Nurse staffing levels ‘still putting patients at risk’, finds major review

Researchers found wards across the NHS in England were still under staffed and putting patient lives at risk, despite new policies coming into force as a result of the 2013 Mid Staffordshire Inquiry.

“You just can’t keep rolling the dice and hoping there will be enough nurses – it’s patients’ lives that you are risking”

Jane Ball

They said “strong” policies introduced in wake of the landmark inquiry were successful in reframing nurse staffing as a critical patient safety issue – but warned these had now become more muted.

They found that national commitments made following the care scandal at the former Mid Staffordshire NHS Foundation Trust were not matched with investment, leaving trusts with the responsibility of ensuring safe staffing but without the resources to deliver it.

Academics involved in the major review, published today, told Nursing Times they were not convinced that enough had been done to prevent something like Mid Staffs happening again.

They warned that, like at Mid Staffs, staying within budgets and costs had been “prioritised over ensuring there’s a sufficient supply of registered nurses to look after patients safely”.

Robert Francis QC was asked by the government to carry out an independent inquiry after concerns were raised about high patient death rates at Stafford Hospital between 2005 and 2009.

“Ultimately staying within budgets and costs have been prioritised over ensuring there’s a sufficient supply of registered nurses”

Jane Ball

In his damning report published in 2013, which sent shock waves through the health service, Mr Francis identified what he described as a “completely unacceptable standard of nursing care”.

From the evidence given to the inquiry, he concluded that the decline in standards was associated with inadequate staffing levels and skills, as well as a lack of effective leadership and support.

The trust was found to have prioritised cutting costs in its pursuit to obtain foundation trust status over patient care, stated the Francis report.

In light of his findings, Mr Francis made a host of recommendations for significant reform of the way nurse staffing was to be established, monitored and managed, and where accountability should sit.

The government at the time gave a strong commitment to act on these recommendations and a host of new policies and guidelines were subsequently introduced.

These included the first set of national guidance on nurse staffing in adult inpatient wards in acute hospitals published by the National Institute for Health and Care Excellence (NICE) in 2014.

It recommended that a registered nurse caring for more than eight patients during a day shift should prompt a staffing review due to the association with increased risk of harm.

This was followed by the first evidence-based tools to help guide decisions around nurse staffing.

In light of this, academics from the universities of Southampton and Bangor were commissioned by the National Institute for Health Research to examine what difference these policies made.

They have today published the findings of the two-year research project in an extensive report – called Implementation, Impact and Costs of Policies for Safe Staffing in Acute NHS Trusts.

The duty of candour was introduced in response to care failings at Mid Staffordshire

The duty of candour was introduced in response to care failings at Mid Staffordshire

It found that the policies introduced after Francis succeeded in making explicit the link between nurse staffing and patient safety and acted as “a lever and a catalyst for change”.

The term “safe staffing” had become embedded in organisational thinking in the NHS, from board level downwards.

This had led to the development of better processes, technologies and systems to support safe staffing in trusts, the document noted.

“The graphic account of events at Mid Staffordshire documented in the Francis inquiries, and the diagnosis of inadequate staffing as a contributing factor, provide a haunting reminder of why, in the interests of patient safety, nurse staffing levels must be considered carefully,” said the report.

“The safe-staffing policies developed post-Francis set out a vision for safe staffing to which trusts have responded as best they can,” it said.

It added: “Despite competing priorities within a shifting contextual landscape, safe staffing as a concept has become embedded and striving to achieve it continues to be high on trust agendas.”

The Francis report was published at a time when registered nurse numbers had stagnated following the financial crisis of 2007-08.

However, the review found that, since 2013, the registered nurse workforce in NHS hospitals increased by 10%.

The same growth was not seen in other areas of nursing that had not received the same level of policy attention – “suggesting the policies may have succeeded in bringing about better staffing levels in acute settings”.

But the report determined that this rise had not been enough to meet demand, with trusts experiencing “persistent difficulty” in filling their rotas.

Directors of nursing interviewed for the study said the biggest barrier to achieving safe staffing was the national shortage of registered nurses. In 2017, 10% of posts were vacant.

One in four trusts surveyed reported that the number of patients per registered nurse had exceeded the recommended one to eight ratio on more than 65% of shifts in the past 12 months.

The skill-mix of the nursing workforce had also been diluted since the Francis report, the document highlighted.

While the registered nurse rise was modest, healthcare assistant numbers increased by 30% since Francis.

Registered nurses accounted for 66% of nursing staff in 2017, compared with 69% in 2013.

“A huge challenge has been the labour market context: the number of registered nurses has been, and continues to be, insufficient to meet demand,” said the report.

“The need for additional nursing staffing identified by trusts through the use of improved nurse planning systems, are translated into posts, but without sufficient supply of registered nurses to fill them,” it added.

A “recurring theme” of the study had been a lack of resources to deliver safe staffing.

The report found that the national message to trusts around nurse staffing had shifted in more recent years to focus on financial sustainability amid austerity.

The requirement that trusts both deliver safe staffing in every situation and remain within budget was described in the study as a “source of tension”.

The report found that the resources required for reducing unsafe staffing levels and implementing NICE guidance were “not estimated, nor committed”.

Without central support, trusts had been left to cover the costs themselves – leaving many in financial deficit.

“Safe staffing policy led by the Department of Health appears not to have been synchronised with Treasury commitments and the funding of national workforce plan, leaving individual trusts with the objectives and responsibility for safe staffing, but without the resources to deliver it,” noted the report.

Mr Francis had suggested that NICE take responsibility for developing the evidence-based safe staffing guidance to maintain independence.

However, this responsibility was controversially taken away from NICE in 2015 and later transferred to NHS Improvement.

“The cessation of NICE’s responsibility for developing safe staffing guidelines and transfer to NHS bodies, who have responsibility for other performance measures specifically funding, productivity and cost control, marked significant shift,” the report noted.

The review document concluded that, while great progress had been made towards NHS safe staffing, there “have been and remain, significant constraints” to achieving it, questioning whether the improvements achieved were sustainable.

Limitations in workforce supply and funding “continue to threaten the achievement of safe staffing in general acute hospital wards”, said the report.

Significantly, the report cited a quote from Mr Francis highlighting concerns that the pressures trusts were struggling with now were similar to those facing Mid Staffordshire when the failings occurred.

Mr Francis said in late 2017: “We’ve got a virtual storm of financial pressures, increased demand, difficulties finding staffing, and pressure on the service to continue delivering. And some of that sounds quite familiar – as it was, those were the conditions pertaining at the time of Mid Staffordshire.”

Lead study author Professor Jane Ball told Nursing Times that the review had uncovered a “big disconnect” between the vision of the policies that were set out after Francis and the actions and investment needed to deliver it.

ball jane 002 web

ball jane 002 web


Jane Ball

“That’s left trusts with this very uncomfortable tension between the responsibility to deliver on safe staffing but without the means and the literally the workforce to do that,” she added.

A key recommendation by Mr Francis was for minimum staffing standards to be considered, but this was not followed through.

Professor Ball, who is based at the University of Southampton, said it was her personal view that these standards were still needed.

“In a safety critical service like healthcare, you just can’t keep rolling the dice and hoping there will be enough nurses – it’s patients’ lives that you are risking,” she added.

Asked by Nursing Times if she believed enough had been done to prevent a scandal like Mid Staffs happening again, Professor Ball said no.

“The situation in Mid Staffordshire where immediate cost savings were prioritised over ensuring that we have got enough nurses to keep patient safe – we need systems in place, not just locally but also nationally, so that that same situation can’t also be pattern that happens nationally,” she said.

“In effect, our report suggests that it is in fact the same pattern, that ultimately staying within budgets and costs have been prioritised over ensuring there’s a sufficient supply of registered nurses to look after patients safely,” she added.

“The policies are very aimed at what trusts had to do but meanwhile there was work that was needed to be done at national level that still needs to be done,” she told Nursing Times.

“So, we will never have safe staffing if we don’t address the national level issues about workforce supply,” Professor Ball warned.

The Royal College of Nursing’s director for England, Patricia Marquis said: “Mid Staffordshire showed us the dire consequences of nurse shortages and yet those precious lessons have been forgotten so quickly.

“Now that there are 40,000 unfilled nurse jobs in England, it is time for ministers and the NHS to get a firm grip on the situation before it deteriorates further,” said Ms Marquis.

“The legacy of the Francis Report was a once in a generation opportunity to increase nurse staffing levels across all health and care settings but any short-term progress in hospitals has fallen away,” she said. “Rising patient numbers are outstripping small nurse increases.

“The report is right to raise concerns around the increased numbers of support staff too – these increases must be matched by rises in registered nurses if we’re to keep the full and appropriate mix of skills in care settings,” she said.

In line with a current RCN campaign, Ms Marquis called on ministers to introduce safe staffing legislation in England, in a similar way to laws introduced in Wales and potentially Scotland.

“The government should commit to a new law for England to provide accountability for staffing levels for safe and effective care, and provide an additional investment of at least £1bn in nurse education to retain the existing workforce and train the next generation of nurses,” she said.

Meanwhile, last week, members of Unison passed a motion this morning to campaign for safe staffing legislation in England and Northern Ireland at the union’s annual health conference.