The Welsh NHS Confederation (WNHSC) welcomes the opportunity to respond to the Health and Social Care Committee’s consultation as part of its post-legislative scrutiny inquiry on the Nurse Staffing Levels (Wales) Act 2016
The WNHSC represents the seven Local Health Boards, three NHS Trusts, Digital Health and Care Wales and Health Education and Improvement Wales (our Members). We also host NHS Wales Employers.
The operation and effectiveness of the Act to date, including its impact on patient outcomes, impact on nurse recruitment and retention, and barriers to compliance with the legislation.
Members recognised that the Act has supported improvements in the nursing workforce on all ward and unit establishments and there has been significant focus within NHS organisations to embed the Act. They were also clear that it supports a systematic and robust approach to reviewing establishments and ensures ward to board reporting and oversight.
Our members have also highlighted that the Act enables the formal, bi-annual calculation of nurse staffing levels throughout all wards covered by Section 25B. These ensure boards are fully appraised on compliance and embodies a collaborative approach.
However, it has been difficult to confirm the Act’s impact on patient outcomes and organisations have brought in other improvements, such as local harm review meetings, increased staff education and the introduction of the Pressure Ulcer Risk Primary or Secondary Evaluation Tool. As a result, attributing change purely to the introduction of the Act is particularly challenging.
The review of the first three yearly assurance reports submitted by health boards in 2021 also identified the number of serious incidents where failure to maintain the nurse staffing level was deemed a contributing factor was very low. Again, this allows for a limited opportunity to see what impact the Act had on patient harm should these measures continue to be used.
Assessing the impact has also been difficult given the dynamic nature of the Covid pandemic, which occurred during the reporting periods 2020 - 2023. Nursing leaders were called upon to manage evolving operational situations and our members did highlight systems put into place to respond to the need for variation in the planned nurse staffing levels.
Members also identified barriers associated with the requirements of the Act, which included national challenges around recruitment and retention. Issues including workload, wellbeing, pay, and professional development are contributing factors to current difficulties being experienced in this area. These challenges have led to a reliance on the use of temporary staff, both bank and agency, which affects patient care and organisation costs. Therefore, the Act must be supported with the provision of a long-term, sustainable funding plan to recruit and train both NHS and social care staff. This will effectively tackle systemic recruitment and retention issues, which affects the wider NHS workforce.
The availability of appropriate IT systems and equipment has also posed challenges to easy reporting on the requirements of the Act. The national focus on enhancing the available systems to support the reporting requirements needs to continue, with a period of review to ensure enhancements deliver the required reporting outcomes.
It was also stated that there is a lack of alignment between the financial cycle and nurse staffing review outcomes.
Further actions needed to ensure a sustainable supply of nursing staff to meet patient needs and the requirements of the legislation going forward.
Members have expressed concern over the inflexibility in implementing the Act regarding alternative roles to support patient care. Due to the current national shortage of registered nurses this can be difficult to manage.
Members have highlighted actions to support recruitment, including the all-Wales international recruitment programme, traditional recruitment methods as well as internal training and development. However, investment and collaborative working across NHS Wales, Social Care, education providers and Welsh Government is needed to ensure a sustainable supply of nursing staff to meet the requirements of the legislation going forward.
Retention, as well as recruitment, will also be key if the requirements of the Act are to be met in future. Actions needed to support both recruitment and retention will be multi-faceted and will start with the development of HEIW’s Strategic Nursing Workforce Plan, which will include the Nursing Workforce Retention Plan.
Progress in developing the evidence base to extend the Act to further settings.
Work streams within district nursing, health visitors and mental health were established to create evidence-based approaches to developing robust methods, tools and techniques to determine appropriate staffing levels within these respective services. These have been undertaken as part of the national nurse staffing programme and the respective tools are at different stages of development. We are aware that the secondments for the work stream programme leads for mental health, district nursing and health visiting came to an end in March 2023 and this will have an impact on timelines for the work’s progression.
However, members did recognise the development of the interim nurse staffing principles for health visiting, mental health nursing and district nursing, which assist NHS organisations with workforce planning.
Further work would be required to understand the evidence base for settings which currently do not have a formal workstream as part of the all-Wales nurse staffing programme, such as critical care.
If extended, the Act would promote an equitable approach to nurse staffing levels and service provision but there is a requirement for additional identified resources to fully enable and embed this. It will also require an overarching steering group to ensure consistency, monitoring and evaluation of effectiveness and impact.
A national IT system with digital solutions and data analytical support would also need to be developed before any changes to the legislation are made. This would ensure the effective and efficient collation and utilisation of data at a local and national level.
Currently, there are issues with developing an understanding of the Act’s impact in settings where it is in force. Organisations have commented on the difficulty of demonstrating the Act’s impact on patient outcomes and have also observed a lack of appetite to reconsider the original metrics. It has been suggested that other metrics should now be considered which could be more effective in understanding the impact on outcomes.
There is also difficulty in assessing whether staffing levels have resulted in patient harm, with some members commenting that the quality metrics can be subjective in this regard. On the use of complaints as a quality metric, it has been suggested that these are often far too multifaceted to be a clear indication of harm resulting from an inability to maintain staffing levels.
The extent to which the Act is ‘future-proof’, and will contribute to ensuring that NHS Wales has the future workforce it needs to deliver effective, patient-centred care that meets the needs of all population groups.
There is an ongoing commitment within NHS organisations to the principles contained within the Act. However, there are a number of issues that need to be addressed if it is to be rendered ‘future-proof’.
Nurses play a key role in achieving the vision we want for the NHS, which includes quality care and outcomes for patients. Nurses are still only one part of the multidisciplinary team (MDT) needed to achieve this aim and we are aware that one of the CNO’s priorities for 2022-2024 is around the workforce, with a focus on MDT’s collaborating to improve outcomes.
However, the Act is considered uni-professional and the tight focus on nursing does potentially impact on the implementation of an MDT approach to patient care. In order to future proof the legislation, it will be important to take into account a multi-professional and multidisciplinary delivery of service provision.
There is a need to simplify data collection and reporting to reduce the impact on staff and free up time to care. Therefore, it is crucial that digital skills and literacy are reflected as a normal expectation of both executive and frontline staff. There is also need for specialist expert digital nursing roles to inform and advise requirements around the pre-procurement and lifespan of the required digital systems.
Alongside digital capability and new digital nursing roles, information technology infrastructure, information governance, cyber security, equipment and devices should be seen as an essential from the outset to ensure safety for staff and patients.
Developing technologies will also impact on how care is delivered, as well as the shape of the workforce. The Act will then need to be considered within this broader workforce transformation agenda.
Concern has been expressed that resources will be prioritised towards area where the second duty of the Act is in effect, which includes adult inpatient medical and surgical wards and paediatric inpatient wards. This may come at the expense of other areas.
Overall, members have welcomed the Act and worked to ensure it is embedded. They have also recognised the benefits on patient care.
However, concerns persist around the impact that the uni-professional focus will have on the implantation of the MDTs in future. Members have also drawn attention to the difficulty in ascertaining the Act’s impact on patient outcomes.