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.
NURSING CARE FOR THE ELDERLY: THE
REGISTERED OLDER PERSON'S NURSE
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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