Safe Staffing

Will patients be harmed by the government’s relentless demand for more efficiency savings in the NHS? Former health minister Norman Lamb believes that the proposed £22 billion savings by 2020 are ‘almost impossible’. And Morecombe Bay investigator Dr Bill Kirkup has warned of disastrous consequences if the NHS focuses on financial savings at the expense of patient safety. Meanwhile Mid Staffs investigator Sir Robert Francis is outraged that NHS England has halted the work on safe staffing levels by the National Institute of Health and Care Excellence. NHS England has instead decided to ‘take over the work’ despite lacking the independent authority and expertise of NICE, and not being able to cope with its current workload. As one senior NHS England manager told MD; ‘I get hundreds of e mails in my in box each day, many of which concern serious governance issues that have arisen out of the confusion of the Health and Social Care Act. I cannot possibly deal with them all – it’s a high risk strategy trying to pick out the urgent concerns.’

The topic was at least debated at the annual Patient Safety Congress (July 6/7) but pressure is being piled onto Directors of Nursing and others to shut up about safe staffing. It shows how little the NHS has changed despite all the rhetoric about encouraging free speech. The government and NHS England knows it cannot safely staff hospitals or indeed GP and community services, so the ‘safest’ political option is to dampen down the evidence to show how importance safe staffing is. A high quality study by NHS England leaked to the Health Service Journal found a significant correlation between the number of nurses on duty in hospitals and 40 indicators of patient safety outcomes such as slips, trips, falls and picking up vital signs such as high temperature, respiratory distress and signs of sepsis. Many hospital inpatients have multiple illnesses and highly complex needs, and can deteriorate rapidly. They require highly skilled staff in sufficient numbers to give them the right care.

The Safe Staffing Alliance is at least prepared to keep shouting and has five important, evidence based messages:

1) Numbers matter when delivering safe and effective care. It is unsafe to care for patients in need of hospital treatment with a ratio of more than eight patients per registered nurse (excluding the nurse in charge) during the day on acute wards. There is evidence that risk of harm to patients is substantially increased when staffing levels fall below this ratio so it must be considered as a ‘red flag’ event and immediate action taken.

2) National standards need to be agreed and enforced. 45% of wards have insufficient staff to meet care needs safely – a situation reflected outside hospitals in the community. Statutory mechanisms should be put in place and guidance issued based on patient dependency, acuity and complexity in different settings.

3) Studies demonstrate that poor care costs more. Employing sufficient nurses and midwives to provide high quality compassionate care, so that patients are treated with dignity and respect, should be viewed as an investment not a cost. Nursing is a 24-hour seven-day-a-week activity and budgets for staffing must be protected to reflect that.

4) There must be genuine transparency over nurse numbers. There is inconsistency in the data recorded with some trusts including the nurse in charge in their nurse/patient ratios. In many areas staff nurses are caring for 10 patients each – more in some cases.

5) Staffing levels based on clear and recognised standards will need investment. Safe, high quality healthcare is expensive and sufficient nurses and midwives need to be trained now to reduce reliance on short term and expensive solutions such as recruiting staff from overseas and reliance on bank and agency staff. There must also be humane jobs available for them when they qualify. Many excellent agency staff started in the NHS but burnt out.

Unless the NHS provides humane and safe staffing levels, it won’t be able to recruit and retain sufficient staff to meet future needs. Junior doctors too are being pressured into dangerous overtime hours, and many are leaving the NHS. The NHS’s greatest asset is its frontline staff, and recruiting them in sufficient numbers to make the job a joy rather than a fast track to burn-out is a no brainer. But tell that to a government demanding immediate and impossible efficiency savings. NHS England needs to start speaking up for NHS staff and NHS funding. As for patients, the safety of NHS care is still hugely variable, propped up by professionalism and good will rather than properly evidenced, planned and resourced safe staffing levels.

MD’s book on how to get the best from the NHS is available here

The Cost of Chaos

MD takes a very simple view on NHS reform. The perfect structure doesn’t exist in any organisation, least of all something as complex as the NHS, and it can be profoundly damaging to keep reorganising in the hope of finding it. The side effects of the unnecessary and ill-judged Health and Social Care Act have been so severe that even lawyers are blowing the whistle to the Eye. As one put it: ‘I get so angry when the government says it’s reduced NHS bureaucracy. It might have cut the number of managers, but the bureaucracy has mushroomed after Lansley’s act. For example, to run community services out of a GP practice used to be simple – a single lease arrangement and contract between the GPs and the Primary Care Trust. Now the PCT commissioning powers have transferred to the Clinical Commissioning Group. The PCT’s interest as tenant transfers to NHS Property Services Limited. NHS PS are now the direct landlord of the provider of the services and the commissioning contract is with the CCG. So now there are four parties to the arrangement to provide simple community services from the GP premises – the GPs, the CCG, NHSPS and the provider.
To review the rent, NHS England needs to give approval if the GPs are to get their rent reimbursed and there is a knock on effect for all the leases in the chain so all parties need to be involved in some way. This simple process now requires the engagement and approval of the GPs, the Landlord, the CCG, NHSPS, the new provider and NHS England, and four leases and one community services contract. With each added party, there are more loops to jump through, more people on the email trails, more people at the meetings, more approval processes, more professional fees, more time wasted and greater delay. Frankly, I’d rather stay at home and nail my testicles to the table.’

The stated aim of government is to move some services out of acute hospitals closer to home, and yet the same government has created absurd bureaucratic hurdles and provided no new money for investment. Providers of essential community services that are just about breaking even are now being asked to pay higher property costs but do not have the money to do so and the government has made it clear they won’t be getting any more. Last month, North Bristol NHS Trust decided not to retender for its excellent community paediatric care services, which covers all community child health, and child and adolescent mental health services for Bristol and south Gloucestershire. The trust’s official reason for ditching such a vital service is that it wants to focus on its hospital based care. But the hidden message is clear. The government has made it near impossible for such services to break even in future and – along with the bureaucratic torture of running them – it’s easier for the NHS providers to give up and leave it to the private sector to tender for.

Meanwhile, an independent investigation into the collapse of the specialist adult dermatology service at Nottingham University Hospitals Trust has described the handling of changes by commissioners and providers as an ‘unmitigated disaster’. The trust had to close its internationally renowned acute adult dermatology service earlier this year after five of its 11 consultants quit rather than transfer to private provider Circle (Eyes passim) Circle is now relying on six long term locums costing £300,000 a year each because it cannot fill vacant consultant posts. Some of the locums are not sufficiently qualified to be included on the General Medical Council’s specialist register for dermatology. The current service faces the imminent loss of a further consultant rendering the acute rota unworkable and the possibility that, if any of the remaining consultants leave, the demise of the tertiary paediatric service. The consultants gave fair warning well in advance they would leave if the service transferred to Circle because of fears about the quality of the service and job security.

The decimation of the excellent Countess of Chester integrated sexual health service has also been an unmitigated tendering disaster by an incompetent local government (Eyes passim). Tendering is not mandatory, and the three sexual health services in Cheshire would have been far better off collaborating rather than competing and fragmenting. Sexual health relies on a complex network of joined up services (e.g. sexual assault, disease screening and treatment, sexual dysfunction, contraception, pregnancy advice). The new slimmed down services can’t cope with the demand. Waiting lists are rising, calls are not answered and the IT system is useless. HIV and syphilis are now treated in separate clinics, miles apart. Although the tendering could not be stopped, the adverse publicity from this appalling decision may explain why Chester bucked the national trend by returning a Labour MP at the slimmest of margins (93 votes) and gained control of the previously Conservative-led council. The scrutiny meeting discussing the tender is online, but probably not for long

http://www.cheshirewestandchester.public-i.tv/core/portal/webcast_interactive/158782

MD’s book, ‘Staying Alive – How to get the Best from the NHS’ is available here