Lintern's Risk Register: The signal and the noise

Numbers of nurses do matter

In case you missed it last week, HSJ published the culmination of a two year investigation into nurse staffing levels in acute hospitals across England. The results make for sobering reading and show almost every hospital in the country is failing to meet its own planned level for nurse staffing during the day and at night. More worryingly, the results show the situation is getting worse rather than better, despite record levels of nurse recruitment since the 2013 Francis report.

The data also reveals most trusts are using more healthcare assistants than planned and that their nurse staffing levels performance started to decline steeply after April 2016 – when much tougher rules on agency spending came into effect.

So what does all this mean? Well, as HSJ pointed out in the article, the data can’t be used to compare trusts as the quality of plans will vary between organisations. Some readers were correct to say that on its own the data doesn’t tell us about the safety of patients, which depends on the quality of staff as well as the number.

NHS Improvement has been clear that where safety is a factor it expects trusts “to break the glass” and use agency staff

A typical line that often emerges when the scale of the nursing shortage is discussed is that it is the whole team that is important and that numbers alone should not be the focus. It is right that delivering safe patient care is a team effort and the team has to be high quality.

But a high quality team can’t provide safe care if there is not enough of them – and that is the case in many acute hospital wards in the NHS. HSJ heard stories of individual nurses left to look after 16 patients at night and in one incident a nurse had 24 patients to care for. Hundreds of research papers and evidence make repeatedly clear findings – numbers of nurses do matter.

Breaking the glass

There are many caveats to the data HSJ unearthed but the crucial message from it is that the situation is getting worse. The agency caps, which really began to bite in 2016, could well be the pressure point that has tipped many trusts further into the red on staffing.

NHS Improvement has been clear that where safety is a factor it expects trusts “to break the glass” and use agency staff. Jim Mackey, Ruth May and health secretary Jeremy Hunt have all been clear on their support for more nurses working on wards.

So the failure to actually achieve staffing plans could suggest something is going wrong in the messaging between the top and the bottom of the system. Could it be that middle management, perhaps at regional levels, who are under pressure to deliver the right answer on the system’s financial performance, is encouraging the wrong kind of behaviour?

What can be done?

It’s welcome that in the last six months pretty much every major national health leader from the health secretary down has been saying we need more substantive registered nurses employed in the NHS. A year ago this wasn’t the case – some even suggested substantive numbers should start to fall and trusts had over-recruited since the Francis report. That nonsense talk has stopped and the shortage of nurses is probably far north of the 24,000 estimated by the Royal College of Nursing.

More nurses need to be trained – but the scrapping of the nursing bursary is a gamble that may not pay off. Anecdotal reports of falls in applications may not be the disaster they first appear, given the huge number of applicants turned away under the previous system and first term drop outs.

As well as recruitment there needs to be action on the retention of nursing and this is already widely recognised by national bodies. But while trusts talk about flexible staffing and improved workplace environments, staff have faced five years of pay restraint with more to come and the government wishes to reform the Agenda for Change deal.

Immigration changes brought in by Theresa May in her last job, plus the Brexit vote, means all of a sudden it’s not so easy to bring in thousands of nurses from abroad to the NHS

Overseas recruitment is a necessary evil. We shouldn’t be plundering other countries of their staff – and in some cases it’s a short term fix when those staff return – but realistically the shortage can’t be reversed without this pipeline staying open. However, immigration changes brought in by Theresa May in her last job, plus the Brexit vote, means all of a sudden it’s not so easy to bring in thousands of nurses from abroad to the NHS.

The NHS needs a real plan for how it will achieve safe nurse staffing levels in five years – this is a forward view that is conspicuous by its absence.

Beware false solutions

In this context many will look to new care models and “innovative working” to save us. But untested solutions carry huge risk. Sustainability and transformation plans are preparing for thousands fewer nurses in the next few years, in what can only be described as fantasy planning.

Simon Stevens himself rubbished these estimates in Parliament. “Some of the staffing projections within individual STPs will now need to be refined,” the NHS England chief executive said. “Anybody who looks at some kind of Excel spreadsheet and infers, ‘oh blimey, there is about to be big reduction’ is wrong.”

What he didn’t say was that those estimates are the result of local areas being made to meet the inadequate financial settlement and £22bn of efficiency savings that Mr Stevens signed up to even if the NHS had received exactly what he asked for.

It is disappointing that when we asked NHS England to respond to our investigation it decided, despite the chief nursing officer being on its board, that it was “one for NHS Improvement”.

Demand on services, patient acuity and the failure to adequately invest in community services at scale will mean acute providers moving rapidly away from STP workforce plans. The danger is that without a supply of qualified nurses, the substitution with nursing associates and HCAs will increase. The research couldn’t be clearer that such action increases harm to patients.