One in four wards in acute hospitals across England are dangerously understaffed, according to a study by researchers at the University of Southampton and Bangor University.


The study, entitled Implementation, Impact and Costs of Policies for Safe Staffing in Acute NHS Trusts, questioned 91 nursing directors, and analysed national workforce data and four case studies at NHS trusts.


Hospitals were found to be experiencing major difficulties recruiting and retaining registered nurses; the average registered nurse vacancy rate was 10% across the country, but up to 20% in some trusts.


On top of this issue, the study found that despite Government workforce data showing that the number of nursing staff has increased since 2013, an increase in patient admissions means that there has been no net improvement in registered nurse staffing levels.


Nursing support staff (e.g., healthcare assistants), however, have increased at three times the rate of RNs since 2013, and the researchers note that this results in a “dilution of skill levels in NHS acute care.”


Francis Report “forgotten”?

The researchers note that the lessons from the Francis enquiry reported in 2013 into the scandal of patient deaths at the Mid Staffordshire Hospital Trust – to put patients first and never let it happen again – have “become more muted.”


The RCN responded to the reports by noting that “lessons from the Francis Report are being forgotten, despite this being a once-in-a-generation opportunity to increase nurse staffing levels across all health and care settings.”


This is not the first study to conclude that dilution of skills is a major issue for patient safety. Replacing RNs with lower skilled nursing assistants for health care assistants was found to be linked to a heightened risk of patient death, as well as other indicators of poor quality care, according to a 2016 study published by the journal BMJ Quality & Safety.



The study found that for every 25 patients, just one professional nurse substitution was associated with a 21% rise in the odds of dying in a hospital with average nurse staffing levels and skill mix. The researchers concluded that “diluting” the hospital nurse skill mix “is not in the public interest.”


Other studies support the observation that low nurse staffing levels are associated with adverse outcomes and have shown that HCAs cannot make up for deficits in patient safety due to a shortage of registered nurses.


The government’s own research institute, the National Institute for Health Research (NIHR), which is funded by the Department of Health and Social Care, agrees that the number of registered nurses is key to safety. In March 2019, it published the review Staffing on Wards, which analysed 20 separate nursing and staff-related studies that had been funded by the NIHR, and concluded that it is the number of registered nurse hours at the bedside that avoids patient harms.

Back in 2013, recommendations from the Francis report stated that the ratio between staff and patient was of fundamental importance to safety and quality of care.  The National Institute for Clinical Excellence (NICE) produced guidance on patient-to-staff ratios for acute wards, with a 1:8 nurse-to-patient ratio after research showed that this is the level at which harm starts to occur to patients.


Safe staffing data dropped

In order to increase transparency on issues such as nursing levels and improve safety, the Francis enquiry also put in place the publication of data on actual nurse staffing levels versus planned levels of staffing for each hospital trust. However, on the same day that the University of Southampton study was released, HSJ journalists reported that this measure had been “quietly dropped.” The data could be used easily as a way of keeping track of how a hospital was performing.


In the past the data has been used to show that hospitals were failing to meet their targets for nursing levels; in 2015 HSJ reported that more than nine out of 10 acute hospitals were failing to meet their targeted numbers and in 2017 the RCN used this data to show that nine out of ten of the 50 largest trusts in England were not staffed with nurses to the planned level.


The data was updated each month and published on the NHS Choices website. It showed the percentage of nurse shifts filled versus the level planned for that hospital also known as the average staffing fill rate. An important aspect of the data was that RNs and care assistants were recorded separately as studies point to the number of nurses being the key to patient safety.  


Now, staff data is still being published on the NHS Choices and the MyNHS website, but using a new approach, the care hours per day (CHPD) metric; this measure combines registered nursing and unregistered care assistant shifts. It is therefore no longer possible to find out how the care hours provided by nurses compare with the level the trust, hospital or department had been planning for, and either exceeded or fell short of – an indication of safety.


The CHPD was put forward by the Lord Carter, the NHSI non-executive director, in his 2016 review, however it has been widely criticised. The measure does not take into account the different skills within the workforce. A major criticism is that its use could lead hospitals to employ more healthcare assistants to increase their average care hours, at the expense of registered nurses.


Overwhelming evidence

The University of Southampton study is one of a series of studies, reviews and reports that have been published in recent years that all highlight the growing workforce issues in the NHS. There are now around 100,000 vacancies in the NHS, with many of these positions having to be filled by agency workers and bank staff at great expense to the NHS.


A report by the think-tanks, The King’s Fund, The Nuffield Trust and The Health Foundation published in March 2019, predicts that based on the current trajectory there will be 250,000 vacancies within a decade if no determined action is taken to change things, including an extra £900 million per year by 2023/24 into the budget of Health Education England.


Despite the evident crisis in the workforce, the ten-year plan for the NHS, published by the Department of Health and Social Care in January 2019, did not include a workforce plan. An interim workforce plan was expected to be published in April 2019, however this plan will not set out how the new staff role will be funded, this will take place in the autumn spending review.  Speaking to HSJ at the end of March, Julian Hartley, the national executive lead on the workforce plan, said that the plan would not “say things about priorities and investments” but “would instead set out a direction of travel for workforce policy.”




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1 Comment

  1. Avatar

    …and yet, with over 90% of nurses female, there remains absolutely no program to specifically target getting more British men into nursing – very strange, given the massive gender imbalance and the current focus on ‘diversity’, and the breaking down of traditional gender stereotyping.