Minimum staffing levels are an example of inflexible regulation which distracts staff from time which they should be devoting to patient care, says Harry Cayton.

Lack of staff is often an excuse for poor care. But is care better where there are more staff and worse where there are fewer? Will minimum staffing levels secure quality? I doubt it. Like many over-simplified regulatory solutions to poor quality, this is the wrong answer to the wrong question.

We know that good quality care is possible; it can be done and is being done. We know that when care is bad the causes are complex and many. There is no direct correlation between number of staff and good or bad care, so mandated staffing levels cannot be necessary. But would mandated staffing levels raise the standard of those that are failing? Research suggests not: “mandatory ratios, if imposed nationally, may result in increased overall costs of care with no guarantees for improvement in quality or positive outcomes”, according to Welton in the Online Journal of Issues in Nursing in 2007.

Good quality care is an outcome not an input. Staff to patient ratios are an input not an outcome. The success of an organisation should be measured against outcomes - what it achieves, rather than inputs - what it does. Right-touch regulation, which we have developed at the Council for Healthcare Regulatory Excellence, looks at the results organisations achieve. We don’t prescribe how they should achieve those results, that’s their business - the demonstration of their professionalism and competence.

The principles of right-touch regulation - risk-based, proportionate, targeted, local and agile - should apply to the way we judge clinicians, managers and organisations in the health service. Suggesting staffing levels may be helpful in the planning of services as a strategic view of workforce needs is essential on a national and regional level. But even in superficially similar settings - care homes, GP practices, hospital wards or clinics - the needs of people, the case mix and complexity will vary day-to-day and month-to-month. 

Most of all is the variability of people. Some teams “work” whereas others do not, and this is due to the unique mix of personalities and talents involved, their leadership abilities and culture. Effective clinical leaders and managers understand, reflect on and interpret these on a regular basis. Thinking about the outcomes that their organisation is working toward, they identify the skills and competences that their staff will need to achieve those outcomes. They are best placed to make judgements about the maturity, experience, efficiency and effectiveness of their teams and how its members can best be deployed. Such detailed considerations in local staffing are out of sight of national regulators. Trying to impose national staffing targets disempowers mangers and clinicians from making their own judgements, and reduces their personal responsibility and accountability. 

To privilege numbers of staff over the quality of staff ignores the evidence of recent healthcare scandals, where it is the quality of care provided not the numbers of people providing it, which has most been at issue. The concern has been about the lack of compassionate, respectful care and that teams lack the necessary skills for their task. Clinicians and managers must be able to decide here and now what skill mix and what level of staffing they need in response to the changing needs of the people they are caring for.

We do know that poor care flourishes in poorly managed places. At CHRE we have scrutinised thousands of cases of individuals whose fitness to practise has been called into question, from which it is clear that the management of the workplace is a crucial factor in the quality of an individual’s work. We’re researching the role of regulators in influencing the behaviour of individuals and in ensuring the quality of the care they provide. The research so far shows that while national regulation plays a part, it is local factors - culture, leadership, personal responsibility and professionalism - that really matter. Regulation is a blunt instrument and regulating staffing levels is as blunt as you can get.

Right-touch regulation is regulation which is fit for purpose, with the minimum regulatory intervention to achieve the desired result.  Regulation itself needs to be flexible and responsive. Inflexible regulation makes things worse, not better, and distracts staff from time which they should be devoting to patient care. Minimum staffing levels are an example of inflexible regulation and a distraction from the proper questions that should be the focus and concern of managers and clinicians. They are an example of a fig-leaf performance measure - one which diverts attention away from what the real indicators of good performance are. 

Mandating staffing levels will not make a bad service better; it may make a good service worse.