Friday, 18 April 2014

What kind of campaign do we need – a review of RCN report “Running the Red Light”

This review was written by a member of the 4:1 Campaign. I reproduce it here as its a valuable contribution to the discussion of what sort of strategy nurses need to effect change in the NHS.

Despite growing calls for mandatory minimum nurse-patient ratios, government cuts are reducing the number of nurses on the wards.
In 2013 three high profile investigations (FrancisKeogh and Berwick) identified inadequate nursing levels as a key factor in high mortality rates and poor patient safety. On the back of these findings, the RCN’s Running the Red Light report warns of a critical nursing crisis.
The report finds that 5,870 full-time equivalent nursing posts have been cut since May 2010 and an estimated 20,000 posts are being kept vacant. 27% of NHS employers have plans to further reduce the nursing workforce this year. By the government’s own reckoning there will be a shortage of 47,545 nurses by 2016 (with a worse case scenario of nearly 200,000 shortfall).
Some trusts are now recruiting but there are not enough student nurses to fill the vacancies. Since 2010 there has been a 15% drop in the number of student nurse placements. 22% of trusts are actively recruiting overseas with a further 9% exploring this option.
The report argues that trusts are not commissioning the universities to train the next generation of nurses. But there is also a problem of retention; many newly qualified nurses leave the profession within a few years, driven away by impossible working conditions.
Low staffing levels create a stressed and demoralised workforce. An astonishing 60% of nurses have considered quitting the profession this year.
Against this backdrop, a number of high profile reports (Francis, Keogh) have stressed the importance of staffing levels for patient safety. The report highlights a growing body of research that shows nurse-patient ratios can be mapped onto a number of health indicators, including mortality rates.
National Nursing Research Unit survey found that 86% nurses agreed with the statement that“at least one necessary activity was left undone on their last shift due to lack of time”. A similar Unison survey found that common tasks left undone included “taking patients to the toilet”, “helping patients to move” and “giving patients food and drink”.
The RCN backs the call of the Safe Staffing Alliance for a mandatory minimum staffing requirement of no more than 8-to-1. The report claims the SSA have “definitively shown” that above this figure “the risk to patients becomes unacceptably high”. They claim “surgical patients in English hospitals exceeding this 8:1 ratio experienced a 20 per cent or more increase in the odds of death” citing a 2007 study by Anne-Marie Rafferty and her collegues.
But the Raffety study contains a number of different figures. The most alarming figure was that patients in British hospitals with the highest workloads were 26% more likely to die (and 29% more likely to die after complicated treatment) than patients in British hospitals with the lowest workloads. Lowest workloads means ratios between 6.9-8.3 patients per nurse. Highest workloads mean 12.4-14.3 patients per nurse. For hospitals with a ratio of 8.5-10 patients per nurse, the mortality rate was 20% higher (the figure quoted by the Safe Staffing Alliance), while for those with a ratio of 10.1-12 patients per nurse the mortality rate was 14% higher.
However, the study also talks of hospitals in USA where it has been found that there is a 31% higher mortality rate in hospitals with ratios of 8:1 as compared with hospitals with ratios of 4:1. According to this study, Safe Staffing Alliance’s 8:1 demand would still leave 1 in 3 patients dying an unnecessary death. In what sense is that “acceptable”?
Alongside the benefits for patient safety the report highlights the the economic benefits of higher staffing levels. It cites a study from America that found that each additional registered nurse was worth $60,000 in reduced medical costs and increased national productivity. The RCN’s own research shows the cost benefits of specialist nurses in reducing the need for hospital admissions. There is a convincing case that below an optimum level of staffing, the costs spiral with extended hospital stays, unnecessary readmissions, and a reliance on temporary agency staff.
The report ends with a “roadmap to safe staffing” which is actually a list of five demands to the government and employers:

  1. A mandatory legislated requirement for safe staffing
  1. The mandatory use of validated workforce planning tools
  1. Robust systems of review supported by reliable workforce data
  1. An end to boom and bust workforce planning
  1. Investment in the current nursing workforce
The demands in themselves are good but this is not a roadmap to achieving safe staffing levels. A roadmap needs to articulate a strategy for winning these demands. The unspoken strategy of all the major health unions at the moment limits the union to a lobbying organisation that seeks to convince the government by reasoned argument. This strategy itself limits the demands, and the actions the unions are willing to take to achieve them.
As we have seen, the 8:1 figure of the Safe Staffing Alliance is arbitrary. It is likely that the senior nursing leaders, organisations and academics that make up the SSA think that a mandatory minimum of 8:1 is a pragmatic and realistic goal, something they can win with some gentle lobbying in the corridors of power (the average ratio across the NHS is about 9:1).
But all the evidence suggests that gentle-lobbying does not work. In fact, this approach that seeks to reach agreement with an hostile employer at all costs is part of the reason why there are so many unfilled vacancies. In the absence of a national strategy to defeat the government’s slash-and-burn agenda, local officials have done all they can to avoid compulsory redundancies. There appears to be an unspoken agreement between many officials to maintain a large bank of unfilled vacancies. As the cuts bite and management shut down services staff can be redeployed into the unfilled vacancies, the employers can avoid costly redundancy payouts and union officials can claim that none of their members have got the sack. However, it is this strategy (or lack of strategy) that has allowed the government an easy ride while they close down sections of the health service.
For an alternative to this lobbying approach we might look to the Australian and American experience where the unions have won mandatory minimum staffing levels. In these cases, safe staffing ratios were won by mass mobilisation of nurses on the streets, using their social power, public pressure, and in the final instance industrial action and strikes. This is a wholly different conception of the union as a mass movement with real social power that is able to force the government’s hand.
Our Australian sisters and brothers built their movement with the radical demand of 4:1. In California they won a ratio of 5:1. Soundly-evidenced, radical demands that can mobilise and unite the nursing workforce have a much more realistic chance of success than the figures made up on the basis that they may sound “reasonable” to our (extremely unreasonable) politicians.
This report is very useful and well-researched. However, it falls short of setting out a strategy to win. Illusions in the government and in the persuasive power of the unions’ negotiators combined with a pessimism about the ability to mobilise a mass movement has got us to where we are now. This paralysing cocktail will not win mandatory minimum nurse ratios and it will not help prevent another Mid-Staffordshire.
Nurses are the most popular section of NHS staff, its time we moved away from passive lobbying and started organising a mass movement of nurses  prepared to take action to defend our profession and the NHS
There is no evidence-base that the government can be won over by reasoned argument. They have told bare-faced lies to the public in order to set in train the privatisation of the NHS. The Secretary of State for Health has absolved himself of the “duty to provide” comprehensive healthcare, promised funding cuts for the foreseeable future and replaced rational planning with the chaos of the market. Our energy must be directed to mobilising our colleagues to defend the profession and our patients.
The 4:1 campaign aims to develop nurses power, both in the workplace and the public arena, to force the needs of our patients and colleagues onto the politicians agenda. By empowering nurses with knowledge, developing collective organisation in the workplace and building a movement across the health service we can create a voice for patients and staff which cannot be ignored and can secure real, long lasting improvements in the NHS.

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