1. Current policy context of safe staffing in A&E Departments Howard Catton, Head of Policy and International Affairs Hallam Conference Centre, London -18 th May 2015

2. Why is safe staffing so important? Right numbers = Safe patients, safe nurses SAFE STAFFING PATIENT SAFETY Lower mortality rates Lower hospital-acquired infection rates Fewer falls Lower failure to rescue rates Fewer medicine errors Better patient experience NURSE SAFETY Lower stress levels Lower illness rates Lower absence rates Better morale Improved retention rates Lower burnout rates Kane et al (2007), Aiken et al (2014)... and many more

3. The evidence for safe staffing Mortality rates and care left undone u Aiken et al. (Lancet, 2014): increase in each nurses workload by one patient increased odds of mortality by 7%. Every 10% increase in bachelor’s degree nursing associated with 7% decrease in odds of mortality. u Ausserhofer et al. (BMJ Qual Saf, 2014): RN4Cast data – worse nurse to patient ratios led to more care reported left undone. Most frequent activities left undone include: – ‘Comfort/talk with patients’ (53%) –‘Developing or updating nursing care plans/care pathways’ (42%) –‘Educating patients and families’ (41%)

4. A lawyer, a doctor and a politician walk into a bar... u Francis – “the decline in skills and standards [at Mid Staffordshire] was associated with inadequate staffing levels and skills, and a lack of effective leadership and support” u “Trust did not have reliable figures for its nursing establishments, either in theory or in practice” u Keogh – “inadequate numbers of nursing staff in a number of ward areas, particularly out of hours - at night and at the weekend...compounded by an over-reliance on unregistered support staff and temporary staff u “reported data did not provide a true picture of the numbers of staff actually working on the wards” u Berwick – “Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future.” u “Staffing levels should be consistent with the scientific evidence on safe staffing, adjusted to patient acuity and the local context. (This includes, but is not limited to, nurse-to-patient staffing ratios, skill mixes..., and doctor-to-bed ratios.)”

5. Dilution of the skill mix Renewed recruitment focused on acute settings Nursing workforce cut from May 2010 until ‘Francis effect’

6. A&E staffing data shows… Nurses FTEBand 5Band 6 Budgeted29.9620.06 Actual2318.34 Temporary2.570.34 Recommended27.2720.38 * Figures based on A&E staffing data from 33 Trusts and actual patient acuity data (Keith Hurst, 2014) u A&E departments are budgeting for more bands 5 and 6 nurses than they can fill and more than they need based on activity data. u Difficulty recruiting, especially band 5 where there is an average 23% shortfall. u A&E trying to plug the band 5 gap with temporary staff, most likely to be bank/agency.

7. Senior nurses in A&E… Nurses FTEBand 7Band 8 Budgeted11.181.17 Actual9.491.1 Temporary2.360.28 Recommended13.563.09 u A&E’s are not budgeting for enough senior nurses based on need. u 15% gap between number of budgeted and actual band 7 nurses. u A significant gap between actual and recommended; the band 8 establishment needs doubling. u Temporary staff likely to be staff working overtime. * Figures based on A&E staffing data from 33 Trusts and actual patient acuity data (Keith Hurst, 2014)

8. Support workers in A&E… u Band 4 assistant practitioners are key to the A&E team (based on the activity analysis). u However, either through vacancy freezes or recruitment problems, there’s a 48% shortfall between budgeted and actual. u Unusually, Band 1-3 actual staffing exceeds budgeted. ** Support workers include healthcare assistants, admin’ and clerical staff, and porters Nurses FTEBand 1-2Band 3Band 4 Budgeted 7.9711.173.68 Actual 9.2711.751.92 Temporary 0.922.530.99 * Figures based on A&E staffing data from 33 Trusts and actual patient acuity data (Keith Hurst, 2014)

9. Policy response to safe staffing in acute adult in-patient wards u Gov response: no nurse to patient ratios but NQB report and CNO letter ; – Board updates + to review every 6 months – Trusts display staffing info present + planned – Trust website + NHS Choices u NICE guideline published in July 2014 – Record red flags – NICE will validate workforce planning tools – No ratio but explains at 1:8 there is increased risk of harm – Programme of guidelines across settings planned u CQC Essential Standard; sufficient, skilled and deployed u Safe Staffing Alliance; ‘never more than 8’

10. Policy response to safe staffing in A&E u NICE safe staffing guideline in A&E (May 2015) 2 RNs to 1 patient in major trauma or cardiac arrest 1 RN to 4 cubicles in ‘majors’ Specialist input for children, older people or those with mental health needs Plan above average number of patients to deal with peaks in demand and allow flexibility

11. Current state of play… u Real time, ward level information for patients and the public u Monthly staffing level indicator as part of patient safety dataset on NHS Choices, broken down into: –% of registered nurse day hours filled as planned –% of non registered nurse day hours filled as planned –% of registered nurse night hours filled as planned –% of non registered nurse night hours filled as planned However… u 4 out of 5 acute trusts are currently missing safe staffing target (Shaun Lintern, April 2015) –85% of hospitals missed own target for nurses working in the daytime –67% of hospitals missed their target for filling night shifts u New ‘traffic light’ rating system for staffing levels in trusts (Shaun Lintern, April 2015)

12. Structure of potential new system envisaged by NHS England Urgent and Emergency Care Review

13. Where are we now? Clear evidence of shortage… u Increased use of agency nurses –150% increase in agency spend in past 2 years (RCN, 2015) –NHS has spent nearly £1bn on agency staff in 2014/15 (RCN, 2015) u Varying vacancy rates –20,000 vacancies (RCN, 2015) –NHS vacancy rate of around 10% (NHS Employers and HEE, 2015) –14% vacancy rate in Ambulance Trusts (Monitor, 2015) u Increased international recruitment –For the first time since UK has moved to being a net importer of nurses –28% of Trusts reporting problems retaining overseas nurses within 2 years (Nursing Times, 2015) u Global shortage –Shortage of 600,000 nurses across EU predicted by 2020 –Shortage of 800,000 nurses in US predicted by 2020

14. Future policy challenges… u Five Year Forward View u 7 day services u Integration of health and social care u Reward and incentives u Numbers, skills and location

15. Thank you – any questions? Howard.Catton@rcn.org.uk