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)

Description: Age Cymru logo (CMYK Coated)Evidence from Age Cymru – SNSL(Org) 08 / Tystiolaeth gan Age Cymru – SNSL(Org) 08





Consultation Response


Safe Nurse Staffing Levels (Wales) Bill

January 2015



1.    Age Cymru is the leading national charity working to improve the lives of all older people in Wales. We believe older people should be able to lead healthy and fulfilled lives, have adequate income, access to high quality services and the opportunity to shape their own future. We seek to provide a strong voice for all older people in Wales and to raise awareness of the issues of importance to them.

2.    We welcome the opportunity to respond to the Health and Social Care Committee’s call for evidence on the Safe Nurse Staffing Levels (Wales) Bill. It has been estimated that around two-thirds of people admitted into hospital across the UK are over the age of 65[1] yet most hospitals have inadequate nursing establishments on older people’s wards[2].



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

3.    Age Cymru welcomes the principle of safe nurse staffing levels for adult inpatient wards across Wales. Over recent years a number of inquiries[3] have sadly demonstrated the impact that unsatisfactory and undignified care have on the quality of care for patients, especially older people. Pressures on staff and low or reduced staffing levels have been identified as a factor in a number of these inquiries.

4.    Legislating in order to ensure safe nurse staffing levels is one potential route to achieving improved levels of care. However, the National Institute of Health and Care Excellence (NICE) guidance on safe staffing levels[4] was only published in July 2014 and it is questionable whether such guidance has had sufficient implementation time for its impact to be assessed effectively.

5.    The Explanatory Memorandum[5] accompanying the Bill does suggest that the Local Health Boards have been making progress towards the principles on nurse staffing levels set out by the Chief Nursing Officer, although progress has been inconsistent. However, if guidelines are felt to be insufficient to ensure implementation by the Local Health Boards in Wales, creating statutory duties would ensure the issue was taken seriously.

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

6.    The provisions of the Bill appear to be appropriate to achieving the Bill’s overall purpose as stated.

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

7.    In these difficult financial times, concerns about the impact of these provisions upon staffing budgets are inevitable. Evidence reviews prepared as part of the development of NICE guidance found that existing economic studies had very limited value with regard to their relevance to the context and situation of the NHS[6]. Concerns have been raised by other professional bodies about the potential implications for staff levels in other speciality. It should be recognised that other different professions make a significant contribution to the wellbeing and care of patients, and the importance of preventative services should not be overlooked.

- Are there any unintended consequences arising from the Bill?

8.    In the wake of the Francis and Keogh reports, focus has switched to recruiting nurses, following earlier reductions in staff numbers. This has resulted in more nurses taking up NHS posts with implications for nursing care homes which may already be struggling to fill vacancies for registered nurses.


9.    There is a risk that this Bill could lead to an even greater shortage of registered nurses available for nursing care home work. Even were recruitment to nursing degree schemes to be increased, the impact on job recruitment would not be felt for a number of years. Posts in nursing homes are often seen as less attractive than NHS work. However, recruitment shortages in the nursing home sector can only exacerbate existing problems allied to delayed transfers of care.


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?

10. The work of the Royal College of Nursing has demonstrated that the ratio of patients to staff (both all staff, including healthcare support workers, and to registered nurses alone) is persistently higher on wards for older people than on other types of ward[7]. These higher ratios often have a negative impact on the quality of care that is provided and the dignity of older people receiving care and, if unaddressed, represent a potential form of discrimination against older people.

11. Older people often have a combination of complex needs that require more time-consuming treatment than other adults in hospital[8].For example, they may need help preparing for mealtimes or going to the toilet in ways that other adult patients do not. They are also more likely to be subject to episodes of delirium and wandering which requires greater levels of care and time. However, older people are often on wards which have fewer staff than general wards.

12. We therefore welcome the emphasis on health service bodies ensuring an appropriate level of nurse staffing wherever NHS nursing care is provided, as this has implications for the provision of care to older people in settings other than adult inpatient wards in acute hospitals. This overall awareness should aim to ensure that the impact of potentially increasing the number of registered nurses working on adult inpatient wards does not have negative implications for the provision of NHS nursing care outside these 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?

13. As highlighted above, there are particular concerns with regard to staffing levels on wards for older people, despite the fact that these patients often require more care than younger adults with regard to carrying out daily tasks that most of us take for granted.

14. Therefore, establishing a duty to have regard to the importance of ensuring an appropriate level of nurse staffing is to be welcomed, especially the recognition of the need for flexibility to take decisions based upon local needs. The demands placed upon nurses can vary between specialties and depending on case mix, levels of acuity/dependence, ward layout and patient turnover. There is therefore no ‘one-size-fits’-all’ mechanism for determining safe staffing levels on a ward.


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

15.This approach fits with the recommendations of the NICE guidelines with the guideline being explicitly written for adult inpatient wards in acute hospitals. In part, this reflects the outcomes of the Francis and Keogh inquiries in England. The implications of introducing this statutory duty require monitoring and effective evaluation before decisions are taken about the appropriateness of extending the duty into other areas of care.


- the requirement for the Welsh Government to issue guidance4 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)?

16. If the Bill is to be passed, it would be appropriate for the Welsh Government to set out evidence-based methods for use by NHS organisations to ensure there is a safe level of nurse staffing. These could be based on the existing guidance.

17. It is important that such methods take into account professional nursing expertise based upon the judgement of lead nurses when decisions of this kind are taken. Safe nurse staffing levels are clearly an important component of ensuring and enhancing quality of care. However, we must not lose sight of the way in which care is delivered, not just who is delivering the care and how many of these staff are on duty.

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

18. Ensuring that minimum ratios are not applied as an upper limit is essential. Employing a higher number of staff may be appropriate to local need and a flat ‘minimum’ rate should not become a target level to be achieved which would be a particular risk if decisions were taken without the input of professional nursing expertise.

19. It also needs to be clear that these nurses should be part of the regular hospital workforce. Relying upon agency of bank staff as a way of meeting a ‘minimum’ level potentially undermines the good intention of safe nurse staffing levels for older people’s wards, as these staff may not always be able to meet the particular complex set of needs presented[9]. In addition, relying upon agency/bank staff can drive up costs further, placing financial pressure upon service delivery.

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

20. If ensuring a safe nurse staffing level becomes a statutory duty, it would be appropriate to ensure that information is available to patients and the public regarding the numbers of staff on duty. Such data should also be provided in formats that are appropriate for people with sensory impairments. It is important, however, that any such data is presented in a format which makes the context clear in order to prevent misunderstandings of what can be expected in terms of nurse staffing levels.

 includes protections for certain activities and particular roles when staffing levels are being determined?


21.Such protections would be in line with the principles of prudent healthcare as promoted by the Welsh Government, where such activities can only be carried out by registered nurses.


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

22. Before final guidance is issued, it would be entirely appropriate for a consultation on the details of its content in order to ensure that it is fit for purpose and will achieve the stated purpose on the face of the Bill.

- the monitoring requirements set out in the Bill?

23. The impact of any duty created as a result of this Bill being approved would need to be monitored, but also carefully evaluated. Data should not be collected for the sake of meeting targets but should be employed in order to improve service delivery.

24. With regard to monitoring indicators, the evidence review[10] carried out in preparing the NICE guidance concluded that while nurse staffing can be linked to a number of patient safety outcomes, the outcomes of the measures used are problematic as indicators of safe nursing care. Careful thought should therefore be given to the indicators used as monitoring the effectiveness of implementation.

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

25. In order to demonstrate that the duties created by the Bill are being met, publication would be appropriate. However, in order to avoid generating additional work through the creation of a separate report, it would be useful to consider incorporating the relevant data into an existing document, such as the Annual Quality Statement.

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


26.It is clear given the potential for unintended consequences of this Bill on levels of staffing amongst other healthcare professionals and in other sectors that this amendment to the National Health Service (Wales) Act 2006 would need to be reviewed. This review would be to ensure that the duty created by the Bill was having the intended effect upon patient safety and quality of care delivered.


Impact of existing guidance

Guidance exists in England and Wales that aims to ensure safe staffing levels. This includes the ‘All Wales Nurse Staffing Principles Guidance’ issued by the Chief Nursing Officer in 2012 and the 2014 NICE safe staffing guidelines for ‘Adult in-patient wards in acute hospitals’ in England.

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


27.As the NICE guidance was only released in July last year, it is not possible to judge its effectiveness at this point.


Other comments

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

28. Age Cymru welcomes the proposal for its potential beneficial impact for older people. However, we recognise that this would only be one step towards improving the quality of care delivered to our older people and ensuring that their dignity and human rights are respected.

29. Age Cymru calls for all frontline health and social care staff to receive mandatory human rights, dignified care and dementia care training. This should include respectful communication, protecting privacy, promoting autonomy and addressing basic needs such as nutrition and personal hygiene.

30. The publication by Abertawe Bro Morgannwg of twelve principles[11] in ensuring quality and dignity in September last year is to be welcomed. It is important that such principles become embedded in the way in which both registered nurses and healthcare support workers operate. To reiterate, we must not lose sight of the way in which care is delivered, not just who is delivering the care and how many of those staff are on duty.

[1] Royal College of Physicians (2012): Hospitals on the Edge? The time for action

[2] Royal College of Nursing (Sept 2012): Safe Staffing for Older People’s Wards

[3] Most specifically, the Francis report into the Mid-Staffordshire NHS Trust and the Keogh review of urgent and emergency care in England.

[4] NICE (July 2014): Safe staffing for nursing in adult inpatient wards in acute adults, Safe Staffing Guideline 1

[5] Kirsty Williams AM (1 December 2014): Safe Nurse Staffing Levels (Wales) Bill Explanatory Memorandum: p

[6] P Griffiths et all (2014): The association between patient safety outcomes and nurse/healthcare assistant skill mix and staffing levels and factors that may influence staffing requirements, Evidence Review 1. Available at

[7] Royal College of Nursing (2010): Guidance on Safe Nursing Staffing Levels in the UK: p22

[8] Royal College of Nursing, Sept 2012

[9] Ibid: p34

[10] Griffiths et al, 2014: p12

[11] Available at: