Written evidence from Royal College of Nursing (UEC0009)

1.0              Introduction

1.1               With a membership of more than 410,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world.  RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

1.2              The RCN welcomes the opportunity to respond to this one off inquiry into urgent and emergency care and the recent performance of Accident and Emergency (A&E) units.

2.0              Executive summary

• The RCN welcomes Sir Bruce Keogh’s review of urgent and emergency care currently underway, particularly its focus on developing new models of care. The RCN believes a new model of the emergency care system should maximise the potential of the nursing workforce if it is to provide safe and effective care for patients.

• Funding for emergency care should be continuous and forward-looking, rather than awarded as quick-fix solutions for crises which could be avoided through long-term planning and sufficient investment.

• The NHS needs to address the issue of staff vacancy rates as a matter of urgency.

• Investment is needed in community and preventative care to take the pressure off A&E departments and reduce the ‘revolving door’ effect of repeat admissions to hospital.

• The recommendations of the Design Council for reducing violence and aggression in A&E should be rolled out across England, to make the environment calmer and safer for patients and staff.

3.0              Keogh review into urgent and emergency care

3.1              The RCN welcomed Prof Sir Bruce Keogh’s first report in November 2013 setting out his vision for transforming the provision of urgent care. Services in their present shape are unsustainable and if the report’s recommendations are implemented, they will go some way to addressing the challenges facing the NHS.

3.2              No part of the health service operates in isolation and the RCN has consistently supported a system-wide approach to dealing with problems. This was echoed by Prof Sir Bruce Keogh in his report recommendations. 

3.3              It is clear that the health service was not set up and is not able to deal with an ageing population. The RCN believes that providing better support for people to self-care would take pressure off the health care system and allow nurses to care for those most in need.

4.0              Additional funding and 2012-13 winter performance of A&E 

4.1              Significant investment is needed to help ease the overwhelming pressure that services and staff are currently experiencing. The RCN believes this funding needs to be continuous and form part of a long term plan, rather than the short term ‘quick fix’ approach of providing one off sums in times of crisis.

4.2              The RCN called for clarity on where and how the additional funding would be spent to ensure it has the greatest benefit at a local level and we would welcome a response from Professor Sir Bruce Keogh to this question.

5.0              New models of care

5.1              The RCN welcomes the focus of Sir Bruce Keogh’s review of urgent and emergency care on developing new models of care.

5.2              New models of care delivery are required because the current emergency care system is outdated and operates without capacity for contingency. This is reflected in NHS England’s recent performance data.[1]

5.3              Models of care which maximise the potential of the nursing workforce are key to viable, safe and effective urgent and emergency care. Nurse led care, ambulatory emergency care, anticipatory care and hospital at home models all mobilise nursing expertise outside of traditional emergency departments. If invested in, these models would significantly improve patient flow.

5.4              The involvement of nurses on the core working groups at NHS England should be increased to reflect the proportion of the urgent and emergency care workforce that are nurses.

6.0              Staffing levels and quality of care

6.1              The RCN believes understaffing is the single biggest challenge facing the NHS today.

6.2              Emergency admissions to hospitals in England have risen year on year, increasing 31 per cent between 2002/03 to 2012/13. Performance data supports what nurses have been reporting to the RCN for a long time: while emergency admissions are increasing, staffing levels are declining. Evidence shows an irrefutable link between staffing levels, patient safety and quality of patient care.[2]

6.3              On average, A&E departments are 9.8% short of their full complement of doctors and nurses. For consultants alone, the vacancy rate is 14.2%. More than two-thirds of hospital trusts have a vacancy rate higher than 5%. The five hospital trusts with the largest proportion of vacant posts were in London. Barking, Havering and Redbridge University Hospitals Trust has 43% of its budgeted posts vacant[3].

6.4              While the RCN was pleased to see the Secretary of State commit to hiring 3,700 extra nurses in the NHS[4], the RCN’s recent Frontline First report Running the Red Light revealed that there are nearly 20,000 nursing posts currently left unfilled[5]. What is needed is an immediate boost to nursing numbers as part of a longer-term approach to workforce planning, with increased nurse training places so that NHS Trusts are able to recruit more nurses when they need to without having to rely on overseas workforces.

6.5              The RCN report shows that the impending crisis in the supply of registered nurses will result in a likely shortage of 47,545 registered nurses by 2016. Following the Health Secretary’s announcement that NHS trusts must regularly publish their staffing level data on a ward-by-ward basis, there is now an easy and transparent way of monitoring safe staffing levels, but it is essential that staff are recruited to fill vacant posts.[6]

6.6              Vacancy rates are a key indicator of the distance between the number of staff in post and the number needed to ensure patient safety and quality of care. The RCN is concerned that the Department of Health stopped collecting vacancy data in 2011. The last available data suggested the vacancies for nursing posts were 2.5 per cent. Evidence collected by the RCN shows current vacancy rates to be around 6%. This is an issue that the NHS desperately needs to address.[7]

7.0              Care in the community

7.1              The RCN believes that having the right numbers of staff with the necessary skills to deliver care in the community would relieve some of the strain experienced in emergency units. However, in the last decade numbers of district nurses, who can deliver care in the community and prevent unnecessary hospital admissions, have reduced by 40%[8].

7.2              In the last three years a quarter of walk-in centres have closed and cuts to social care budgets have made it difficult to discharge older patients from hospital. This can result in a ‘revolving door’ effect, where healthy patients are discharged from hospital only to be readmitted days or weeks later due to in adequate community care and support. 

7.3              Better health and social care provision in the community is vital so patients can be assessed and treated appropriately and so that hospital staff can confidently discharge patients knowing they will receive the care that they need in the community. Nurses see the revolving door effect all too often and it has a negative impact on morale.

7.4              Without significant investment in community services and preventative care, it is likely that A&E units will continue to take on avoidable admissions from patients who have nowhere else to go.

8.0              A&E workplace environments

8.1              Evidence first identified in the 2009 Boorman review of the health and wellbeing of NHS staff linked investment in staff health and wellbeing with better patient outcomes.

8.2              The review demonstrated that with appropriate investment in maintaining staff health and wellbeing, recurring savings of £555 million a year could be made across the NHS. It showed that even in times of economic uncertainty, NHS organisations cannot afford to take their eye off protecting and promoting the health, safety and wellbeing of staff[9].

8.3              A major cause of distress, injury and absence to nurses working in A&E is exposure to physical and verbal abuse. 

8.4              The RCN welcomed the Design Council’s project on reducing violence and aggression in A&E, which sought design solutions to make A&E departments calmer and safer for patients and staff. 

8.5              The evaluation report into the project was published in December 2013[10] and found that measures introduced at the pilot sites resulted in:

• a 50% reduction in threatening body language and aggressive behaviour towards staff
• improvements in patient experiences e.g. improved signage reduced their frustration during waiting times
• A reduction in patients’ complaints relating to information and communication
• For every £1 spent on improvements, £3 was generated in benefits

January 2014