Failure to publish safe staffing guide ‘a damaging step back’

Plans to publish guidance on safe staffing levels in emergency departments (EDs) have been shelved after weeks of speculation about when or if the guidance will appear

Plans to publish guidance on safe staffing levels in emergency departments (EDs) have been shelved after weeks of speculation about when or if the guidance will appear.

A draft guideline on ED staffing ratios was published by the National Institute for Health and Care Excellence (NICE) in January, but the programme has since been suspended.


Guidance on safe staffing has been issued by the National Institute for Health and Care Excellence

This decision drew criticism from Sir Robert Francis who recommended in his 2013 report on care failings at Mid Staffordshire NHS Trust that the work should be undertaken.

The RCN joined other nurse leaders, unions and patient groups in signing a letter to The Times describing the move as a ‘damaging step back’.

At RCN congress in June, there was anger among members about the decision to stop the NICE work.

Need to fight

An emergency resolution condemning the move won overwhelming support. Jason Warriner, who proposed the resolution, said: ‘Safe staffing is not just about the right number of nurses but rather having the right people in the right roles with the right skills to deliver the best care possible. We need to fight for this. Not doing so would put lives at risk.’

The RCN suggested cost may have been a reason for halting the work but chief nursing officer (CNO) for England Jane Cummings, explaining the move in a letter to directors of nursing, denied this. ‘This is not about saving money, more about using the money we have efficiently,’ she wrote. ‘I would not suggest anything that would compromise safety.’

More than numbers

Her letter went on: ‘To see NICE’s work as the totality of our focus on safe staffing is to miss the point. Good quality care is influenced by more than how many nurses are on a shift.

‘We must take into account all the staff involved, not just nurses. In urgent and emergency care, as in other care settings, we need to look at doctors, paramedics and other allied health professionals, as well as nurses.’

However, NICE then said its unofficial guidance on safe staffing would, after all, be made available on its website at the end of July.


This decision was also reversed, with some commentators suggesting that NHS England and the Department of Health (DH) had put pressure on NICE not to publish. The DH denied this and health secretary Jeremy Hunt said that NHS England would work with the new regulator, NHS Improvement, to develop a safe-staffing programme.

According to RCN head of nursing practice JP Nolan, January’s draft guidance from NICE had included much that the college was happy to support. Putting it into operation would have been challenging because of the fluctuating demands placed on emergency departments, he says, ‘but it absolutely would have made a difference’.


Commissioned by the DH and NHS England, it proposed minimum staffing ratios based on the seriousness of a patient’s condition: two registered nurses to one patient in cases of major trauma or cardiac arrest, for example.

At the time of publication, director of clinical practice at NICE Mark Baker said: ‘Nursing staff are often among the first to see patients and we know that the care they provide is essential for successful treatment of every patient.

Safe care

‘Ensuring there are enough available nursing staff, with the right skills, helps to make sure people in need of immediate medical help will get safe care, whatever the time of day or night.’

So is it certain that existing emergency department ratios are inadequate? Yes, says Mr Nolan. ‘It’s a universal factor that nurses are struggling and our members are being held accountable for their inability to nurse properly.’


He adds: ‘It’s very troubling. Nurses in emergency departments are not ringing us to talk about pay and conditions. They’re ringing us because they are not able to spend time with their patients, and that’s disheartening.’

Nurses working in EDs have little control over staffing ratios, or ‘input and output’, he says. As a result, year in, year out, they struggle, and departments haemorrhage staff.

Mr Nolan acknowledges the possible financial implications of having officially sanctioned safe-staffing levels, saying: ‘High quality staff and care does cost money but that’s what patients deserve.’

Cost effective

A wealth of evidence demonstrates that well trained staff, graduate nurses in particular, help to improve patient safety, he says: ‘Ultimately, it’s cost effective.’

According to a member of the NICE advisory committee on ED staffing levels, James Bird, the NICE guidance, had it been published, would have demonstrated that some emergency departments were under-staffed.

Not cheap

In June, Nursing Standard reported on a safe-staffing event in London, quoting Mr Bird, an emergency department matron at the capital’s Imperial College Healthcare NHS Trust, who told the conference that if publication of the guideline had gone ahead, ‘there would be a number of trusts that would have realised that they were inadequately staffed’. He added: ‘It was not going to be a cheap guideline.’

Meanwhile, the CNO’s assertion that patient safety will not be undermined has been questioned by patients’ representatives.

'Seriously comprised'

The Patients Association said last month that safety in the NHS is being ‘seriously compromised’. It quotes Care Quality Commission (CQC) figures that it claims shows that nearly half of the 105 hospitals the CQC has inspected since 2013 have been criticised over patient safety issues.

Katherine Murphy, the association’s chief executive, says: ‘The welfare of patients should always be the priority and the starting point for all treatments. There is an urgent need for a decisive change in culture and priority to put patient needs at the heart of the care sector.’

Parliamentary group

The association has launched an all-party parliamentary group (APPG) on patient safety to be chaired by Conservative MP Andrea Jenkyns, a member of the Commons health select committee.

Staffing levels will be on the APPG’s agenda, Ms Murphy says. ‘The group will be looking at all the issues we hear about on our helpline affecting patient safety, from waiting times and bed shortages, to patient nutrition, medical errors, safe staffing and waiting times.’






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