Feature

Never mind the quality, feel the mix

If skill mix reviews are solely cost-led then care standards will fall, warns Malcolm Wing

Skill mix review is now a key industrial relations issue in the NHS. Dramatic shifts are already underway in the skill levels of nursing wards. Last year, a survey of nurses by NUPE found a third of all nurses reporting skill mix changes on their wards. Changing the staff skill mix is a fashionable management concept, but is fraught with danger. All too often, skill mix changes degenerate into deskilling exercises which replace relatively expensive qualified staff with cheaper less qualified staff - with scant heed paid to the consequences for health outcomes and the quality of care provided.

An NHS management executive (NHSME) commissioned paper adopted a broad definition of skill mix as ’the balance between trained and untrained, qualified and unqualified, and supervisory and operative staff within a service as well as between different staff groups’.¹ Skill mix reviews examine the skills balance within departments, the relationship between cost and skills and should examine the implications for standards of care and health outcomes. Skill mix charges blur and redefine the boundaries between various health service workers and their scope can be very wide.

There are several reasons for the emergence of skill mix reviews. First, the ‘internal market’ exerts strong downward pressure on the cost of services. Hospitals competing for contracts cut costs so they can offer a lower price to the purchaser. Since labour costs make up 72% of NHS spending, cutting staff costs through skill mix changes - replacing more expensive qualified staff with cheaper less qualified staff - is increasingly being pursued. In the words of a North East Thames RHA guide: ‘Those providers who re-profile their labour force will enjoy a competitive advantage over those who do not.’² Skill mix changes are seen by managers as an easier source of cost savings than attempting to hold down pay rises directly.

Second, demographic and training changes are resulting in skill shortages. The number of suitably qualified school-leavers available to enter the health service has fallen sharply and Project 2000 is estimated to cut the contribution of student nurses on wards from 80% to 20%. Third, changes in health care delivery - with an ageing population, more emphasis on community-based care and an increase in day surgery -require reappraisal of whether current skills will be appropriate in the future.

Skill mix changes are already having an impact. According to the Department of Health (DoH), the number of registered nurses fell sharply between 1990 and 1991. Registered nurses made up 61.4% of the nursing work-force in 1990 and non-registered nurses 24.1%. A year later, the figures were 58.7% and 28.4% respectively. Particular specialties experienced particularly sharp falls in registered nurses. In care of the elderly nursing the number of registered staff fell by a third.

In First Community Trust in Staffordshire, 69% of staff were on F, G, and H grades - but following a skill mix review this fell to 31%. In North Mersey Community Trust, G and H grades accounted for 51% of staff. A skill mix review proposed that only 18% of staff should remain on these grades.

Unfortunately, most skill mix reviews are primarily, and often solely, cost-led. While securing value for money is important it should not be at the expense of lower standards and fragmentation of care. Although much lip service is paid to providing a better quality of service, the NHSME report concedes that: ‘quality is rarely given prominence in skill mix reviews...’value for money’ and cost cutting dominate the expressed rationale for most studies’.

The standard of care aimed for is the minimum acceptable to the purchaser - not the highest or best standards. Reviews adopt a lowest common denominator approach which compile the cheapest work-force consistent with minimum standards. Skill mix exercises should evaluate the services provided critically to see how improvements in quality and service provision can be made. They should not be about cutting salary bills at the expense of quality care.

The DoH commissioned an authoritative study into the relationship between skill mix and quality of care from the Centre for Health Economics at York University.³ It was completed in August 1991, at a cost of £250,000, but its publication was delayed by the DoH until October 1992. The scale of the study means that it remains the definitive word on skill mix issues.

It found that higher nursing grades give better quality care: as grade mix has ‘higher grade staff on average, then the quality of care delivered is better’. Overall quality and health outcomes fell with clinical grade. Primary nursing methods performed particularly well in terms of the service to patients. A study conducted in North Western region also found ‘an important trade off between cost and quality’ in most cases.

NUPE has produced guidelines on skill mix reviews, highlighting the widespread de-skilling taking place, and suggesting ways to ensure that reality matches rhetoric when quality of care is at stake.⁴ There is positive potential in a skill mix review but safeguards are required to ensure that patients and staff are not worse off as a result.