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 Professor Anne Marie Rafferty CBE – SNSL(Ind) 04 / Tystiolaeth gan Yr Athro Anne Marie Rafferty CBE – SNSL(Ind) 04


Health and Social Care Committee: Written Evidence on Safe Staffing Bill, Anne Marie Rafferty CBE

I am making my comments in my capacity as Professor of Nursing Policy, King’s College, London and researcher in the area of workforce, specifically, nurse staffing and patient outcomes, not as a member of an organisation or stakeholder.


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

Safe staffing legislation could provide a helpful vehicle to set and ensure adherence to ‘best practice’ staffing guidelines in the absence of responsiveness within the system to changes in demand such as acuity and dependency and alignment with capacity. There is significant evidence of variation in workload management and workforce planning practices and methodologies across England (see attached papers) including historical methods with consequent negative impacts on nurses and patients where these fall short. The chronic understaffing of wards had serious impacts on the welfare of patients and nurses and poses a major threat to the sustainability of the NHS.  History suggests that nurse staffing patterns are sensitive to the economic cycle of ‘boom and bust’ and that variations are unrelated to demand or patient need though this is not the only driver of staffing as the draft Bill indicates. Setting staffing levels on a safe, secure and scientific footing would bring benefits to patients, carers, the multidisciplinary team and the system as well as nurses making it attractive to enter and remain in as a career. Safe staffing should, however, be seen as part of a wider Human Resources strategy with clear accountability for staffing at Board level and not an isolated event or end in itself.

Are the provisions in the Bill the best way of achieving the Bills overall purpose? 

England has implemented ‘safe staffing guidance’ but stopped short of setting ratios. The provisions made in the proposed Bill have much in common with those proposed and currently being implemented in England but Wales would be unique in going a step further by enacting legislation. It is too soon to appreciate the impact of implementing safe staffing guidance in acute wards in England but setting out provision in legislation would provide a strong signal that the Welsh Assembly was serious about supporting safe staffing. It would also provide an opportunity to compare the impacts of different approaches to safe nurse staffing across devolved administrations, especially England, which has implemented guidance on the issue by comparing the differential implementation as a natural experiment.

What, if any, are the potential barriers to implementing the provisions of the Bill?

The Bill takes account of the potential costs but savings that can be off set against those costs, including the costs of operationalising implementation.  Costs are not simply economic but have to be considered in terms of the costs of not acting and the calculus of human suffering associated with poor staffing, which is well documented in The Report of the Francis Inquiry referred to in the background Memorandum. Barriers beyond the economic to implementation could be recruitment in ‘difficult to recruit to areas’ both in geographical and sub-speciality terms.  Recent experience of implementing safe staffing guidance suggests that staff may be redeployed from better to less well staffed areas and this may not prove popular with staff but could form part of an evaluation and options appraisal framework underpinning the review outline in the Bill.


Are there any unintended consequences in the Bill?

These seem to be well covered in the Bill

Provisions in the Bill

The duty on health services bodies and holding Boards accountable for staffing decisions is essential for safeguarding standards and providing stewardship of resource. Specifically, the public reporting of data is and risk management surrounding decisions are central to ensuring public accountability for safe staffing.  The wording on the other two provisions has changed from minimum to safe staffing and I concur with the provisions as outlined. It is prudent to adopt an incremental approach to implementation since different environments and specialities may have needs and demands. 


The requirement for the Welsh government to issue guidance setting out methods and other items outlined in the draft Bill are positive in supporting the enactment of the Bill. The requirement to review the operation of the Act is to be welcomed. 


Impact of existing guidance


It is too early to tell but liaising closely with experience in England would be crucial to guiding implementation of provisions made.


Powers to make subordinate legislation and guidance


These elements seem well covered at present.


Financial implications


I have no further evidence to add beyond that outlined in the Explanatory Memorandum.


Other comments


Only that safe staffing needs to go hand in hand with good human resource practice and be capable of responding to changes in patient acuity and dependency not seen as a ‘magic bullet’ or isolated event.  Everything depends on how it is implemented at local level. The opportunity for implementing safe staffing as a complex intervention through a randomised controlled trial, for example, could also be considered.