40% decrease in the number of community matrons and a 44% drop in the number of district nurses, which of course has had a major impact on providing responsive care.
Whilst acknowledging that some extra money has been invested in the NHS, the report notes that this “risks being undermined” by the lack of any long-term solution for funding social care.
The CQC warned two years ago that social care was approaching a “tipping point”, well now this point has already been reached, according to the CQC Chairman Peter Wyman, where some people are not getting the social care they need.
In November 2017 a report by the organisation representing NHS management, NHS Providers, “There for Us - A Better Future for the NHS Workforce” found that “the gap between the workforce that providers need and the staff they are able to recruit and retain is now unsustainable, putting patient safety and quality of care at risk.” The report notes that
“workforce concerns have become the single biggest risk facing services.”
In the same month, Andrew Foster, chief executive of Wrightington, Wigan and Leigh Foundation Trust, told the Health Service Journal that if no workforce plan is developed then the NHS will be "lurching from crisis to crisis and people will be dying due to a lack of safe staffing levels. "
The most recent figures for the NHS workforce released by NHS Improvement in September 2018, show understaffing across the NHS as a whole is the worst it has ever been, with a record 107,743 vacancies, which includes a shortfall of 11,576 doctors and 41,722 nurses .