Why won't the government implement safe staffing levels in the NHS?

Legally binding ratios of nurses to patients are essential to improving patient care, according to a wealth of evidence and the recommendations of those investigating failures at mid-Staffordshire. So why is Jeremy Hunt dragging his heels? 

Mark Boothroyd
10 October 2013

Image: Four to one campaign

The devastating effects of understaffing created by the dismantling of the NHS are being revealed for all to see. 

Nurses in tears as they struggle to cope with falling staff levels and rising patient caseloads. 43% of wards with more than 8 patients to every nurse.

4 out of 5 nurses saying they go to work when sick, often due to fear of sanction by management.

Work-related stress among NHS workers is soaring, with the percentage of staff reporting them in the NHS staff survey increasing from 29% in 2010 to 38% in 2012.

More than 6 out of 10 nurses have considered leaving the profession in the past year - up from less than 3 out of 10 in 2008.

The simple truth, that a finite number of nurses can only provide a finite amount of care, is ignored.

The government's reforms create a vicious circle; falling bed numbers, increasing patient acuity and throughput and falling staff numbers are making it impossible to provide good patient care and making conditions unbearable for nurses, driving them out of the NHS, further increasing the pressure on those who remain.

As the government and media scapegoat nurses for poor care at Mid-Staffordshire and other hospital trusts, its not surprising that thousands are considering voting with their feet.

Maybe this is what the government wants; roughly two-thirds of the NHS budget goes on wages and nurses are the largest staff group within the NHS. So nurses are always near the front of the queue when the axe starts to fall. The RCN has identified 68,880 NHS posts marked for cuts by 2015; of these 24,836 have already gone, of which 4,837 are nurses, midwives or health visitors, and 4,042 are healthcare assistants.

The government certainly doesn’t want to pay for the nurses it already has – Jeremy Hunt’s threatened withdrawal of NHS workers 1% pay rise, was accompanied by emotional blackmail. If nurses want safely staffed wards, they must accept their wages falling in real terms for yet another year, he said - even as they see £3 billion wasted on a reorganisation that fewer than 5 per cent think will mainly improve patient care. Hunt’s pronouncement showed a shocking lack of care for NHS workers who provide the services patients depend on.

Nurses are doing their best. The Royal College of Nursing reports that three quarters of nurses work overtime each week, with four out of ten doing so several times a week due to understaffing. One in ten nurses puts in a whole extra day (8 hours) of overtime each week. If the College’s figures are reflective of the whole NHS nursing workforce, then nurses collectively perform over 1 million hours of overtime per week, nearly all of which are unpaid. This is equivalent of an extra 26,000 full time nurses being provided for free. The results? Burnout.

Despite overwhelming evidence, the Department of Health opposes any attempt to implement the one reform which would directly improve patient care, and make conditions bearable for nursing staff: mandatory minimum staffing levels.

In response to the post-Mid Staffordshire Berwick enquiry, Jeremy Hunt reiterated his opposition to minimum patient/staff ratios.

Hunt said “I don’t believe that I,...should tell every hospital “you should recruit this many doctors or this many nurses”. Hunt’s preferred alternative is essentially the status quo. Hospitals set their own staffing levels: “what you actually need to do is on a ward-by-ward basis see what a hospital needs and thats the way we’ll get the safe staffing...”

Both the Francis and Berwick reports recommended that evidence based guidelines be drawn up by the National Institute of Clinic Excellence (NICE). This recommendation was made over 6 months ago. But Hunt has stalled - he has simply not referred the work to NICE.

The status quo is failing. Leaving staffing levels in the hands of individual trust management is what lead to Mid-Staffordshire and almost every other NHS scandal in the last 30 years.

Senior NHS managers have been willing to compromise patient care by inadequately staffing wards to cut costs, compete with neighbouring hospitals and meet budget targets - including the 20% cut to the NHS budget currently underway.

The government may point to the increase in the number of doctors, but doctors don’t provide hands on care for patients. Outside of an emergency, doctors rarely even administer medications. The overwhelming majority of contact with patients is by nurses and healthcare assistants; washing, feeding, toileting, talking with and comforting them, taking observations, administering medications, liaising with relatives and social services, and communicating with all the other specialist practitioners involved in the patient’s care.

Anyone who has visited a ward can make the simple connection between the lack of staff and the care needs of patients not being met. So why doesn’t the government act?

Austerity and ratios

Any mandatory ratio, even a relatively low ratio like 1:8 as suggested by the Safe Staffing Alliance, would prevent managers cutting the number of nurses below a certain level.

Ratios would be a constraint on any private providers taking over NHS services, preventing them running down staffing levels to increase profits.

Ratios would also increase nurses power in the workplace, and reduce the ability of managers - shielded from the daily reality of work on the wards - to run wards as they see fit. Nurses would have the power to demand the staffing they need.

Introducing ratios for one staff group would also embolden other staff groups to campaign for ratios for their areas. All NHS workers are feeling the squeeze of austerity and the drive to perform more work with less labour power. Minimum safe staffing levels, protecting workers ability to do their jobs properly and safely should really exist in all areas of the health service.

Are minimum staffing ratios possible?

There is a global nursing shortage and introducing ratios in the NHS would increase demand further. The nursing workforce is ageing, with roughly 200,000 nurses aged over 50 and set to retire in the next 10-15 years. Austerity has hit nurse training, with 12.7% fewer training places (2,500 positions) in the last three years. 108,000 people applied to nursing courses in 2010. The majority were turned away due to lack of space on courses, not lack of ability.

These long term issues require much greater investment in training and education provision. They are not an argument against ratios, but a barrier to their implementation.

There is plenty of money in the NHS to pay for safe staffing levels. This year the NHS handed back a £2.2 Billion underspend to the treasury, money squeezed out of its finances by the cuts. The NHS also has large cash reserves, projected to be almost £4 billion. Rather than be spent on “deficit reduction” (ie given to the banks who own Britain’s debts) this money could be used to fund safe staffing levels and increase the well being of patients and staff.

The biggest cost is that borne by the patients. The deaths at Mid Staffordshire, and abuse and neglect of vulnerable patients reported across the NHS is a the ultimate price paid for chronic understaffing and a failure to properly resource frontline care.

A wealth of research

There is ample evidence that improving nursing ratios, leads to reduced mortality and better health outcomes.

A large-scale American study of 197,961 patient admissions and 179,696 nursing shifts showed patient’s risk of mortality increased by between 2% and 4% for every understaffed shift they were exposed to during their time in hospital.

A study by the Florence Nightingale School of Nursing a Midwifery found patient mortality was 26% higher in hospitals with the worst patient to nurse ratios (around 13 patients per nurse) than those with the best (around 7 patients per nurse).

The most recent study measuring care left undone found that the best staffed wards reported all care tasks completed 21% of the time, while those with the worst staffing reported all tasks completed only 11% of the time. Those wards rated as failing by their staff had the lowest number of nurses to patients.

In Western Australia a minimum staffing method, Nursing Hours Per Patient Day (NHPPD) was introduced in 2002. Wards were divided into 7 categories, and assigned a specific number of nursing hours based on patient need, turnover and acuity. These nursing hours had to be met and were assessed regularly by the government. Staffing levels increased dramatically. 

An analysis of the impact of introducing these higher staffing levels in three Australian adult acute hospital showed a marked improvement in patient outcomes.

Mortality rates subsequently dropped by a quarter. According to the study; “Surgical patients had a 54% drop in central nervous system complication rates, a 17% decrease in pneumonia and a 37% reduction in ulcer/gastritis/upper gastrointestinal bleed rates.”

Shock and cardiac arrest rates, sepsis, and pressure ulcers fell by between 25 and 63%. The average length of stay decreased by 2/3 of a day.

The research demonstrating a link between nurse staffing levels and patient well being is comprehensive and conclusive. The debate cannot any more be about whether minimum mandatory staffing levels are necessary; it is clear from the evidence they are and they should be implemented.

But the Department of Health lacks the political will. It seems more important to it, are to continue the austerity financing which is damaging NHS provision - and to avoid any regulation which would prevent the encroaching private sector putting profits before patients.

How could we secure ratios?

In California nurses won statutory minimum staffing ratios after a 13 year battle between the private healthcare corporations and the California Nurses Association. Similarly in Victoria and Western Australia, nurses had to take strike action before statutory ratios were won.

To secure nursing ratios has taken public pressure and ultimately, nurses forcing public and private health providers to acknowledge their discontent by disrupting the operation of the health service with industrial action.

Currently the main unions representing nurses - RCN and Unison - have voiced support for mandatory minimum ratios. It has been RCN official policy since 2011, and Unison surveys have shown more than 90% of its members support such a policy - but more needs to be done to organise members to put pressure on the government to implement them - including willingness to take industrial action where necessary.

A temporary stoppage, to secure better conditions for patients and staff, is preferable to the long term decline and dismantling of the NHS, and the danger of the more mid-Staffordshires. This wouldn’t have to be all out strikes. A work to rule, refusing to do unnecessary paperwork and concentrating solely on providing patient care would free up nursing time and be beneficial to patients, while hitting the bureaucratic target driven regime that currently operates within the NHS.

Unions need to give their members a chance to discuss the options, both in the workplace and nationally. Why not organise a genuinely grassroots nurse-led staffing enquiry? Why not organise lobbies and demonstrations for safe staffing in every community, to mobilise the public support that was so crucial in winning ratios in both California and Australia?

We also need to make sure we always highlight how privatisastion makes safe staffing less likely. In the largely privatised Californian system, ratios were mandated as the legal minimum by the California Department of Health, after a long struggle. Yet there implementation was fought bitterly by the private hospitals who claimed it would drive them out of business. In contrast in the publicly owned hospital system in Western Australia, extra funding was provided to ensure the axe wasn’t just shifted elsewhere.

Nurses work with the most sick and vulnerable people in society gives us immense social weight, far beyond the economic pressure we can bring to bear through industrial action. Nurses need to organise themselves to start exercising this power and force the government to implement the changes we need to provide safe, quality care for our patients.

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