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 a year later even more evidence has been presented by those same organisations that shows that patient safety is still being compromised and the NHS is being stretched almost to breaking point by lack of funds and lack of staff.
There is clearly a consensus was 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 first report.
Nurses - stretched to the limit
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 2016 survey of Heads of Midwivery (HoMs) carried out by the Royal College of Midwives (RCM), staff shortages are leading to unit closures, reduced services, and large sums being spent on agency staff.
Well over a quarter of HoMs - 29.5% in 2014 and 29.6% in 2015 - reported that they simply did not have enough midwives. The shortage of midwives in England remains critical with the country still short of 3500 full-time midwives.
As a result of staff shortages and increased demand temporary unit closures are common - well over a third (38.6%) had to close temporarily. Units closed their doors on 281 separate occasions, with the average being 8.3 times, but one unit closed 50 times in the year.
In addition, budget cuts are leading to a reduction in services. Almost a fifth (18.8%) said their budget had decreased in the last year compared to 14.6% in 2015. Over a third of HoMs (38.6%) said they were short of staff, with not enough to cope with demand; this is up from 29.6% in 2015. As a result of cuts and staff shortages 13.6% had to reduce services in 2016 compared to 11% in 2015, this includes cuts to parenting classes, and breast feeding and bereavement support.
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 and Chorley Hospital.
GPs - surgery closures
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.
The problems with GP recruitment are one factor in the record number of GP surgery closures and mergers in the year from April 2016 to April 2017, according to an investigation by Pulse. The investigation found that more than a quarter of a million patients in England were forced to move GP surgery last year, a 150% increase on 2014 figures, and a 15% increase on 2015. 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.
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.
In October 2017, GP leader Richard Vautrey wrote to the health secretary asking for a meeting to discuss urgent challenges and ‘huge pressures’ facing the profession. He said swift action is needed to help address the indemnity crisis, unsafe workload levels and frontline funding levels.
Earlier in 2017, the BMA’s GP survey found that 32% of GP practices in the south-east of England had been unable to recruit staff during the previous 12 months.
Mental health - a postcode lottery
Within the past few months numerous studies have been produced showing the dire situation for patients with mental health conditions. In October 2017, the CQC reported on child mental health services, saying they were a "postcode lottery" with some children having to wait of up to 18 month 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 children and adolescent mental health services (CAMHS) falling from 1,015 full-time equivalent posts in May 2013 to 948 in May 2017.
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 - the NHS is straining at the seams
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 2017 is not gentle reading. It describes an NHS that is working at “full stretch” whilst a “complex patchwork of health and social care strains at the seams”. Acute hospital wards have been over-occupied since 2012 and the situation is getting worse. Staff are under “huge pressure”, and hospitals now continually face the “severe pressures” usually only seen in winter. Patients are having to wait longer for treatment, including cancer treatment, and patients’ operations are frequently cancelled and rearranged. This describes an NHS where patient safety has been compromised and this is also the picture being painted by numerous other organisations.
Although there are other issues, including reduced skill levels on wards, the rationing of treatments and delays in treatment that all contribute to patient safety, staffing levels are undoubtably the number one issue when it comes to patient safety.
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 Digital in July 2017, show the number of vacancies in the NHS soaring - up over 15.8% compared with the previous year. The figures show that the number of full-time equivalent posts available rose from 26,424 in March 2016 to 30,613 in March 2017 – the highest number on record. However according to NHS staff groups and NHS Digital, itself, this likely to be an underestimate, especially for nurses. The data also did not cover staff employed by GP surgeries, such as practice nurses.