Acute Hospital Wards (Staffing)

Dan Poulter Excerpts

Wednesday 15th January 2014 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

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.

[Jeremy Lefroy (Stafford) (Con)]

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?

[Dr Poulter]

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.

[Andrew George]

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.

[Dr Poulter]

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.