Following on from the Francis and Berwick reports, the Department of Health and NHS England asked NICE to develop evidence-based guidelines to advise the NHS about safe staffing.

Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE said: “Safe staffing is more complex than setting a single ratio. The emphasis should not just be on the available number of staff, it should be on delivering safe patient care and making sure that hospital management and nursing staff are absolutely clear on best practice to do this.”

The guideline states that patient needs must come first when making decisions about safe staffing for nursing on acute wards. It sets out ‘red flag events’ which warn when nurses in charge of shifts must act immediately to ensure they have enough staff to meet the needs of patients on that ward. ‘Red flag events’ include patients not being provided with basic care such as pain relief or help to visit the bathroom. An appropriate response could be to provide more skilled nurses or increase numbers of staff.

The guideline also identifies measures that can be used by management to help determine whether staffing on each ward is meeting expected standards. These ‘safe nursing indicators’ include incidents affecting patient safety such as falls and pressure ulcers or staff reported outcomes such as missed breaks and overtime.

Miles Scott, Chief Executive Officer, St George’s Healthcare NHS Trust said: “Acute wards see a variety of patients, from appendicitis to broken bones, from young to very old, and each individual has very different needs. The guideline clearly sets out the factors that must be taken in to account to work out what is the adequate skill level and number of nursing staff required on that particular ward. Safe staffing needs to be about ensuring you have the right staff, in the right place, at the right time, to give patients the care they need and deserve.”

Patients’ needs differ from day to day and there is no single staff number that can be safely and adequately applied across the wide range of wards in the NHS. The committee concluded that when each registered nurse is caring for more than 8 patients this is a signal to check that patients are not at risk of harm. At this point senior management and nursing managers should closely monitor red flag events, analyse safe nursing indicator data and take action if required. No action may be required if patient needs are being adequately met.

Professor Leng said: “Safe care is also a good investment and, following Robert Francis’ report, a lot of trusts have already put plans in place to ensure safe numbers of staff are available.”

Between March 2013 and February 2014, registered nurse numbers increased by approximately 3% (full time equivalents, FTEs) and healthcare assistant numbers also rose by approximately 7% (FTEs).

Professor Leng added: “The current national cost for nursing staff in acute wards is estimated at around £4 billion. Implementing the NICE guideline is unlikely to have significant financial impact in many trusts, as they may simply need to adapt their processes to work out where nursing staff should be at any given time. Nor will any financial impact be felt in a one year period. Many trusts are already rolling out planned staffing changes, which will spread the cost across a number of financial years. The expected increased training numbers for nursing staff will also see a gradual increase between now and 2017*.”

Precise estimates of the cost of the guideline nationally are very difficult to produce because of local variation, because changes are already being made, and because of the impact of safe staffing on reducing errors. The important estimates are those that will be made by individual hospitals. We think that it is possible that a headline additional cost of around 5% (around £200m) could be incurred, building up over more than one year, but it could well be less. In any event, over time, the savings from safer care will be significant and may even match or exceed the upfront cost.

For instance, reducing the number of infections patients get after surgery could save up to £700m a year alone. For every fall avoided because a nurse was available to help a patient to the bathroom another £1,400 is saved.

Professor Leng added, “The NHS cannot afford to be unsafe – neither morally nor financially. The benefits of better care, such as cost savings that could be achieved from dealing with fewer infections, falls or pressure ulcers, will go a long way to helping hospitals balance limited budgets.”

To support use of the guideline a new endorsement process will be applied to staffing decision support toolkits to highlight those that are consistent with the recommendations.

NICE has also issued separate information for members of the public to explain the guideline and help make sure they are aware of the quality of care they deserve.

Jean Gaffin, patient representative on the safe staffing advisory committee said: "Every hospital patient and hospital visitor has sat and watched what goes on in their ward. I have, and I have seen how if the ward is well staffed the bell will be answered and there will be time for some moral support. I have seen nurses rushed off their feet with hardly time to do the basics let alone show the care and compassion patients need. This guideline on safer staffing takes the patient experience and uses evidence to advise all hospital trusts how to ensure there are sufficient nurses on every ward and on every shift. This is done by looking at the patients, identifying their nursing needs and building up from that. It encourages patients and relatives as well as front line nurses to alert senior staff when too few nurses leads to too little care. Once implemented this guideline will drive quality as well as safety in our adult wards."

Jane Cummings, Chief Nursing Officer for England, said: “Each ward needs the right team of staff to provide high quality care for their patients and their individual needs. This doesn’t happen by accident – it requires an evidence based approach, clinical judgment and regular monitoring, with the flexibility to quickly adapt to changing circumstances. NICE have brought together expert evidence to produce a set of guidelines that hospitals can use to ensure that patients are always at the centre of every staffing decision.”

Ends

For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.

Notes to Editors

*Reference: Health Education England workforce plan 2014/15

About NICE

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