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Getting staffing right is the aim of new NHS Improvement guidance but will it work?

How far will a new resource, designed for NHS commissioners and providers, go in helping to reverse a staffing crisis, and sustain safe and effective services for people with learning disabilities?

How far will a new resource, designed for NHS commissioners and providers, go in helping to reverse a staffing crisis, and sustain safe and effective services for people with learning disabilities?


Picture: iStock

Guidance to help learning disability services employ the right number of nurses to provide safe care has been published by NHS Improvement.

The resource is designed for commissioners and providers to create, review and sustain safe and effective specialist NHS health services for people with a learning disability, autism or both. 

Nearly half

Care Quality Commission-assessed learning disability services in 2012 failed to meet care, welfare and safeguarding standards

(Source: Care Quality Commission)

NHS Improvement says the document, which includes 29 recommendations, is intended to standardise staffing decisions to reduce health inequalities and increase the life-expectancy of people with learning disabilities. 

The document, called An Improvement Resource for Learning Disability Services, is one of six staffing resources published by NHS Improvement, which were developed on behalf of the National Quality Board (NQB). 

These provide a framework based on the NQB’s 2016 report Supporting NHS Providers to Deliver the Right Staff, with the Right Skills, in the Right Place at the Right Time.

Damning reports

A robust approach to informed decision-making on staffing can reduce a number of negative factors, including the numbers of staff leaving, the use of restraint, assaults on staff and inappropriate hospital admissions, as well as improving service user experience, NHS Improvement says.

'The feedback from services is that it is helpful to give a benchmark of where they are at’

David Harling

A damning report into learning disability services by the Care Quality Commission in 2012 assessed 145 services against care, welfare and safeguarding standards, and almost half failed to meet them. 

1,700

learning disability nursing posts cut since May 2010

(Source: RCN)

The new recommendations cover many areas, such as using workforce planning tools and considering the impact of staff leaving, but nursing leaders have asked how achievable staffing improvement plans are, after the NHS struggled through a difficult winter.

Many services are cash-strapped and the RCN has highlighted high rates of nursing vacancies in all settings that cannot be filled.

An RCN report on learning disability services in England in 2016 found 1,700 learning disability nursing posts had been cut since May 2010, a 40% reduction in band 7 and 8 nurses, and a 30% reduction in pre-registration training places in the past ten years. 

A literature review by the University of West London, on behalf of NHS Improvement, pointed out that healthcare providers have no control over the size of the workforce available and were working with limited funds. 

Patient input

Head of learning disability at NHS Improvement David Harling said that the resource had been developed with input from people with learning disabilities and their families. 

40%

reduction in band 7 and 8 nurses

(Source: RCN)

A consultation received more than 800 responses and 25 trusts have already used the resource. It is aligned with other key developments taking place to improve learning disability services.

These include the Transforming Care strategy to move more people with learning disabilities into the community and out of acute settings, and efforts by NHS regulator Monitor to improve care for people with learning disabilities.

‘The feedback from services is that it is helpful to give a benchmark of where they are at,’ he says.

The resource stresses that the NQB expects organisations to do annual strategic staffing reviews and then prepare a comprehensive report for their board. 

30% 

reduction in pre-registration places

(Source: RCN)

The recommendations call for all healthcare providers to combine professional judgement with the use of evidence-based tools for devising the right number of staff.

It also calls for all workforce plans to consider the skills required to achieve holistic, person-centred health outcomes and identify the staff most appropriate to deliver them.

There should be sufficient uplift applied, with consideration for holiday, maternity leave, study leave, shift patterns and leadership time.

Employers should also consider trends in attrition, including retirement profile and the impact of maternity leave, and these should be part of workforce plans.

‘It tells you what you need and what the patients need. You also consider job satisfaction, stress and burnout, so there is a focus on staff’

Trish Bailey

Providers should have retention strategies and consider flexible working, especially for those who wish to work beyond retirement age.

Staff survey results should be reviewed and acted on to improve staff experiences. People with learning disabilities should be involved in service development and staff recruitment, the document says.

How useful is it? 

Clinical care group director for children’s and learning disability services Trish Bailey at Humber NHS Foundation Trust, which helped develop the guidance, has used the resource since it was published. 

The trust has found the context of care tool, which was developed by the University of West London and is supported by the guidance, particularly useful. This looks at factors including staff stress and burnout, staff attributes, job satisfaction and client need.

The fact it focuses purely on learning disability services is rare and has made it particularly valuable, she believes. 

The tool helps tackle rigid numbers for doctors and nurses, when some clients may benefit from different support, such as a higher number of speech and language therapists and activity workers, Ms Bailey says. 

‘It feels aspirational. Workforce figures around learning disability nursing give a dramatically stark picture’

Ann Norman

‘It takes just 60 minutes to complete and is simple,’ she says. ‘It tells you what you need and what the patients need. You also consider job satisfaction, stress and burnout, so there is a focus on staff. It is a discussion tool to get your staff talking. It is not just about, ‘you need two qualified staff and six nursing assistants on this shift’.

'We have moved away from that to the context of care that we are providing.’


RCN's Ann Norman

Ms Bailey expects the tool to help inform staffing and recruitment for Humber's acute wards in the future, which provide different intensities of care but currently have similar staffing. She also says it will be useful when it comes to Transforming Care work in the community. 

Although RCN professional lead in learning disabilities and criminal justice Ann Norman welcomes the document’s sentiments, she is not optimistic about its impact. 

‘It is useful to a point and has some good principles,’ she says. ‘But it feels aspirational. Workforce figures around learning disability nursing give a dramatically stark picture.

'You can have all the documents you want but what does a good, safe, sustainable services look like if you haven’t got the key component, which is the right workforce. Our workforce needs massive investment.’

New roles

The development of new services and models of care is a chance to introduce new roles, NHS Improvement says. Emerging roles in learning disability services include: advanced practitioner, apprentice, nursing associate, car navigator, non-medical prescribing roles, experts by experience, clinical academic and physician’s associate.  

The increasing use of non-nursing staff in a range of settings to provide many elements of care that used to be part of the nursing role has provoked much debate in the profession.

The nursing associate, a new regulated role, is intended to fill the gap between healthcare support workers and nurses.

The new guidance on staffing says emerging roles should only be used at the appropriate level of assessed skill, competence and attitude, and organisations must be confident that the staff have the prerequisite skills to provide safe care. 

‘Providers should ensure professional leadership of all professional groups is in place and sufficient time for leadership development,’ NHS Improvement says. 

Health Education England has published a set of five generic role templates to support the development of different roles in learning disability community services. 



Erin Dean is a freelance health journalist
 

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