29 September 2011

How do you really know you have the right staffing levels at your hospital?

Calculating the right level of staff for a ward is not a simple matter. Midstaffs shows us some of the pitfalls that other Hospitals are falling into right now.
The Background.
Two things I have learned from the months of listening to evidence at the Mid Staffs Public inquiry are : that there is nothing easy about running the health service; and that we go through periods were thinking  about the NHS is focused on particular themes.  
The priorities of the last ten years were how to stop people dying on waiting lists, or on trolleys at A&E, and how to tackle alarming hospital infections.  Now that these problems are largely resolved we are thinking about quality in other ways.
As life expectancy has grown, we are now seeing many very old and very frail people in our wards, and the Mid Staffs story is in part about what happens when we have not fully grasped the size and complexity of this problem.
The current focus on staffing levels and staffing mix.
A major criticism of Stafford Hospital is that the Staffing levels and staffing mix were wrong.
Midstaffs is by no means alone in this, and the high profile statements from Peter Carter of the Royal College of Nursing show us this is a major national problem. The staffing levels that we have in the hospitals are not high enough to allow us to deal as well as nursing staff would like with the very frail and very dependent people that there are in many wards.
Peter Carter is provocative on this issue. He uses the press to forcefully make the point that hospitals are not doing a perfect job, and that they cannot do all that is needed. He suggests that families can and should play a part in providing some of the basic care including getting people mobilised and making sure they eat.  It was designed to get a reaction and it did.
There have also been a series of high profile statements about the fact that increasing amounts of care are being provided not by trained nurses, working within a professional code, but by untrained and unregulated care staff, who may or may not be able to do what they are expected to do.
Why Midstaffs got into a tangle with Staffing.
The Mid Staffs Public Inquiry has been wrestling for weeks with the question of staffing levels and staffing mix. What all the witnesses have said is that you cannot set staffing levels. There is no hard and fast measure, no formula a manager can refer to, you have to work out what is right for each ward.
 David Nicholson, in his evidence finally threw some light on why the levels were probably wrong at Stafford, and why the managers did not at first see the problem.
The hospital had, as all hospitals now have to do, to work out how to balance their books. David Nicolson explained this had happened when the big story run by all the media is that we were spending too much on the NHS, and it was therefore essential to cut back any unnecessary spending. This meant rationalising the work that hospitals did. Stafford were perhaps ahead of the game in believing that the right thing was to have less beds, and to keep people in for less time, so they reduced the number of beds and reduced the number of nurses in line with this. So far so good!   
But …. This only works if you actually have less people coming in and you are able to move people out faster.  Achieving this means that there has to be a fully co-ordinated approach with the GPs and primary care, in treating more people at home, and with Social care in having transitional care or residential care beds to pass patients on through the system.  These things did not happen.
The result of this is not good. The same number of people kept on coming through A&E. The beds filled up so that some patients end up in an assessment unit, for which the hospital had insufficient trained staff. More people are passing through the beds in the wards, causing increased pressure on admin, cleaning and nursing, and because many of the care homes in the area had recently closed you end up with bed blocking with a build up of the most highly demanding patients who are simply unable to be discharged to their own homes.  My guess, though I do not have access to any records to prove this point, is that the level of nursing and care needs of the patients within the ward increased dramatically.
This is like boiling a frog. Maybe in the first few weeks people would have been coping, but the effects of this are cumulative. It would have been steadily more pressured, and once managers had understood the problem it then took months to get the approvals to recruit more staff.
What do you count? Beds or Patients?
David Nicholson explained it simply.  The Hospital management thought in terms of nurse to bed ratio which looked pretty much as it always had been.   The changes to have a higher level of care assistants to nurses would also have looked justifiable, because the case load did have many people with low nursing needs but high care needs.  The measure that he says the hospital should have used is the Nurse to Patient ratio, which would have told a different story.
This, as an indicator of how many staff you might need, (and the Vacancy factor which attempts to tell you how many staff you have - I could not get my head around this!), are not straightforward, and the fact that the managers, the board, the govenors, and anyone else with an interest in the hospital could not see the problem should come as no surprise. David Nicholson himself said he would have been hard put to see it.
Like everything else that I have seen about the Mid Staffs story, this is not a story of callous disregard for the welfare of patients, it is about something that did not work out the way it was intended to do.  
Why we urgently need to learn these lessons now.
The reasons why it is important to tell this story are apparent if you look at David Nicholson’s vision for the future of the NHS. What the management of  Midstaffs were trying to do, is something that many other hospitals are trying to do right now.  Everyone is looking for Cost improvement programs. Where are they going to find them?
Look at the intention.
·         Keep costs to a minimum.
·         Do not use more wards than you need.
·         Do not carry surplus staff.
·         Employ care staff to carry out caring functions.  
·         Put in the community support to keep patients at home under primary care.
·         Discharge patients to their homes or to other care facilities unless they need acute care.  

All of that sounds like good practice, and it is exactly what Midstaffs probably tried to do.

For any hospitals that are working on their cost improvement programs the only safe lesson to take from Stafford is that you have to assume for any action that you take that there may be unintended consequences. You have to actively monitor the effects of any change you make on staff and patients.  If your staff are telling you they are feeling the heat, you had better believe them.