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Employ enough trained staff and engage with them better: key lessons of the Keogh Review

Roger Kline, 17 July 2013

See also our Duty of Care handbook and advice notes by Roger Kline with Shazia Khan

The key lessons of the Keogh Review into 14 NHS Trusts were drowned out yesterday when Government and Opposition politicians responded to its publication by acting out a blame game.

In fact, this is an excellent report, criticising poor care but full of praise for NHS staff. It identifies concerns about staffing levels, skill mix, support for staff and a fear of raising concerns - all of which impact on patient care and safety.

The Medical Director for NHS England reported:

1. Trusts were not being truthful about their staffing levels

“Contrary to the pre-visit data, when the review teams visited the hospitals, they found frequent examples of inadequate numbers of nursing staff in some ward areas. The reported data did not provide a true picture of the numbers of staff actually working on the wards.”

2. There were often not enough staff on duty and the skill mix was flawed:

“The review teams found inadequate numbers of nursing staff in a number of ward areas, particularly out of hours - at night and at the weekend.”
“This was compounded by an over-reliance on unregistered support staff and temporary staff.”

3. There was a link between staffing ratios and patient care

“Statistical analysis performed showed a positive correlation between the in-patient to staff ratio and a high HSMR (hospital standardised mortality rate) score.”

4. Staff engagement is not good enough and that hurts patients

“From talking to people in the 70 focus groups we conducted as part of the review, it was clear that staff did not feel as engaged as they wanted or needed to be: yet academic research shows that the disposition of the staff has a direct influence on mortality rates.”

5. A climate of staff fear continues in too many trusts.

“During several of the reviews, staff came forward to tell the review teams about their concerns in confidence. These staff felt unable to share their anxieties about staffing levels and other issues with their senior managers, which suggested that staff engagement at some of the trusts was not good.”

NHS staff do not go to work to cause harm. As the report concludes:

“We also found numerous examples, in every hospital we visited, of staff working extremely hard to deliver great care for their patients. Many patients and former patients told us about staff who had ‘gone the extra mile’ to be kind and generous or to save their lives or those of their families.

Too many NHS leaders see staff as a cost but not an asset. Yet the evidence is overwhelming: treat staff better and they care better for patients; engage with staff and don’t tolerate bullying and it becomes much easier to create a health environment where staff admit and report mistakes and learn from them. 

Keogh is by no means the first to draw those lessons. For example, in his first report into failings at the Mid Staffs NHS Trust, Robert Francis found “the overwhelmingly prevalent factors were a lack of staff, both in terms of absolute numbers and appropriate skills, and a lack of good leadership”. (Francis Report, 2010. P.186 Vol 1.)

But just because the NHS has failings does not mean it is failing. As Keogh made clear:

“The NHS embodies the social conscience of our country. Every week, our NHS positively transforms the lives of millions of people and we should be deeply proud of this fact. Sadly, there are times when the NHS falls well short of what patients and the public rightly deserve. The harrowing accounts set out by Robert Francis in his two reports into the failures at Mid Staffordshire NHS Foundation Trust highlight the lasting physical and emotional damage we can cause to patients and their families when we get things wrong and fail to make quality our primary concern.

“Our NHS is the only healthcare system in the world with a definition of quality enshrined in legislation. It is simple. An organisation delivering high quality care will be offering care that is clinically effective, safe and delivering as positive an experience as possible for patients. These are not unreasonable expectations. The NHS should be good in all three. Being good in one or two is simply not good enough.”

Those problems must be solved, which means acknowledging them and examine their causes rather than engaging in the political ping pong we saw yesterday.

If we are serious about improving the care and safety of patients we have to treat NHS staff – all NHS staff - better. The 2012 NHS staff survey showed how far we have to go in many Trusts.

If you really care about NHS patients, then NOW is the time to prioritise that work, Mr Hunt.

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