EXCLUSIVE: Ministers to order staffing reviews in response to Francis

Action on nurse staffing is expected to form a significant part of the government’s much anticipated full response to Robert Francis QC’s report into care failings at Mid Staffordshire Foundation Trust, which is expected on Tuesday.

HSJ understands the government will say it either fully or partially accepts the vast majority of the report’s 290 recommendations and will publish a line by line response that runs to two volumes.

However, despite the length of the response, it is understood it will set out few major new policies. It is also expected to reject Mr Francis’s call for a statutory duty of candour to be imposed on individuals.

A statutory duty of candour for organisations, announced back in March as part of the government’s initial response to the report, will still be implemented.  

In his report, Mr Francis disappointed many in the nursing profession by rejecting calls to back the introduction of a minimum nurse staffing level. However, he has since said he has been convinced by evidence from the Safe Staffing Alliance, which includes nursing and patient groups, that the ratio of nurses to patients should never fall below one to eight on general hospital wards.

Subsequent government-commissioned reports, including the Keogh review of trusts with persistently high mortality rates and the Berwick review of patient safety, have also highlighted the importance of adequate staffing.

It is understood that a major focus of next week’s response will be the launch of a new “how to” guide on staffing levels. This will set out a series of “expectations” including that hospitals should use recognised evidence-based tools to determine what staffing levels are required, review them on a regular basis to ensure they are appropriate, and publish them twice a year.

The guidance will urge boards to consider staffing at a ward level and not just across their whole organisation. However, the guide will not specify a minimum staffing level or skill-mix ratio of registered nurses to healthcare assistants. Sources said the government was anxious not to mention specific ratios and expected the implications of implementing the guidance on hospital finances to be widely debated.

Development of the guide has been led by Ruth May, regional director of nursing for NHS England’s Midlands and East region, as part of the chief nursing officer’s strategy Compassion in Practice. It advocated transparency about staffing levels when it was launched a year ago.

The guide has been approved by the National Quality Board, which includes representatives from the Care Quality Commission, Monitor and the NHS Trust Development Authority.

The government’s response is also expected to reconfirm it will ask the National Institute for Health and Care Excellence to develop guidance on staffing levels in different settings, as recommended by Mr Francis.

A tender document published by NICE last week seeks a contractor to produce evidence reviews to inform the development of the first guidance topic referred by the Department of Health. The document says NICE anticipates the first topic will be “safe nurse staffing levels, including nurse support staff, for acute adult inpatient wards in the NHS”.

The successful bidder will be expected to review evidence on “the most effective and cost effective balance of nursing and support staff to achieve patient safety outcomes at a ward level”, as well as “the most effective organisational culture, structure and policies to support safe nurse staffing at a ward level”.

The first “guideline” is anticipated by next July.

It is understood ministers have rejected some of Mr Francis’ recommendations on the basis that NHS structures have changed. However, many of those not being taken forward are proposals that would have involved the greatest expense and upheaval.

As indicated in the government’s initial response to the report, it will not press ahead with either the regulation of healthcare assistants or a merger between Monitor and the CQC.

Many of the 290 recommendations are already being implemented by other organisations, such as the creation of a “specialist cadre” of inspectors by the CQC.