Hitting the target but missing the point

Dean Royles

13 / 5 / 2014 2.22pm

The consultation launched by NICE at the weekend on nurse staffing ratios feels likes an enormous missed opportunity for the NHS. There is evidence that staffing levels are important to patient care. Even without this evidence it seems to make intuitive sense. There is also evidence about the particular contribution of nurses to safe care. Most professionals will be aware of the studies, have read and engaged in the debates, used the tools and will also rely on their professional judgement.
When there aren’t enough staff, I have heard people say you can “smell” poor care in an organisation and people will also say you can tell when a ward is too stretched and the staff aren’t caring. Safe staffing is self-evidently a good thing but safe staffing and good care involve more than crude nurse ratios. I don’t want a situation when we have one nurse trying to care for too many patients but for years all NHS professionals have highlighted the importance of multi-professional care, the role of the multi-disciplinary team, the importance of the right member of staff with the right skills at the right time.
Nurses are absolutely essential to safe care and to great care. But if the NHS has learnt anything in the last few years, it is the danger that comes from hitting the target but missing the point.
I had hoped that NICE would be able to consult on a more sophisticated model of care - one that included the contribution of other staff. Without that it is clear that the NHS will hit a ward nurse ratio if it becomes mandated but it will come with risks. Let’s be upfront about them:

  • A minimum will become seen as a maximum and staff from busier wards will be redeployed to meet ratios
  • With no additional funding nursing numbers will become protected but cost improvements will have to be found amongst other staff
  • Skills are important too – will we see more junior members of staff at the expense of specialist nurses?
  • Nurse ratios don’t take account of the role of speech therapists, occupational therapists, physiotherapists, dieticians, etc. Will vacancies be held in these staff groups to pay for more nurses?
  • The ratios are about acute ward nurse levels – that’s really important but does this mean that, until further reports are published, we give less priority to areas like community nursing, learning disabilities, mental health nursing, health visitors and so on?
  • Health care is changing fast. Thirty years ago the average length of stay in hospital was 12 days and that required a particular set of skills. Now the average length of stay is less than 5 days. Physios and other therapists help recovery. If we concentrate solely on nursing then getting the right skills mix at the right time will become harder.

Some people will highlight the minimum staff required on a plane before it takes off. But we ultimately judge on a safe outcomes. I have no idea whether there are minimums for mechanics, engineers, ground crew, baggage handlers, security, receptionists etc - all crucial to my safe flight. Safe health care is equally complex and we too need to judge on outcomes.
It is important that we are thoughtful when presented with apparently simple solutions. Today, 12 May, is International Nurses Day and it is right to celebrate the contribution of nurses to the modern NHS, but great care involves other professionals too. Let’s not put that at risk simply because it is easier to come up with a model for one group of staff.

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