In the wake of the Francis inquiry and Berwick review, Nice's new safe staffing guidelines, for which I produced the statistical and economic analysis, may have caused surprise by stopping short of setting minimum staffing levels. Yet doing so would have been a mistake. It would have led to repeated mistakes across management of health services, abdicating responsibility for the correct completion of checklists and targets, while failing to acknowledge human experience.
Many have been hoping for Nice to mandate a minimum staff-to-patient ratio, although that was never the intention. The certainty that comes with establishing a minimum staff ratio is appealing; it's simple to ascertain compliance and therefore easy to hold providers to account. Yet it would have been misplaced. The experience of this approach in America and Australia has proved misguided.
While adequate staffing levels are necessary for safe and high-quality care, they are not sufficient to ensure it. Targets, guidelines, and checklists allow organisations to abdicate responsibility for ensuring that they are doing the right things by simply allowing them to report they are doing things right, ticking boxes rather than delivering care.
These new safe staffing guidelines show that slowly the tick-list mentality is changing, but they are not without problems. The recommendations are, of course, based upon the best available evidence. But is this the right evidence?
Hospitals are staffed at ward level, composed of individual patients with different and often changing needs. From shift to shift, the number, dependency and acuity of patients on any particular ward may change, and therefore so
The right staffing level may also depend upon the ward speciality, its physical layout, or the time of day. Having a single ratio would therefore be misleading, especially if this was set at a more aggregated level such as by the hospital or trust.
Nice's work in this area has unfortunately been plagued by a lack of good quality data and by the lack of existing studies. To date, research has either focused on the macro level (hospital/trust) performance or on micro level (patient) outcomes, but there is very little work done at ward or clinical team level where the care is actually carried out.
Similarly, most studies are plagued by confounding variables such as not observing the quality of hospital management. Until there is collection and analysis of ward-level data, in conjunction with management performance, we will not know whether providers are doing the right thing.
Without this detail, it's not clear exactly what outcomes at a ward or patient level are most sensitive to nurse staffing. Crucially, it is also unclear how the staff mix – the combination of registered and unregistered nurses – affects outcomes.
This is another area the guidelines rightly stay silent on. Healthcare assistants (HCA), or unregistered nurses, are obviously not direct substitutes for nurses, but can have an important role to play. Nice's new guidelines suggest that having more than eight patients to one nurse on a ward should trigger a red flag that care may not be adequate. However, we should be looking at how HCAs complement nursing staff and add them to the mix.
Current models treat all HCAs as equal, but some trusts provide greater training and development, allowing HCAs to take on more highly skilled or specialised tasks.
Much more work is needed to understand what elements of the HCA role can be moved up to this specialist level. Here, a lot can be learned from the developing world. Lord Crisp's fabulous book, Turning the World Upside Down illustrates a number of these, such as being able to train practically anybody to do C-sections.
While that is clearly an extreme example, we would do well to consider the general concept further, by taking individual HCAs and training them to do a specialised task at a much lower cost than a fully trained nurse.
Nice's guidelines and the recent inquiries have been produced in the wake of shocking cases of poor care. It is precisely because of these cases that we need not only to assess staffing levels, but to reassess what evidence we use to
determine good care.
Our view of the NHS and of the nursing role is still based on the traditional picture of matrons in white caps, but we need to look at the evidence and rethink who is best placed to deliver care of a high quality, and how to ensure that this also represents value for money.