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National Institute for Health and Care Excellence

Volume 764: debated on Monday 13 July 2015


Asked by

To ask Her Majesty’s Government why the National Institute for Health and Care Excellence was asked to suspend its work on safe staffing guidelines regarding nurses.

The Government are committed to supporting NHS trusts to put in place sustained safe staffing by using their resources as effectively as possible for patients. The existing National Institute for Health and Care Excellence guidance on maternity settings and acute in-patient wards will continue to be used by NHS trusts. NHS England, working with NICE and other national organisations, will continue with this work in other areas of care and other healthcare professional groups.

I am grateful to the noble Lord, but that does not explain why NHS England put pressure on NICE to stop working on guidelines on safe staffing levels, despite the recommendation of Sir Robert Francis following the Mid Staffordshire inquiry. Was it because NHS England was no longer prepared to fund the implications of such work? Given that NICE has now decided to continue with work on A&E guidelines, will the Minister assure me that the Government will insist that the NHS implements those guidelines?

The noble Lord is right that the responsibility for safe staffing is now with NHS England. It will take into account any advice given by NICE, whose guidelines for acute in-patient wards and maternity services still stand. The main reason why the responsibility has been transferred to NHS England has nothing to do with funding. It has to do with the fact that the new models of care, such as the new emergency care vanguards, are much broader than just A&E; therefore, we need to take into account other factors.

My Lords, this Answer does not empower any validation at all, unless we have criteria by which all trusts could be judged. We have the safer nursing care tool, which was produced in Sheffield and London and validated by Leeds University; it has been adopted by NICE and rolled out by the Shelford Group and other major trusts. This is a tool that would give all acute trusts the ability to judge safe staffing ratios based on acuity and patient need. Can the Minister give this House an assurance that that will be mandated to all acute trusts and then rolled out elsewhere?

I think it might be worth while for the House if I read out four lines from the NICE guidance on safe staffing:

“There is no single nursing staff-to-patient ratio that can be applied across the whole range of wards to safely meet patients’ nursing needs. Each ward has to determine its nursing staff requirements to ensure safe patient care. This guideline therefore makes recommendations about the factors that should be systematically assessed at ward level to determine the nursing staff establishment”.

I read out that paragraph because it is important to realise that every ward is different. Where there are tools to help assess the acuity of patients in wards, those tools will be used. I do not think we are planning to mandate any particular tool at this time.

Twice I have raised with the Minister the question of a different standard of training, particularly that of entrants to nurse training. We face this great shortage. He has replied to say that the Government have it in mind to introduce such a thing. Will he tell us more about what they are proposing and when?

I am sorry—I did not quite understand the question. I realise that I cannot ask my noble friend to repeat it, so I wonder whether I could pick it up with her outside the House.

Is the Minister aware that in Wales 12% of NHS staff have made complaints about staffing levels in the past few years? Will the Minister join me in welcoming the fact that the Labour Government of Wales will be held to account for that next year?

From what I understand, the problems in Wales mean that there is a lot more for the Government to be held to account for there.

My Lords, from personal observation from being in hospital, nurses spend a awful lot of time behind a desk ticking boxes when it would be much more helpful and better for patients if they could deal with patients more. Is there any way of alleviating the need to fill in boxes so that they can look after patients? Can they cut the paperwork?

The noble Countess makes a very insightful point. Non-productive time—by which I mean the time when nurses are not dealing directly with patients—varies considerably, but the average seems to be about 20% to 25% of their time. The better-organised wards—which takes me back to an earlier point—where there is strong local leadership from the ward sister will be organised in such a way that staff will spend much more time with patients. I agree entirely with the noble Countess’s point.

My Lords, is part of the problem due to the specialisation of nurses? Are far too many of them being trained only as specialists so that they are therefore unable to be moved from one part of a hospital to another? Would more general training be better?

I do not think that is a problem. In many ways, in acute hospitals we lack generalists. That is true of consultants as well of nurses. That is actually my noble friend’s point. Possibly there are too many specialists, but on a cardiac ward or a specialist acute ward you need specialist nurses who know how to operate the equipment as well as how to look after the patient. You need a good balance between the two but, if anything, I fear we have, as my noble friend said, become too specialist and insufficiently generalist.

My Lords, what is the Minister’s opinion of the Government’s decision to deport nurses from overseas who do not reach the £35,000 a year income level within five years?

The noble Lord raises a good point. We need to train as many of our own nurses as possible. There will be times when we get those calculations wrong and it will be necessary to bring in nurses from overseas. That is not a desirable outcome for many reasons, which there is not time to go into today. We need to train more ourselves.

My Lords, will the Minister have another go at the Question? I still fail to understand why an independent body, NICE, was instructed by NHS England to discontinue work on safe staffing guidelines. What on earth caused NHS England to do that?

NICE has not been instructed to cease its work on safe staffing standards; on the contrary, it has been asked by NHS England to provide it with appropriate guidance.

My Lords, the noble Countess rightly raised the amount of time that nurses spend filling in forms and ticking boxes. Is the Minister aware that much of this work comes from the rather microregulatory requirements of the regulatory bodies, and indeed NHS London? There are some very precise measurements, and if those were monitored carefully government Ministers and NHS England would know well whether services were being managed properly. Would the Minister consider revisiting the degree of microregulation of our health services?

I am not entirely convinced by the argument about regulation when it comes to managing wards. My own observation is that when you have strong leadership from strong ward sisters, ward managers or charge nurses, many of the problems that we identify seem to disappear and there is very high staff morale, low absenteeism and little use of agency staffing. So much comes down to local leadership, and sometimes regulation is used as a scapegoat.

My Lords, given that everyone accepts that the new safer staffing guidelines will require more nurses, what will the Government and Health Education England do to reduce the number of nurses who do not qualify from their training, which is currently running at about 20%?

That is a very high figure. It is quite revealing that most of the people drop out in their first placement, and it behoves universities and Health Education England to ensure that they are recruiting new nurses who have done some work in a care home or hospital so that they know what the realities and practicalities of being a nurse are.