The Few

 

 

 

The BBC has been looking at the NHS, the number of nurses in particular.

 

This, which might have some relevance, they haven’t looked at:

 ‘Stealth’ pay rises for NHS staff costing £1bn a year

 The NHS is spending almost £1 billion a year on a “stealth” system of automatic pay rises, which have seen some workers’ earnings rise by up to a third in five years, an investigation discloses today.

The system means the cost of employing 1.3 million NHS workers is constantly increasing above inflation.

The system, known as increments, have led to pay increases as high as 45 per cent over the last seven years for some staff without any promotion or improvement in performance.

 More than half of NHS staff received an incremental rise last year, giving an average total rise of 4.5 per cent last year, well above the rate of inflation.
 
The nationally announced pay settlement was a one per cent rise last year.

Last night Dr Dan Poulter, the health minister, said he system was not fair because it meant senior managers gained far more in cash terms than low-paid workers, and was not affordable.

Abolishing the system would allow the NHS to recruit at least 10,000 more front line staff, he suggested.

 

 

The BBC asks if there are enough nurses in the NHS and informs us that below a certain number patients will die:

Are there enough nurses in the NHS?

A recent study by the National Nursing Institute seems to confirm this.
It found that half of hospitals are regularly running wards with fewer than one nurse to every eight patients.
The one-to-eight ratio is considered the minimum level – below this research shows that an average-sized hospital could expect to see as many as 20 extra deaths a year.
According to official data from the Health and Social Care Information Centre, there are just under 307,000 midwives and nurses working in England (in terms of full-time equivalent posts).
Once you strip out the midwives, health visitors and school nurses, which are not employed by the NHS, there are about 275,000 nurses working across the health service in both hospitals and community services.
That represents a drop of 6,000 – or 2% – since the election.

 

This raises two questions…firstly are the BBC’s figures for the number of nurses accurate, secondly are the claims made regarding the effectiveness of certain nurse to patient ratios correct?

Answering the first, it should be noted that getting an accurate number of staff in the NHS seems to be fairly difficult.
The BBC limits it here to the number of nurses in England, full time ones at that…and limits it further specifically to fully qualified nurses…disregarding Health Care Assistants as well as Midwives, despite right at the very end of the article stating that the mix of staff should also be considered.

This is the total NHS figure in 2012 (not just England):
Professionally qualified clinical staff? There were 687,810 professionally qualified clinical staff in the NHS Workforce, an increase of 1,063(0.2%) since 2011.

For the NHS as a whole these figures are relevant and put things in perspective:

2011-2012  the NHS lost 3238 staff members in total.

A total of 8602 non-medical staff were made redundant.  That would indicate that at least 5364 more frontline medical staff were employed.

The number of nurses lost was 2409.…but there were 2239 doctors employed, and 1,063 professionally qualified clinical staff added to the payroll….and 6000 Health Care Assistants have been recruited as well as hundreds of Midwives.

The total figure for nurses lost since 2010 seems to vary….but the usual figure is between 5,000 and 6,000.…but, the BBC does mention…by the end of this financial year the NHS will be employing an extra 3,700 nurses.

Even the government can’t get its figures to add up though, this from Aug 2012:

“There are 2,400 more clinical staff working in the NHS than there were two years ago in May 2010, including over 3,700 more doctors, and over 900 extra midwives. In contrast, the number of admin staff has fallen by over 17,500, creating savings that will be reinvested into frontline patient care.
“Funding will increase by £12.5bn over the next three years, protecting the NHS for the future.”

This from March 2013:
Health minister Dr Dan Poulter said: “These figures are exaggerated. There are now more clinical staff in the NHS than in 2010, including around 5,500 more doctors, 1,300 more midwives and more than 900 more health visitors. In contrast, the number of admin staff has fallen by over 18,000, and the money saved put back into frontline patient care.

But no doubt qualified nursing jobs have gone.

It should be noted though that highly qualified nurses are not needed for all the tasks that patients need to have done for them….these can be done by the HCA’s, allowing the qualified nurses to concentrate on the patients with the most need…thereby possibly improving care.

So you have to look at the whole picture…which the BBC doesn’t.

Also whilst nurses leave the NHS they are not lost to nursing…and in fact are often still employed, via private companies, by the NHS, often providing care in the community.
Midwives should not have been dismissed by the BBC here either….for if they provide services in the community that means mothers to be don’t have to go to hospital…and therefore fewer nurses are required in hospital:

NHS figures reveal 5,000 fewer nurses since 2010
Trade unions and Labour blame drop on coalition’s cuts, but figures may also reflect nursing moving to private firms or charities.
The drop in nursing numbers is significant because it represents in part a shift from state employment to working for private companies and charities. Nursing is moving out of hospitals and into the community, where staff work for private firms or the voluntary sector but are paid for by the NHS.

 

The BBC article paints the loss of nurses as a bad thing…telling us that below a certain nurse staffing level and…an average-sized hospital could expect to see as many as 20 extra deaths a year.

So the next thing is to ascertain whether claims about the nurse/patient ratio are correct.

The figures on which the BBC is basing its report comes essentially from a single piece of research in the USA, in California, where they made it  law to maintain a certain ratio of nurses to patients.

These are some qualifications in that research itself which might be relevant but again the BBC doesn’t mention them:

Our study is cross sectional and we cannot establish causality in the associations we observe.

Although our data are cross sectional and lack baseline measures, our positive findings are bolstered by other research showing improved nurse staffing in California hospitals between 2004 and 2006 (Bolton et al. 2007) and increases in satisfaction of California nurses between 2004 and 2006 (Spetz2008

There is little evidence in the research literature that having more unlicensed personnel in hospitals adversely affects patient outcomes.

 

So no causality, no baseline and little evidence elsewhere.  

 

Here is the Royal College of Nursing’s take on the report:

The potential consequences of such ‘compromised’ care were made explicit in recent research (Aiken et al., 2010) which found that lower patient per nurse ratios (as a result of mandated minimum staffing levels in California) were associated with significantly lower mortality rates.

Put bluntly, the research concludes that fewer patients die in hospitals with better nurse staffing levels.

 

But here is a report on that research from Bristol University in the UK in 2012, ignored by one and all, and the BBC:

New study reveals increasing nurse-to-patient ratios do not extend patient safety
Press release issued 27 February 2012

We evaluate the impact of California Assembly Bill 394, which mandated maximum levels of patients per nurse in the hospital setting……We find persuasive evidence that AB394 had the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards.
However, these improvements in staffing ratios do not appear to be associated with relative improvements in measured patient safety in affected hospitals.

A study into the effects of a law requiring increased nurse-to-patient ratios on patient mortality finds that mandating such changes do not reduce adverse patient outcomes.
Dr Andrew Cook, lead author of the study, said:  “Our findings suggest that mandating nurse-to-patient ratios, on its own, does not lead to improved patient safety.”
Martin Gaynor added: “While we do not find evidence that the regulation improved patient safety, that does not necessarily mean that nurse staffing levels are unimportant.  Improved nurse staffing might be crucial in improving patient safety, but only in combination with other elements. It is important that analysts, policy-makers, and healthcare providers sort out these important issues.”

 

And there are many more doubters:

Many registered nurses believe that nurse staffing in acute care hospitals is inadequate. In 1999 California became the first state to mandate minimum nurse-to-patient ratios in hospitals. State officials announced draft ratios in January 2002 and expect to implement the legislation by July 2003. We estimate that the direct costs of compliance will be small. However, mandatory ratios could generate opportunity costs that are not easily measured and that may outweigh their benefits. Policymakers elsewhere should consider other strategies to address nurses’ concerns, because other approaches may be less costly and produce greater benefits to nurses and patients.

A key finding from this synthesis is that the implementation of minimum nurse-to-patient ratios reduced the number of patients per licensed nurse and increased the number of worked nursing hours per patient day in hospitals. Another finding is that there were no significant impacts of these improved staffing measures on measures of nursing quality and patient safety indicators across hospitals. A critical observation may be that adverse outcomes did not increase despite the increasing patient severity reflected in case mix index.

We find persuasive evidence that AB394 had the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, these improvements in staffing ratios do not appear to be associated with relative improvements in measured patient safety in affected hospitals.

 

What is certain is that more nurses means a happier staff as noted by all reports…naturally I suppose…a lighter workload is going to make life easier and more manageable with some benefits all round….less stress and less burnout.

 

Here is the RCN’s look at staffing levels from 2009:

A key theme in the 2006 RCN ward staffing level guidance was the recommendation that skill-mix on acute wards should not be more dilute than the benchmark average of 65 per cent registered nurses
A large-scale RCN survey of 9,000 nurses in 2009 (Ball and Pike, 2009) found that on average NHS hospital wards have a ratio of eight patients per registered nurse during the daytime, and 11 at night (see Table 5.1). Across all specialties, on average 5.4 nursing staff are on duty during the daytime – roughly three RNs and two HCAs/auxiliaries per ward

 

So the average Registered Nurse ratio was around 9 patients per nurse in 2009.…the ratio the BBC tells us is ‘acceptable’ on average is 8 to 1.

The BBC discounts the number of other staff, such as HCA’s, helping…and with those on hand the ratio drops to around 5 patients per staff member….well below the 8-1 ratio.

The HCA’s do much of the lower skilled work thereby allowing the more qualified nurses to deal with patients who have the most serious problems rather than having such highly qualified nurses running around emptying bed pans etc.

So for the BBC to just make a blanket claim that a ratio of 1 nurse to 8 patients saves lives doesn’t give a full and sophisticated explanation of the mix of skills that could be used on a ward.

 

Here is a brief summary of the research from California:

Aitken and colleagues compared outcomes from common surgeries in the three states. Nurses in California care for an average of one fewer patient per shift, and these lower ratios have sizable associations with surgical mortality.After adjusting for extensive patient and hospital characteristics, the investigators found that better nurse staffing was associated with a decreased risk of 30-day mortality and failure-to-rescue. The effect of adding an additional patient to hospital nurse workloads increased the odds of a patient dying by 13% in California, 10% in New Jersey, and 6% in Pennsylvania. The effects of increased workloads on failure-to-rescue were similar. The investigators then estimated how many fewer deaths would have occurred in New Jersey and Pennsylvania from 2005-2006 if those hospitals had the same nurse staffing ratios as California.

The findings suggest 222 fewer surgical deaths, (a 13.9% reduction) in New Jersey, and 264 fewer surgical deaths, (a 10.6% reduction) in Pennsylvania. Thus, in the two states alone, 486 lives might have been saved among general surgery patients in a two-year period if the hospitals adopted California nurse staffing levels.

Although this study cannot draw cause-and-effect conclusions, it strongly suggests that better nurse staffing is associated with better nurse and patient outcomes.

 

 

Here is the actual study and its own conclusions:

Implications of the California nurse staffing mandate for other states.

We have tried to minimize this source of potential bias by obtaining reports from nurses in states without legislation and by using in-dependent patient data to validate the better outcomes for California hospitals. Our study is cross sectional and we cannot establish causality in the associations we observe.

Although our data are cross sectional and lack baseline measures, our positive findings are bolstered by other research showing improved nurse staffing in California hospitals between 2004 and 2006 (Bolton et al. 2007) and increases in satisfaction of California nurses between 2004 and 2006 (Spetz2008

There is little evidence in the research literature that having more unlicensed personnel in hospitals adversely affects patient outcomes.

When we use the predicted probabilities of dying from our adjusted models to estimate how many fewer deaths would have occurred in New Jersey and Pennsylvania hospitals if the average patient-to-nurse ratios in those hospitals had been equivalent to the average ratio across the California hospitals, we get 13.9 percent (222/1,598) fewer surgical deaths in New Jersey and 10.6 percent (264/2,479) fewer surgical deaths in Pennsylvania

 

This is the important bit where they lay out what they conclude are the odds on a patient dying if one more patient is added to the nurses’ workload:
The effect of adding an additional patient to hospital nurse workloads increases the odds on patients dying by a factor of 1.13 in California, 1.10 in New Jersey, and by a factor of 1.06in Pennsylvania. The effects of increased workloads on FTR were substantially similar, with odds ratios of 1.15 in California, 1.10 in New Jersey, and 1.06 in Pennsylvania.

 

What that says is that in California the odds of you dying are actually greater than in States where they don’t have mandatory ratios when you add one more patient to the nurses’ workload.

This proves that mandatory ratios save lives?……

That might seem odd…..but I can only assume that because the death rate in States with higher ratios is already higher than in California one more patient will make little difference to the odds of you dying…if the odds are already, for example, 100%, then you can’t really get much worse can you?

But then you look at the figures and the Californian odds are a factor of 1.13 as opposed to 1.10 or 1.06…..very marginal differences.

As suggested above the cost effectiveness of employing highly trained nurses may be less than adopting other measures that will also save lives…possibly more lives……mandatory ratios could generate opportunity costs that are not easily measured and that may outweigh their benefits. Policymakers elsewhere should consider other strategies to address nurses’ concerns, because other approaches may be less costly and produce greater benefits to nurses and patients.

 

What isn’t in doubt is that more nurses/HCA’s reduces the workload on them and must reduce stress and ‘burnout’……whether that is a factor to consider is one any employer has to think about….but the BBC is presenting this as a life and death matter….that maybe each hospital could see 20 extra deaths per year if they don’t adopt these lower ratios….but only mentions qualified nurses…without considering the mix of skills that could actually be utilised cost effectively for the same health outcomes….telling us that:

…half of hospitals are regularly running wards with fewer than one nurse to every eight patients.

But as seen from the chart above that isn’t the true picture when other staff are considered who also help with patients….and right at the end the BBC admits….

But it is not just about numbers. Skill mix is important too.

The support they receive from healthcare assistants varies too.

Some do no nursing roles, while others have been trained to change dressings and monitor a patient’s vital signs.

As in any work environment a mix of experienced and junior staff is needed.

 

But that is after a long article which is essentially a promotion of the higher ratio of qualified nurses to patient concept.

In other words the article is highly misleading and, well, wrong about its central claim….at least based on much contrary evidence and the less than certain evidence of the research all this is based on….a study which admits there was no causality, no baseline and little evidence elsewhere to say that staff, like HCA’s, were detrimental to patient outcomes.