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 Chartered Society of Physiotherapy - SNSL AI 08 / Tystiolaeth gan Cymdeithas Siartredig Ffisiotherapi - SNSL AI 08


CSP Wales Office

1 Cathedral Road

Cardiff CF11 9SD


Health and Social Care Committee

National Assembly for Wales

Pierhead Street

Cardiff CF99 1NA


11th February 2015


Dear Chair and Committee Members


Re:  Safe Nurse Staffing Levels (Wales) Bill – Follow-up written evidence from the Chartered Society of Physiotherapy




As a follow-up to our oral evidence session with the Health & Social Care Committee, the CSP would like to submit some further written evidence. This includes references that support key points made during our session.


Key points made by the CSP


Our concern remains to ensure that patients receive the highest standards of care. By this, we mean safe and effective care that is delivered both with compassion and sensitivity to individual needs. While we appreciate this also forms the rationale for the Bill, we do not see patient to staff ratios as the way to achieve this.

Similarly, we recognise the central, fundamental role that nursing staff play in delivering safe care to patients at all times of the day, seven days a week. However, we are concerned that the proposed legislation risks looking at numbers of nursing staff in isolation from all the other factors that ensure safe, compassionate, good-quality patient care and the fulfilment of outcomes that fit with individual patients’ goals and needs. Again, we believe that this singular focus will work against achieving safe, effective patient care across the diversity of settings in which this is delivered.

We expand on points relating to these concerns below, underpinned by currently available evidence. 

1.    There is limited evidence to indicate that setting staffing levels ensures safe, effective, good-quality care. There is a lack of evidence either of the impact of specific nurse staff to patient ratios on patient outcomes or of a correlation between ratios and positive outcomes for patients. Evidence reviews have also highlighted the lack of transferability of models from other countries to the UK and NHS. To date, very little evidence has been generated in the UK, as the NICE-commissioned review last year affirmed (University of Southampton, 2014).


2.    Staffing levels cannot be looked at in isolation from all the other factors that affect safe, effective, high-quality patient care. These include ensuring care is responsive to patient need (in terms of acuity, dependency, complexity, length of stay/turnover and overall caseload); taking account of the impact of service models (including in terms of environment, layout, context/integration with wider delivery, use of technologies, etc.); and recognising the significance of wider issues of staffing (skill mix, team-working, leadership, education/CPD), not just numbers of staff.


3.    Legislating for nurse: patient staffing levels risks creating inflexibility to changing needs and forming a significant distraction from achieving safe, effective, good-quality care (King’s College London, 2009). This includes creating a focus and bureaucracy that restricts staff and organisations' ability to respond to changing patient needs and demonstrate their accountability for delivering safe, effective care. A review of the impact of mandated nurse to patient ratios in California has affirmed this. This has highlighted that the legislation has compromised how nurses are enabled to exercise their professional judgment, generated an increased dependency on agency staff, created perverse incentives for health care organisations not to comply, and reduced their true accountability (Tevington, 2011).


4.    It is too simplistic to look at one staff group and in one care setting. This risks diverting attention away from optimising patient care across the whole patient journey and focusing attention on fulfilling a narrow target. Mandating staffing levels in the way proposed therefore risks creating unintended consequences. These include diverting resources away from other services; diverting workforce supply from other areas of service delivery; diverting resources away from other staff groups that make a strong contribution to patients receiving safe, effective, high-quality care and the most effective/efficient delivery of services (so that care is provided in the right place/at the right time for patients); reducing staff and organisational focus on service improvements and accountability for achieving this; and therefore impacting negatively on the quality of patient experience and outcomes and service delivery (King’s College London, 2009; Tevington, 2011; University of Southampton, 2014). 













King’s College London (2009) RN+RN = better care. What do we know about the association between Registered nurse staffing levels and better patient outcomes? Policy + .Issue 20.


Tevington, P. (2011) Mandatory nurse-patient ratios. Medsurg Nursing. 22 (5), 265-268


University of Southampton (2014) The association between patient safety outcomes and nurse / health care assistant skill mix and staffing levels & factors that may influence staffing requirements.


Concluding comments


We hope committee members will find this additional evidence useful.

The CSP is content for this evidence to be made available publicly.

Submitted by:

Dr Sally Gosling – Assistant Director of Practice and Development at the Chartered Society of Physiotherapy

Philippa Ford MBE MCSP – Public Affairs and Policy Manager for the Chartered Society of Physiotherapy in Wales