The National Institute for Health and Care Excellence will publish recommended nurse staffing levels for accident and emergency departments despite being asked by NHS England to drop the work, HSJ can reveal.

  • NICE plans to publish controversial guidance on safe staffing in emergency departments despite NHS England asking the institute last month to halt its safe staffing work
  • The A&E work - which will not be official NHS guidance - is expected to propose minimum nurse to patient ratios
  • Its publication could put pressure on NHS England and ministers to adopt it or explain why it should not be used
  • Senior NICE figure reveals it also continued evidence reviews on safe staffing in other healthcare settings after the NHS England decision

Since NHS England’s decision last month, NICE has also continued evidence reviews on safe staffing for four other healthcare settings, a senior figure from the institute has told HSJ. NICE plans to publish these evidence reviews, alongside its controversial A&E work, at the end of this month.  

The publication of its final A&E proposals - even though it will not be badged as official NHS guidance - could put pressure on NHS England and ministers to adopt the measures or explain why not.

The news comes little more than a month after NHS England asked NICE to stop its work developing safe staffing guidance. NHS England intends to carry on the work itself through ongoing reviews of services including mental health and urgent and emergency care.

NICE’s A&E recommendations are expected to include proposed minimum nurse to patient ratios for a number of different scenarios – an approach NHS England chief nurse Jane Cummings has resisted. A member of the NICE advisory committee on safe staffing last month said the A&E guidelines would expose a number of trusts as being “inadequately staffed”.

Mark Baker, director of the centre for clinical practice at NICE, told HSJ that the organisation stood down its safe staffing committee following NHS England’s decision.

However, it used its own staff to continue evidence reviews on safe staffing for four healthcare settings: community and inpatient mental healthcare, learning disability services, and community services.

Mark Baker

NICE’s work is ‘the only systematic review on this scale’, Mark Baker said

Professor Baker said: “All of that work will be finished by the end of July and made available in the public domain and given to Jane Cummings to be done with as she wishes.

“It is the only systematic review on this scale that has probably ever been done.

“It will certainly be useful to whoever is looking to set staffing levels, now or in the future.

“Perhaps more importantly, it should lead to definitive research so that in future we can develop evidence based guidance.”

He added: “The A&E work has already been sent to Jane Cummings. We sent it to her within a day of the [NHS Confederation conference] where the decision [to suspend the work] was announced. So it has not been consigned to the dustbin at all.

“What we have done is going to be used in one form or another and will be publicly available,” he said.

Asked about which organisation was best placed to evaluate the evidence on safe staffing, Professor Baker said: “I think most people would say that the developer of guidance should be independent of the [commissioner], but you can understand the [commissioner’s] concern about that when the impact of the guidance may directly affect their costs.

“We have no real idea as to why NHS England did what they did. We had been pressing the [Department of Health] and NHS England about where this work was going because if it was going to be of use we had to look at how services were staffed and not just one profession within those services.

“That potentially wider staffing guidance could well have had profound effects on the organisation of healthcare and almost certainly more profound than would be comfortable for either commissioners of services or their political masters.”

He called for more research on staffing levels and its link with patient outcomes and pointed to a lack of overall evidence. He said: “NICE produces guidance which is based on the most reliable evidence. With the exception of general acute ward staffing, there isn’t any reliable evidence of the relationship between nursing staff numbers and patient safety. Because of that, it is difficult for the guidance to have any real scientific credibility, whoever produces it.

“We were asked the wrong question in restricting it to nursing and, even if it had been broader, I’m not sure the guidance would have deserved any greater credence because it is not a well researched area.

“I think there should be a commitment to do research into the relationship between staff seniority, numbers and outcomes for patients.”