Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under-the-radar stories. From patient safety correspondent Shaun Lintern

Several important workforce policies are beginning to converge. What new risks might this pose? Contact me in confidence here.

Shaun Lintern, patient safety correspondent

First evidence emerges of substitution of nurses

A number of significant developments have emerged in the past fortnight relating to safe nursing numbers. Specifically, there are the evolving plans for the new nursing associate role and Lord Carter’s “care hours per patient day” metric. To understand the risks these two policies potentially create, they must be viewed together in the context of an NHS under severe financial strain and a quality regulator being increasingly weakened by cuts.

In October a leaked Health Education England curriculum for nursing associates sparked a row over whether they should be able to work independently of registered nurses, including being able to calculate doses of and administer controlled drugs. Defending the policy, four senior chief nurses in England said the role was necessary in light of new care models and that some nursing duties would be taken on by nurse associates, but that they should be regulated.

Regulation of nursing associates is being promoted as a measure to ensure safety. But while a regulator will set clear standards, regulation cannot make patients any safer. At best it is a retrospective measure for accountability and, in the case of the Nursing and Midwifery Council, debate rages as to how well it delivers on even that function.

Regulation of nursing associates is important for another reason. Under Lord Carter’s “care hours per patient day” metric the workforce will be split into two categories: registered and non-registered. If nursing associates are regulated they could easily be counted as “registered” workforce. NHS Improvement has yet to decide how to categorise nursing associates.

But if they are counted alongside qualified nurses, there is a clear risk that any trust under pressure to increase its registered nursing care hours would find it cheaper to employ nursing associates instead of registered nurses. The temptation to do this would be even greater during times of financial stress such as the NHS finds itself in today.

Why does this matter? New research published last week showed a clear link between the dilution of nursing skill mix and an increased risk of death. The study found that for every 25 patients, substituting one registered nurse with a non-nurse increased the possibility of the patient dying by 21 per cent. This research is only the latest in a growing number of studies showing the clear link between registered nurses and outcomes.

In an interview with HSJ, NHS Improvement’s chief nurse Ruth May said the regulator’s forthcoming guidance on safe staffing will be “evidence based”. She also said that she would intervene and support directors of nursing to make evidence based decisions on staffing.

Her first intervention may be just around the corner. Buckinghamshire, Oxfordshire and Berkshire West’s draft sustainability and transformation plan openly said it planned to make £34m of workforce savings by “reducing registered nursing input” and using more “generic support workers” and healthcare assistants.

Under its plans, a forecast growth in the workforce of more than 4,500 had been reduced to a growth of just 978. Meanwhile, it acknowledges activity will rise, and that some of the new support worker roles have “not yet been evaluated”. That’s hardly an evidence based position.

Viewed together, the policies on nursing associates, the care hours metric, and safe staffing guidance show there is now a clear risk that registered nursing roles are being undermined. What is lacking is any discussion from national bodies about how they will ensure care does not become less safe. The chief executive of HEE, Ian Cumming, told HSJ it was up to the CQC and local trusts to ensure nurses were not substituted but news this week reveals the CQC faces 400 posts being cut and a shift towards a “light touch” model with a greater reliance of information supplied from trusts. We have been here before.

In the interest of safeguarding patients, NHS Improvement should quickly confirm that nursing associates will not be counted among registered nurses in the care hours metric. And the Department of Health should make its decision on whether it intends the role to be regulated or not. NHS Improvement should also issue clear unambiguous guidance on how trusts should implement this new role.

Beyond that though, NHS central bodies and the DH need to recognise the lessons of history. It only takes one poorly led board to make catastrophic decisions on workforce skill mix to result in horrifying poor care for patients. Not having clear safeguards and relying only on the CQC to catch a problem after it has occurred isn’t learning from the past.

The Buckinghamshire, Oxfordshire and Berkshire West STP provides the first evidence that registered nursing may be reduced and replaced with care support workers, to make savings. It is unlikely to be the last. Taken together it is hard to see how the NHS is not walking with its eyes wide shut into the next care scandal.

Support staff are valuable and deserve recognition

Highlighting the dangers set out above should not be seen as failing to recognise the valuable contribution of healthcare support staff. I have had the privilege to shadow excellent, skilled healthcare assistants and this important staff group are often our most patient facing staff. Without this vital group the NHS would be in a much poorer position.

We should recognise their role and contribution and one of the best ways of doing this would be to make the care certificate, introduced after the Francis Inquiry, a mandatory requirement. This should be followed by proper registration of HCAs with nationally set standards and training. It remains the case today that a taxi driver, pub bouncer or nursery worker is more regulated than an HCA providing care to people when they are at their most vulnerable.

We are failing these staff by not investing in their existing roles, which would allow them and the public to appreciate their skillset, which is distinct from that of registered nurses.