Acute Hospital Wards (Staffing)

Phillip Lee Excerpts

Wednesday 15th January 2014 Commons Chamber

[Andrew George (St Ives) (LD)]

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.

[Dr Phillip Lee (Bracknell) (Con)]

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.

[Andrew George]

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.