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 Unison Cymru Wales – SNSL(Org) 06 / Tystiolaeth gan Unison Cymru Wales – SNSL(Org) 06





Safe Nursing Staffing Levels Bill

UNISON Cymru Wales written evidence (January 2015)



UNISON is the UK’s largest healthcare union with over 400,000 members working in the NHS.  In Wales, UNISON represents 35,000 members providing NHS services.  Our health members are nurses, student nurses, midwives, health visitors, healthcare assistants, paramedics, community care workers, cleaners, porters, catering staff, medical secretaries, clerical and administration staff and scientific and technical staff.

Unless there is a mandatory minimum, quality patient care will suffer.  Over 90% of respondents in UNISON’s 2013 staffing levels survey said they support mandatory minimum staffing levels, but it has to be acknowledged that quality is more important than quantity; staff numbers are only part of the problem.    We believe that compassionate care would not only benefit the patient but also the working lives of our members.



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

UNISON believes that there should be a legally enforceable minimum nurse to patient ratio.  We support and recognise the role which workforce planning tools have to play in helping organisations identify the right levels, but the use of these must be mandatory and, in the absence of this, the default position should be a legal minimum.

UNISON Cymru Wales has extensively sought the opinions of our members about the Bill, as we believe ongoing consultation with staff on the ground is crucial. Our Welsh members are overwhelmingly in favour of mandatory minimum nurse staffing ratios as they believe that this is the only way to provide a better quality of service for patients, increase staff morale and increase satisfaction in the workplace. For example, some of our members have described scenarios where they have had to oversee 26 patients in acute areas at one time. This is not only clinically for patients, but also a dangerous working environment for staff.

Our UNISON survey in 2013 found that an alarming 45% of nurses were caring for eight or more patients on their shifts which highlights the need for a safe staffing levels bill.  Validated workforce planning is effective in producing safe staffing levels as it is predictive, rather than retrospective and takes into account the fluctuations among the Local Health Boards.  It is known that hospitals are the busiest at the weekends and on Mondays, when they are dealing with the backlog of pressures from the weekend’s admittances.  A workforce planning tool would take into account these issues and therefore could weigh staffing levels differently at the weekend to during the week.  On the other hand a legislated ratio is static and does not take these factors into account.  UNISON welcomes the reference to validated workforce planning tools in the Bill under Clause (6), but argues that further work needs to be undertaken to decide whether they can be used further.


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

As highlighted in our original consultation response UNISON believe that, as the proposed application of safe staffing levels doesn’t apply to all staff in every health care setting, it detracts from the overall impact and purpose.  From our perspective, this is a signification omission and we are disappointed that the Bill does not develop the point further.  Extending application to all healthcare staff would allow our dedicated and hardworking members, in all pay bands and in all clinical areas, the time to provide the high level of care they desire, in a safe environment that engenders compassion.

We welcome that the Bill does make reference to healthcare support workers but this definition needs to be tightened up in several regards.  The application of ratios of health care workers, other than nurses, should be applied to safe staffing levels in adult care in acute hospitals and beyond. Our members have described situations in which nursing staff are drawn away from clinical duties to undertake basic cleaning duties.   Similarly, if inadequate numbers of clerical staff in medical records or wards are employed, nurses end up being diverted from their clinical tasks to clerical duties. 


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

The chief barrier to successful implementation of the Bill and consequential improvements in the Welsh health care system would be the adoption of unrealistic nurse staffing ratios. 

UNISON advocates a 1:4 nurse to patient ratio as we believe this will provide the best quality patient care at all times.  Studies have shown that there are better clinical outcomes with a ratio of 1:6 or lower and that harm starts to occur when nurses are caring for 8 patients or more, although, clearly, “one size does not fit all”.  Therefore, each ward/clinical area must be assessed for its particular appropriate staffing levels both in the day and at night. 

Moreover, by only applying a safe staffing ratio to nurses the Bill does not adequately consider the pressure on nurses’ duties that are the consequence of inadequate numbers of other healthcare workers, e.g. domestic and clerical staff as previously stated.

The Safe Staffing Alliance, of which UNISON is a member, recommends that nurses must at all times be supported by a sufficient number of healthcare assistants. Yet, the Bills’ priorities remain solely focussed on the employment of qualified nurses, often at the expense of Healthcare Assistants.  Whilst UNISON welcomed the additional £10 million given by Welsh Government to Health Boards for the employment of additional nursing staff, we have seen examples of Health Boards in Wales downgrading Healthcare Assistants’ posts to pay for additional qualified nurses.  This is not acceptable and means that qualified nurses are not getting the appropriate level of support to enable them to undertake their duties effectively.


Q: Are there any unintended consequences arising from the Bill?

On no account should the Bill lead to a ‘plug gap’ situation where staff are robbed from one unit and moved into the inpatient adult acute sector.  

The majority of our members believe that there should be a requirement in the legislation for “protected time”, for staff training and development built into nurse staffing ratios.  Currently there are too many incidences when staff are pulled off mandatory training days to cover sickness on the ward, leaving those staff without the training they need.  It should not be an unintended consequence that the Bill increases such situations.



Q: 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?

UNISON agrees with Clause 2.5 (b) ‘allow for the exercise of professional judgement’ as NHS employees are often in the best position to know when systems in the Service are working efficiently and therefore when an appropriate level of nurse staffing is provided. 

Education is a crucial force in the protection of both the patient and the worker.  Aiken et al. 2004 found that a 10% increase in employment of degree-level educated nurses led to a 7% reduction of an inpatient dying.   Increased staffing levels would also alleviate the pressures on practice placement settings, which would make it easier for nurses to dedicate time to support students.  This would also benefit the health community at large.


Q: 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?

It is important that there is a duty on health service bodies in Wales to take all steps to maintain these recommended nurse to patient ratios.  




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

We understand that the duty will first apply to adult inpatient wards in acute hospitals because this is where the main body of evidence lies, however UNISON believes that agreed ratios should not only be restricted to adult care in acute hospitals.   UNISON believes that in order for patients to receive the highest possible quality of care, the agreed ratios should be applied and extended to all clinical areas, including Community settings. Applying the duty only to acute hospitals will not sufficiently meet the standards required across the NHS. We understand that in order to extend the ratio there needs to be robust data collection methods and results in place.   For this to occur, data collection in other healthcare setting should commence as soon as possible in order to identify reasonable staffing levels.


3 Ibid- the requirement for the Welsh Government to issue guidance 4 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 (including methods set out in section 10A(6) inserted by section 2(1) of the Bill)?

We welcome the use of validated workforce planning tools and the exercise of professional judgment within the planning process as methods.  However, we believe there should be further consultation and agreement with all interested stakeholders, including employee representative organisations on the tools and methods to be used in establishing staff ratios. 


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

UNISON believes that the Bill highlights the importance that minimum ratios are not applied as an upper limit in Clause (5) of the guidance and Clause 6 (b). Safe staffing levels should represent a high quality of staffing levels, and agreed ratios should reflect requirements and circumstances in each hospital. Hospitals should be monitored to ensure that the agreed ratios are not regarded as upper limits, instead ensuring that the applied ratios mean they can deliver a high quality level of care.  It is important that NHS organisations regard the agreed ratios as an absolute minimum, and broadly view these minimum ratios as “a level of care below which standards do not fall”.


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

The Francis Report was clear about the positive role that information sharing can play.  We believe that transparency of staffing levels is an important driver of patient confidence, and patient awareness of roles. Detailing responsibilities and numbers of staff on duty will aid this process.

UNISON agree that information on the numbers and roles of nursing staff on duty should be published in areas accessible to patients and their families, but it is essential that the recording, monitoring and reporting process is streamlined.  This view has been echoed in both the Francis Report and the Berwick Review which both found that there needs to be a systematic and responsive approach to determining nurse staffing levels. There are too many examples where nurses, and other health care workers have been caught up in bureaucratic systems which force them to take time away from the patient.  NHS staff are already over-worked so any process for reporting data must not increase this burden. The streamlining of the process will not only improve administration for nurses and ward clerks and other staff, but will ensure the clarity required for an accurate system of monitoring.

Publication of such figures is meaningless unless the standards are clearly set and allow for the fluctuations of patient acuity and dependency.


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

- the requirement for Welsh Ministers to consult before issuing Guidance?

UNISON strongly welcomes the requirement for Welsh Ministers to consult before issuing Guidance.

- the monitoring requirements set out in the Bill?

We suggest that the monitoring requirements set out in the Bill are extended to first include collecting data on whether a nurse’s break was taken at an appropriate time, for example if a healthcare worker is working a long day and doesn’t receive a break until 8 hours into their shift.  Secondly, we believe that indicator 3.1 (h) should be expanded to include staff wellbeing alongside nursing overtime and sickness levels.  Thirdly, an additional monitoring requirement that should be included is ‘care undone’.  In UNISON’s report ‘Running on Empty: NHS Staff Stretched to the limit’, 55% of our members said that due resource constraints care was left undone, even though many of them had not taken their breaks and had worked overtime. 

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

We welcome the requirement for each health service body to publish an annual report and that it can be published as part of a wider report. 

- the requirement for Welsh Ministers to review the operation and effectiveness of the Act as set out in section 3?

UNISON would suggest that for the first year, internal reviews in operation and effectiveness of the Act should be taken on alternative months to confirm that the staffing levels are appropriate.  This would increase after the first year of the organisation.  In conjunction, we agree that a first whole system review must be carried out as soon as practicable after the end of the one year period beginning with the date when the Act comes into force.  We do not agree that subsequent reviews should be carried out at intervals of no more than 2 years.   This has the potential to leave long periods of where harm could have occurred, this is especially true for the second review.  The monitoring of the Act should be built in to the annual review to ensure that there is continuity across the processes.

We also believe that success of the Bill would be demonstrable improvements in the measures of healthcare as set out in 3(5), including for example, the measures should also include a monitoring of reductions in length of stay in hospital.


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

UNISON supported both the 2012 All Wales Nurse Staffing Principle Guidance and the 2014 NICE guidelines on ‘Safe staffing for nursing in adult inpatient wards in acute hospitals’.   The All Wales Nurse Staffing Principle Guidance was based on acuity rather than solely patient numbers and many of the Local Health Boards defined a range of safe staffing nurse’s levels rather than a single defined figure. The 2012 guidance issued to the Health Boards in Wales recommended that the number of patients per registered nurse should not exceed 7 by day, which although is a move in the right direction, is still too high to provide a safe level of care.  The guidance also lacked effective implementation as it was not a statutory requirement.  The 2014 NICE guidelines are more similar to the proposed Bill and share similar issues such as ‘plugging the gap’ and the lack of reference to ‘care undone’ (where a number of staff reported that care was left undone).


Q: 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 ability to extend the bill to additional healthcare settings that is currently subordinate legislation is welcomed and should not be disregarded.


Financial implications

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

Costs are always a concern and how the upfront costs impact the Welsh Public Health service is extremely important.   However, findings by Bray et al. 2004 suggest that there is no evidence of overall cost increases, as the increase in funding for more nurses balances out with reduced costs associated with the length of stay of a patient and fewer infections.   We would like a commitment from the Government that upfront costs will not be cut to the disadvantage of the Welsh Healthcare worker. 


Q: Do you have any other comments you wish to make about the Bill or specific sections within it?

This Bill, if enacted properly, should lead to a marked improvement in the standards of healthcare in Wales.  The 2009 Boorman Review into NHS Health and Wellbeing established solid links between understaffing, stress, job satisfaction and patient care.

While safe staffing levels are a positive move we believe that this should be applied to the whole health care system.  To be a truly first class health care system the Welsh Government need to improve staffing ratios for all healthcare workers.

UNISON welcome further consultation throughout this process and look forward to speaking to the Committee in due course.

















Http://Teams.Unison.Org.Uk/Regions/Cymruwales/Organising/Health/DB Safe Staffing Levels Submission To Health And Social Services Cttee Jan 2015.Docx