Safe staffing levels should be decided locally

Safe staffing decisions need to be made locally and not be governed by ratios.

According to University Hospitals Coventry and Warwickshire NHS Trust chief nurse Mark Radford who is leading work on new NHS staffing guidance, examples of poor care can be found even with a ratio of one nurse to eight patients.​​​​

‘In some environments, [ratios] are relatively fixed and defined in terms of the needs of patients; in other areas it is less clear – mandating does not mean quality will be achieved,’ he said.

Three expectations

Professor Radford has helped produce the National Quality Board's new safe sustainable and productive staffing resource for NHS boards, refreshing its 2013 incarnation.

The new guidance updates three expectations of how NHS providers should approach staffing decisions: based on patients’ needs, acuity and risks, and monitored ‘from ward to board’.

The document, Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time, deems it critical that each month, NHS boards review workforce metrics – indicators of quality, outcomes and measures of productivity – as a whole, not in isolation.

Strategic plan

‘The key thing we are introducing is the board oversight of having a strong, strategic plan,’ Professor Radford explained.

‘Decisions need to be made in the local context about what the local health economy is trying to do.’

Boards should also implement February’s Carter Review recommendations on performance and productivity, and record the deployment of staff on wards by measuring care hours per patient day (CHPPD), the guidance said.

The CHPPD metric measures the combined number of hours of care provided to a patient over 24 hours by nurses and healthcare support workers.

However, it has attracted criticism due to concerns that care hours will be met by using healthcare assistants in instances when registered nurses are needed.

Fabulous contribution

Professor Radford said: ‘Support workers are such an important part of the workforce – wider delegation makes a fabulous contribution.

‘I think it is entirely appropriate as part of a measure to understand their contribution alongside nurses.’

Safe Staffing Alliance chair Susan Osborne said a multi-professional approach to workforce planning made sense, but should not mean any workers are used as a substitute for registered nurses.

She also said safe staffing was not being properly addressed by England’s non-legislated approach, and pointed the blame at a drive to save money. 

Adequate staffing

‘Everyone is cutting corners at the expense of efficiency and patient care,’ Ms Osborne said, arguing for a baseline of adequate staffing levels.

‘If you have mandated ratios, at least you know what your workforce plan should look like, what it costs and what you are working towards.’

Ms Osborne pointed to a recent case in which a patient lay dead for up to four-and-half hours in the emergency department at North Middlesex University Hospital before being noticed. The nurse to patient ratio was one to ten, rather than the one to four it should have been, she said.

‘If ratios were mandated, at least the regulators could have looked at the provider and said it was non-compliant.’

Further information

NQB guidance on safe staffing

Safe Staffing Alliance

Carter Review

Nursing Ratios: Call for Unity on Safe Staffing