Lintern's Risk Register: Nice one Jim, now let's see results

Warm words on staffing is one thing. Action is quite another

NHS Improvement chief executive Jim Mackey is clearly a regular reader of the Risk Register.

In his first ever in-depth workforce interview with HSJ Mr Mackey told me he accepted there were risks associated with emerging workforce policies and that the regulator had a role to play in ensuring patients remained safe.

In contrast to comments he made earlier this year, Mr Mackey was clear he accepted there was evidence supporting safe staffing ratios, including the 1:8 nurse to patient ratio. He said there were lines trusts should not cross when it came to safety.

Even more encouragingly Mr Mackey appears to have taken recent warnings in this column to heart, announcing that NHSI’s executive director of nursing Ruth May is working on a safeguard to prevent nursing associates being used as substitutes for registered nurses.

He said the regulator would “provide a floor that people can’t go beneath… because the evidence is they haven’t always got that right” adding later that the development of nursing associates should not be interpreted “that you can get away with a cheaper, less skilled workforce.”

This welcome messaging and hints at future action follows the decision by the Department of Health to seek regulation for the nursing associate role.

After the interview NHS Improvement also confirmed nursing associates would be counted separately from nurses under the in-development “care hours per patient day” metric which was highlighted in the previous edition of the Risk Register. This is separate to the “safeguard” mentioned above.

Mr Mackey’s intervention may well be vulnerable to critics who will see the regulator as guilty of sending mixed messages on staffing and cost reduction, but Mr Mackey certainly doesn’t accept NHSI has done that. He believes providers need to be smarter and informed by evidence when making workforce changes rather than seeking simplistic cost cutting approaches. He is not saying there should be no change - on that, he is of course right.

In summary then, Mr Mackey did not have to give this interview nor did he have to say any of the things he did on safe staffing and patient care.

He deserves credit for being the only national leader in the health service prepared to actually address and comment on some of the risks that current emerging workforce policies could create.

However, warm words on safe staffing is one thing. Action following them is quite another.

At a time when NHS providers have what many consider to be unrealistic control totals and Sustainability and Transformation Plans are faced with finding billions in efficiencies if they’re to come even close to achieving the wishful thinking underpinning the Five Year Forward View, some will say that reducing workforce costs is inevitable.

While the draft Buckingham, Oxfordshire and Berkshire West STP was rare in explicitly stating it was going to save £34m through workforce changes which included a “reduction in nursing grade input”, it is likely that this approach will not be unusual elsewhere.

So if Mr Mackey is genuine in his comments that he wants evidence and assurance care won’t be put at risk there is a very real chance many STPs will be unable to satisfy his demands.

Given that NHS costs are dominated by workforce, many STPs could find it even harder to meet their numbers if risky changes to skill mix are challenged.

But let’s be clear – evidence shows diluting the skill mix increases mortality. Patients will die if trusts get this wrong, and they have and continue to do so as Care Quality Commission reports often attest.

So Mr Mackey shouldn’t back down, but it does underline the flimsy foundation of much of the NHS’s current plan for sustainability.