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Consequences, costs and cost-effectiveness of workforce configurations in English acute hospitals

Consequences, costs and cost-effectiveness of workforce configurations in English acute hospitals
Consequences, costs and cost-effectiveness of workforce configurations in English acute hospitals
Background: the NHS faces significant challenges recruiting and retaining registered nurses (RNs). Recruiting unregistered staff is often adopted as a solution to the RN shortage, but recent research found lower RN staffing levels increase hospital mortality with no evidence that higher levels of assistant staff reduced risk.

Objectives: to estimate the consequences, costs, and cost-effectiveness of variation in the size and composition of the staff on acute hospital wards in England. To determine if results are likely to be sensitive to staff groups such as doctors and therapists, who are not on ward rosters, associations between staffing and outcomes for multiple staff groups, including medical, are explored at hospital level.

Design: a national cross-sectional panel study and a patient-level longitudinal observational study using routine data.
Setting: All English acute hospital Trusts and a subsample of four Trusts for the patient-level study

Interventions: naturally occurring variation in the size and composition of the workforce.

Participants: patients experiencing a hospital admission with an overnight stay and nursing staff providing care on inpatient wards.

Outcomes: death, patient and staff experience, length of stay, readmission, adverse events, incidents (datix), staff sickness, costs, and quality-adjusted life years (QALY).

Data sources: publicly available records of hospital activity, staffing and outcomes (cross-sectional study) and hospital administrative systems (longitudinal study).

Results: In the cross-sectional study, lower staffing levels from doctors and allied health professionals were associated with increased risk of death. Higher nurse staffing levels were associated with better patient experience and staff wellbeing. In the longitudinal study, for adult inpatients, exposure to days with lower-than-expected registered nurses or nursing assistant staff was associated with increased hazard of death (adjusted Hazard Ratio [aHR] 1.08/1.07, 95% confidence interval [CI] 1.07-1.09/1.06-1.08) and longer hospital stays. Low registered nurse staffing was also associated with increased hazard of readmission (aHR 1.01, 95% CI 1.01-1.02 . Eliminating low staffing cost £2,778 per QALY gained. Avoidance of RN understaffing gave more benefits and was more cost-effective for highly acute patients. Although high bank or agency staffing was associated with increased hazard of death, avoiding low staffing using temporary staff still reduced mortality but was more costly and less effective than using permanent staff. If costs of avoided hospital stays are included, avoiding low staffing generates a net cost saving. Exploration of thresholds for low staffing indicated a greater beneficial effect from registered nurse staffing higher than current norms.

Limitations: this is an observational study. Causal inferences cannot be made from these results in isolation. QALY gains were estimated, although conclusions are not sensitive to assumptions or discount rates. We used current ward norms as reference for low staffing.

Conclusions: Our results show the adverse effects of low nurse staffing but also show that medical and allied health professional staffing are important considerations for patient safety. Eliminating low RN staffing gave more benefits than eliminating assistant staffing.

Future work: research is needed to validate methods to determine nurse staffing requirements and the interaction between RN and assistant staffing needs further exploration.

Study registration: ClinicalTrials.gov NCT04374812
2755-0060
Griffiths, Peter
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Saville, Christina
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Ball, Jane
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Culliford, David
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Jones, Jeremy
270b303b-6bad-4be7-8ea0-63d0e8015c91
Lambert, Francesca
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Meredith, Paul
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Rubbo, Bruna
dc31cd48-3d84-41ab-a8b8-351c9914dca4
Turner, Lesley
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Dall'ora, Chiara
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Griffiths, Peter
ac7afec1-7d72-4b83-b016-3a43e245265b
Saville, Christina
2c726abd-1604-458c-bc0b-daeef1b084bd
Ball, Jane
85ac7d7a-b21e-42fd-858b-78d263c559c1
Culliford, David
25511573-74d3-422a-b0ee-dfe60f80df87
Jones, Jeremy
270b303b-6bad-4be7-8ea0-63d0e8015c91
Lambert, Francesca
0e60e1b4-7c8d-4182-9f18-e984a85d1157
Meredith, Paul
652fc110-7cba-48c3-bfba-264c43324626
Rubbo, Bruna
dc31cd48-3d84-41ab-a8b8-351c9914dca4
Turner, Lesley
7c4a1fe5-21a1-4634-a1cc-0230322603d1
Dall'ora, Chiara
4501b172-005c-4fad-86da-2d63978ffdfd

Griffiths, Peter, Saville, Christina, Ball, Jane, Culliford, David, Jones, Jeremy, Lambert, Francesca, Meredith, Paul, Rubbo, Bruna, Turner, Lesley and Dall'ora, Chiara (2025) Consequences, costs and cost-effectiveness of workforce configurations in English acute hospitals. Health and Social Care Delivery Research. (In Press)

Record type: Article

Abstract

Background: the NHS faces significant challenges recruiting and retaining registered nurses (RNs). Recruiting unregistered staff is often adopted as a solution to the RN shortage, but recent research found lower RN staffing levels increase hospital mortality with no evidence that higher levels of assistant staff reduced risk.

Objectives: to estimate the consequences, costs, and cost-effectiveness of variation in the size and composition of the staff on acute hospital wards in England. To determine if results are likely to be sensitive to staff groups such as doctors and therapists, who are not on ward rosters, associations between staffing and outcomes for multiple staff groups, including medical, are explored at hospital level.

Design: a national cross-sectional panel study and a patient-level longitudinal observational study using routine data.
Setting: All English acute hospital Trusts and a subsample of four Trusts for the patient-level study

Interventions: naturally occurring variation in the size and composition of the workforce.

Participants: patients experiencing a hospital admission with an overnight stay and nursing staff providing care on inpatient wards.

Outcomes: death, patient and staff experience, length of stay, readmission, adverse events, incidents (datix), staff sickness, costs, and quality-adjusted life years (QALY).

Data sources: publicly available records of hospital activity, staffing and outcomes (cross-sectional study) and hospital administrative systems (longitudinal study).

Results: In the cross-sectional study, lower staffing levels from doctors and allied health professionals were associated with increased risk of death. Higher nurse staffing levels were associated with better patient experience and staff wellbeing. In the longitudinal study, for adult inpatients, exposure to days with lower-than-expected registered nurses or nursing assistant staff was associated with increased hazard of death (adjusted Hazard Ratio [aHR] 1.08/1.07, 95% confidence interval [CI] 1.07-1.09/1.06-1.08) and longer hospital stays. Low registered nurse staffing was also associated with increased hazard of readmission (aHR 1.01, 95% CI 1.01-1.02 . Eliminating low staffing cost £2,778 per QALY gained. Avoidance of RN understaffing gave more benefits and was more cost-effective for highly acute patients. Although high bank or agency staffing was associated with increased hazard of death, avoiding low staffing using temporary staff still reduced mortality but was more costly and less effective than using permanent staff. If costs of avoided hospital stays are included, avoiding low staffing generates a net cost saving. Exploration of thresholds for low staffing indicated a greater beneficial effect from registered nurse staffing higher than current norms.

Limitations: this is an observational study. Causal inferences cannot be made from these results in isolation. QALY gains were estimated, although conclusions are not sensitive to assumptions or discount rates. We used current ward norms as reference for low staffing.

Conclusions: Our results show the adverse effects of low nurse staffing but also show that medical and allied health professional staffing are important considerations for patient safety. Eliminating low RN staffing gave more benefits than eliminating assistant staffing.

Future work: research is needed to validate methods to determine nurse staffing requirements and the interaction between RN and assistant staffing needs further exploration.

Study registration: ClinicalTrials.gov NCT04374812

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Accepted/In Press date: 28 January 2025

Identifiers

Local EPrints ID: 498904
URI: http://eprints.soton.ac.uk/id/eprint/498904
ISSN: 2755-0060
PURE UUID: a9aa6871-6e73-48f2-a2e1-4026d65a3102
ORCID for Peter Griffiths: ORCID iD orcid.org/0000-0003-2439-2857
ORCID for Christina Saville: ORCID iD orcid.org/0000-0001-7718-5689
ORCID for Jane Ball: ORCID iD orcid.org/0000-0002-8655-2994
ORCID for David Culliford: ORCID iD orcid.org/0000-0003-1663-0253
ORCID for Francesca Lambert: ORCID iD orcid.org/0000-0003-0327-4325
ORCID for Paul Meredith: ORCID iD orcid.org/0000-0002-5464-371X
ORCID for Bruna Rubbo: ORCID iD orcid.org/0000-0002-1629-8601
ORCID for Lesley Turner: ORCID iD orcid.org/0000-0003-1489-3471
ORCID for Chiara Dall'ora: ORCID iD orcid.org/0000-0002-6858-3535

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Date deposited: 04 Mar 2025 18:00
Last modified: 22 Aug 2025 02:34

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Contributors

Author: Peter Griffiths ORCID iD
Author: Jane Ball ORCID iD
Author: David Culliford ORCID iD
Author: Jeremy Jones
Author: Paul Meredith ORCID iD
Author: Bruna Rubbo ORCID iD
Author: Lesley Turner ORCID iD
Author: Chiara Dall'ora ORCID iD

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