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Observational Study
. 2025 Jul;13(25):1-107.
doi: 10.3310/ZBAR9152.

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

Peter Griffiths  1   2   3 , Christina Saville  1   3 , Jane Ball  1 , David Culliford  1   3 , Jeremy Jones  1 , Francesca Lambert  1 , Paul Meredith  1   2   3 , Bruna Rubbo  1 , Lesley Turner  1 , Chiara Dall'Ora  1   3
Affiliations
Observational Study

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

Peter Griffiths et al. Health Soc Care Deliv Res. 2025 Jul.

Abstract

Background: The National Health Service faces significant challenges in recruiting and retaining registered nurses. Recruiting unregistered staff is often adopted as a solution to the registered nurse shortage, but recent research found lower registered nurse 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, re-admission, adverse events, incidents (Datix), staff sickness, costs and quality-adjusted life-years.

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 well-being. 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 1.08/1.07, 95% confidence interval 1.07 to 1.09/1.06 to 1.08) and longer hospital stays. Low registered nurse staffing was also associated with increased hazard of re-admission (adjusted hazard ratio 1.01, 95% confidence interval 1.01 to 1.02). Eliminating low staffing cost £2778 per quality-adjusted life-years gained. Avoidance of registered nurse 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. Quality-adjusted life-years 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 registered nurse 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 registered nurse and assistant staffing needs further exploration.

Study registration: This study is registered as Current Controlled Trials ClinicalTrials.gov NCT04374812.

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128056) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 25. See the NIHR Funding and Awards website for further award information.

Keywords: ADULT; AGED; ALLIED HEALTH OCCUPATIONS; ALLIED HEALTH PERSONNEL; ANALYSIS; COST-EFFECTIVENESS; CROSS-SECTIONAL STUDIES; HUMANS; INPATIENTS; LENGTH OF STAY; LONGITUDINAL STUDIES; MORTALITY; NURSES; PATIENT RE-ADMISSION; WORKFORCE.

Plain language summary

Staffing shortages are a major concern for the National Health Service. A lot of research shows that low nurse staffing in hospital is correlated with worse patient outcomes, including an increased risk of death. However, a lot of this research has only looked at hospital average staffing and has not considered other staff, such as doctors and allied health professionals, so it is hard to be sure if improving nurse staffing on wards leads to better outcomes. It is also hard to know the most cost-effective approach to addressing staff shortages. Our study used existing data from national reports and daily staffing data from hospital wards to answer some of the main uncertainties from past research. Using data from national reports, we found low staffing levels from doctors and allied health professionals were linked to increased risk of death. Nurse staffing levels were linked to important aspects of patient experience and staff well-being, but to properly understand the effects of nurse staffing we needed to know the staffing patients experience when on hospital wards. Our study included 626,313 patients in 4 hospitals. We found that when patients spent time on wards with fewer-than-expected registered nurses or nursing assistants, they were more likely to die and their stay in hospital was longer. Low registered nurse staffing was also associated with more re-admissions. We looked at the cost of avoiding low staffing and the cost of gaining the equivalent of 1 year of healthy life. We compared these ‘cost-effectiveness’ estimates for different ways of avoiding low staffing and for different patient groups. Overall, we concluded that a focus on avoiding low registered nurse staffing gave more benefits than using assistants to fill any gaps, and should be the priority, although it is still not clear what the best level of staff is.

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