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 the Minister for Health and Social Services - SNSL AI 20 / Tystiolaeth gan y Gweinidog Iechyd a Gofal Cymdeithasol- SNSL AI 20


Safe Nurse Staffing Levels (Wales) Bill


Further evidence from the Welsh Government in respect of the acuity tool




  1. The Bill’s stated aim is to achieve safe nurse staffing levels in “adult inpatient wards in acute hospitals" by creating a legal requirement for local health boards “to take all reasonable steps to maintain minimum registered nurse: patient ratios and minimum registered nurse:healthcare support workers ratios.”  There are no ratios on the face of the Bill, as it is intended that the ratios be set in guidance to be issued by the Welsh Ministers. 


  1. The Minister for Health and Social Services gave evidence to the Health and Social Care (HSC) Committee on 5 March 2015 and subsequently, at the Committee’s request, provided an evidence paper about using his existing powers to achieve the aims of the Bill.


  1. The Member in Charge, Kirsty Williams AM, gave evidence to  the Committee on 19 March 2015 and referred to the Minister’s evidence paper.  As a result, the Committee has asked for further clarification, namely:


Will the Acuity Tool Governance Framework (when validated) include a fixed staffing ratio that applies to all medical and surgical adult in-patient wards, that sets out:

·         a number by which the number of patients per registered nurse should not exceed by day and night (as currently set out in the CNO’s All Wales Nurse Staffing Principles, for example 1:7 by day and 1:11 by night)

·         a skill mix ratio of Registered Nurse to Healthcare Support worker?


Adult Acute Nursing Acuity & Dependency Tool


  1. The acuity tool does not generate a fixed ratio for registered nurses to patients, nor for registered nurses to healthcare support workers, which could be applied as a minimum staffing ratio figure for the purposes of the Bill.


  1. The acuity tool is based on the Association of UK University Hospitals (AUKUH) tool. It is an adaptation of the Safer Nursing Care Tool, which has been endorsed by NICE.  There is more detail about the acuity tool in the documents previously sent to the HSC Committee namely the Fundamentals of Care System User Guide: Adult Acute Nursing Acuity & Dependency Tool and the Adult Acute Nursing Acuity & Dependency Tool Governance Framework.


  1. The acuity tool is a piece of software which records workforce pressures over a given period of time in order to assist in the planning of future workforce needs.  Once a day at a set time, for one month, ward staff input data into the tool about the funded posts on their ward; the number of beds; the number of patients on the ward and their individual levels of acuity and dependency, and the movement of patients to and from the ward.  The level of care each patient requires is described using one of five defined levels.


  1. The software processes these data to show variations in the levels of acuity, dependency and the associated care required by the patients on that ward during that time-frame. It provides a snapshot of the conditions on that ward during that month only, at one point during each day.


  1. On an acute ward, patient needs change from hour to hour.  The daily snapshot recorded in the acuity tool only describes the situation on the ward at the moment the information was recorded.  If it were recorded an hour later, the snapshot would be different.  The data for that ward on the next day will be different.  The data recorded in each acute ward at the same time will also be different for each ward.


  1. Therefore, because the conditions on each acute ward vary so much over time, it is not possible to take the information recorded daily and use it to produce a single fixed staffing ratio that would be appropriate 24 hours a day, seven days a week, on every acute ward. 


  1. The acuity tool is not an e-rostering system i.e. it is not designed to determine the staffing levels required for an individual shift.  It is designed to establish an average over time, in order to help Local Health Boards (LHBs) with long-term workforce planning; specifically, to determine how many funded posts there should be on a ward. 


  1. LHBs must use the acuity tool in conjunction with their professional judgement and analysis of nurse-sensitive indicators for each ward area, (the triangulated approach) to determine nurse staffing levels.


  1. The All-Wales Nurse Staffing Principles were agreed as an interim measure to be used whilst the acuity tool was being developed and validated.  Once the acuity tool is implemented, LHBs will no longer be required to use the principles, nor to report to the Chief Nursing Officer (CNO) about their use.  However, LHBs may choose to use the principles alongside the triangulated approach as part of their local decision-making process.


  1. Following the agreement and issue of the principles in 2012, there was a debate by the nurse directors about staffing at night. The ratio of 1:11 was proposed as a guide which some nurse directors use.  However, this was never formally adopted into the principles and is therefore not part of the monitoring by the CNO.