New staffing metric 'may lead to unsafe nursing levels'

Concerns have also emerged that the “care hours per patient day” metric, set out in Lord Carter’s efficiency review report published today, will not recognise the complexities of nursing care or variations in patient acuity between hospitals and wards.

According to the Labour peer’s report for the Department of Health, the metric will become “the principal measure of nursing and healthcare support worker deployment” from April. It also proposes hospitals benchmark themselves against average performance on the metric.

It will be calculated by adding the hours of registered nurses to the hours of healthcare support workers and dividing the total by every 24 hours of inpatient admissions.

Nuffield Trust senior policy analyst Sally Gainsbury said: “Without appropriate adjustments to account for skill mix and patient acuity, there is a risk that measuring hospital efficiency on this basis could drive down staffing numbers to unsafe levels.”

She said benchmarking may cause trusts to seek to move towards the average, which could lead to understaffing. “We know NHS hospitals have historically been understaffed. So using average levels as the basis for setting safe levels risks continuing that trend into the future,” she said.

Lord Carter, speaking to HSJ yesterday, said trusts would “absolutely” be expected to report results for nurses and HCAs separately to their boards, alongside the headline results.

Concerns have also been raised that the new metric may overshadow work to move hospitals to safe staffing levels, which was set in train after the Francis public inquiry report.

One acute trust nursing director told HSJ: “The worry for me, and I know other directors of nursing share this view, is that this appears to have no reference at all to the safe staffing work.

“Someone could look at it out of context and say, ‘Why is that hospital spending so much on nursing compared to everybody else?’ And directors of nursing are going to spend their whole time being reactive. There could be a whole industry reacting to this.”

Jane Ball, a professor at Southampton University and a former director of the National Nursing Research Unit, said research was “unequivocal” about the specific link between nurses and patient outcomes, which was not the case for HCAs.

She said: “If a unit has slightly better staffing will they now come under pressure to reduce that? It is almost like a pressure to go down that line and I think that is a very dangerous direction to travel in when there isn’t any evidence. Workforce decisions are being taken without the regard for the effects on patients, it is a form of experimentation. It feels very high risk and worrying.”

Alison Leary, a professor and chair of healthcare and workforce modelling at London’s South Bank University, and whose research for NHS England last year identified a link between nursing numbers and quality, said: “If care were a simple and linear process of time filled with tasks, then simple arithmetic like this would suffice.

“Care is far more complex and the work left undone is never quantified and thus such a simplistic approach may well underestimate workload and fail to take account of such complexity.”

Lord Carter told HSJ that comparing different types of wards on the metric would be “incredibly powerful”, and said evidence was “mixed” about the importance of nurses to patient outcomes.

He said: “The skill mix is absolutely critical. What the skill mix should be is a matter of debate. The sense we have got from across the system is 65 [per cent nurses] to 35 [per cent HCAs].”

Lord Carter’s review found there was at present an average of 9.1 hours of care per patient day, but that this varied across the NHS from 6.3 to 15.9 hours.

The final report said: “We are now working to establish how the data, which can be collated from existing sources without imposing additional reporting burdens, can be systemised to help standardise its use.

“The data will be a feature of the nursing dashboards we are developing as part of the model hospital and will be reported as total nursing hours, split by registered nurses and healthcare support workers to provide a complete picture of care and skill mix.”

The review estimates up to £2bn could be saved through better workforce productivity and recommends that NHS Improvement develops a national people strategy by October this year to improve staff engagement, people management and leadership capability.