Why Harry Cayton is wrong on minimum staffing levels, and hardwiring the patient voice into the system

Hearing aids

I read with great interest Ciarán Devane’s article, in which he clearly sets out the importance of “true patient voice in service design” (opinion, page 24, 22 March).

I agree that this voice is of critical importance, which is why it lies at the heart of the government’s ambition for HealthWatch as the new consumer champion for people’s experience of their NHS and social care services. The voices and experiences of service users and the wider public should have “parity of esteem” and local HealthWatch having a mandatory seat on the statutory health and wellbeing board will help to make this a reality.

As Mr Devane describes, the best commissioning matrix is one where the clinical commissioning group, NHS Commissioning Board and their local partners operate well together to ensure that the voice of users is at the heart of decision making. Local HealthWatch is pivotal to achieving this. In turn, the evidence gathered from patients and public will support HealthWatch England, at the national level, to influence national bodies such as the NHS Commissioning Board.

I welcome the expertise of national patient charities, such as Macmillan, and other voluntary and community sector organisations to help us shape the future landscape so that patients’ voices really are “hardwired” into the new system to really embed ways of working that they can really hear, engage with and respond to patients, service users and carers.

John Wilderspin, national director for health and wellbeing board implementation

The right touch

Harry Cayton argues that minimum staffing levels are an example of inflexible regulation that distracts staff from patient care (opinion, page 16, 15 March). He asserts: “There is no direct correlation between number of staff and good or bad care.” But more than a decade of published research challenges this perspective.

A previous UK study found that proportionally fewer patients die in hospitals with better nurse to patient ratios (Rafferty et al, International Journal of Nursing Studies 2007). And more recently, research from across Europe published last week in the BMJ demonstrates two key points: staffing varies hugely, even on wards of the same specialty; and differences in patient to nurse ratios are associated with differences in both patient and nurse outcomes (Aiken et al 2012).

As Mr Cayton rightly acknowledges delivering high quality care is complex and ensuring adequate staffing is not the only factor involved. Good management and leadership plus investment in supporting staff through continuing professional development, good career prospects and relationships with doctors as well as having scope to influence decision making within the practice environment, are all required.

Investing in staffing needs to track with creating practice environments. None of this is rocket science. But it depends on how staffing regimes are defined and implemented. Could it be any worse than the wide variation we see at present? Many specialties set benchmarks while still leaving room for local flexibility and professional judgment. What we need is rigor in implementing the research base to provide the right touch in “right touch” regulation.

Anne Marie Rafferty and Jane Ball, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College, London

Wrong on many levels

Harry Cayton clearly has a strong sense of irony (opinion, page 16, 15 March). His claim that setting minimum staffing ratios is “the wrong answer to the wrong question” manages to ask the wrong question itself. Minimum staffing ratios are being seriously considered by the Mid Staffordshire Foundation Trust inquiry precisely because the current regulatory regime and management culture between them failed dismally to ensure both minimum staffing levels and appropriate staffing ratios between skilled and less skilled staff.

The real questions Harry should have asked are twofold. The first question is not whether nationally mandated staffing ratios are intrinsically flawed, but whether there is any link between staffing levels and quality of care. It is correct that higher staffing levels do not ensure better quality of care if the management and staff culture is wrong. It is equally true however that lower staffing levels make it less likely that quality care will be provided. Harry Cayton nowhere addresses this issue, preferring to focus on the quality of individual staff instead, and whether they show compassion and have the appropriate skills. I suggest these are certainly a necessary but are not a sufficient precondition for quality care, as my own experience of representing staff in health and social care demonstrates. Sufficient staffing is certainly a precondition.

The second linked issue Harry mentions, but in respect of which he does not clarify the regulators’ role, is “good management”. One priority for regulators, in which both the professional regulators (including Harry’s own Council for Healthcare Regulatory Excellence) and the service regulators (notably the CQC) have signally failed is to help create a culture where organisations “learn”, are self critical, and above all encourage staff at every level to raise concerns safe in the knowledge that doing so assists good care and will not lead to victimisation. It is important that individual poor practice is held to account. It is at least as important that organisational leadership that prevents staff and patients effectively raising concerns is relentlessly challenged. The evidence base that such challenge would assist patient care is robust. The evidence that Harry’s regulators are doing sufficient to help bring that about is thin on the ground.

Contrary to Mr Cayton’s case, the recent review of international evidence on staffing ratios by the National Nursing Research Unit suggests mandated ratios could “improve nurse staffing and lead to better recruitment, generate a more stable workforce, and more manageable workloads for staff [whilst] the impact on patient outcomes is less clear but there is evidence that the resultant lower caseloads are related to lower levels of patient mortality”.

Until both sets of regulators, and trust management, demonstrate they can be trusted to have sufficient staff, of the right mix, in place and able to raise concerns, it is inevitable that there will be calls for measures such as minimum staffing levels.

Roger Kline, employment rights consultant, East Barnet