After Francis: making a difference - Health Committee Contents

5  Nursing and healthcare assistant staff in the NHS

Staffing ratios and patient care

141. Throughout Robert Francis' analysis of the warning signs ignored or not acted upon, the prioritisation of financial performance over considerations of adequate staffing appears to have been a significant factor in the poor care delivered at Stafford. One of his recommendations on fundamental standards of care specifically addresses this point:

    The standard procedures and practice [for setting fundamental standards] should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff. These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios.[100]

142. In oral evidence Mr Francis expanded on this recommendation:

    To lay down in a regulation, "Thou shalt have N number of nurses per patient" is not the answer. The answer is, "How many patients do I need today in this ward to treat these patients?" You need to start, frankly, from the patient, as you do with everything. "How many nurses or what proportion of a nurse do I need to treat Mrs Smith in bay 3?"[101]

    The obvious thing is that on a day-in-day-out basis, the ward sister, the director of nursing or whoever else it is in a hospital, needs to know, "I have enough nursing staff of the right calibre on this ward to deal with the patients I have there today." The board needs to know that is happening on a day-to-day basis. In order to do that, having a standard in my regulations, as I will propose, that says, "Thou must have X number of nurses" will not, in my view, work—certainly not on what we know at the moment. What we need is evidence-based guidance, which, if followed, would mean that the hospital would say, "We have done our level best to produce that and actually we do have enough staff" We then need to look, if that is the position, at why the individual nurses are not providing the work.[102]

143. While Mr Francis considered that one element of ensuring adequate staffing on the ward was the leadership provided by senior nurses in allocating staff properly and ensuring that they worked effectively, he recognised that leadership alone could not overcome the difficulties caused when wards were in fact fundamentally understaffed:

    Leadership is about producing effective work from the work force that you have. But if you assume that your nurses are working effectively and you still do not have enough staff to go round, then that is where you have the problem. I am afraid all these things are difficult and I am not going to pretend they are not, but it is a combination of having enough staff and the right leadership. One without the other is not sufficient.[103]

He was clear that Trust Boards needed to have enough information to determine whether they had enough staff on the ward to ensure that fundamental standards could be complied with:

    What we need is to make sure, through the guidance, the research and the evidence base that every board has a means of knowing whether, on a day-to-day basis, a ward is [adequately] staffed. That is not quite the same as saying it is one of the fundamental standards. It is how you get to comply with the fundamental standards; it is how you deliver the fundamental standards.[104]

Government response

144. The Government has recognised that high quality care on the ward requires "the right staff, with the right values, skills and training available in the right numbers", and that the right staff mix "depends on the needs of patients on each ward at any time".[105] The Government does not, however, favour the introduction of minimum staffing numbers or ratios, arguing that this would lead to a lack of flexibility in workforce planning as staffing decisions were made according to formulae rather than in response to the identified needs of particular groups of patients The Government argues that skill mixes among the workforce are best determined by local providers rather than determined by Government, contending that local NHS organisations "must have the freedom to deploy staff in ways appropriate for local conditions."[106]

145. The Government's response goes on to endorse Mr Francis' recommendation that evidence-based guidance should be issued to inform local decisions on staffing levels, and proposes to work with NICE, the CQC and NHS England to develop such guidance. The new Chief Inspector of Hospitals in the CQC will have a remit to inspect staffing levels and to report if wards are inappropriately staffed, and the CQC is to require providers to use evidence-based tools to determine staffing numbers. Compassion in Practice, the Government's nursing strategy, indicates that Trust Boards should receive, endorse and publish information on staff levels "at least twice a year".[107]

146. Questioned on how the Government proposed to implement the recommendation on evidence-based guidance on staffing levels, the Secretary of State indicated that it could be achieved through inspection of providers to ensure that they were complying with best practice on reporting staffing levels. He cited the example of Salford Royal Infirmary, which uses a management tool which adjusts recommended staffing levels to match the requirements of patients admitted to a ward, and suggested that providers who did not use similar tools would eventually be encouraged to adopt them to comply with the Chief Inspector's requirement for hospitals to demonstrate how they were meeting fundamental standards:[108]

    What that Robert Francis recommendation says is that every hospital should have a proper tool that is able to guide it accurately as to the number of staff needed. That is what we are talking to NICE about at the moment. Then we will be inspecting them against the use of that tool.[109]

147. Salford Royal NHS Foundation Trust has provided a briefing note for the Committee on its staffing practices, together with the prototype design for a staffing board which it proposes to display on each ward to share information on the numbers of nursing staff on each ward with patients and relatives. These are reproduced at Appendix 2.

148. Una O'Brien CB, Permanent Secretary at the Department of Health, added that the development of data reporting would be essential to monitoring progress:

    The essence of this is timely transparent data. We need to make sure that the tools are fit for purpose. There needs to be more work on the quality of evidence behind the tools. The second stage is to ensure that they are systematically adopted and, thirdly, that there is adjustment and management on a daily basis.[110]

The Committee's view

149. Good quality care in hospitals relies on the availability of sufficient numbers of clinically-qualified registered nurses supported by well-trained, properly-motivated and well-led healthcare assistant staff on wards who are dedicated to providing the best care possible for the patients entrusted to them. It is manifestly clear that this was far from the case on many of the wards at Stafford General Hospital. As a consequence, vulnerable patients suffered abuse and neglect which was in all cases disturbing and degrading, and in many cases is likely to have been dangerous.

150. Ensuring adequate levels of both clinically- and non-clinically-qualified staff in all circumstances is therefore a fundamental requirement of high quality care, whatever the financial circumstances. The Secretary of State has argued that this is not best achieved by attempting to set minimum staffing ratios for all circumstances, but by developing evidence-based guidance and expecting providers to respect the guidance.

151. The Committee believes that this approach will only win public confidence if it is supported by a clear commitment to open and public accountability for the staffing record of providers. While the Chief Inspector of Hospitals will have a role in inspecting staffing levels and ensuring that the tools used by hospitals deliver staffing levels which can meet fundamental standards of care, the Committee does not think that periodic inspection of a provider's staffing practices is sufficient to achieve this on its own. Nor does it consider that twice-yearly reporting of staffing figures by Trust Boards is adequate to ensure proper staffing. Staff management practices in specialties where minimum staffing levels are mandated, such as paediatric care and intensive care, should be analysed for best practice recommendations.

152. The bodies which do have a continuing relationship with care providers, and an interest in ensuring the proper provision of services at local level, are commissioners of health and care services. As the tools for tracking and reporting on staffing levels are developed and refined, they will become more useful not only to Trust managers but also to commissioners and to the public. Tracking and reporting will also allow staffing levels to be compared against best practice benchmarks, especially for registered nurses. The Committee recommends that commissioners should, via the NHS standard contract, require all care providers to collect information on the deployment of registered nurses and other healthcare staff at ward level on a daily basis, and make it available immediately to commissioners for publication in a standard format which will enable ready monitoring, analysis and comparison by all stakeholders. This should include making the information available in individual health and care settings.

153. The Committee has not undertaken an in-depth review of safe staffing issues, but has been impressed by the approach of Salford Royal NHS Foundation Trust to the development of a staffing management tool. This appears to the Committee to be good practice, and the Committee recommends the adoption of this or similar systems across the NHS.

Training and status of nurses

154. The Government's initial response to the Francis report stated that every student seeking NHS funding to undertake a degree in nursing would be required to serve up to a year as a healthcare assistant as part of the nurse training programme. This would "promote frontline caring experience and values, as well as academic strength" and would provide helpful experience for students who would later be required to manage healthcare assistants after qualification. The Government has also suggested that the scheme might be extended to trainees in other (unspecified) fields of NHS activity. The proposal is in addition to a system of "values-based recruitment" to NHS careers which Health Education England proposes to introduce for all students entering clinical education programmes funded by the NHS.[111]

155. Questioned about the merits of this proposal, the Secretary of State referred to evidence from Health Education England which indicated a high drop-out rate by those studying for nursing degrees following—and presumably as a result of—the practical experience element of the course. It was therefore desirable that those wanting to undertake nursing degrees paid for from public funds should be required to test their vocation for a period before taking up a place on a course.

156. While the Secretary of State conceded that some nursing leaders had voiced opposition to the proposal, there was also "a great deal of support for it in parts of the nursing profession, particularly among some older nurses, who recognise this as being quite similar to how nurse training used to be."[112]

157. Una O'Brien suggested that the measure was also intended to address an unwelcome separation between the role of the healthcare assistant and the registered nurse:

    While it is true that we have to recruit for values across the piece for all professions, in the end it is the nurses who coach, train and line manage healthcare assistants on the ward. So they are in a unique relationship to that part of the work force. That provides a linkage between what the aspirant trainee nurse does and the actual outcome of how good they are in that supervisory role at the end of it. One of the lessons from the Francis report is the sense of a disconnect between the role of the healthcare assistant and the role of the qualified nurse; that was never intended by policy but it actually turned out to be the case in practice. What we want to see now is a much broader continuum drawn between those two very important professional roles.[113]

158. While a requirement to properly test a vocation before undergoing training for it at public expense is in principle worthwhile, the Committee questions whether the maximum twelve-month period proposed is necessary. The Committee is concerned that such a lengthy period of compulsory pre-training could itself deter potential recruits.

159. The Committee recommends that any proposal to require those seeking NHS funding for a nursing degree to first serve a period as a healthcare assistant should be fully piloted and carefully evaluated before full implementation in order to establish evidence about the value of the proposal and to determine the optimum length of time for such placements. The Committee also believes that it is important that such a system takes account of other lifetime experiences of potential trainees, including lived experience and voluntary work.


160. Robert Francis recommended the establishment of a new category of nurse, the registered older person's nurse, in order to recognise the specific skills required from the nursing workforce to provide care for the elderly.

161. While the Government has recognised that caring for older people is "core to the job" of many nurses in hospitals and community care, and the proper care and support for the elderly requires removing barriers to service integration, it has decided not to proceed with the Francis recommendation, arguing that the elderly often require support from specialist teams with their own skills as well as from care workers in community and care home settings. Instead of establishing a separate role, the Government proposes to strengthen the overall focus of nursing and other healthcare training on the complex physical and emotional needs of older people. The Secretary of State explained to the Committee that

    we just did not want people inside the nursing profession to think that older people's care was the job of specialist other people, when actually this is something that is central to everything that all nurses have to do in the modern NHS.[114]

Una O'Brien added that "there is a risk of putting older people's nursing into a silo, which is the opposite of what we want."[115]

162. The Committee agrees with the Government that training requirements for the healthcare workforce should properly recognise the complex needs of older people so that they can be addressed across the health and care system. While it is understandably undesirable to encourage the development of an older people's nursing silo, we agree with Mr Francis that it is also desirable to encourage the development of specialised skills and training in the care of the elderly. The Committee sees no reason why registered nurses should not concurrently hold the status of registered older people's nurse, and we recommend that those nurses and care assistants who have successfully completed training in the skills required to care for older people should have those skills formally recognised and certified.

Training and regulation of healthcare assistants

163. Robert Francis recommended the establishment of a registration and regulatory regime for healthcare support workers. Mr Francis makes this recommendation because he concludes that healthcare assistants are often mistaken by patients for the registered nursing staff responsible for delivering quality care:

    A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are dependent on such care by reason of disability and/or infirmity) in a hospital or care home setting. The system should apply to healthcare support workers, whether they are working for the NHS or independent healthcare providers, in the community, for agencies or as independent agents. (Exemptions should be made for persons caring for members of their own family or those with whom they have a genuine social relationship.)[116]

164. Mr Francis also recommended a code of conduct and national training standards to apply to such workers, all of which (registration, regulation, code of conduct and training) should be undertaken by the Nursing and Midwifery Council. The Department of Health should supervise these activities to protect patients from harm while the NMC prepared to adopt these responsibilities.[117]

165. The Committee has in the past supported the progressive development by the Nursing and Midwifery Council of a registration process for healthcare assistants: in its 2011 report on the NMC accountability hearing the Committee noted the lack of regulation for healthcare assistants, and argued that the a statutory regulation scheme, operated by the NMC, should be introduced to cover healthcare assistants. The Committee also recognised that NMC performance of its current responsibilities has historically fallen well below acceptable levels and it did not favour extending the scope of regulation to cover healthcare assistants until NMC performance of its current core functions had demonstrably improved.[118]

166. The NMC subsequently confirmed that the Government had commissioned Skills for Health and Skills for Care to develop training standards and a code of conduct for healthcare support workers, which, alongside proposals for assured voluntary registration to be administered by the Council for Healthcare Regulatory Excellence (now the Professional Standards Agency for Health and Social Care) would provide "an effective framework for public protection."[119]

167. The Government has resisted any form of regulation of healthcare assistants:

    The idea of compulsory, statutory regulation can seem an attractive means of ensuring patient safety, yet Robert Francis' report demonstrates that regulation does not prevent poor care. Regulation is no substitute for a culture of compassion, safe delegation and effective supervision. Putting people on a centrally held register does not guarantee public protection. Rather it is about employers, commissioners and providers ensuring they have the right processes in place to ensure they have the right staff with the right skills to deliver the right care in the right way to patients.[120]

168. Instead, the Government plans to apply a version of the vetting and barring scheme operated by the Home Office to ensure that unsuitable healthcare assistants are not employed in care roles. The new Chief Inspector of Hospitals in the CQC is to provide assurance that hospitals are meeting their legal obligations to ensure that the barring regime is properly and consistently applied, and the new Chief Inspector of Social Care in that organisation is to ensure that unregulated care and support staff have the induction and training necessary to meet the registration requirements placed on their employers.[121]

169. The question of the induction, training and performance management of healthcare assistants is one of the issues addressed by Camilla Cavendish in the post-Francis review of training and support for healthcare assistants which she has undertaken for the Secretary of State. The Government undertook to review the subject again in the light of the report of Camilla Cavendish's review.

170. The terms of reference of the Cavendish Review did not include mandatory registration for the healthcare assistant workforce, and this issue was not covered in the report of the Review.[122] Cavendish did recommend that Health Education England should develop certified qualifications for healthcare assistants, in the form of a Certificate and Higher Certificate of Fundamental Care. She further recommended that the CQC should require healthcare assistants in health settings, and support workers in social care settings, to have completed the Certificate of Fundamental Care before they can work unsupervised. She made further recommendations designed to establish caring as a career, and recommended that the Professional Standards Authority provide advice on how employers can more effectively manage the dismissal of unsatisfactory staff.

171. The Committee agrees that the issue of induction, training and performance management of healthcare assistants should be reviewed again in the light of the recommendations in of the Cavendish Review of training and support for healthcare assistants.

172. Healthcare assistants have an important and valued role, especially in caring for older people in their own homes and in formal care settings. The Committee believes that they should be encouraged and supported in undertaking continued professional development. The Committee does not believe the current unregulated status of healthcare assistants should endure, but it remains mindful of the need to ensure NMC performance improves before additional responsibilities are laid at its door.

100   Francis Report, recommendation 23, chapter 21 Back

101   Q13 Back

102   Q20 Back

103   Q23 Back

104   Q24 Back

105   Patients First and Foremost, Cm 8576, para 5.2 Back

106   Ibid.  Back

107   Ibid., para 5.6 Back

108   Q507 Back

109   Q511 Back

110   Q509 Back

111   Patients First and Foremost, Cm 8576, para 5.13 Back

112   Q519 Back

113   Q520 Back

114   Q570 Back

115   Q571 Back

116   Francis Report, recommendation 209, chapter 23 Back

117   Francis Report, recommendations 212 and 213, chapter 23 Back

118   Health Committee, Seventh Report of Session 2010-12, Annual accountability hearing with the Nursing and Midwifery Council, HC (2010-12) 1428, para 64 Back

1 119  18 NMC response to the Seventh Report of the Health Committee, Session 2010-12, published as Appendix 2 to the Fifteenth Report of the Health Committee, Session 2010-12, Annual accountability hearings: responses and further issues, HC (2010-12) 1699 Back

120   Patients First and Foremost, Cm 8576, para 5.22 Back

121   Ibid., para 5.23 Back

122   The Cavendish review: an independent review into healthcare assistants and support workers in the NHS and social care settings, July 2013, para 2.1.3 Back

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Prepared 18 September 2013