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.
Evidence?
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.
