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Acute Hospital Wards (Staffing)

Volume 573: debated on Wednesday 15 January 2014

Motion made, and Question proposed, That this House do now adjourn.—(Karen Bradley.)

I am delighted to have secured this important debate on the staffing of acute hospital wards, on which I know the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter)—I am pleased to see him in his place—is aware I have been campaigning for a number of years.

The pressures on acute hospitals have, without question, intensified over the past couple of decades. There are now a third fewer general and acute hospital beds than there were 25 years ago. The past decade alone has seen a 37% increase in emergency admissions. An increasing number of older patients are being admitted to hospital: 65% of admissions are of people over the age of the 65. These patients are more likely to present more complex and multiple comorbidities, and the increased demand on acute care and the increased complexity of patients’ needs will have a knock-on effect, including placing greater demand on hospital resources and increasing pressure on registered nurses, doctors and other health care professionals. It will also, of course, have an effect on patient care itself.

I intend to concentrate on the staffing levels of registered nurses. Although much of the health debate has become obsessed with changing and tweaking management tools for commissioners—for example, by incentivising health systems with payment by results and more sophisticated tariffs, creating new pathways of care and, as far as the previous Government were concerned, wasting billions on fancy information technology systems—front-line nurses are often run ragged and overstretched on hospital wards.

The background or history to this debate goes back to the case of Graham Pink, who was sacked by Stepping Hill hospital in Stockport in 1990 for speaking out about poor staffing. I raised the matter as long ago as 2001 with John Hutton, now Lord Hutton, who wrote in response to a question from me:

“The work force commitments to recruit additional nurses, doctors and therapists in the NHS Plan take account of the need to increase the number of staff necessary to deliver diagnosis and treatment within the agreed clinical standards set out in the National Service”.—[Official Report, 17 July 2001; Vol. 372, c. 114W.]

There was therefore recognition in 2001 about the need to increase the complement of staff within NHS hospitals.

Since that time, there has been an acceleration of activity. To a certain extent, that activity was stimulated by the publication on 6 February 2013 of the Francis report on Mid Staffordshire NHS Foundation Trust, which has been debated a great deal in the House and elsewhere. As a member, as the Minister once was, of the Select Committee on Health, I know that it has exercised our consideration on many occasions.

To respond to the concerns about the arguably inadequate registered nurse staffing levels in many acute hospitals, the Safe Staffing Alliance has been formed with members from the Royal College of Nursing, the Patients Association, the Florence Nightingale Foundation and many other bodies. In an important launch on 12 May, it released a statement on the risk of excess deaths, indicating that the risk was significantly increased by lower registered nurse to patient ratios. I met the Minister on 14 May, after which I submitted a substantial file of evidence to back up the argument in favour of improving those ratios.

On 16 July, Professor Bruce Keogh published his study on 14 hospitals. Certainly one of its key themes was the inadequate registered nurse to patient ratios on wards, which caused concern within those hospitals, and that has been debated on many occasions. On 16 August, Professor Don Berwick published a very significant report on patient safety, from which the same theme arose that we cannot achieve safe patient outcomes if we do not have adequate safe staffing levels.

On 9 October, the Safe Staffing Alliance held a reception, which I was pleased to host, and I tabled early-day motion 643 on safe staffing on 29 October. The Government have since responded, with the National Quality Board—headed by the chief nursing officer, Jane Cummings—publishing a “How to” guide on using the right tools to establish safe staffing levels on hospital wards. On 19 November, the Government responded to the Francis report, as did the Health Committee on the same date, and announced further initiatives to address the issues, which I will come on to in a moment.

The question is how bad the problem is now, when there is so much attention on it. Interestingly, a report in the Nursing Times this week stated:

“Serious concerns over staffing levels and patient safety were raised last week at four hospitals in different parts of the country”

as a result of Care Quality Commission reports. A number of CQC reports in recent years have highlighted inadequate staffing levels.

One of those CQC reports was on Wexham Park hospital, which serves part of my constituency. There have been reports of pretty woeful nursing standards, particularly on acute medical wards. Does the hon. Gentleman agree that part of the challenge is that we have too many acute hospitals in the 21st century to deliver the appropriate care that we would all want our constituents to receive? A reconfiguration of hospital services, with fewer acute sites, would allow proper staffing of acute medical wards.

The hon. Gentleman speaks with great knowledge on this subject. Of course, we have fewer acute hospitals than we used to have, but we still have serious staffing problems. On its own, that idea is not the answer, but it does need to be considered if we are to address the issue of patient safety.

As the hon. Gentleman rightly says, the report on Wexham Park hospital stated that CQC inspectors found evidence of regular short staffing on “almost all wards” and a culture in which

“staff did not always feel they could raise concerns”.

The inspectors concluded that the trust was more focused on “responding to…targets” than on

“ensuring that overall patient experiences were positive”.

The article in the Nursing Times states:

“Despite a previous CQC warning in May, almost all the wards inspected were found to be regularly short staffed. Staff did not always feel they could raise concerns, with a number expressing concerns about bullying and harassment, the CQC said.”

The article states that there were similar problems at Bradford Teaching Hospitals NHS Foundation Trust and that, last Wednesday,

“Belfast Health and Social Care Trust declared a ‘major incident’ at its Royal Victoria Hospital due to a backlog of A & E patients. At one stage, 42 people were waiting on trolleys.”

A hospital porter, Pat Neeson, is quoted by the BBC as saying that he was

“fed up watching our nurses cry”

as a result of long-standing A and E pressures. There are significant pressures in many hospitals. Although those examples have been in the press this week, we all know that the problem is not exclusive to those hospitals.

This is also a political issue. The question is whether the reports implicate uncaring nurses or whether the problem is that there are not enough nurses on hospital wards. The Prime Minister has become involved in this issue through his presentation of the Francis report to the House last year and what he has said elsewhere. On 6 January 2012, he said:

“If we want dignity and respect, we need to focus on nurses and the care they deliver. Somewhere in the last decade the health system has conspired to undermine one of this country’s greatest professions.”

Last year, in the light of the Francis report, the Government proposed that all trainee nurses should have one year’s experience as a health care assistant before they become fully qualified. The Prime Minister said:

“We have said in the light of that report that nurses should spend some time when they are training as healthcare assistants in the hospital really making sure that they are focused on the caring and the quality and some of the quite mundane tasks that are absolutely vital to get right in hospital”.

The question is whether the problem is the attitude of nurses or nursing numbers.

The Safe Staffing Alliance suggests that there are excess deaths as a result of there being insufficient nurses. Some people ask how many excess deaths there are. Given the statistics and methodologies that are available, academic statisticians would blanch at suggesting what the figure might be. I have been cautioned by House of Commons statisticians and the academics who back up the Safe Staffing Alliance about ever doing so. It is suggested that there were at least 20 excess deaths per annum in hospitals with unsafe average staffing. The RN4CAST survey of 32 English hospitals, including more than 400 wards, showed that 43% had registered a nurse staffing ratio of more than 1:8.

There are about 240 acute hospitals. I have been heavily cautioned by the House of Commons Library and other statisticians not to extrapolate a figure, and I appreciate that I am doing what academic statisticians would never do, but I am going to step off the tightrope of academic equivocation and be a brazen politician and suggest only an indicative figure. While surrounded by so much caution and so many caveats—I do not have time to list them all—the number of excess deaths will be higher than zero and much lower than the approximately 248,000 patients who die each year in acute and community hospitals. Taking those statistics together, the indicative figure would be 4,000 excess deaths in acute hospitals in England. Clearly, this issue needs to be seriously addressed.

All the review reports last year showed that nurse staffing was a critical issue to prevent poor care, and they absolutely corroborate the research findings of the link between registered nurse staffing and quality of patient outcomes. The National Institute for Health and Clinical Excellence has been commissioned to give guidance on acute ward nurse staffing by July and it will look at validating methodologies. I have spoken to Professor Gill Leng of NICE and it is clear that it will be conducted on a robust evidential basis.

The Berwick report, the Nursing and Care Quality Forum and the Council of Deans have all publicly endorsed never having more than eight patients per registered nurse on acute wards, based on current known evidence. A number of trusts are now displaying nurse staffing on boards at ward level, with some trying to ensure that they take account of the “never more than eight” standard. A lot of action is being taken to address this issue.

As well as avoiding excess deaths, the issue needs to be addressed by health care economists, too. Recent evaluations in Perth, Australia, which has mandated levels of safe staffing, show that investment has more than paid for itself in reductions in patient harm, fewer bedsores, less complications and infections, and fewer falls. California, which has the same arrangement, has shown a 25% reduction in readmissions. These are important benefits, which health economists need to look at when they address this issue.

Jane Cummings, the chief nursing officer, has looked at the issue and I will read a key quote from her in the National Quality Board report:

“There has been much debate as to whether there should be defined staffing ratios in the NHS. My view is that this misses the point—we want the right staff, with the right skills, in the right place at the right time. There is no single ratio or formula that can calculate the answers to such complex questions. The right answer will differ across and within organisations, and reaching it requires the use of evidence, evidence based tools, the exercise of professional judgement and a truly multi-professional approach. Above all, it requires openness and transparency, within organisations and with patients and the public.”

My concern about this kind of management babble, and those who possess the presentational skills to get away with it, is that it throws a warm comfort blanket around the issue and creates a cloud of obfuscation. We need some of the hard lines proposed by the Safe Staffing Alliance, and we need fundamental standards below which no service should fall.

I have given the Minister advance notice of my questions. Does he accept that there are still a significant number of hospital settings where the number of registered nurses on duty is insufficient to ensure patient safety, professional standards and morale among many in the nursing profession? Does he agree that the Safe Staffing Alliance proposal for a fundamental standard of never less than one registered nurse to eight patients would be a useful tool for inspections and act as a benchmark for management to use, alongside other safe staffing tools? Does he agree that the CQC should in future concentrate more on using safe staffing tools and clear measurements of how many registered nurses are on a ward? Does he agree that as part of future work force planning, hospital managers should not conflate or blur the distinction between registered nurses and advanced care practitioners? Finally, without pre-empting NICE’s conclusions this summer, what can Ministers do to guarantee that hospital boards follow, or at least apply, its proposed guidance? I look forward to his response.

I pay tribute to the dedication and commitment to safe staffing and minimum staffing levels that my hon. Friend the Member for St Ives (Andrew George) has shown over the last year. I have much enjoyed our many conversations about the matter, and although he understands that we have different views about the right thing to do, both he and we are coming from the right position, which is about ensuring that we properly respond to the scandals exposed as a result of the Francis inquiry into Mid Staffs and ensuring we support all staff and hospitals to look after patients.

Given that one of the problems at Stafford hospital in the mid-2000s was a sharp reduction in the number of nurses in order to cut costs, will my hon. Friend and the Department of Health be looking at cases where trusts substantially reduce the number of nurses at one point to see whether that constitutes a risk to safety?

As I will come on to say, if my hon. Friend will bear with me, it is now a matter for the CQC to inspect trusts on issues such as quality of patient care and safety. I will outline those measures later in response to my hon. Friend the Member for St Ives.

It is important that we support staff as much as possible when they raise concerns, whether about minimum staffing levels or other quality-of-care issues—this was the point just raised by my hon. Friend the Member for Stafford (Jeremy Lefroy)—and to do that we are facilitating and enhancing a duty of candour on trusts to ensure a more candid and open approach and to ensure that staff who have concerns are better supported and are better able to raise them.

Turning specifically to the matters at hand, superficially the principle of minimum staffing ratios sounds seductive, but when it comes down to it, we will see that they do not guarantee safe staffing or care. For those reasons, the Government do not support them. The principle of good care is about having the right staff in the right place at the right time. As we will all be aware, the needs of patients can change not just daily, but hourly—a patient can rapidly deteriorate—and just having ticked a minimum-staffing box does not mean that the right care is necessarily being applied. The lesson to learn from Mid Staffs is that we followed the bureaucratic tick-box approach and that led to failings in care, and that just ticking boxes saying we have done something, however seductive or good it might sound, does not necessarily mean that patients are being treated right. That is a matter of clinical circumstances and the clinical judgment of staff.

I am well aware of the Minister’s line, but if we followed its logic to its conclusion, we would withdraw minimum staffing levels from paediatric wards, intensive care and, in other sectors, child care, which is a topic that has been hotly debated politically as well.

As my hon. Friend will be aware, the CQC inspection regime inspects all parts of hospitals. Good care in a cardiac or intensive care unit is not necessarily about having one-on-one nursing; it is also about ensuring that all the other additional supports and other parts of the multidisciplinary team are in place to deliver high-quality care. That is at the heart of what the Government are trying to do. I believe that the CQC, looking not just at staffing levels but at wider determinants—for example, using the NHS safety thermometer, which looks at the issues my hon. Friend raised about bedsores—and putting together a whole picture of what the care at a trust is like, is well placed to make judgments. Part of the CQC’s inspection regime entails full clinical involvement, so it has become more of a peer-review process about what “good” looks like from one hospital to another—an important improvement in the quality of the inspection regime, which enables it to weigh up staffing issues.

My hon. Friend will be aware that we are going to support the CQC and provide greater transparency throughout the health system—in regard to staffing levels, by ensuring that they are published in future. Trust boards will have a requirement specifically to look at their staffing levels and to address problems. We shall not simply wait for the CQC to react to staffing issues as part of its wider inspection regime; there will be a requirement on trust boards to look at them. On Christmas day, I visited my local trust and found that staffing levels were discussed on a daily basis, in direct response to improvements following the Francis inquiry. I believe the same thing is taking place in a number of hospital trusts throughout the country.

Let me deal with my hon. Friend’s specific questions. He asked whether there were a significant number of hospital settings in which the number of registered nurses on duty was insufficient to ensure patient safety, professional standards and morale among many in the nursing profession. Our patients, their families and the public need to be assured that, wherever they are cared for and treated, there is a strong and positive patient safety culture, led from the top and embedded in every organisation.

There can be cases where hospitals are under-staffed and there is an impact on the quality of care provided, but these cases need to be addressed from a whole-care perspective, in which staffing numbers form just one element of a broader safety assessment. It is right that clinicians and trust boards have the freedom to agree their own staff profiles, which should not be dictated from Whitehall or by some blanket tick-box approach saying “You have met the minimum staffing number; you are therefore delivering good care”. We know from what happened at Mid Staffs that that is not the case. We must do everything we can to support good decisions made in the best interest of patients on the ground. This approach will give trusts the flexibility to respond swiftly to changes in patient demand or to meet the urgent needs of patients who have deteriorated, ensuring that safety and quality care is available.

We need to make sure that patient safety is a constant concern to each and every NHS trust and NHS employee, ensuring that risks to patient safety are always acted on as soon as they are identified, whether it relates to a “never event” or to the number of staff on a ward at any time of the day or night. We expect trust boards to sign off and publish information on staffing levels at least every six months to demonstrate that they are using evidence-based tools to calculate their staffing levels and provide assurance on the impact on quality of care and patient experience.

My hon. Friend asked whether the Safe Staffing Alliance proposal for a fundamental standard of no less than one registered nurse to eight patients would be a useful tool for inspection, surveillance and as a benchmark for management to use alongside other safe staffing tools. I hope he will understand that no single dimension and no single tool can ensure patient safety and that setting minimum staffing levels does not necessarily ensure that patients get the best possible care. Patient safety is not just about safe staffing; it is about listening to patients, assessing their needs and staff taking action where there are concerns. The number of staff—not just nurses, but doctors, physiotherapists, health care assistants and all other important members of a multidisciplinary team—needed to look after patients in a cardiac intensive care unit will differ from the numbers and skill mix required in a rehabilitation setting or another care setting—and it will differ from day to day, ward by ward and sometimes even from hour to hour, depending on the care needs of patients.

Ticking boxes on minimum staffing levels does not equate to good care. As the Berwick review made clear, ticking boxes in relation to minimum staffing levels does not equate to good care. Patients must be assessed individually, and the level of care required to ensure their safety must be determined by front-line staff locally, supported in their decision making by a range of factors that determine safe care. That should include staffing levels, but they are not the only issue: the Berwick review made that clear as well.

The Care Quality Commission also considers staffing levels in its inspections of registered providers, including acute hospitals. All providers registered with the CQC must ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced staff. In time, the guidance that we are developing on safe staffing will help providers to understand how to calculate reference staffing levels. It will also be used by the CQC when it assesses whether the right number of staff are employed to provide safe patient care.

My hon. Friend asked whether I agreed that in future the CQC should concentrate more on using safe staffing tools and clear measurements, and on how many registered nurses were on a ward. I do not want to dictate from Whitehall—indeed, I am sure that none of us do—the details of what the CQC will look for; it is important for the CQC to take a flexible approach to its inspections, and to be prepared to pursue different avenues depending on what it finds. What we can all agree on is that the provision of enough trained and skilled staff is vital to the delivery of acceptable care, and that CQC inspections should continue to consider staffing levels.

I must end my speech shortly, so I will write to my hon. Friend about the other points that he raised. I know that we are approaching this issue from the same position, and that all of us care about supporting staff and delivering high-quality care. However, I hope my hon. Friend will agree that safe staffing levels could have perverse consequences, that they are only a part of the picture when it comes to delivering good care, and that it is for the CQC to ensure that it takes an accurate and holistic view when carrying out its inspections to ensure that high-quality patient care is provided in the future.

Question put and agreed to.

House adjourned.