Medicine Balls, Private Eye Issue 1348

Safe Staffing Levels

A key feature of the Health and Social Care Act is for every hospital to become a Foundation Trust, managed by the market rather than central control. But the government has skewed the market so hospitals only receive 30% of the tariff for each emergency patient ‘above the 2008 level’. In essence, successful hospitals lose money if word gets out that they’re good and patients choose to go there. And with the NHS at the start of the toughest financial slowdown its ever faced, the only way to balance the books is front line staffing cuts that lead to the Mid Staffordshire scandal and the problems at many other trusts.

NHS England’s in-house response to the Berwick safety review, ‘Lines to Take’, claims that all providers use recognised tools to evaluate and decide staffing levels and skill mix for different ward types and occupancies, and to regularly publish their staffing levels, along with the evidence underpinning them, in their board papers.’ But a ‘recognised tool’ is no use when there is no money. The reforms have created a hideous labyrinth of new management organisations that soak up money producing tools and guidance, but don’t treat patients.

There is already far greater evidence for the importance of safe nurse staffing levels than there ever was for the hugely disruptive market reforms. On medical and surgical wards the risk of ‘adverse patient events’ rises rapidly  if one registered nurse (RN) cares for more than 4 or 5 patients per day shift. If an RN has to care for 8 or more patients, staffing becomes unsafe. This is hardly rocket science. Medicine is now so complex and fast moving that everyone – staff, patients and relatives – have to be vigilant to spot errors or potential errors. Not enough nurses means that errors get missed, harm isn’t picked up and the side effects end up costing the NHS far more than of it got the staffing levels right first time.

The NHS’s response has traditionally been one of denial. Nurses who report the adverse incidents caused by under-staffing discover these reports are ignored or discarded, as they were at Mid Staffordshire. Patients and relatives who try to complain face a system with a huge backlog and fiercely defensive NHS lawyers, and their experience of speaking up  is often a protracted torture. And we all know what happens to whistleblowers who go outside the NHS. A recent survey of 41 English hospitals showed that the overall average day shift ‘registered nurse to patient ration’ (RNPR) was 1:8,  and in some wards 1:11. This is simply unsafe and in a system that took safety seriously, mandatory safe staffing levels would be enforced, and services would be suspended, investigated and possibly decommissioned if they didn’t comply.

NHS England argues that the situation is far more complex than mandatory safe staffing levels and has to be judged on a ‘ward by ward’ basis. But with the overriding pressure to break even, rather than keep patients alive and healthy, ‘basic’ care is delegated to unqualified, cheaper staff. Alas, basic care is anything but basic. Most NHS patients are frail and elderly, with multiple and complex mental and physical illnesses. Advances in technology means many will also be on multiple complex treatments that require vigilant monitoring even when they are on ordinary wards. As Jenny Hunt, Visiting Professor of Nursing at Anglia Ruskin University, puts it:  ‘’Basic’ nursing requires care and compassion, sound knowledge of relevant biological sciences, the socio-psychological needs of the patient, excellent assessment, communication, observation, evaluation and decision making skills and expert clinical skills.’ You’re unlikely to get that for £6 an hour.

Professor Hunt believes that every patient deserves to receive a high proportion of their care from a registered nurse, with ratios of 1: 4 or 1:5 as the overall average. The extra cost of more qualified staff is recouped in fewer drug errors, better outcomes and a need for fewer care assistants. If you’re going into hospital soon, ask how many registered nurses per patient are on your ward every day. If it’s 1:8 or more, demand to see who’s responsible. It won’t be anyone from the government, the Department of Health or NHS England. They’ve all become experts in washing their hands. MD

Medicine Balls, Private Eye Issue 1347

Lines tom take on Berwick

After the deeply divisive, market-based drivel of the Health and Social Care Bill, Don Berwick’s review of the NHS is a welcome and well argued call to arms for everyone (especially politicians) to unite around better, safer care. At just 44 pages and 10 recommendations,  ‘A Promise to learn – a commitment to act’ is a practical report setting out clearly what individuals and organisations must do to achieve a culture of learning that is completely honest and transparent, with no more spin, denial and cover up. So how would the NHS respond?

First up, NHS England which Andrew Lansley promised us would be ‘small and lithe’ but under the leadership’ of Sir David Nicholson has become a massive uber-quango employing thousands of staff and enforcing the reforms from the centre just as the old DoH did under… er… Sir David Nicholson. Even before the Berwick Review reached MD’s inbox, a distraught senior NHS manager had forwarded NHS England’s ‘internal eyes only’ response. The first document is entitled ‘Berwick Review – Lines to Take’ and the second, Berwick Review – Questions and Answers – NOT FOR PUBLICATION.’

The ‘lines to take’ starts with a list of all the things the NHS already does to ensure patients are safe. The National Reporting and Learning System, the Patient Safety Alerting System, the NHS Safety Thermometers (both ‘classic’ and ‘new’), the Patient Safety Collaborative, the Patient Safety Expert Groups, the Key National Patient Safety Issues Analysis, the Cross-cutting Safety Strategies, the New System-wide Patient Safety Measurement and Core Patient Safety Functions.

Next, how to put compassion back into the NHS? There’s a Compassion in Practice implementation plan, recognised tools to evaluate and decide staffing levels and skill mix for different ward types and occupancies, a compassion in practice vision and strategy and a ‘network of care-makers’. The NOT FOR PUBLICATION Q+As  ask important questions like ‘Is the NHS safe?’ ‘Is zero harm impossible?’ ‘Was the PM wrong to ask for this?’ and ‘Are staff working conditions so poor that patient safety is compromised?’ The ‘answers’ do anything but, and largely evade the important substance of the questions. As my source put it ‘Lots of us are really disappointed with this response. Here is this wonderful report saying all the things we all feel; a new culture, an investment in teaching improvement science, let’s do things differently, and the response feels like some ‘tell them we’re doing it already’. It feels like ‘meet the new boss, same as the old boss’. Please do something with it and please don’t identify me.’ So much for a culture of speaking up without fear.

If Nicholson has already fixed safety, how did the CQC find a ‘catalogue of failings’ at Whipps Cross University Hospital? How can a hospital fail to meet 10 of 16 national standards for quality and safety when it has two types of safety thermometer (classic and new) at its disposal? ‘Unsafe, dirty… bloodstained gowns… some staff lacking compassion’. Was it because they lost hadn’t got a ‘network of care makers?’ Or was it because Barts Health Trust – which runs six hospitals including Whipps Cross – faces a £50 million debt and crippling PFI costs, and is having to cut services to the bone?

Meanwhile Nicholson has started writing a blog. It kicked off with ‘Seven Steps to Cultural Heaven’ on July 26. ‘After what feels like 10 years of the NHS and those with an interest in the NHS obsessing about structures and systems, culture is starting to get the profile it deserves. In fact, it is hard to read anything about the NHS these days without culture getting a mention. This is how it should be. But to say this is the real challenge facing the NHS is to grossly underestimate its importance (sic)’ Is Nicholson really the best the NHS has to offer? Sadly it’s the only NHS issue that unites Labour, the Lib Dems and the Tories. Nicholson stays to stop him dishing the political dirt while the NHS burns.