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 Welah NHS Confederation – SNSL(Org) 03 / Tystiolaeth gan Conffederasiwn GIG Cymru – SNSL(Org) 03

Briefing for:	National Assembly for Wales, Health and Social Care Committee.
Purpose:	The Welsh NHS Confederation response to the Inquiry into the general principles of the Safe Nurse Staffing Levels (Wales) Bill
Contact:	Nesta Lloyd – Jones, Policy and Public Affairs Officer, Welsh NHS Confederation XXXXXXXXXXXXXXXXXXXXXXXX Tel: XXXXXXXXXXXX
Date created:	08 January 2015.

Introduction.

1. The Welsh NHS Confederation, on behalf of its members, wholeheartedly welcomes the opportunity to respond to the inquiry into the general principles of the Safe Nurse Staffing Levels (Wales) Bill.

2. By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent.

3. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Members’ involvement underpins all our various activities and we are pleased to have all Local Health Boards and NHS Trusts in Wales as our members.

4. The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales.

Summary

5. As with our response to the earlier consultations on this Bill,^{^[i]} we feel it is important to highlight that the Welsh NHS Confederation wholeheartedly supports any initiative aimed at proactively improving patient safety. Our members are committed to delivering high quality care which results in the best possible outcomes for patients and their families. However, we must emphasise that, while vital, nursing ratios and nurse staffing levels are one of many elements to consider - alongside technology, training, education, planning and good leadership - when it comes to patient safety.

6. It is also important to highlight the need for flexibility when it comes to staffing levels. The number of nurses required may vary depending on local need, the complexity of an individual patient’s condition and the type of ward the patient is on. Any changes to nurse staffing should be evaluated on the basis of their impact on patient outcomes and patient experience.

7. Nurses, working as part of a wider multidisciplinary team, play a vital role in achieving the outcomes that we want for the NHS: an NHS that provides quality care and excellent outcomes for patients. Our vision for the NHS is that it meets the needs of the people it serves, and is ready to change to meet those needs in the future. This vision includes:

· Looking after patients as a ‘whole person’. Patients are fully informed about their care and involved in decision-making.

· Supported self-care will be the norm for the 800,000[ii] people living in Wales with long-term conditions, with technology supporting choice, self-reporting, and monitoring.

· Everyone will receive fully integrated care, built around general practice and extended primary care teams alongside social care, the third sector and carers.

· Acute and elective episodes will be dealt with in a bed in hospital where necessary. Hospitals will be designed to be the most local they can be and be appropriately staffed and set up to be sustainable by working closely with local GPs, councils and community services.

· Specialist centres will be at the heart of delivering world class outcomes, leading the way in innovation, research and development and cutting edge medicine.

· There will be seven day urgent and emergency care because it shouldn’t be the case that people are more likely to die in hospital on a Sunday than a Tuesday, or that when people fall in care homes the only place to take them is A&E.

· Nursing staff, along with other NHS staff should make every contact count, collaborating with individuals and the public in improving individual and population health outcomes.

· The effective commissioning of registered nurse training places will be key to meeting safe staffing targets in acute and community settings, thereby reducing the need for overseas recruitment.

8. To demonstrate that we have achieved our vision we must ensure:

· Positive outcomes for patients;

· A reduction in health inequalities;

· A passionate, highly-trained workforce; and

· Helping more people avoid hospital admission through improved community and social services.

9. Nurses play a vital component in this vision. However they are still only one part of a wider multidisciplinary team that can achieve this. We believe a more appropriate approach would be to ensure wards have both the right numbers of staff and skill mix to meet patients’ needs, recruiting staff more on their values and better training for nurses to make sure all care is delivered in a safe and compassionate way.

Questions

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

10. Improving patient safety is the heart of the NHS in Wales but mandatory staffing levels cannot guarantee safe care. While it is absolutely the case that good nursing is vital if high quality care is to be delivered everywhere, it is too simplistic to say any issues with care can be resolved through increasing resources and safe nurse staffing levels. Overall we do not agree that introducing legislation that imposes a crude system of staffing ratios is the right way to tackle poor patient care, and inquiries, including the Mid Staffordshire Public Inquiry,[iii] found that minimum staffing levels do not necessarily improve patient outcomes.

11. The Mid Staffordshire Public Inquiry heard evidence from California, where minimum nurse to patient ratios were introduced in 2004. A research paper, presented by Leeds University professor Dawn Dowding, found no apparent difference in outcomes between California and other states that did not have minimum staffing levels. The report suggests that there are many other variables which have a high impact on the quality of patient care – such as quality of medical technology, culture, ongoing staff education and management practices.[iv]

12. Furthermore, when comparing the UK health systems with other countries in relation to equity and safe care, the UK ranks highly. The 2014 Commonwealth Fund report[v] compared the UK health system with the healthcare systems of eleven other countries (including Australia, Canada, Germany, Netherlands, New Zealand and USA), and the UK NHS was found to be the most impressive overall. The NHS in the UK was rated as the best system in terms of co-ordination, efficiency, effectiveness, safety and providing person-centred care.

13. There is the potential for safe nurse staffing levels to be further implemented through other ways rather than legislation. Safe staffing could become a Tier 1 standard/indicator that could be implemented with more speed than legislation. Further assessment of efficacy in delivering safe staffing levels could be introduced via the performance management mechanisms between Welsh Government and the Health Boards and Trusts.

14. Instead of introducing legislation, a better response could be ensuring we get the right staffing pattern and skill mix to meet patients’ needs; to recruit staff more on their values; better training of nurses; the further commissioning of registered nurse training places and making sure all staff operate in organisations that value compassion and care.

15. There are also concerns about the proliferation of documentation that frontline nurses are now expected to complete in response to a range of national developments and programmes. All of these have value, but an unintended consequence of this administrative workload can detract from their ability to provide patient focused care. Overall we believe that any initiative to improve patient safety, whether legislation or otherwise, must be based on evidence that demonstrates the best results for patients.

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

16. Section 1 of the Bill states that its purpose is to ensure nurses are deployed in “sufficient numbers” to enable “provision of safe nursing care to all patients at all times”. However, there is no definition of what would be regarded as “safe nursing care” therefore it is unclear what the overall purpose of the Bill is and what patient outcome it is attempting to achieve in practice.

17. While NHS Nurse Director’s in Wales support the setting of safe staffing levels, they would stress that there needs to be clear professional judgment applied to ensure that flexibility in staffing remains a critical part of meeting patient needs. The use of workload and acuity tools should help inform the setting of staffing levels.

18. Already in Wales, in response to the Francis Report,[vi] there is an assessment process to determine staffing levels on wards, based on the severity of patients’ conditions (acuity) rather than solely patient numbers. The core principles, developed by the Chief Nursing Officer and issued to all Health Boards in Wales in 2012,[vii] include:

· the number of patients per registered nurse should not exceed seven by day;

· a night time ratio of one nurse to 11 patients;

· the skill mix of registered nurse to nursing support worker in acute areas should generally be 60:40.

19. In July 2013 the National Assembly for Wales Research Service produced a research note^{^[viii]} which highlighted that most Local Health Boards in Wales are meeting, or exceeding, these ratios.

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

20. One of the potential barriers to implementing the provisions of the Bill is that it takes little consideration for the workforce needed for the future and how it links with patient outcomes. When considering the best outcomes for patients, we need to help create a workforce that is fit for the future, including the nursing profession. The healthcare system must be redesigned around the service user, supporting people to maintain their own well-being and staying as healthy as possible and utilising community and local services rather than going to hospital or to a GP surgery.

21. The population of Wales is projected to increase by 4% to 3.19m by 2022[ix] and we have a rapidly ageing population, with the number of people over 65 in Wales set to rise to 26% of the total population by 2033.[x] The NHS will need to respond to significant future challenges in respect of high rates of chronic conditions, long-term limiting illness, obesity, poverty and health inequalities. Demand for services is set to increase significantly and the NHS workforce must be ready to change, respond and react to the challenges ahead.

22. The NHS will always need to treat people with high level, emergency, specialist and intensive care. However, there is a need for system-wide changes if models of care that are more community based are to be implemented.As the Welsh NHS Confederation discussion paper ‘From Rhetoric to Reality - NHS Wales in 10 years’ time’[xi] highlighted: “With ongoing financial constraints, the previous growth in the workforce has ceased. Yet the future supply and availability of clinical staff is crucial to the quality, range, shape and organisation of health services as we seek to do more with fewer staff. Delivering more of the same through traditional roles and ways of delivering care will not be an option. NHS Wales and its staff will simply have to work differently to meet increasing demands, and to be responsive to needs at the same time as ensuring high quality, compassionate, effective care.”

23. There is a need to think radically about the workforce of the future, the skills that NHS Wales will need and who will be the key decision makers in patient pathways, coupled with the need to design workforce models which are deliverable and the impact of ‘prudent healthcare’. We need help to build consensus around what a sustainable future workforce will look like and how it will be developed.

24. A workforce that is fit for the future must include people who can work effectively across professional and organisational boundaries - including across health and social care; and harness and promote innovation and technological development. The need to balance the development of generic skills required to provide care to an ageing population and recognition of the place of self-care in developing models will all impact on how we think about and plan the workforce. More generalist and less specialist competencies are needed throughout the workforce to support the increasing number of people with complex health and care needs.

25. Further information about the future workforce will be highlighted in a briefing produced by Welsh NHS Confederation, NHS Wales Employers and Workforce Education Development Services. The briefing is due to be published at the end of January and will provide a summary of the key issues facing the NHS Wales workforce based on the elements of Integrated Medium Term Plans produced by Health Boards and Trusts, together with a high level review of other UK and Wales data and information sources.

iv) Are there any unintended consequences arising from the Bill?

26. There is some concern from NHS Wales Nurse Directors that mandatory staffing levels may result in less flexibility, a lower value and reliance on professional judgment and may mean that staffing levels do not respond to changes in patient acuity and dependency.

27. Other unintended consequences arising from the Bill includes:

a) While Section 10 (A) (5) (e) states that the guidance to health service bodies in Wales “must include provision for ensuring that the recommended minimum ratios are not applied as an upper limit in practice” it is unclear what this provision will be and therefore minimum staffing levels could be interpreted as maximum which potentially puts additional stress into clinical areas regarding safe staffing levels.

b) Clear consideration needs to be given to circumstances where recruitment into posts is a key constraining factor. Already nurse supply and demand issues are proving challenging for a number of NHS organisations across the UK at present. Recently NHS Employers conducted a survey[xii] for Health Education England to gather robust and timely intelligence from employers in England about the current nurse workforce demand and their views on supply issues. Of the 90 organisations surveyed, 83% reported that they are experiencing qualified nursing workforce supply shortages, and of 49 organisations surveyed 45% had actively recruited from outside of the UK in the last 12 months to fill nursing vacancies.

c) Each NHS hospital and service has different demands on its services. Arbitrary ratios could limit organisations' ability to plan care in a way that is best for the patient and limits the way we use the skills of other staff like physiotherapists and occupational therapists.

d) There is potential for one part of the system, nurses in adult acute wards, to be prioritised in relation to staffing above others. One example is that community nursing could see reductions in staffing in order to comply with legislation in hospital settings.

e) The role of nurses could be adversely modified to take on broader roles which would not have ordinarily be seen as nursing, thus impacting on the time to care of registered nurses in particular. There is already some evidence that nurses are utilised for many differing roles including, for example, bed management and patient flow, presenting a challenge to direct clinical care.

f) There is potential diversion of funds away from other members of the healthcare team that play an important role in patient care. Nurse numbers and ratios do not take into account the role of speech therapists, occupational therapists, physiotherapists, dieticians and others. Will vacancies be held in these staff groups to pay for more nurses? This would be significantly detrimental to holistic patient care and outcomes.

g) Any legislative framework is likely to become outdated over time. This may be more prominent in relation to staffing where models of health and social care are changing, as highlighted above in response to question iii.

h) Having more staff does not equate to a more productive service. As highlighted within a recent report by The King’s Fund,[xiii] on the future financial sustainability of the NHS in Wales, increased funding over the last decade has allowed the Welsh NHS to employ more staff, and in general to produce more activity. However, productivity, measured by hospital activity per head of staff, has fallen among medical staff. While activity among medical staff has also fallen in England over the same period, the decrease has not been as great, and nursing productivity, which has remained stable in Wales, has increased across the border. Many of the most significant opportunities to improve productivity will come from focusing on clinical decision making and reducing variations in clinical practice across the NHS, and shifting the focus away from hospital-led, acute services. Reducing variations in clinical service delivery and improving safety and quality should be key priorities for providers.

v) 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?

28. Health Boards and Trusts presently take full responsibility for the quality of care provided to patients and for nurse staffing capacity and capability. Health Boards and Trusts ensure there are robust systems and processes in place to assure themselves that there is sufficient staffing capacity and capability to provide high quality care to patients on all wards, clinical areas, departments, services or environments day and night. This includes identified time set aside for nurses to have continued professional development.

29. The current arrangements for recording, monitoring and reporting nurse staffing levels in NHS Wales is adequate and appropriate. Most areas are utilising rostering systems that support a focus on staffing levels to meet the requirements of individual wards and can be used for monitoring purposes (planned versus actual staffing). These also help to identify the level of additional/flexible staffing required such as bank or agency staff.

30. In addition, currently there are periodic but regular reports into Welsh Government in relation to the implementation against the Staffing Principles for acute medical and surgical wards.

vi) 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?

31. As highlighted previously, it is essential that professional judgment and the use of acuity type tools help inform decisions locally regarding staffing levels. It's not just about numbers but the right staff with the right skills within the service.

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

32. There is clear evidence that staffing levels in acute medical and surgical settings impact upon care quality and patient outcomes. However, there is not as much evidence to support this in other settings.

33. Safe staffing levels should only be developed with the use of professional judgment and a risk balanced approach to settings other than acute medical and surgical wards. The development of community services will require, for example, sufficient numbers and skill of community nurses often within and as part of multi-professional and multiagency teams. Other settings include mental health, learning disabilities, health visiting and critical care settings for example. In some areas of practice Royal Colleges and other professional associations (such as neonatal) already produce guidance in relation to staffing and the use and emphasis on these could be more useful.

34. It is imperative that safe staffing plans are also developed for community hospital, community health, mental health and child health services.

viii) The requirement for the Welsh Government to issue guidance in respect of the duty set out in section 10A(1)(b) inserted by section 2(1) of the Bill which:

35. It is important to emphasise that each hospital and service has different demands on its services and often it is down to professional judgement to make sure organisations have the ability to respond to these demands. Although section 10 (5) (b) says guidance would specify the minimum nurse to patient ratios, “which individual health service bodies may adjust so as to increase the minimum numbers of nurses for their hospitals,” mandatory staffing levels may result in less flexibility than the current system.

36. Section 10A (1) (6) (b) of the Bill says the guidance must “allow for the exercise of professional judgement within the planning process.” However there is concern from Nurse Directors that the setting of staffing levels will lower the value of this professional judgement. As a result, staffing levels may not be able to respond to changes in patient acuity and dependency.

ix) 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)?

37. As highlighted previously it is important that when considering safe staffing it is important to involve the use of evidence-based and workforce planning tools, allow for the exercise of professional judgement within the planning process, makes provision for the required nursing skill-mix needed to reflect patient care needs and local circumstances. Many of these methods are already being implemented across health services in Wales.

38. Staffing agreements should be based on a triangulated approach, including professional judgement and an acuity tool. The acuity tool currently being tested has shown variable and some unexpected results; further validation would be welcome to demonstrate its reliability as a workforce tool. Until the acuity tool is finally validated nursing principles should remain in place.

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

39. The setting of minimum nurse to patient ratios should not be read to mean ‘maximum’. There is a concern that this Bill may have unintended consequences in that the minimum may well be applied as the maximum. Although section 10 A (1) (5) (e) says the guidance must include a provision for ensuring that the recommended minimum ratios are “not applied as an upper limit in practice” there are questions over how this will be monitored. Also, each ward should have flexibility depending on the needs of its patients. Many of the most significant opportunities to improve productivity will come from clinical decision making and reducing variation in clinical practice across the NHS, which will also improve safety and quality.

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

40. NHS Wales has become more transparent and accountable and is further developing a culture of honesty and openness so the service can learn from mistakes and improve activities. Increased transparency is a key driver in improving quality across the NHS as a whole, highlighting both those areas where good practice is in place and those where there is scope for improvement. All Health Boards and Trusts are improving visibility and ease of access to information to ensure that patients and the public are informed. Adopting an approach where organisations volunteer such information as part of quality improvement should enable a clear move in the direction of full openness and transparency.

41. While we are in support of the publication of information, the value of publically available reports would not be in simply publishing how many staff are on duty, but rather the numbers of occasions where safe staffing could have been compromised and the outcome. This must engender a collective responsibility and consideration of the actions that brought about a ‘shift of concern’, sending a clear message to staff of the commitment to ensure staffing meets the patient needs on a risk balanced and professional judgment basis.

xii) Includes protections for certain activities and particular roles when staffing levels are being determined?

42. As highlighted previously, it would be difficult to protect certain activities and particular roles when staffing levels are being determined because each NHS hospital and service has different demands on its services and patients have different clinical needs.

xiii) The requirement for Welsh Ministers to consult before issuing guidance?

43. It is important that the Welsh Minister consults with Local Health Boards and Trusts, and others who are likely to be affected by the guidance. Due to some uncertainties within the Bill, for example what is the definition of “safe nurse staffing levels” the guidance will be key to achieving the Bill’s overall purpose.

xiv) The monitoring requirements set out in the Bill?

44. The current arrangements for recording, monitoring and reporting nurse staffing levels in NHS Wales is adequate and appropriate.

xv) The requirement for each health service body to publish an annual report?

45. Section 10A (10) of the Bill highlights the need for information to be made public and for each health service body in Wales to publish an annual report. As highlighted previously, the NHS in Wales is committed to transparency in the interests of accountability and has worked hard to improve this. A wide range of information, including performance data, mortality rates and inspection reports are all published in the public domain.

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

46. In reference to some of the measures mentioned in the Bill under section 3 (5), there is concern about how these would be defined and monitored. For example, in terms of the number of falls on a ward, what would be the number that would be a cause for concern? Also in relation to mortality rates as a measure of hospital quality and safety, a number of reviews have highlighted that the measure is not always a meaningful measure of quality, and can be misleading.[xiv] There needs to be a multidimensional approach to measuring healthcare, given the complexity of this area. Furthermore, many of the measures listed in the Bill will depend on the kind of ward.

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

47. The existing guidance is effective and does have an impact on staffing levels. The Chief Nursing Officer (CNO) together with Nurse Directors have embarked on a programme of work aimed at collating evidence regarding staffing levels that improve patient/client outcomes; and the application of evidence in the form of tools for calculating and implementing staffing levels. This work preceded that being undertaken by NICE on acute wards staffing and will be largely in line with timetables for other areas of nursing practice.

48. Regular monitoring of progress against the Nurse Staffing Principles for acute medical and surgical wards has been taking place by Welsh Government (via the CNO Office). This does not currently however form part of the Tier 1 indicators and measures of Welsh Government.

xviii) 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?

49. It is important that certain aspects of the Bill should be on the face of the Bill and not left to subordinate legislation and guidance, for example a clear definition of what is the “provision of safe nursing care” should be defined within the Bill and what it is attempting to achieve.

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

50. This can only be truly understood when the scope of the Bill is clearly articulated, including the publication of the subordinate legislation and guidance. Not taking account of the above unintended consequences, and ensuring an equitable application of safe staffing levels in all settings, is likely to incur considerable costs. This would include additional data collection, collation, validation and publication.

51. As highlighted in our response[xv] to the National Assembly for Wales Finance Committee inquiry into Welsh Government draft budget proposals for 2015-16 the demand on the health service is growing and the rising cost of providing the service means that the NHS faces a significant funding gap, at the same time as an understandable expectation of improving the quality and safety of services. This means that the NHS will not be able to continue to do all that it does now, and certainly not in the same way.

52. The key critical factor when considering the financial implications of the Bill is whether the outcomes desired by this Bill can be achieved by means other than legislation. The cost and complexity of this Bill may mean that there are more cost effective and more rapid means of achieving the same outcomes.

53. There must be appropriate funding to ensure that safe nurse staffing levels are not resourced through the depletion of other services. There would need to be a clear commitment by the government that legislated staffing levels are also fully funded if safe staffing principles were to be implemented within Wales.

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

The importance of multidisciplinary teams

54. As previously highlighted multidisciplinary teams are vital to ensure that patients receive quality of care and receive excellent outcomes.

55. International evidence suggests that mandated registered nurse to patient ratios can improve nurse staffing and lead to better recruitment, generate a more stable workforce, and more manageable workloads for staff. The impact on patient outcomes is less clear but there is evidence that the resultant lower caseloads are related to lower levels of patient mortality. However, if we are to resolve possible issues within the Welsh NHS and improve patient care, we need to take a broad and deep view that looks honestly and openly at all aspects of the NHS, not just one group of staff.

56. Staffing levels may well be an issue in some parts of some hospitals in Wales, but it is not the case that we need more nurses everywhere. A better response would be to ensure we get four things right - the right staffing pattern and skill mix for each service, recruitment of NHS staff based more on their values, better training for nurses at the ward leader level, and ensuring nurses operate in organisations that value compassion and care. It is critical that we empower senior clinicians and managers at a local level to take greater responsibility for setting high standards of care, including determining the right staffing pattern for delivering these standards for their patients.

57. Multidisciplinary working has the opportunity to significantly reduce the strain on our services in the future, alongside building and learning new skills, we must collaborate and support our partners in other sectors, including social services, housing, education, transport and the third sector. This collaboration “between specialists and generalists, hospital and community, and mental and physical health workers”[xvi] will play a big part in making sure our services are sustainable for the future.

Engaging with the public

58. To ensure positive outcomes for patients we must engage with the public and consider their views about staffing issues and the impact that improved nurse staffing levels have on their individual care.

59. We know that the NHS in Wales must do more to involve the public and patients, staff and partner services in explaining and working through the choices that need to be made. In our discussion document ‘From Rhetoric to Reality - NHS Wales in 10 years’ time’[xvii] we referred to building a new understanding of how the NHS should be used, embodied by an agreement with the public that would represent a shared understanding: “Involving the public is central to realising an NHS where patients and the public are key and valued partners, where they are seen as ‘assets’. ”We highlighted the importance that as time progresses we must ensure we work with the public to co-produce services and reduce demand, releasing capacity in the system. While some people will not want to engage, all have the right to be given the opportunity to do so.

60. Although co-design and co-production are beginning to happen in some parts of the public sector, the prevailing mindset in many areas is still one in which citizens and service users are passive recipients of services. In order to move towards the kind of engagement needed there is a major cultural shift required to move away from the view of public services as delivery agents to passive populations, to a greater focus on localities in which everyone does their bit.

61. The future success of the NHS relies on us all taking a proactive approach to health and ensuring that we create the right conditions to enable people in Wales to live active and healthy lifestyles. The sustainability of the NHS and other public bodies is the responsibility of everyone in Wales, but there appears to be a real lack of understanding that this is the case.

Integration

62. In addition to the role multidisciplinary health teams play in providing quality care and excellent outcomes for people, it is important that the role of other sectors should also be considered in people’s well-being and care.

63. Integration and multi-agency working is key for the Welsh NHS Confederation because to tackle the culture of ill health in Wales we must recognise that health is much more than health services. As ‘From Rhetoric to Reality – NHS Wales in 10 years’ time’[xviii] highlighted, better health is the responsibility of all sectors and engagement is necessary with all our public service colleagues, from social care to housing, education and transport, to take us all from an ‘ill-health’ service that puts unnecessary pressure on hospital services, to one that promotes healthy lives. In serving the public the NHS must consider its own success with regard not only to treating healthcare needs, but more importantly, in relation to the ability of other sectors to impact on the quality of life for individuals. As the paper highlights: “Health and healthcare must be premised on how we best support people to maintain their health, with the aim of eliminating or reducing their potential to require NHS services, and we must work in an integrated way with all sectors across Wales.”

64. The NHS must build on how it might improve its ability to work and support partners and colleagues in other sectors to reflect the multi-disciplinary demands required to run public services in a holistic way. There is a need for wholesale change to ensure that there are positive outcomes for patients, a reduction in health inequalities and to help people avoid hospital admission through improved community and social services. To achieve these outcomes it is vital that health is not seen as a stand-alone issue and that integration is prioritised. All public bodies in Wales must build on how we might improve our ability to work together and support our partners and colleagues in other sectors to provide the best outcomes for the people of Wales.

65. The Welsh NHS Confederation is already working closely with ADSS Cymru on the ‘Delivering Transformation’, previously ‘Strengthening the Connections’, project to take the practical steps required for the integration of health and social care services. Our close work with this body, and other key partners, is ensuring that there is no compromise in the quality of the service and the ability to safeguard individuals from the services operated by our members.

Conclusion

66. The Welsh NHS Confederation welcomes the debate on safe nurse staffing levels, but there are a number of important questions to be answered in order to determine whether legislation is the most appropriate approach.

67. Improving patient safety is at the heart of the NHS in Wales but mandatory staffing levels cannot guarantee safe care. While it is absolutely the case that good nursing is vital if high quality care is to be delivered everywhere, it is too simplistic to say any possible issues with care can be resolved through increasing resources.