In short supply: pay policy and nurse numbers

In April 2017, the House of Lords Select Committee on the Long-Term Sustainability of the NHS concluded that the biggest internal threat to the sustainability of the NHS is the lack of a comprehensive national strategy to secure the NHS and care system the workforce it needs. This briefing, and its two supplements, examines two of the most important issues in workforce policy today which pose both immediate and long-term risks to the ability of the NHS to sustain high quality care: staffing numbers and standards and the future of NHS pay policy. It highlights that the lack of a coherent workforce strategy which is integrated with funding plans and service delivery models is one of the Achilles heels of the NHS.

Staffing matters: funding counts: workforce profile and trends in the English NHS

Health care is labour intensive, regardless of the nature of the health system, its structural characteristics, levels and sources of funding, or political underpinnings. The effective delivery of care requires decisions to be made about how much funding to allocate to staffing and what mix of skills to deploy. At the same time, quality of care relies on the number and skills of the people providing it. But staffing is not just about numbers. High levels of morale and engagement are vital to the delivery of good quality care, free from avoidable harm. This report examines the salient features of the health care workforce in England and reviews associated health labour market trends and dynamics. It also explores some specific health care workforce 'pressure points' for the NHS in England, where workforce profile and effectiveness is at risk and which require attention from policymakers.

Ethnic and social inequalities in women's experience of maternity care in England: results of a national survey.

OBJECTIVE: To examine ethnic and social inequalities in women's experience of maternity care in England. DESIGN: A 2007 national survey of women (16 years or over) about their experience of maternity care. Multiple logistic regression analysis, controlling for several maternal characteristics, was used to examine inequalities by ethnicity, partner status and education. SETTING: Sample of records of 149 NHS acute trusts and two primary care trusts (PCTs) providing maternity services in England. RESULTS: A total of 26,325 women responded to the survey (response rate 59%). Ethnic minority women were more likely than White British women to access services late, not have a scan by 20 weeks, and experience complications during pregnancy and birth. They were more likely to initiate breastfeeding and say they were treated with respect and dignity. Single women responded more negatively to almost all questions than women with a husband/partner. They were less likely to access care within 12 weeks of pregnancy (OR 0.45, 95% CI 0.39-0.52), have a scan at 20 weeks (OR 0.49, 95% CI 0.39-0.63), attend NHS antenatal classes (OR 0.56, 95% CI 0.49-0.65), have a postnatal check-up (OR 0.67, 95% CI 0.60-0.75), and initiate breastfeeding (OR 0.57, 95% CI 0.51-0.62), and were more likely to experience complications. Women completing education at 19+ years were more likely to access services early (OR 1.21, 95% CI 1.04-1.40), attend antenatal classes (OR 1.48, 95% CI 1.31-1.67), have a postnatal check-up (OR 1.19, 95% CI 1.07-1.32) and initiate breastfeeding (OR 3.88, 95% CI 3.56-4.22) than those completing education at 16 years or younger, and were less likely to experience complications. CONCLUSIONS: Ethnic minority women, single mothers, and those with an earlier age at completing education access maternity services late, have poorer outcomes, and report poorer experiences across some--though not all--dimensions of maternity care. Ethnic differences were absent or inconsistent between groups for some aspects of care. We recommend these findings are used by commissioners, trusts and healthcare professionals to inform improvements in maternity services for high-risk groups and reduce inequalities.

Do associations between staff and inpatient feedback have the potential for improving patient experience? An analysis of surveys in NHS acute trusts in England.

OBJECTIVE: To examine whether staff feedback on quality, safety and workforce issues is reflected in patient-reported experience. SETTING: 166 NHS acute trusts in England. PARTICIPANTS: Respondents to the 2006 surveys of adult inpatients and staff in 166 NHS acute trusts in England. METHODS: Multiple linear regression was used to model the relationship between responses by "frontline" staff and inpatients at trust level. Staff survey items were the explanatory variables and inpatient responses the dependent variables. Adjustments were made for location (London and non-London) and trust type. RESULTS: 69 500 staff and 81 000 patients responded to the surveys. There were several significant associations between staff and patients' responses, including that staff availability of hand-washing materials was positively associated with patient feedback on cleanliness and hand washing by doctors/nurses (p<0.00). It was a significant predictor of patient experience also in several other models. Other significant predictors of patient experience were managerial support, witnessing and reporting of errors (positively associated with patient experience), working extra hours and stress (negatively associated). London trusts performed worse on patient experience than trusts outside London and specialist trusts performed better than other acute trusts. CONCLUSIONS: Staff feedback was associated with patient-reported experience. Positive staff feedback on availability of hand-washing materials was broadly reflective of positive patient experience. Negative staff experience was reflected in poorer patient experience and vice versa. Although we cannot demonstrate causality, the consistent direction of the findings is indicative of it. Management boards of trusts and clinicians and other staff should monitor and act on the results of their staff surveys. This has the potential for improving quality, safety and patient experience.

Do patient surveys work? The influence of a national survey programme on local quality-improvement initiatives.

OBJECTIVES: To assess current attitudes towards the national patient survey programme in England, establish the extent to which survey results are used and identify barriers and incentives for using them. DESIGN: Qualitative interviews with hospital staff responsible for implementing the patient surveys (survey leads). SETTING: National Health Service (NHS) hospital organisations (trusts) in England. PARTICIPANTS: Twenty-four patient survey leads for NHS trusts. RESULTS: Perceptions of the patient surveys were mainly positive and were reported to be improving. Interviewees welcomed the surveys' regular repetition and thought the questionnaires, survey methods and reporting of results, particularly inter-organisational benchmark charts, were of a good standard. The survey results were widely used in action planning and were thought to support organisational patient-centredness. There was variation in the extent to which trusts disseminated survey findings to patients, the public, staff and their board members. The most common barrier to using results was difficulty engaging clinicians because survey findings were not sufficiently specific to specialties, departments or wards. Limited statistical expertise and concerns that the surveys only covered a short time frame also contributed to some scepticism. Other perceived barriers included a lack of knowledge of effective interventions, and limited time and resources. Actual and potential incentives for using survey findings included giving the results higher weightings in the performance management system, financial targets, Payment by Results (PbR), Patient Choice, a patient-centred culture, leadership by senior members of the organisation, and boosting staff morale by disseminating positive survey findings. CONCLUSION: The national patient surveys are viewed positively, their repetition being an important factor in their success. The results could be used more effectively if they were more specific to smaller units.

Overseas mobility of U.K. based nurses.

This paper examines trends in international mobility of U.K. nurses. Inflow and outflow of qualified nurses from the U.K. are assessed, and source and destination countries identified. The reasons for mobility are also examined. The paper reveals that mobility of nurses to and from the U.K. has declined in the 1990s, after having increased markedly in the late 1980s. Mobility to and from North America and Australasia has reduced significantly, as a result of organisational change and reduced career opportunities, whilst inflow and outflow to and from other European countries has remained more static, but at a lower level.

Managing nurse absence.

Examines in detail the issue of absence among nurses in the National Health Service (NHS) in the UK. Three main objectives are to: investigate levels and reasons for absence among nurses; assess the abilities of NHS management to monitor and control nurse absence effectively; and examine the impact of nurse absence on organizational costs and care delivery. Draws on data generated from four linked studies: a survey of back-injured nurses, conducted in 1992; a survey of 4,000 qualified nurse members of the Royal College of Nursing, conducted in March/April 1993; a postal survey of 119 NHS employing units, conducted in May/June 1993; and detailed case studies, conducted with management in ten NHS hospital sites in May/June 1993.

Sickness absence and health at work in the NHS.

Presents summary results from two surveys which the Institute for Employment Studies conducted in 1994 for the Health Education Authority. The first of these surveys reports national benchmarking data on rates of sickness absence and accidents at work in NHS provider and purchaser organizations. The second survey concerns implementation of the Health at Work (HaW) in the NHS initiative in NHS hospital worksites. Discusses structures and processes of HaW implementation.

The international mobility of nurses: a United Kingdom perspective.

This paper examines available information on the flows of qualified nurses to and from the United Kingdom, and reports on the results of a questionnaire survey of U.K.-based nurses who had worked abroad. The data examined reveals an upward trend in both "inflow" and "outflow" of nurses in the period 1984-91, with indications of a net outflow. The survey results indicated that Australia was the most common destination; most nurses working abroad had moved to the English-speaking countries of North America and Australasia. Barriers and incentives to international mobility of nurses are discussed, and likely future trends in mobility are examined.