Staff shortages, equipment shortages, inadequate supervision, delays all round, poor observation of sick patients, staff not sufficiently trained, call bells going unanswered, drugs not given at all or on time, problems with cleanliness, insufficient beds - is there an acute trust chief executive that can answer “none of the above”?

I suspect we have all got this to varying degrees. What makes this description different is its association with a very high hospital standardised mortality rate plus a trust subject to the rigours of a Healthcare Commission inspection. Mid Staffordshire gets added to the growing list of trusts that failed to protect patient safety. The report into Mid Staffs criticised the board for saying patient safety was their first priority - and doing nothing to prove it.

‘There is a much wider question for society about whether the NHS can ever provide the number of staff needed to cope with all the needs of our patients’

My own trust has had “no avoidable deaths, no avoidable harm” as a number one board strategy for years and believe we do lots to prove it, including reporting a comprehensive dashboard of indicators tracking our progress against our goal of saving 600 lives and avoiding 3,000 patients being harmed over the next three years.

Our executive and non-executive directors go out onto the wards for safety walkarounds on a regular basis and we invite patients and relatives to our board meeting from time to time to tell their stories.

All of this helps inform our board about the safety of our patients and we have shifted down our HSMR from above to below average since 2005 (111 to 90) and have kept it below average for some years now. But it has been difficult to shift downwards further and we know we still have a long way to go in creating a culture of safety and no avoidable harm or death.

Staffing levels

So we are interested in the debate about high nurse (and doctor) to patient ratios and low HSMRs. Or more negatively: low staffing and high HSMRs. Following our own “winter crisis” of admissions and staff shortages we have begun to look more closely at the actual staffing levels on our wards. 

We have always collected turnover rates and vacancy levels, sickness rates, bank use, agency costs, etc, but it took six months to give the board what they had asked for – a reasonable real-time assessment of when minimum staffing levels were being breached on a shift by shift basis. It seems to be happening too often and we need to make it unacceptable.

The recent Nursing Times article on research carried out by Dr Simon Jones, chief statistician at Dr Foster Intelligence, suggested that about a third of the variation in HSMR across trusts can be explained by the difference in nurse staffing. So other factors are also important. Just having more nurses is not the answer, but we do need to avoid breaching safe staffing levels.

I was thinking about this one Sunday night in March when I did a stint observing a junior doctor on the care of the elderly wards. There was an endless stream of inserting or replacing cannula into patients with arms like black and blue pin cushions. Patients were too confused to co-operate or know what was going on, or were resisting the treatment being offered. Patients were continuously calling out, disturbing other patients trying to sleep in the six bed bays.

The staff were caring and hard working but just not capable of meeting the very substantial needs of these patients. 

So there is a much wider question for society about whether the NHS can ever provide the number of staff needed to cope with all the individual needs of our sick, elderly patients and what role the acute hospital should actually play?

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