Lintern’s Risk Register: Through the looking glass, nothing is what it seems

Beware the optical illusion on safe staffing

NHS Improvement chief executive Jim Mackey provoked angry rebuttals from royal colleges and nursing experts following his recent interview with HSJ in which he claimed between 30 to 40 trusts may have recruited too many nursing staff and some had gone too far on safe staffing. Aside from Mr Mackey’s misunderstanding of the 1:8 nurse to patient ratio – which is the point at which harm starts to occur and is supported by evidence – the interview also exposed a concerning view of staffing levels more generally at senior levels in the NHS.

We know there is a view within the Department of Health, NHS England and NHS Improvement that hospitals overreacted to the Francis report and the drive for safe staffing which contributed to the rising spend on agency staff. Mr Mackey seemed to suggest that in some trusts staffing growth had exceeded demand pressures and should be curtailed.

The problem is that NHS regulators and the government appear to be starting from a position that the Francis report was somehow day zero without considering the context of more than a decade of poor workforce planning and a failure to appreciate nursing as a safety critical job. They are ignoring the historically poor baseline for safe staffing which trusts are now trying to tackle and as such their view is not a full one. Regulators are suffering from an optical illusion on safe staffing.

Consider for example the recent report by the Migration Advisory Committee which laid bare the scale of the nursing shortage in the UK which, it said, had its roots in a failure over many years to anticipate obvious challenges from rising pressures and workforce planning driven largely by financial considerations. NHS trusts are now trying to fix this while demand continues to rise and patients are frailer and sicker.

The National Audit Office recently highlighted the NHS was training 19 per cent fewer nurses now than a decade ago.

Hospitals, under pressure from government, have continually underestimated what level of nursing they would need so that in 2014 demand for nurses was 24,000 more than what was predicted only two years earlier. On a regular basis NHS trusts have predicted moving activity to the community but Health Education England says only 0.6 per cent of nurses have actually shifted to a community setting in the last decade.

These plans, which at worst were mere wishful thinking when it came to reducing workforce costs, are what now informs the position of national bodies. NHS Improvement must recognise that the current desire for nurses is not solely about meeting demand growth this year. It’s about correcting the unsafe level of staffing and demand that has been prevalent on many NHS wards for a number of years. The view that trusts may have overstaffed can be right only when the wider context is ignored.

This effort to provide safer wards and higher quality care is also far from finished. After Francis many trusts have established locally what they believe to be safe levels of staffing and vacancy rates are running at 9.4 per cent, nearly double the level recommended by NICE. In London it is nearer 17 per cent.

Even if these posts were filled with substantive staff one in three nurses are expected to retire in the next 10 years and according to the MAC report there are not enough entering the service to fill this gap.

NHS Improvement’s own analysis of the nursing shortage shows the rapid growth in nursing numbers in the last two years has barely kept pace with demand. Alongside the increase the NHS has seen reductions in average lengths of stay and without this it would have required 5,000 more nurses at a cost of £250m – just to maintain the status quo.

It is hard to see, when all factors are taken into account, how any NHS trust has too many nurses and even if that is the case those organisations are likely experiencing a benefit and will be better prepared to weather the nursing shortage storm that is here now and likely to worsen.

NHS Improvement and the government have repeatedly ducked the problem of safe staffing saying responsibility and decision making rests with local providers. Those same local trusts should keep this in mind when NHS Improvement comes knocking.

Where NHS Improvement could help is in establishing evidence-based guidelines for what is safe and make a plan with the government for the NHS to achieve it over a number of years.