Nina Kamalarajan is a paralegal, and former critical care nurse, in Michelmores' Clinical Negligence team. Here she writes on who the hospital regulators are, and how they are approaching the crisis in NHS understaffing.
Addenbrooke's, a large teaching hospital in Cambridge, has been filling headlines as it became one of 15 hospitals nationwide to be put into 'special measures'. The move was prompted by a report from the Care Quality Commission (CQC), which identified several areas of serious concern.
Behind the report there will no doubt be a story of incredible strain on the hospital's resources and a desperate situation in many of its wards. While patients are most often the victims of these crises, medical staff themselves suffer enormously when a hospital is struggling to cope.
What is the CQC?
The CQC is an independent regulator of health and social care services in England. It is tasked with monitoring and inspecting services to ensure that they meet 'fundamental standards', and to take action when services are identified as falling short.
One of the key findings of the CQC inspection of Addenbrooke's revealed significant concerns about patient safety, staff levels and skill mix, including;
'…a significant shortfall of staff in a number of areas, including critical care services and those caring for unwell patients…'
'…services often had staff with an inappropriate skill mix…patients were being cared for by staff without training relating to their health needs…'
These conditions are unenviable, not only for patients but for the clinical staff treating them.
Struggling with depleted resources and a lack of support, consultants, nurses, midwives and other staff often find themselves holding back a seemingly impossible tide to keep wards functioning.
NHS standards – on paper and in practice
The NHS Constitution (2013) sets out the principles and values that underpin our NHS. A key component of this is;
'…the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality. '
Although the safe delivery of care at Addenbrooke's raised serious concerns, staff were praised for showing patients compassion, dignity and respect. Care itself was rated as 'outstanding' at the hospital. This is testimony to those on the frontline who work tirelessly in the most challenging of conditions and are, arguably, at times forced to go against their professional codes of conduct, when staffing levels and inappropriate skill mixes present a danger to the safe delivery of care to patients.
This presents a new dilemma to staff – does one blow the whistle, exposing the failings, and will it make a difference?
Many staff fear that their concerns may be ignored; there can also be a feeling, as in so many institutions, that to break ranks would be a betrayal of one's beleaguered but dedicated colleagues.
Staffing across the NHS
The UNISON staffing levels survey (2015) found that 62% of respondents who had raised a 'red flag' event on their ward said that they were not immediately allocated extra staff when they needed them. 45% felt that there were not adequate staff members to deliver safe and compassionate care, and 88% supported mandatory nurse-to-patient ratios.
Unsurprisingly, there is a growing body of evidence linking nursing cutbacks and staffing levels to poorer patient outcomes.
The Francis report published in 2010, following the Mid-Staffordshire inquiry, cited understaffing as one of the reasons why care had been so poor.
Over the years, a number of high-profile enquiries into hospital failings have reached similar, if perhaps all too foreseeable, conclusions of understaffing and lack of training and support for staff, all of which have been shown to lead to devastating outcomes.
Where next for the staffing crisis?
There is currently no legally enforced 'safe staffing level'. One wonders whether the findings of all the inspections and reports, conducted at huge expense following serious hospital failings across our NHS year on year, are being properly implemented. The fundamental issues faced by Addenbrooke's are recurrent themes that are raised time and again; we saw similar issues over a decade ago in the Bristol Royal Infirmary scandal, culminating in the Kennedy Report of 2001. However, a current review of children's heart services at Bristol is once again grappling with concerns over staffing and under-resourcing identified by the CQC in 2012. 12 years on from Kennedy, Sir Robert Francis' recommendations following the Mid Staffs largely mirror the Bristol findings.
Hospitals must have a way to provide an identifiable, acceptable ratio of qualified staff to patients, and legislation appears to be a meaningful way to approach this.
As the demand for health services grows in our ageing population, and ground-breaking but expensive advances in modern medicine continue to arise, the strain on the limited resources of our NHS will surely only increase. It seems inevitable that these same issues will resurface.
Understaffing and inadequate skill mixes will continue to put our patients at risk and our precious frontline staff under unacceptable pressure. More departures of experienced NHS clinicians, who feel unable to offer safe care with the resources available to them and are then criticised in bruising investigations, will only accelerate the cycle of damage to care provision. Something has to change.