Lessons from Lanarkshire

The rapid review of practice at Wishaw, Monklands and Hairmyres Hospitals in NHS Lanarkshire recently had been triggered by above-average mortality rates at the hospitals. It could conclude no definitive cause for the spike, but rather a number of problems could have been contributory factors. One thing it was clear on was the inadequate levels of staffing.

“The review team found there were gaps in nurse staffing levels on some wards and an imbalance between registered and unregistered nursing staff. There was also a high use of bank staff and movement of staff between wards. This is impacting on the ability to consistently meet basic care needs and reliably carry out vital observations that would alert staff that a patient’s condition is deteriorating,” the report said.

Theresa Fyffe, director of the Royal College of Nursing in Scotland, wasn’t surprised. After all, her organisation’s own staff survey in December had revealed only around a quarter of Scottish nurses think there are enough staff for them to do their job properly.

“I think that what the NHS Lanarkshire report did do is that it showed that the quality of patient care is inextricably linked to the right number of suitably skilled staff in the right place, at the right time. Lanarkshire as a board has consistently had one of the lowest nursing staff levels of any health board in Scotland,” she tells Holyrood.

For UNISON regional health officer, Matt McLaughlin, it is an issue of contingency: “If one or two senior members of staff, experienced members of staff being on annual leave creates a staffing crisis in a ward then you can assume staffing levels are not right,” he says. Staffing levels have always been a challenge because staff costs form the largest part of budgets: “If NHS organisations need to find savings then they do that through not filling vacancies, taking their time to fill vacancies, or keeping staffing levels at a point where, effectively, there’s little contingency in the overall level,” he says.

Recruitment of medical consultants and qualified nurses has risen recently, more student nurses are being taken on, but Labour’s health spokesman, Neil Findlay, calls the Government announcements “spin” because they follow a period of decline: “The number of student nurses were cut around 20 per cent, and they’ve now increased it by four per cent to try and start recovering our position, so inevitably that’s going to have an impact on the NHS,” he says.

A gradual cut in hospital beds because of perceived innovations in medicine allowing more people to be treated as day cases or at home has impacted on staff levels. Theresa Fyffe blames unforeseen circumstances: “What we had not understood was the frail elderly. So we’ve had this generation of older people getting sicker. We didn’t know the impact of that,” Other financial implications have hit the NHS recently, she says, including more expensive drugs and treatments “so the budget very quickly gets outstripped by innovation and medicines and all of that.”

Reducing the beds allowed health boards to reduce staff levels, and in turn informing student intake numbers. Fyffe calls it “flat lining” and argues Scotland should be training nurses whether they can work here or not, because many nurses can go abroad to get experience. “We became exercised about not having student nurses without jobs, rather than ask the question, ‘why did we think we didn’t have the posts to employ them?’” she says.

As a result, the nursing population is also getting older. McLaughlin suggests the NHS could make better use of a retiring or retired workforce. “I think as a service we should be trying to facilitate people tapering down, but not losing their skills or their knowledge. I think it’s entirely sensible for maybe some of our retired professionals to come back, work short shifts during peak time of day to try and help us get our staffing levels right,” he says.

Findlay calls the idea a “commendable” one. “Everybody seems to be talking about the ageing population in only negative terms. I think there’s a huge opportunity. People who have great experience, a lifetime of knowledge – we shouldn’t just be dismissing these people as being some sort of burden on the state. They can be tremendous assets,” he says.

Health Secretary Alex Neil mandated use of the workforce planning tools last year, a move welcomed by the Royal College of Nursing. “We had some boards, despite those tools being available, not using them. Scotland is rightly proud of those tools. The cabinet secretary was right: ‘Why are we not using something we’re proud of?’ It was because it wasn’t giving them the answer they wanted,” says Fyffe. For her, the tools need to be constantly evolved and brought up to a standard, because they currently only give you numbers, not the skill mix: “It doesn’t help you understand how many registered nurses versus how many healthcare support workers.” McLaughlin believes it is not about a lack of knowledge, but a lack of resource. “It shouldn’t just be mandatory to apply the tools, it should be mandatory to staff up to the tools,” he says.

Labour and the RCN have called for a system-wide review of the NHS, but McLaughlin suggests whether we have five years is “debateable”. There are things that could be done now, he argues, to alleviate pressure: “Health boards should be looking at their bank budget, they should be looking at how many people are breaching the Working Time Directive by working in bank, they should be looking at their vacancy levels, and they should be getting up to a staffing complement of nearer 100 per cent than it is at the moment,” he says, “we certainly don’t have a decade to do a review around staffing levels.”

New moves toward the integration of health and social services and 24/7 provision mean the whole system will need a review, argues Fyffe. Modelling 24/7 care will need to be in line with staff requirements: “Do we mean ‘Tesco open-all-hours’, which was in the Keogh review in England? Open all hours to everything? I just don’t think we can afford it,” she says.

More community staff nursing will be needed if more patients are to be treated in the community, she says: “You want to have the experienced decision-makers near those patients.”

Findlay argues the care sector as a whole is not ready for integration. “Contracts have been driven down to the lowest price. The only way contractors can go is cutting wages. It’s now a minimum wage sector. That is not dignity in old age,” he says.

Upskilling care workers and other support staff is a way of easing pressure on staff, McLaughlin suggests: “There are many young people in this country unemployed with the skills to come in and work as nursing assistants, or domestics, or admin workers.”

Fyffe warns this must not be at the cost of registered nurses. “You have to have the right number of registered nurses, to be able to support and supervise your unregulated workforce,” she says. Boards may have been hiring more, cheaper healthcare support workers instead of registered nurses, she fears: “Anyone trained to do a particular role will have the training and experience of that role alone. It’s that level of decision-making that worries me,” she says, “the registered nurse, whether in a ward or on a team in the community, the ward sister, team leader is accountable for the quality and standards of care.”

Recent research from King’s College London and elsewhere shows a direct link between staff health and wellbeing and the quality of care. For Fyffe, the RCN staff survey suggests nurses feel too stretched to do their job properly. In worst-case scenarios, there may be diminished compassion. “When people can’t cope and feel under pressure, they can become immune and less compassionate, and thereby at risk of poor judgement. You don’t want that when you’re dealing with people’s lives,” she says. Improving the working environment will make the job more attractive, she argues, and the confidence of staff to speak up and know they will be heard. NHS Lothian was found to have had a culture of “bullying and intimidation” after it manipulated waiting times figures in 2012, and the most recent NHS staff survey found 17 per cent of NHS Lothian staff still reported bullying from a colleague, the highest of all the health boards in Scotland. Fyffe isn’t surprised there has been little improvement. “Think about what they did. The changed the top. They changed the chief executive. No new chief executive will bring about change just by being in that size of board. If staff in there were used to thinking that’s the way to work, it’s going to take a lot of modelling to change it. Cultural change,” she says.

Cultural change is exactly what she put to the First Minister and other party leaders in a “productive meeting” recently. “The Cabinet Secretary and Mr Salmond listened and responded they would look robustly at what we were proposing,” she says.