Before the pandemic the NHS had a staffing crisis which was making the service less safe…

Is the current guidance for staffing levels being followed?

Prior to the challenge of Covid, services were regularly being understaffed which meant a fall in the quality of care and an increase in serious events. At the end of last year Nine out of ten NHS bosses said that the staffing crisis was endangering patients.

It is a longstanding problem. The 2018 publication of staffing guidance by the Royal College of Physicians was prompted by concern that levels of medical staffing had fallen dangerously low.

The RCN’s 2019 report Standing up for Patient and Public Safety noted that if there is understaffing, nursing staff are more likely to report that care is: compromised, of poor quality, or left undone.

In April 2019, the study Implementation, Impact and Costs of Policies for Safe Staffing in Acute NHS Trusts, published by the University of Southampton, warned that the new workforce guidelines had not led to significant improvements on the hospital wards.

Data from the 2019 Heads of Midwifery survey showed that staffing levels often do not comply with the Birthrate Plus (BR+) guidance for the minimum staffing levels a maternity service needs. Almost half of HoMs (48%) said that they did not have the funding for the right numbers of staff to meet the demands on services. This level was up from 32% in 2018.

What is safe staffing in healthcare?

Safe staffing is a level of staff on a ward or within a service, such as district nursing or health visiting, that means that the highest quality of care is maintained for both the patient and the members of staff.

In 1967 a ‘Gold standard’ ratio of 1 registered nurse to 1 patient was set and this continued to be the ideal for decades. However, over more recent years, it became clear that safe staffing is often not as simple as the number of staff, it is also concerned with having the correct mix of staff and having staff with certain levels of training within a team.

How are staff levels determined?

Staff levels are determined by both government and professional bodies.

In 2018, NHS Improvement produced guidance on safe staffing to guide trusts and health service providers.covering maternity, urgent and A&E, neonatal and young people’s service, learning disability services, district nursing, mental health services, and adult inpatients in acute care.

The RCN publishes its own guidance on staffing levels in various settings, including general wards and older people’s wards.

The Paediatric Intensive Care Society (PICS) has published the Standards for the Care of Critically Ill Children for workforce planning around critical care.

The Royal College of Psychiatrists (RCPsych) has developed Quality Standards covering minimum staffing levels/skill mixes for psychiatry liaison teams.

In maternity the accepted model for determining what minimum staffing levels a maternity service needs is called Birthrate Plus (BR+), published by the Royal College of Midwives (RCM).

In resuscitation areas in A&E guidance published by the Faculty of Intensive Care Medicine and the Intensive Care Society in 2015 recommends 1:1 or 1:2 nurse to patient ratios.

In 2018, the Royal College of Physicians produced the report Guidance on safe medical staffing aimed at helping planners answer the question: ‘How many doctors or their alternatives, with what capabilities, do we need to provide safe, timely and effective care for patients with medical problems?’

How did the idea of safer-staffing levels become more prevalent?

Health unions, such as Unison and the RCN have run campaigns about the impact of understaffing over many years to raise the issue, but in 2014 a body of evidence emerged through large scale EU funded studies concluding that death rate rose as nurses had to deal with more patients.

In 2013, four reports pushed the idea that minimum safe staffing levels lead to the best quality of care for a patient. The most famous of these reports was the Francis inquiry that examined failures in care in the Mid Staffordshire NHS Foundation Trust. The inquiry recommended that NICE should draw up minimum safe staffing levels, including nurse levels, and policed by the Care Quality Commission (CQC).

What safe staffing plans were developed?

NICE published guidance in 2015 that included a 1:8 nurse-to-patient ratio for general wards after research showed that it was the level that if exceeded harm started to occur to patients.

NICE continued to work on guidance for maternity and A&E, but before it could publish any more guidance, the organisation was asked to stop all its work on safe staffing.

The work was moved to NHS Improvement, but by June 2016 it was clear that further guidance on safe staffing levels containing strict guidelines and patient to staff ratios was unlikely.

What happened next?

NHS Improvement continued to work on guidance, but using different methodology from NICE.

Eventually in 2018, NHSI produced its guidance on the level of safe staffing. It covered maternity, urgent and A&E, neonatal and young people’s service, learning disability services, district nursing, mental health services, and adult inpatients in acute care.

But none of these guidance documents contains a staff to patient ratio.

Differences between the home nations?

It was a different story in Scotland and Wales, where legislation on safe staffing was made law.

In 2019, the Scottish Government passed the ground breaking Health and Care (Staffing) (Scotland) Act. Almost three years in the making, the Act is the first in the UK to set out requirements for safe staffing across both health and care services and most clinical professions.

In 2018,  the Nurse Staffing Levels (Wales) Act came fully into force. This contained high level recommendations for the Welsh Government and Health Boards looking at effective practice, the sustainability of the workforce and progress needed.

What needs to happen now to ensure safe staffing levels?

A growing body of healthcare professionals, including the RCN and UNISON, believe that the only way to ensure that safe staffing levels are maintained is to introduce legislation as has been done in Wales and Scotland.

However in England, neither The Long Term Plan published in 2019 or the subsequent NHS People’s plan called for legislation around workforce levels.

The RCN is calling for a legal framework of accountability for workforce planning and supply which covers all publicly funded health and care services. This includes social care and public health. This will also include the independent sector when they are providing publicly funded health and care services.

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