Eve Mitchell

Claire, I am so sorry you feel like this. As I reflect on your words and feelings it makes me think of the three psychological phases of crisis: 1) Emergency where we have shared goals and a sense of urgency which make us feel energised, focused and even productive, which then moves to 2) Regression, where we realise the future is uncertain and lose the sense of purpose, feel tired, irritable, withdrawn and less productive (which is where so many of us seem to be right now) and then to 3) Recovery, where we begin to reorient, revise our goals, roles and expectations, and focus in moving beyond rather than in getting by. My question is how do we work to take the positive from all that has happened so we have ‘post traumatic growth’ rather than distress. Leaders have a choice to support their teams and to codesign  a future that works and is stronger. I hope they use their choices wisely.

The SNCT tool has a number of benefits and limitations as identified by the study. The authors report that the actual and required staffing levels varied considerably between the hospital trusts, between wards within trusts and also within wards, which we also identify using Establishment Genie across all settings of care (and is one of the reasons we created the Genie).

The levels of variation don't always make sense even when professional judgement is applied, and are often more to do with subjective judgements on acuity and dependency based on experience, risk aversion, or other environmental or organisational factors. The SNCT tool measures 'on the day' and so planning an establishment for a new model of care or service is not possible, and every day we are seeing necessary changes in the delivery of care through increased access and use of technology, changed roles and responsibilities, and different working practices.

Safety of our patients and our staff should be paramount in establishment setting. An 'on the day' tool used for 30 consecutive days to review the establishment is a good start and temperature check, but should not be used in isolation. Triangulating with other tools, peer review, benchmarking, and most importantly measuring and tracking patient and staff outcomes is the best way to design and measure an appropriate establishment to ensure we are able to deliver safe care.

However, we must also make sure that we do not close our eyes to new ‘untested’ models of care, and we learn to embrace and adapt to new possibilities as the health and care landscape continues to change. Traditional workforce models are unsustainable based on current demand and capacity, and unless we try something different our system will become so rationalised that care from cradle to grave will be a forgotten dream rather than a celebrated reality.

Many organisations, like East London NHS FT (ELFT) publish information about their staffing in terms of 'fill rates' - the difference between planned and actual staffing - and also using 'Care Hours Per Patient Day' (CHPPD). However, as can be seen by the published data, this doesn't really tell us very much about staffing capacity or capability, more whether there were more or less staff on the units than planned in the roster - and in the majority of cases in ELFT this shows that the units were 'over-filled' with staff i.e. more staff than planned were distributed to each area. So, this begs the question whether the plan was right in the first place?

If we wind our memories back to the Keogh Mortality Review, there was a recommended ambition that "nurse staffing levels and skill mix will appropriately reflect the caseload and the severity of illness of the patients they are caring for and be transparently reported by trust boards." It is hard to see how data on over- or under- filling against a roster gives transparency to the board if they do not know what was being filled in the first place, or on the acuity and dependency of the patients being cared for. 

The NQB guidance, first published in 2013, was updated in July 2016 with additional guidance to help organisations think about their workforce to include questions and inclusion of outcome measures and measures of patient safety https://www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf  

We need to remember that the purpose of the recommended bi-annual establishment review is to ensure that the Executive Board is satisfied that nursing and midwifery staffing is set at an appropriate level to deliver safe care. This does not mean that we should not monitor our fill-rates and CHPPD monthly, but does mean that we need to be sure that our workforce plan is appropriate through understanding and comparing our levels of care both internally and with peers, looking at our outcome measures, and through thinking about the training and skills that are required now and into the future so our staff both within and outside of organisational boundaries have the skills, capability, capacity and support to deliver great, safe, person centred care whatever the setting.