National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol


Safe Nurse Staffing Levels (Wales) Bill/ Bil Lefelau Diogel Staff Nyrsio (Cymru)

Evidence from Healthcare Inspectorate Wales – SNSL(Org) 21 / Tystiolaeth gan Arolygiaeth Gofal Iechyd Cymru – SNSL(Org) 21


Response to consultation on the Safe Nurse Staffing Levels (Wales) Bill

About Healthcare Inspectorate Wales:

Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of health care in Wales.

HIW’s primary focus is on:

·         Making a contribution to improving the safety and quality of healthcare services in Wales

·         Improving citizens’ experience of healthcare in Wales whether as a patient, service user, carer, relative or employee

·         Strengthening the voice of patients and the public in the way health services are reviewed

·         Ensuring that timely, useful, accessible and relevant information about the safety and quality of healthcare in Wales is made available to all.

Our response:


-    Is there a need for legislation to make provision about safe nurse staffing levels?

Healthcare Inspectorate Wales (HIW) strongly supports the objectives of the Bill to:

·      Enable the provision of safe nursing care to patients at all times;

·      Improve working conditions for nursing and other staff;

·      Strengthen accountability for the safety, quality and efficacy of workforce planning and management.

Most of our findings relating to staffing come from our dignity and essential care inspections and our mental health inspections. During the current year we have published 30 dignity and essential care inspections. We have identified issues relating to staffing in half of these.

The issues identified have tended to relate to shortfalls in staffing numbers, difficulties encountered with recruitment and retention and a high degree of reliance on bank and agency staff. In three instances we sought  immediate assurance from the Health Boards that the issues were being addressed.

Guidance on the principles underpinning safe nursing were issued to Health Boards in Wales by the Chief Nursing Officer in April 2012 and acuity tools for adult acute hospital wards were introduced in April 2014. Progress is being made, but we continue to find that implementation is inconsistent: not all ward areas have set their own local safe minimum staffing levels and wards are not regularly using an acuity tool to reflect and match staffing numbers to patient needs.

It is possible that legislation in this area may help to provide the focus and momentum necessary to embed this guidance fully in daily practice.

We are pleased to see that the proposals recognise that it is important to look beyond simple ratios. Safe staffing is dependent upon more than numbers: it must also reflect the need of the patients, the environment in which care is being provided, the skills and experience of the staff members and the proportion of care provided by bank and agency staff who may have limited experience in the area. We therefore support the intention to ensure that minimum staff ratios are seen as a baseline and not as a target.

-    Are the provisions in the Bill the best way of achieving the Bill’s overall purpose (set out in Section 1 of the Bill)?

-    What, if any, are the potential barriers to implementing the provisions of the Bill? Does the Bill take sufficient account of them?

The availability of Registered Nurses and the ability to recruit is likely to be a barrier. The Bill will need to be supported by effective workforce planning and provision of education to ensure that there are sufficient trained and experienced nurses available to meet the identified needs.

It is right to recognise that determining appropriate staffing levels is not straightforward and cannot be done by applying a simple formula. However, the need to balance professional judgement, and the constantly changing nature of demand, will make it difficult to be specific in the guidance. This in turn will make it challenging to communicate clearly to patients how the staffing in place meets the guidance. It will also make it more challenging to hold health bodies to account for delivery against the legislation.

The current financial environment facing Health Boards is likely to present challenges for them in meeting safe staffing levels at all times

-    Are there any unintended consequences arising from the Bill?

It is possible that, at least in the short term, attempts to maintain staffing numbers would significantly increase the proportion of bank and agency. This may impact on continuity and quality of care.

There is a possibility that Health Boards may move resource from areas without statutory guidance in order to meet the requirements of the guidance in acute adult wards. For example, we have already identified staffing problems in NHS Mental Health inspections and have highlighted  these in all reports on these inspections published so far this year.

Provisions in the Bill

The Committee is interested in your views on the individual provisions in the Bill and whether they deliver their stated purposes. For example, do you have a view on:

-    the duty on health service bodies to have regard to the importance of ensuring an appropriate level of nurse staffing wherever NHS nursing care is provided?

There is a lack of clarity over the intended scope of this provision. It would be helpful to establish whether the provision is intended to encompass care commissioned from providers in other administrations such as England or commissioned from/ provided in independent care settings.

-    the duty on health service bodies to take all reasonable steps to maintain minimum registered nurse to patient ratios and minimum registered nurse to healthcare support workers ratios which will apply initially in adult inpatient wards in acute hospitals?

-    the fact that, in the first instance, the duty applies to adult inpatient wards in acute hospitals only?

We have also found staffing challenges evident in mental health wards and in community hospitals which would not be covered by the initial guidance. We therefore welcome the provision to enable guidance to be provided in these and other settings.

However, given our comments about scope in relation to provision 1(a) we would question whether the reference to “settings within the NHS” is too restrictive and whether this might more appropriately be “settings in which NHS care is provided”.

-    the requirement for the Welsh Government to issue guidance in respect of the duty set out in section 10A(1)(b) inserted by section 2(1) of the Bill which:

·      Sets out methods which NHS organisations should use to ensure there is an appropriate level of nurse staffing

·      Includes provision to ensure that the minimum ratios are not applied as an upper limit

·      Sets out a process for the publication to patients of information on the numbers and roles of nursing staff on duty

We support the need for openness and transparency in communicating to patients.

·      Includes protections for certain activities and particular roles when staffing levels are being determined.

We have conducted three inspections where the Ward Sister has had to undertake a direct care role due to staffing difficulties and had therefore found difficulty in undertaking their role in providing leadership, co-ordination of care and support to other staff.  This can result in poor communication, lack of attention to care planning and documentation and also weak discharge planning. We therefore welcome inclusion of protection for the supernumerary status of persons providing supervisory clinical expertise and leadership functions.

We also welcome the recognition of the need to make time available for training. A number of our inspections have highlighted incomplete mandatory training. We have also highlighted instances where staff have not been able to be released for training or have completed training in their own time.

-    the monitoring requirements set out in the Bill

-    the requirement for each health service body to publish an annual report

We welcome the recognition within the Bill that each of the above requirements could be incorporated within existing monitoring and reporting processes. It is important that the requirements of the Bill do not impose additional and excessive bureaucratic overheads on health bodies.

Impact of existing guidance

-    Do you have a view on the effectiveness and impact of the existing guidance?

The existing guidance applies only to general medical and surgical wards. It is a useful baseline, but is not sufficient on its own and needs to be applied alongside acuity tools and professional judgement. Currently the acuity tool is mandated twice a year. Although it could be used more frequently we do not see this often during our inspections and its use could be encouraged further.

Powers to make subordinate legislation and guidance

-    Do you have a view on the balance between what is included on the face of the Bill and what is left to subordinate legislation and guidance?

The balance proposed appears to provide sufficient flexibility for the substantive guidance to be readily amended in light of new research and understanding and in responses to changes in the delivery of care.


Financial implications

-    Do you have a view on the financial implications of the Bill as set out in part 2 of the Explanatory Memorandum?

HIW is not in a position to comment on the financial implications of the Bill.