How many reports highlighting staff shortages does the government need before it takes the one concrete action that would make a huge difference?

An article I wrote for Our NHS, with some additional reporting by Caroline Molley.

A shortage of nursing staff has been a chronic problem in the NHS since its inception - and it is getting worse. 

The last few months have seen a stream of reports into poor patient care - first Francis, last month Keogh, and yesterday Professor Don Berwick’s report into patient safety. Each highlights the problem of lack of staff, particularly nurses.

Yesterday Berwick recommended that new guidance to protect patients against “the dangers of inadequate staffing” be set up “as soon as possible.”

It also emerged yesterday that Sir Robert Francis - author of the landmark report into mid-Staffordshire - is now calling for a “benchmark” level of staffing, “below which you cannot be safe”. 

Francis’s intervention is significant because his February report shied away from recommending mandatory minimum ratios of nurses to patients. He told concerned healthcare professionals and patients last week that he had seen evidence that persuaded him to revisit the issue.

Jeremy Hunt has so far resisted growing calls for mandatory minimum staffing ratios, saying yesterday that he was opposed to “mandating things from the centre” and laying the responsibilty for any issues that “may” exist at the door of individual Trusts and the Care Quality Commission. 

Last month’s Keogh Review into 14 NHS Trusts with the highest mortality rates within the NHS found widespread chronic under-staffing and the inability to retain well qualified staff in all clinical roles. His report focused mainly on senior management, including their inability to address long standing staffing issues which are leading to poor patient care. He highlighted a combination of poor working conditions, geographical and clinical isolation, bad management, high levels of sickness absence and dependency on agency staff and locum doctors to cover vacant posts.

Keogh’s team also found that some wards had extra staff assigned to them during announced inspection periods to plug staffing gaps.

Whilst Keogh also shied away from originally recommending minimum staffing ratios, his honesty was at least refreshing. He located the problems of the NHS in the decades of underfunding and cut-backs of the 80s and 90s. The Labour government responded by massively increasing NHS funding, though the effects of the funding increase were hampered by the expansion of marketisation and privatisation. But nonetheless, increased funding started to rebuild the NHS to a point where it could adequately meet patients needs.

But the expense and fragmentation of the Health & Social Care Act - along with the 20% cut inflicted on the NHS by the Department of Health - is unravelling the NHS. Most of the Trusts in the Keogh review had a poor financial rating from Monitor, pointing to the source of many pressures on management and staff. Nearly 5,000 nursing places have been cut since 2010, and nearly 800 have gone in April this year alone.
The comments of Keogh, Berwick and Francis are markedly different to the government and media narrative of the NHS which portrays it as being ripped apart by greedy GPs, callous nurses, thieving health tourists and incompetent management. Of these, only the last is true. The others are all attempts to scapegoat staff or patients for the failings of the market reforms and the impact of austerity budgets on hospital and community services.

The Tories are sensitive on this issue and unwilling to properly acknowledge and take responsibility for the need for safe staffing. The issue robs them of their scapegoat. If Jeremy Hunt was to admit that there was a serious problem of understaffing the focus would shift from the individual nurse or doctor caring for a patient, to the management of the hospital - and ultimately to the management of, and accountability for the whole NHS which allows these situations to arise. 

Government policy would fall under the spotlight, and Hunt might have to answer uncomfortable questions about how he expects health services to be adequately staffed when management are having to reduce their budget by 5% a year. With 60% of the NHS budget going on labour costs, and areas like privatisation and PFI deals exempt from cuts, the majority of budget cuts will fall on staff.

A mandatory minimum patient-to-nurse staffing ratio of 4:1 has been shown to be the minimum staffing level at which nurses can provide safe and dignified care. It’s time the government did its duty and acted to safeguard patient care. A failure to act will show the government places financial targets and meeting austerity budgets ahead of patient safety.