8th June 2015

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Dr Mark Porter
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News and Comment from Roy Lilley

Robert Francis is in high dudgeon. He's copped the needle and got the hump. He doesn't like the idea that NHSEngland has suspended work on his recommendation that NICE should figure out safe staffing guidelines. He is wrong.


He is not wrong to want safe staffing guidelines. Who doesn't? He is wrong to want NICE to do it. The guidance they have already produced is a bureaucratic quagmire. Anyone, who has actually read it, knows it. But, as is always the way in the NHS, people are too frightened to speak out.


Let's look at the facts. NICE say, of their own guidance (Sec3):

  • there is a lack of high-quality studies exploring and quantifying the relationship between registered nurse and healthcare assistant staffing levels and skill mix and any outcomes related to patient safety, nursing care, quality and satisfaction;

  • a lack of appropriately designed interventional studies relating to the outcomes;

  • a lack of evidence from UK data;

  • a lack of good quality research;

  • no evidence found relating to organisational policies;

  • a lack of economic studies and a lack of data collection.

Instead of saying 'there's no evidence, we can't do this', they pressed on and published guidance based on averaging, uplift factors, DIY-tool-kits and hocus-pocus with 'Red Flags' that mean patients may wait more than 30 minutes for pain relief.


The whole thing is as easy to follow as a Heston Blumenthal recipe and as useful as a set of instructions... how to inflate a lilo.  


NICE also say (1.5.3); "... take into account that there is evidence of increased risk of harm associated with a registered nurse caring for more than eight patients during the day shifts".


As a result of these 27 words, the NHS got the idea that it is safe to run a ward with a nurse patient ratio of 1:8. It's not.  Indeed a March 2013 survey by Unison found only 1/3rd nurses say there are enough staff on the wards and the average ratios of 1:9 on medical wards and 1:11 on elder care.


The closest any evidence gets to 1:8 is the work of Anne-Marie Rafferty and others in Table 4; placing ratios of 1:8.6-10 patients at the margins, scoring mortality, failure to rescue, emotional exhaustion, poor quality and job dissatisfaction.


NICE have produced toolkits and calculations for:


 "nurses to systematically assess that the available nursing staff for each shift or at least each 24-hour period, is adequate to meet the actual nursing needs of patients currently on the ward".


Let's do the maths; Say only 300 'hospitals' and say just 30 wards each, means 9,000 calculations. Two shifts a day; 18,000 calculations, 365 days a year = 6,570,000 bits of paper. Well, that's a nice practical idea.


Do you think it's being done? No, neither do I. In fact with the evidence of my own eyes I can tell you it isn't. I can also tell you; if, during an evening, a 'red-flag' incident arises, the only way to get more staff is to pull them off another ward and hope they don't get a red flag as a result.


The Queen of Hearts, the chief nurse, is now going to tackle the problem of safe staffing. Quite right, too. This is a nursing matter and nurses must be trusted to resolve it. Nurses are close to the front-line, NICE is too close to the DH.


The government don't have the stomach to legislate for safe-staffing, as in California. Nothing will dissuade me the box of fudge that NICE produced wasn't because they were leant on by the DH (who were consultees for the guidance) to produce something 'manageable'.


We need a zero-based start. Just what is the right compliment of nurses and HCAs for the English NHS? Does anyone know? I don't think so. Don't confuse 'more nurses' with 'enough nurses'. How many is enough to be safe without 'red-flags', forms, and fiddling the numbers to make it look like three nurses are as safe as five.


This task is a defining moment for Jane Cummings as a registered nurse and a professional manager. She has to prove to the sceptics she is not swayed by the Professors who have no evidence; the Nurse Directors, who have budgets to protect; the DH who have politicians to defend; the directors of finance with regulators on their backs; not consultants nor anyone else. 


This is the toughest of tasks.  Nurse numbers cannot be defined by balance sheets in the boardroom, they can only be determined by facts from the frontline.  Cummings will need a lot of support and we should be prepared to offer it.


Go on the wards, ask real nurses.  They'll tell you what's safe, can they cope, what's the right skill mix and the right numbers.  Start at the front-line and work backwards. 


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