Does the NHS need a minimum staffing ratio?

Elliot Bidgood, 19 November 2013

The government’s long-awaited official response to February’s Francis Report recommendations is being published today, following on the from the government’s initial response in March. At the time, Health Secretary Jeremy Hunt’s main pledges were to bring about a ‘zero-harm’ culture in the NHS, to detect and tackle problems more quickly and to strengthen staff standards and accountability for wrongdoers.

However, one of the most debated Francis Report elements has been on safe staffing, as understaffing was a key problem at Mid Staffordshire and current cuts to frontline NHS staff present further risks. Francis recommended using “evidence-based tools” to determine “what each service is likely to require as a minimum in terms of staff numbers and skill mix”, based on input from both professionals and the public and on “consideration of the benefits and value for money of possible staff: patient ratios”.

Some influential voices have called for minimum mandated staff-to-patient ratios, an idea with a straightforward and understandable appeal. The Safe Staffing Alliance (an umbrella group including the Royal College of Nursing, Unison, the Florence Nightingale Foundation, the Patients Association and Nursing Standard) has called for a minimum 1:8 ratio of patients to registered nurses, based on their research. The Prime Minister’s own Nursing and Care Quality Forum has also called for minimum ratios, at least to “bridge the gap” until more detailed analysis is available, as did the government’s safety czar, Don Berwick.

However, government recommendations are stopping short of this, instead mandating that trusts publish clear data on their patient-to-staff levels and pledging to make this data available from April on a public website. Meanwhile, NICE is to publish recommendations for staffing in acute hospital wards (now expected in July).  NHS England Chief Nursing Officer Jane Cummings defended this approach, arguing that a mandated minimum ratio could be inflexible and “quite dangerous”, instead arguing that the appropriate recommended ratio may well vary in different contexts according to evidence. Yesterday, three senior nurses similarly criticised the idea of mandated minimums as “Whitehall second-guessing”.

Appearing to follow Cummings’ advice is arguably also consistent with the “outcomes not targets” approach the government has indicated in past, moving away from centrally-set targets in favour of general accountability and the publication of information. This is on the ethos that while well-intentioned targets are helpful in some instances, in others they can fail to substantively tackle problems or can create perverse incentives – this too was a lesson of Mid Staffs.

This means there may be merit to the decision not to rush in a one-size-fits-all mandated ratio, but it also creates a greater onus on the government to publish their recommendations and data as soon as possible and make sure they are accessible to patients.

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