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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 Public Health Wales – SNSL(Org) 22 / Tystiolaeth gan Iechyd Cyhoeddus Cymru – SNSL(Org) 22


Public Health Wales’s Response to the Consultation on the Safe Nurse Staffing Levels (Wales) Bill

December 2014

Consultation Questions


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

The safety of patients is paramount and any move to improve this further is to be welcomed. However, nurses are part of a multidisciplinary team and there are also other factors to consider such as training, education etc, in the delivery of quality care.

If legislation is agreed there needs to be consideration for the local needs of patients, and flexibility in the application of the legislation to allow for local interpretation. The complexity and needs of patients vary, and setting a minimum standard for one area, may not be sufficient for another area if they have very complex patients with a high level of need.

The Mid Staffordshire Public Enquiry identified that having minimum staffing levels in place does not necessarily improve patient outcomes. Overall we feel the focus should be on ensuring the correct levels of all staff (including nurses) to meet the needs of patients in order for them to gain their optimal outcome, rather than legislation.

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

The purpose of the Bill sets out to provide “safe nursing care to all patients at all times” but does not then define what “safe nursing care” is. It is therefore difficult to determine whether the overall purpose of the Bill is met by the provisions set out within it.

The focus needs to remain on the ability for professionals to use their judgement and flexibility in the use of staffing to meet the needs of patients. Workforce and acuity tools are already in place across Wales as are a number of core principles set out by the Chief Nursing Officer which includes a suggested staff to patient ratio.  

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

The main barrier to the implementation of the Bill is having sufficient numbers of qualified nurses available to meet the suggested minimum staffing levels.

In addition to the increasing aging population in Wales and increase in chronic conditions we are increasingly working within an austere environment. Previous growth in workforce numbers has stopped and traditional roles and means of delivery are not going to provide the workforce of the future. The future workforce needs to be adaptable and wok within the principles of Prudent Healthcare.

Consideration needs to be given to future workforce planning and related training and education.

4.   Are there any unintended consequences arising from the Bill?

The main consequence arising from the Bill is that the professional judgement of nurses could be compromised in relation to the need and acuity level of patients. This could result in less flexibility to move staff around wards to respond to changing needs and demands.

There is a concern that the “minimum staffing level” could become accepted as the “maximum staffing level” despite guidance stating that this should not be the case. It will be difficult to monitor the application of the levels and adopting the minimum as the maximum levels could put increasing stress on clinical staff.

The introduction of minimum levels could also result in staff being moved from other settings such as community to cover acute wards (where the levels apply). Settings such as the community traditional have less staff than the acute setting and as a consequence of the Bill could be further depleted causing an impact on their ability to care for patients within their own homes, and potentially having a negative impact on the acute setting.

Another unintentional consequence could be the diversion of money away from other professional groups such as physiotherapists to fund additional nursing posts in order to meet the minimal requirement. As previously stated nurses are one group of professions within a multidisciplinary team and any diversion away from other members would have a detrimental impact on patients’ outcomes and length of stay.

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:

5.   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

Within Health Boards and Trusts there are robust systems for monitoring the levels of staffing. This is regularly reported to the Health Boards Board and also Welsh Government.

6.   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

As previously mentioned nurses need to be able to exercise professional judgement in relation to their patients’ needs and complexity.

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

If the intention is at some stage to roll out this duty further across the NHS consideration needs to be given to needs of patients in different settings such as community. Patients nursed at home are often highly complex but do not have nurses with them 24 hours/ day, and are often visited by many members of the Multi Disciplinary Team.

Should this duty be extended in the future to include those patients funded under NHS funded nursing care or NHS Funded Continuing Health Care, within Nursing Homes this would cause a significant increase in workload for Health Boards and they would not have the direct authority to influence nursing staffing levels.

8.   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)?

As previously mentioned there is concern that the Bill will lower the value of nurses professional judgement which may result in organisations not being able to respond to changes in patient acuity or complexity of need.

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

As previously stated there is concern that the minimum levels proposed will be applied as a maximum. This does not allow for any flexibility to change depending on the professional judgement of the nurses, relating to patient complexity and acuity.

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

Overall we support the move to greater transparency and openness although care should be given to how this reflects the complexity and needs of the patients.

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


Different hospitals provide different services, with different demands, so it would be difficult to protect certain activities and roles.

9.   the requirement for Welsh Ministers to consult before issuing guidance?

We welcome the opportunity for Health Boards and Trusts to comment on any guidance before issuing.

10.              The monitoring requirements set out in the Bill?

Current arrangements for monitoring staffing levels within NHS hospitals are adequate and appropriate.

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

All NHS organisations are currently required to publish an annual report. This could include information on staffing levels for acute hospitals.

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

Whilst a level of scrutiny is to be welcomed, as this can assist in improving patient safety, examining data alone can be misleading. Data needs to be looked at within context on the area it relates to and a triangulated with additional quality indicators/ information. There is also concern about the lack of definition in relation to the measures – without clear definition or explanation it is unclear how the measures would be monitored.

Impact of Existing Guidance

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

The CNO and Nurse Directors have a programme of work in place relating to collating evidence on staffing levels that improves patient outcomes. There is also regular monitoring of progress against the Nurse Staffing Principles by the Welsh Government.

Powers to make subordinate legislation and guidance

1.   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?

The Bill requires a clear definition of the “provision of safe nursing care”.

Financial implications

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

It is likely that the implementation of the Bill will incur significant costs, not just in relation to additional staff costs but also in relation to administration. In austere times any additional expenditure could have an adverse impact on the delivery of services. Consideration needs to be given as to whether the outcome proposed (improving patient safety) could be achieved by other means.


Other comments

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

As previously stated, nurses are one professional in a much larger multidisciplinary team. If minimal levels are to be set for nurses, then the question needs to be asked as to whether they should be set for all professional groups?

Concern remains that the professional judgement of nurses will be undermined in relation to the need and complexity of their patients, and the flexibility to move nurses around to respond to changing demands. Not all wards are the same, or require the same level of patient to staff ratio. What is important is ensuring that there are sufficient nurses when and where patients need them, to meet their care needs.

Whilst we support the principle of having a minimal nurse staffing level, there has to be recognition that this will not necessarily improve the quality of care provided, and may in fact indirectly, due to cost and reallocation of resources, have a detrimental effect on care received by patients.