HSJ’s patient safety correspondent Shaun Lintern argues that NICE’s leaked accident and emergency recommendations mean providers must take action.

Having spent time and substantial funds on developing safe staffing guidelines for accident and emergency departments, the National Institute for Health and Care Excellence has since June refused to reveal the final fruits of its labour.

HSJ has today published this final guidance revealing, critically, that it recommends a minimum nurse-to-patient ratio.

The work was authored by NICE’s safe staffing committee, which was composed of experts drawn from across the NHS and specifically from emergency care. They made the recommendations based on their assessment of the evidence and their expert view on what was needed to safeguard patients.

The detail of the guidelines will not please everyone.

The detail of the guidelines will not please everyone

They leave a lot to local interpretation and judgement, for example. Some will argue this means they are not specific enough; others will argue they go too far in setting rules for the system.

Red flags

The system of ‘red flags’ adopted by the guidance – which involves warnings being triggered by incidents – has already been included in guidance for acute wards, and been criticised by some as it cannot prevent the initial harm.

However, the guidelines are the best evidence based, expert guidance which is currently available to us about how to plan safe nurse staffing levels in NHS accident and emergency departments.

This remains the case, regardless of whether NICE or the Department of Health deems them to be formal guidance.

At present they do not, and they are not expected to do so in the immediate future. It was the DH, along with Simon Stevens, after all, which decided to suspend NICE’s safe staffing work in June last year. This move remains, in my view, a permanent stain on the government’s patient safety record.

Our leak will lead to wider debate about the implications of minimum nurse staffing ratios

The most important point today is that the guidelines are now in the public domain, and trusts running emergency departments should have regard to what they say.

Inevitably, though, our leak and its contents will lead to wider debate about the implications of minimum nurse staffing ratios, and their merits.

This calls on us to revisit the arguments in favour.

The cost fallacy

Minimum staffing requirements are common in other safety critical industries such as the nuclear industry or aviation. There are even safe staffing requirements at football matches, put in place in response to the Hillsborough disaster.

Some opposed to ratios have argued meeting the cost of minimum nursing levels will mean something else will be lost.

In my view this is a fallacy: the Care Quality Commission has argued its findings show trusts with high quality care also perform better financially. This illustrates why choosing to have unsafe staffing would be to grasp for short-term financial relief while storing up more costly consequences for the future.

Furthermore, staffing is an essential ingredient of safe care – a cornerstone of delivering and maintaining high standards around which good leadership, education and the right culture can flourish. We should no more decide against having a safe level of nurses on wards or in communities than we should consider whether to run hospitals without electricity, running water, or sufficient beds for patients to lie in.

Those grappling with severe financial challenges in the NHS may be tempted to dismiss the arguments for safe nurse staffing as an abstract and unaffordable policy – a ‘nice to have’ that isn’t realistic now.

Safe nurse staffing is anything but abstract. It is the only thing that matters

But for the patient lying in their own urine desperately pressing their call buzzer for help and forced to wait because ward nurses are stretched too thin; safe nurse staffing is anything but abstract. It is the only thing that matters.