Winter warner: increasing pressure on local health services

Local independent health provision is in crisis.

The vast majority of older people with long-term needs are looked after by non-statutory providers. Across this sector – and as we come into the challenging winter months – there is a 15% shortfall in staffing levels in nursing homes across Northern Ireland.

The Royal College of Nursing carried out a sectoral survey last year, which had a response rate of 85%, and found that providers are struggling to both recruit and to retain staff, bringing immediate pressure on the quality of care while also creating potentially bigger problems down the line.

The Bengoa report, an independent analysis on the future of the health service, is due to be published soon by new Health Minister Michelle O’Neill.

However, we are in a relatively odd situation - there is little doubt over what it will say about the big picture for local health services.

2011’s Transforming Your Care (TYC) and the subsequent Donaldson report, which was finished a year before the RCN paper, both say similar things. Bengoa will not differ much from their path.

They recommend sweeping reforms to service models and, in the context of independent care, the picture could not be clearer – provision closer to home (and outside of major hospitals) needs to have a much bigger role in how we care for the long-term sick or infirm.

Decisions will have to be made about how exactly much of this comes from independent providers and how much is direct public service but all indications so far is that non-statutory providers will have an increasing role to play.

Regardless, the sector as a whole will need to be able to cope with much greater demand than it currently faces. The fact it is on its knees at the minute is concerning.

Shortfalls

Never mind the future, with its anticipated and likely planned rise demand, services are risking unsustainability right now.

At the time of the RCN research there were “265 registered nursing homes with the capacity to provide care for 12,008 patients, three independent hospitals with the capacity to provide care for 121 patients and four hospices with the capacity to provide care for 65 patients, with extensive additional nursing care being provided in peoples’ own homes.”

Responders to the RCN’s call for evidence said they have 1,726 full-time nurses, and 1,016 registered part time, while 72.1% of facilities reported vacancies equating to 374 full-time-equivalent positions.

“The majority of reported vacancies are within nursing homes and equate to 15.1% of the reported nursing home workforce. Independent hospitals and hospices did not report significant recruitment and retention difficulties. The survey asked about the length of time positions were vacant and found that 41% of positions had been vacant for longer than six months… Furthermore, the vacancies that have existed from under three months to six months depict a steady flow of registered nurses leaving the sector.”

Interesting, regulators the RQIA appear to have shifted the goalposts on oversight of what comprises safe practice as pressures have increased.

According to the RCN paper:

“To inform the inspection process, the RQIA measures performance against care standards8 specific to each service. These care standards are developed by the DHSSPS and were recently reviewed in April 2015. During this review, the staffing standard statement was changed from: The number and ratio of staff to patients is calculated using a criteria determined by and agreed with the RQIA, to: The number and ratio of staff on duty at all times meet the care needs of residents.

“Subsequently, the RQIA has removed from its website the additional staffing guidance that had previously been used as a baseline to assess minimum staffing levels. This decision makes it fairly evident that the responsibility to determine safe and adequate staffing rests with the providers. The decision is questionable when we consider that neither the DHSSPS or the RQIA has given the providers any alternative guidance as to how they can determine what staffing is adequate, or how the RQIA as the regulator will judge if staffing levels are adequate. When we consider the importance of appropriate staffing to the delivery of care, it is difficult to reconcile this with the vacuum that has been created.”

Altogether the Royal College made a dispiriting assessment of non-statutory provision: “The independent nursing home sector in Northern Ireland is currently facing a significant registered nurse recruitment and retention crisis which shows little sign of recovery and is a direct result of poor or non-existent workforce planning by the DHSSPS. This situation is impacting negatively on both the registered nurses employed within the sector and the patients being cared for.”

This issue could meet a second problem, over time. If retention of new nurses is a disproportionate problem within this issue generally then the ongoing staff cohort will find its average age increasing.

Eventually there will be a raft of retirements of experienced nurses – their posts will both struggle to be filled if retention remains an issue, while the staff left behind will itself have huge gaps in experience due to the effects of poor retention over time.

Pathology

One of the ostensibly strange findings in the paper is that, as well as a general shortage of nurses, recruitment in the independent sector is being effectively undermined by statutory services

“The majority of respondents state that their biggest recruitment and retention challenge comes from the HSC trusts. Survey responses show that the majority of staff who have moved employer in the past 12 months have taken a position within a trust. The inability to compete with the terms and conditions and opportunities for career progression and development were largely viewed as the primary reasons for this continual exodus of staff to the trusts. In some situations, nursing recruitment by trusts has severely depleted registered nurse staffing to unsafe levels.”

This would be notable at any time but, in the context of plans to increasingly rely on the independent sector, it betrays a fundamental lack of forward thinking. And, it should be remembered, these problems with staff shortages do not begin and end with the work stress of nurses in the independent sector. Quality of care is diminished.

The RCN cites recent research that found “deaths are significantly lower in hospitals with fewer patients per nurse and more nurses educated to degree level” and “every one patient added to a nurse’s work load is associated with a 7% increase in deaths after common surgery and every 10% increase in nurses educated to degree level is associated with 7% lower mortality.

It goes on to say: “If all hospitals in the study had at least 60% of nurses educated to degree level and nurse workloads of no more than six patients each, more than 3,500 deaths a year might be prevented.”

This parallel study does not cover the local independent sector – but it does give an indication of the stakes involved with appropriate staffing in healthcare.

Underfunding

Underlying all these problems is what providers say is a chronic lack of financial resources.

Ultimately the trusts, Health Department, and Stormont itself, are not awash with cash and are struggling to make ends meet generally. So, instead of spending more, existing funds have to be spend more wisely.

Which brings us right back to health reform: TYC, Donaldson, and soon Bengoa. Per the RCN:

“The strategic direction mapped out within Transforming your Care concludes that there is an unassailable case for change with how we currently deliver health and social care to the population of Northern Ireland. The review highlights the existence of an ageing and growing population and provides statistical figures suggesting that by 2020 the number of people over 75 years will have increased by 40% and the population of over 85 year olds will have increased by 58%...

“This would suggest that successful implementation of the strategic direction mapped out within Transforming your Care is highly reliant on the commissioning of services from within the independent sector. It would therefore seem reasonable that the workforce requirements of a sector primarily concerned with the delivery of care to some of the most vulnerable people in our society should be included in regional workforce reviews conducted by the DHSSPS.”

The RCN called for a number of changes in practice: an increase in the number of nurses being trained; more funding for the independent sector; a broader, obligatory schedule of postings for new nurses (with rotation across all sectors, including independent providers); and better continuous professional development and career pathways for nurses, both in general and specifically within non-statutory settings.

These are all sensible suggestions but, unfortunately, there simply is no short-term fix.

Not much has changed in the 10 months since this RCN report and Northern Ireland is left hoping for a fair winter, in every sense.