Thursday, 22 December 2016

The guideline must be built!

Thanks to @ShaunLintern and @SJaneBernal for sharing the new ‘Safe staffing improvement resources: learning disability services’, published by NHS Improvement on 21st December. This blogpost contains some quick first impressions based on a skim reading, mainly in the hope of bringing more people’s attention to this. The resources include an ‘improvement resource’ with appendices, and a separate rapid mixed methods systematic review conducted by the University of West London.

Before getting into the documents themselves, I must say that I have a bit of a bee in my bonnet about the phrase ‘safe staffing’ and safe staffing levels. Among many other things, #JusticeforLB showed us that there is no such thing – Connor Sparrowhawk died a preventable death in a highly staffed unit stuffed with specialists. There may well be levels of staffing below which a service can be guaranteed to be unsafe, but there is no level above which a service can be guaranteed to be safe. And in services for people with learning disabilities, for me this isn’t idle semantic pedantry – commissioners, NHS Improvement and others are always looking for easy proxy measures of ‘quality’ or ‘safety’ so they don’t have to confront the reality of people’s lives in these services.


In looking at these documents, I’m going to start with the rapid systematic review, conducted by Mafuba, Gates and Sivasubramanian – there is a reason for this that will hopefully become clear later. The first thing that struck me (and this applies throughout all the resources) is how staff-centric the review is, presumably based upon the terms set by NHS Improvement. The terms of the review are described as follows:  “The current literature review is more broadly based, regarding the interdisciplinary range of staff working in learning disability services, and needed to consider the sustainability of these staff within a framework of compassionate, safe, effective and efficient care.”

Quite a tough brief, given the state of the published evidence and the time the authors were presumably given to conduct the review. The full brief and the review largely exclude the voices of people with learning disabilities and family members – for example the review actively excluded 9 papers because they focused on the views of adults with learning disabilities (families aren’t even mentioned). This slant towards staff perspectives is exacerbated by the reviewers deciding that “…because of the dearth of empirical studies that specifically addressed the objectives of the current review, opinion papers (published in peer reviewed journals and unpublished) were included.” So the ‘evidence’ admissible to be reviewed contains large slugs of professional opinion, including professionals working in those very inpatient services that are supposed to be drastically reducing under NHS England’s Transforming Care/Building The Right Support.

Reflecting the state (as in ‘Just look at the state of your bedroom’) of the literature, the material included in the review is incredibly heterogeneous. Given there were only 37 publications included in the review, the decision to exclude 17 publications concerning social or community care seems odd, as was the decision to exclude anything published before the year 2000, which excludes a whole strand of UK research relating to staffing levels, staff behaviour and the lives of people with learning disabilities in housing services conducted mainly in the 1980s and 1990s. This strand of research clearly established that, in a range of types of residential care and supported housing for people with learning disabilities in the UK, there was no relationship between higher staff ratios and better lives for the people living within them. A higher staffing ratio was no guarantee of a more active life, more engagement in people’s local communities, or more choice (Felce & Emerson, 2005). And of course, in inpatient services higher staff ratios may be a consequence of service failure, in a self-fufilling vicious spiral (a person becomes more distressed by being put into an inpatient service, the answer is more staff to follow them around and restrain them, the person becomes more distressed as a consequence, the answer is…).

Experts by experience?

The findings are unsurprising and (initially) pithily expressed: “No empirical evidence was located that directly relate to sustainable safe staffing.”

But of course, stopping there would derail the whole machinery of guideline production. A guideline must be produced, and minor details like a complete lack of evidence upon which to base a guideline can’t be allowed to get in the way (I’ve been involved in similar processes so this is a criticism of myself as much as anyone else). What this means is that the production of these guidelines becomes a hermetically sealed jar of professional opinion, created from ‘experience’: “While there is little previous research and a lack of strong evidence in this area, many professional publications identify experience-based strategies and indicators related to safe and sustainable staffing.”

Is this a problem? After all, professionals are the experts, right? Well, particularly when it comes to inpatient services for people with learning disabilities, it’s not as simple as that.

First, inpatient services have been around for a long time, and are highly resourced with psychiatrists, clinical psychologists and others for whom research is supposed a part of the skillset. If this is the case, why isn’t there a substantial research literature already on staffing in inpatient services? 40 years ago, there were national minimum standards set for doctor : resident ratios in learning disability hospitals (1 doctor per 250 residents, 3 out of 61 big hospitals failed this standard), and for nurse : resident ratios (1 nurse per 4.4 residents, 3 hospitals failed this standard too). Now there is no equivalent data for inpatient services across England, and very little work investigating what happens in inpatient services, with what staff, with what effect in terms of the lives of people using them? Would independent sector and NHS services routinely reveal what staff (of what type, at what grades) are actually working in inpatient services day by day, or is that now in the realm of ‘commercially sensitive’ information for fear of exposing to commissioners and the public gaps between what’s being paid for and what’s actually happening?

Second, most obviously, a lot of bad stuff happens to a lot of people with learning disabilities in inpatient services, either actively at the hands of staff (seclusion, restraint, antipsychotics and rapid tranquilising medication) or through neglect/inattention (most obviously, people dying). Despite five years of national policy to close a large proportion of these inpatient services, there is little progress, partly due to the resistance of many of the professionals employed in these services, who invoke ‘complexity’ with little evidence to back them up. I’m not convinced that professionals who preside over these services should be the only voices at the table when it comes to guidance on staffing.

Good things are good things

Coming to the ‘improvement resource’ itself (finally!), I must admit to being a bit bemused. I’ve only had a quick look, but I’m struggling to identify much content that sets a clear direction. I find it useful applying  Simon Hoggart’s law of the ridiculous reverse to this stuff, “When I hear resounding stuff like this I mentally reverse it, since it's a good rule that if the opposite of something is absurd it wasn't worth saying in the first place.”

Try it on the following quotes. This one, from the introduction, invokes ‘complexity’ again – note here that this ‘complexity’ is all about fragmented service systems (which presumably someone could do something about if it’s that much a problem, rather than assuming this is a fixed feature of the landscape?):
“Sustainable safe staffing in learning disability services must take account of the complex nature of the care models and the number and skill mix of professionals and agencies involved in meeting the healthcare needs of people with a learning disability.”

“Workforce planning should be an integral part of an organisation’s strategy.”

On a quick read, the whole document is like this, expressing the view that good things should be good things, without any recognition of why services aren’t doing these good things already.

Within the resources available…

There is a very characteristic rhetorical push and pull throughout the document, that gives with one hand and takes away with the other. Take this quote from Section 2: Right Staff:
“There must be sufficient and sustainable staffing capacity and capability in learning disability settings to provide safe and effective care to patients at all times. These decisions must take account of the financial resources available, so that high-quality care can be provided now and on a sustainable basis”.

The ‘Right skills’ section starts with this statement on context:
“New models of transformed and integrated care will rely on healthcare professionals providing expert care to more people at home ‘living in the community’ alongside families, personal assistants and social care providers. Learning disability services need to respond to the increasing complexity of need. Clinical intervention should always be based on ensuring safety, minimising risks, reducing health inequalities and improving health outcomes within the resources available.”

I don’t really know where to start with this statement. Why is ‘living in the community’ in quotation marks? What are these ‘new models of transformed and integrated care’ – the vast majority of adults with learning disabilities already live with their families or in supported housing/residential care, where they should be getting some support from community teams? What are the ‘risks’ to be ‘minimised’, and what about supporting people to lead fulfilling lives?

And in the most sinister turn, always the phrase at the end that negates the rest of the sentence -  ‘…within the resources available’. What if the resources aren’t available? Who is responsible for making sure the resources are available, and what happens if they don’t? I find it alarming that a resource on safe staffing seems to imply that safe staffing is conditional on the resources being available.
A number of recommendations in the document that could be positive are also written in ways that make me worry about their consequences in a ‘within the resources available’ world. So, for me there is some attraction in the recommendation of having flexible banks of staff to support people in times of crisis without them having to be shipped off to inpatient units, but at the same time is this a route to a zero hours staff cadre who only react to crises rather than proactively support staff to reduce the chances of going into crisis in the first place?

Similarly, the ‘Right place, right time’ section is almost wholly about reducing inefficiencies and costs. It makes sense to make the experience of getting support as smooth as possible for people, but the section is framed in terms of staff productivity rather than what support will work best for people with learning disabilities. Quotes from a focus group of people with learning disabilities are included at various points in the document, but the content of the document doesn’t match what people with learning disabilities are saying they want/need.

Don’t mention the nurses

Another consistent theme throughout the resource is to not mention professional groups or professional training wherever it can be avoided, presumably with the aim of deprofessionalising the workforce to the cheapest level possible. This, from section 3 on ‘Right skills’:
“We need to build an adaptable contemporary workforce to respond to the changing world as a profession, using our resources wisely, while ensuring that careers remain attractive and accessible to all. Our ability as a profession to adapt and innovate is critical to achieving high-quality care in the right place and at the right time. By modernising, we can shape a workforce that is fit for purpose for the next decade and beyond and positively demonstrate care, outcomes and experience for those for whom we care.”

What the quote above seems to mean is a route to de-professionalisation. Given the stranglehold of some professions on the direction of services for people with learning disabilities, this might not always be a bad thing. But the ‘generic role templates’ mentioned in the resource are not reassuring, providing five templates from ‘Support Worker’ (level 3) to ‘Advanced Practitioner’ (level 7) with very long lists of largely unspecific professionally derived core competencies which do not include the core competencies of staff that people with learning disabilities and families are looking for.

This avoidance reaches some sort of peak in the discussion of liaison roles. There is some consistent evidence that specialist learning disabilities liaison nurses, in both acute general hospitals and primary care settings, have a positive impact on the healthcare provided to people with learning disabilities. However, the resource stops short of any requirements or even strong recommendations with respect to liaison nurses, and the document itself studiously calls them liaison practitioners, avoiding any mention that they are overwhelmingly nurses:
“Commissioners and workforce planners should consider the importance of providing these posts in a range of services including primary healthcare, acute physical healthcare, mental healthcare and forensic/prison healthcare.”

In the ‘right staff’ section, the document says this:
“It is predicted that there will not be enough learning disability nurses and other professionals with experience of learning disability in the future. NHS organisations must promote this career choice and closely monitor those entering graduate placements as well as considering alternative routes to qualification.”

There aren’t enough now, and the number of learningdisability nurses in the NHS has been plummeting in recent years. No mention of those publicly available facts – who are these ‘other professionals’ going to be in the future?

Bizarrely, the section on learning disability inpatient services doesn’t talk about staffing at all, simply restating other documents’ recommendations about the number of inpatient places ‘needed’.

How will they know?

The final major section of the resource concerns the ‘Safe staffing dashboard’, asking crucial questions about how to check that services for people with learning disabilities are ‘safe’ and what to do with that information. My heart sank at the ‘dashboard’ word though, heavily conditioned by my reading of years’ worth of Southern Health Board papers for #JusticeforLB. These Board papers had dashboards a gogo, some of them measuring (or mismeasuring) exactly the proxy indicators for ‘safe staffing’ recommended by NHS Improvement here. Southern Health said they were doing all the walk-rounds and other ‘assurance’ practices presented here, and yet we know from the Mazars report how the practices of Southern Health were the very opposite of ‘safe’.

Below is the list of ‘measures that matter’ (yes, the Draft watermark is on the final publicly available version) – are these really going to get to the bottom of unsafe staff practices when the management are determined to look the other way?

And what are NHS Improvement going to do about it? For some years, NHS Improvement have had a good set of six questions about reasonable adjustments to health services for people with learning disabilities. Every 3 months, all NHS Foundation Trusts report to NHS Improvement if they’re meeting all six of the criteria set by these questions. The last time any data were made available (through a Parliamentary question – NHS Improvement do not publish these returns) every single NHS Foundation Trust reported that they were compliant with all six criteria – which is a patent nonsense. Do NHS Improvement check? Not as far as I can see. They are no doubt ‘assured’. The ongoing train wreck of NHS Improvement’s role in Southern Health, not to mention how they ‘handled’ the Mazars report, gives me precious little confidence that they will be fearless champions for patient safety. They will be much more interested in the finances, and use this guideline as another stick with which to beat NHS Trusts.

What does it all mean?

I’ve only had a skim read and I’m probably being a little unfair. One thing that worries me is that from a near complete lack of evidence, there is now a ‘thing’, an ‘improvement resource’, which will assume a reality far beyond its foundations. There are consistent themes of deprofessionalising the workforce, under the threatening shadow of ‘within the resources available’, on the hermetically sealed basis of professional ‘expertise’ in the very services that government policy says should be closing. There is no firm guidance here at all, with a shrugging of the shoulders about the dangerously fragmented service systems within which people live and staff work. The world of people with learning disabilities shrinks to one of being protected. And firm ideas about how to find out about safe/unsafe staffing and governance are there none.

So beyond the fact that there has to be a guideline, I’m struggling to see what impact this ‘improvement resource’ will have. Sorry – I think I need a mince pie.


Felce D & Emerson E (2005). Community living: Costs, outcomes, and economies of scale: Findings from UK research. In R.J. Stancliffe & K.C. Lakin (eds.), Costs and outcomes of community services for people with intellectual disabilities (pp. 45-62). Baltimore: Brookes.