Evidence Paper


Health and Social Care Committee


Date: 5 March 2015

Time: 9:30 – 10:30

Venue: Senedd


Title: Safe Nurse Staffing (Wales) Bill




To provide an evidence paper for the Health and Social Care Committee.  The evidence paper provides additional evidence to support the paper provided by the Chief Nursing Officer.


In this evidence paper:


•           “NHS in Wales” is used to refer to NHS local health boards and NHS trusts

•           “acute ward” means medical and surgical adult in-patient acute wards

•           “establishment” means the total number of staff allocated to work in a ward




The need for legislation to make provision about safe nurse staffing levels


1.    The Welsh Government fully agrees with the need for safe staffing levels and already has a number of policy initiatives in place to achieve this aim for nursing and other professions, to improve the patient outcomes under existing powers.


2.    In Wales the responsibility for determining a safe, appropriately skilled workforce lies with the Local Health Boards and NHS Trusts, since they have the statutory authority to respond to the needs of the population they serve.


3.    The factors that support the decision making framework for safe staffing levels are complex and the ‘All Wales Nurse Staffing Principles Guidance’ was developed in recognition of that fact.  The Welsh Government has deliberately never set mandatory minimum ratios of registered nurses to Healthcare Support Workers nor minimum numbers of staff per in-patient bed. However working together with Local Health Boards, these principles were agreed, along with the introduction of an acuity tool as an interim measure, pending the full validation of the acuity tool.


4.    The adult acute acuity tool is robust and evidence based; it measures acuity and dependency of patients and helps determine the appropriate nursing establishment for the clinical area. Acuity describes how sick a patient is and dependency how much nursing care a patient requires. It is therefore a tool for forward planning rather than being designed for day to day rostering. The validation of the tool will be completed shortly and it will then be fully implemented across NHS Wales.  Staff use a triangulated approach, which includes the acuity tool, professional judgement and nurse-sensitive indicators to provide safe levels of staffing, which is a more responsive and effective approach than imposing rigidly-defined fixed staffing numbers.


5.    Research highlights the importance of quality initiatives and sound evidence of the effectiveness of nurse staffing levels to be determined through quality patient outcomes/nurse-sensitive indicators.  Transforming Care is an example of a quality initiative in Wales, introduced under the 1000 Lives improvement programme, which has reaped significant rewards in terms of ward organisation, management and quality patient care using patient outcomes/nurse sensitive indicators.


6.    The Bill places undue emphasis on reporting against a list of indicators by the Welsh Ministers, overshadowing the responsibility of the NHS in Wales to ensure the provision of safe services, assess that provision and report upon it.



7.    The existing tools and levers that the Welsh Government has deployed already go some way to satisfying the aims of the Bill, and could be further strengthened, for example by mandating the use of the acuity tool once it has been fully validated.


8.    Subject to the Committee’s recommendations, the Government’s view is that legislation as introduced would require amendment in order to add value to the current policy direction.


Achieving the Bill’s overall purpose


9.    The Welsh Government does not intend to set any form of minimum ratios for the NHS in Wales as the evidence indicates that this area is far too complex to take such a reductionist approach.  Working in partnership with NHS Wales, the Welsh Government has developed a triangulated approach for NHS organisations to implement, based on the use of the acuity tool, professional judgement and nurse-sensitive indicators.


10. The Bill focuses on only nurse staffing, whereas Welsh Government policy is to integrate care across the professions and the sectors.  The Welsh Government has defined its health policy as a move towards an integrated health and social care framework, with patients’ needs at the centre of service delivery, as evidenced in the Social Services and Well-being (Wales) Act 2014.  This integrated approach requires multi-disciplinary and multi-professional working with each profession utilising their skills when the patient needs them, and seeks to eliminate unhelpful demarcations of different roles.


The barriers to implementing the provisions of the Bill


11. The reporting requirements for Welsh Government as set out in the Bill present a significant barrier because many of the existing reporting mechanisms are not currently aligned to these requirements, both in terms of the structure of the reporting mechanism and the frequency of reporting.  The Explanatory Memorandum does not explain clearly why there is considered to be the need for reports every two years.   The Welsh Government considers it more cost effective and efficient to follow the three year planning cycle that Local Health Boards already use, so that the frequency of reporting appropriately responds to emerging patterns in data. The NHS planning framework which follows a three year cycle supports the development of Integrated Medium Term Plans which Local Health Boards and NHS Trusts are required to develop. The NHS Planning Framework simplifies and clarifies the planning requirements and process within NHS Wales.  The Integrated Medium Term Plans contain information that support the calculation/assessment of staffing levels, but the data in its current format do not report on each of the indicators identified in section 3(5)(a) to (i) of the Bill.


12. Data collection to support reporting is currently driven through different management information systems within NHS Wales.  As with other data collection systems, to report accurately on the Bill, the existing data collection would not only require significant modification, it would also need quality assurance from hospital ward level and upwards. 


13. The Explanatory Memorandum, paragraph 220, acknowledges evidence from the Royal College of Nursing that the ICT systems in Local Health Boards are not identical, but nonetheless suggests that these systems would not need to change in order to implement the Bill.  The Welsh Government considers that a full impact assessment would need to be carried out on the existing systems because these  systems were not designed to report on the indicators set out in the Bill requirements; rather they are for the collection of patient information or other aims.  The assessment would need to identify how to ensure that data were collected at ward level, were consistent, quality assured and fully triangulated to the indicators set out in s3(5).   However this is not just a matter of gathering and reporting information; there is a wider issue of analysing the data to make sense of it. The systems available in the NHS are not designed or intended to support the kind of fine-grained analysis that would be required, nor are there currently experts in place either in Local Health Boards or Welsh Government to make sense of the raw data for the purpose of the Bill.


14.  Careful and detailed analysis of data gathered would need to be undertaken to understand any causal link between the patient outcome information and the nurse staffing level. Given the absence of evidence base to substantiate any direct causal links of nurse staffing to the listed patient outcome indicators, this analysis would need to establish such an evidence base in order to have validity. For example a patient may be cared for in hospital and on discharge may have an injury or a different illness that requires readmission. It would be entirely wrong to link the staffing levels on one or more wards from the initial admission to the cause of the readmission. It would be wrong to suggest that hospital acquired infections can be solely linked to nurse staffing when the reality is there are many factors that needs to be considered, such as: antibiotic prescribing, competence of staff in infection prevention measures; hand hygiene of all staff; introduction of infection by visitors; cleanliness of the clinical area; availability and competence of cleaning staff; layout and maintenance of the clinical area.



Unintended consequences arising from the Bill


15. Some of the unintended consequences arising from the Bill are:


16.  The Welsh Government’s Prudent Healthcare initiative, introduced in 2014, aims to minimise avoidable harm; carry out the minimum appropriate intervention and promote equity between the people who provide and use services.  As a result, some existing services will need to be reconfigured to the new requirements.  A mandatory nurse staffing ratio could hinder these developments, as it creates an inflexible set number for staff that does not allow for role development and the contribution of other professionals to patient care on the ward.


17. The demand for registered nurses increased following the adoption of the Chief Nursing Officer and Nurse Director Principles and the associated funding announced to support the work of nurse staffing in adult acute hospital wards. One way to mitigate the impact of meeting a mandatory level of staffing that is not achievable due to difficulties in recruitment, could be bed closures, thus reducing capacity in the acute setting.


18. Where there is an increased demand for registered nurses the effect of this demand will mean that care homes will need to compete to recruit and retain their nursing staff as well.  Following a White Paper consultation on the Regulation and Inspection of Social Care in Wales, the Welsh Government has prepared a Bill which will be introduced to the Assembly on the 23 February 2015.  The Regulation and Inspection of Social Care (Wales) Bill will propose a new requirement for local authorities and Welsh Ministers to consider and publish reports on the stability of the care sector, in the present and in the future, which will include staffing information, and may be used to help mitigate against this unintended consequence of the Bill.


19. As this Bill is only focussed on nurse staffing, one consequence may be that NHS organisations will pull resources to fund other staff, such as cleaners to fund the mandatory minimum ratio or nurses. This may result in pressures on nurses to carryout non nursing duties. Similarly as the Bill is only focused on adult acute hospitals, one consequence may be that resources of registered nurses will be pulled away from other settings to satisfy the statutory requirement.


20. The Bill makes no mention of grade/experience mix in its requirements; it merely focusses on nurse numbers. Therefore a consequence may mean a bias towards recruiting junior nurses rather than more senior nurses with enhanced and advanced skills as they may be deemed as too expensive. This lower level of experience and competence within the nursing team will have a material impact on the quality of patient care.







Provisions in the Bill


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 under section 10A(1)(a)


21. NHS Wales has a legal framework and governance structure in place to ensure that all health service bodies meet the obligations and duties placed upon them.  There are also non legislative support mechanisms in place such as the e-governance manual which supports NHS organisations in defining, implementing and maintaining their governance arrangements.  It provides direction, guidance and support to Board members and NHS staff to enable them to fulfil their own responsibilities and ensure their organisations meet the standards of good governance set for the NHS in Wales.


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


22.  Evidence has been used to inform the work in Wales to adopt the triangulated methodology approach to setting staff levels, which challenges the effectiveness of using a ‘minimum’ ratio.  It is the Welsh Government’s deliberate decision not to set minimum ratios for nurse staffing levels as this is not considered to be workable or an efficient use of resources.


23. Requiring minimum ratios of nurses to patients and nurses to healthcare support workers is a very inflexible and impracticable approach which fails to take into account the way in which the NHS operates on a day to day basis. This view is supported in the latest NICE guidance, Safe Staffing for Nursing in Adult Inpatient Wards in Acute Hospitals published in 2014. 


24. The Health and Social Services Committee has received a copy of the Fundamentals of Care System User Guide: Adult Acute Nursing Acuity & Dependency Tool.  It includes care quality indicators that can be linked to nurse staffing issues, such as leadership, establishment levels, skill-mix and training and development of staff, for use at a local level. This information can be used together with the acuity and dependency information to help determine local ward staffing requirements.


Duty under section 10A (1) (b) which applies to adult inpatient wards in acute hospitals only


25. If the Bill is enacted, the Welsh Government considers it appropriate to implement this duty in a single setting first and evaluate its impact carefully before considering applying a similar duty to other settings.


26. However, there needs to be a distinction between an acute ward and an acute hospital.  Were the Bill to be enacted, it should be enacted for acute adult medical and surgical wards, rather than acute hospitals, as an acute hospital may also provide other, non-acute services.  There is an opportunity to clarify this in the guidance to be issued, by defining the terms used, as is required by the Bill, or an amendment could be made to set out these key definitions on the face of the Bill, which is the preferred option of the Welsh Government.


Guidance to be issued by Welsh Ministers to include provision about the publication to patients of information on the numbers, roles and responsibilities of nursing staff on duty under section 10A(5)(g)


27. The Welsh Government already makes data available to patients through My Local Health Service.  This is a website specifically designed for the transparent communication of data on the performance of the NHS in Wales, so that the public are kept informed and are able to prompt and recognise improvement. The site uses intuitive graphs and charts and detailed explanations to present NHS Wales quality and safety data from health boards, hospitals and primary care.


28. The website currently publishes data at a local acute hospital level on a suite of mortality rate indicators, and at Local Health Board Level on hospital-acquired infections and staff sickness levels.  The website also publishes data on the number of nurses per available bed, stating that “in the light of recent reports, it seems clear that the level of nursing staff on wards is important in ensuring that the right quality of care can be provided for patients. The Welsh NHS is accordingly giving closer attention to this matter. Work is in hand on developing a revised calculator (i.e. the adult acute medical and surgical in patient acuity tool) to help ensure that staffing levels match the needs of patients on acute hospitals wards.”


29. The Welsh Government considers that when prescribing (through guidance), the publication requirements for compliance with the duty under 10A (1) (b), it is important that the information is meaningful for patients and families.  Information on ‘quality experience measures’ for example, would be far more relevant to patients as a means of quality assurance.


The requirement for Welsh Ministers to consult before issuing guidance section 10A (8) inserted by section 2(1)


30. It is standard policy for the Welsh Government to consult with stakeholders and citizens before issuing new guidance.  Consultation helps the Welsh Government to understand how a law, policy or guidance might affect the people of Wales. It also helps to find out their views and citizen input helps to improve ideas and shape work to make policies more effective.


31. When a new consultation is launched, the Welsh Government makes the relevant documents available to organisations and individuals with an interest in the area of consultation.


The monitoring requirements set out in 10A (9) inserted by section 2(1)


32. Section 10A (9) the Bill suggests that the NHS Delivery Framework could be suitable for the purpose of monitoring the Bill.   The NHS Delivery Framework provides clarity about delivery priorities and is aligned with Ministerial policy and the need to drive up standards and outcomes. However, the Framework in its current form does not meet the monitoring requirements set out in the Bill, and would therefore need significant adaptation to be fit for such a purpose.


The requirement for each health service body to publish an annual report under section 10A (10)


33. It is presumed that the obligations on Welsh Ministers to report on the review of the Bill at section 3 must be based on the requirements for Local Health Boards and NHS Trusts to publish their own annual reports (10A(10)).  However, for such a reporting regime to be workable in practice, it would need to be aligned to existing reporting systems and cycles which already in operation.  Currently they all relate to an annual cycle, with the main Annual Report being published and presented at an Annual General Meeting before the end of September each year. 


34. Section 10A(10) has a mixture of reporting and planning obligations that would, under standard Local Health Board business, be discharged by different publications, either through their Annual Report or through an Integrated Medium Term Plan.  Both are annual cycles but different, the former to be completed by end of September after the end of each financial year and the latter before the end of March following the next planning period.


35. Any new reporting requirement which a Local Health Board could not incorporate into existing reporting and publication systems would necessitate additional workload and costs, diverting resources away from patient care.  Additionally, separate new reporting requirements on one group of clinical staff potentially consolidates a silo approach to staffing and is against the general direction of both integrated multidisciplinary services and integrated reporting.


Requirement for Welsh Ministers to review the operation and effectiveness of the Act under section 3


36. The Explanatory Memorandum suggests a number of existing vehicles for reporting on the operation and effectiveness of the Bill to help minimise the administrative burdens of health service bodies.  These include the NHS Delivery Framework and the Annual Quality Statement.  However, these methods of reporting do not align fully with the requirements in section 3 of the Bill and would therefore need to be adapted.  For example:


·         The NHS Delivery Framework sets out the processes in place to monitor progress and provide support and intervention as necessary. Allocation and use of resources (staff and finance) is one of the areas covered by the framework. This platform is currently not being used for public reporting, but does capture the data to support the indicators set out in 3(5), with the exception of overtime and agency/bank nursing.  The data are not currently provided to Welsh Government at ward level, with the majority (but not all) of data being reported at hospital level for major acute sites.  To meet the reporting requirements of section 3 of the Bill, additional data would need to be collected and would need to drill down to ward level, which would be costly and resource intensive.


·         The Annual Quality Statement is designed to outline progress by health boards and other NHS organisations by comparing data and patient feedback to previous years. It is published by Local Health Boards in ways adapted to local circumstances and does not have a statutory footing.  It would not therefore offer a suitable framework to report progress against this Bill. 


·         The NHS Planning Framework is the mechanism by which Health Boards and Trusts respond to day to day pressures without losing sight of how they plan to align key services, staff, finance and the public to delivering the outcomes intended for the populations they serve over a medium term (three year) time frame. The existing template for the Integrated Medium Term Plans that are produced by Local Health Boards already includes information such as the overall change in nursing levels and recruitment difficulties.  It is possible that the template could be adapted further to capture information that will track the progress of a Local Health Board in terms of achieving the aims of the Bill, but this would require a significant change to the framework which would again incur further costs. 


37. The Welsh Government is moving towards an NHS Outcomes Framework as a method of measuring performance.  The NHS Wales Outcomes Framework 2015/16 will demonstrate the annual improvement in the health and wellbeing of the citizens in Wales.  It is a set of outcomes and indicators for the population of Wales supported by the NHS Delivery Framework as set of measures identified to focus NHS delivery in year. The aims of the Outcomes Framework are to:


·         Determine the NHS’ success in planning and delivering quality safe care;

·         Determine the NHS’ success in planning and delivering services to support the public to achieve and maintain health and wellbeing and;

·         Be the foundation for the future direction of health and care for Welsh Government, the NHS and the public.


38. The Outcomes Framework will be measured annually and reported at an all Wales level, and broken down to individual health board/trust level as appropriate.  The NHS Outcomes and Delivery Framework will allow better reporting by exception and will use a range of different indicators that could be assessed to identify ‘trigger points of concern’ which would require further attention and review, part of which would include an assessment of nurse staffing levels.


39. The Bill as currently drafted requires Welsh Ministers to include progress against a list of indicators at section 3(5).  This relies on a number of management information systems at various levels which may not be consistent, requiring the need to undertake a full assessment to establish an alignment of information and quality assurance.  The causal link between these indicators and safe nurse staffing levels also remains a central concern.





Frequency of reporting


40. Many of the mechanisms for reporting are on an annual basis, rather than every two years as specified in the Bill.  If a new reporting mechanism were to be developed and set to report every two years, it would not be consistent with other planning and reporting cycles.  The Welsh Government considers that the NHS Planning Framework may potentially offer an appropriate fit for Local Health Boards to prepare to demonstrate compliance with the Bill as part of a rolling three year planning cycle, if the Bill’s requirements were amended, for the following reasons:


·         Local Health Boards and Trusts could have a lead in period to become fully compliant with the requirements in the Bill after guidance is published.


·         Integrated Medium Term Plans already include data on nursing levels to support planning over a three year rolling period, which will also reflect how an Local Health Board is preparing and planning for compliance with the Bill


·         It would allow for a lead in time to develop and implement new guidance, similar to the existing guidance ‘All Wales Nurse Staffing Principles Guidance’ that used a three year introductory phase. 


41. The NHS Planning Framework could accommodate both a lead in period for Local Health Boards to familiarise themselves with the guidance requirements, and feature as part of the longer term data collection to support a modified reporting mechanism. 


Impact of existing guidance


Existing Guidance


42. The Explanatory Memorandum recognises the £10 million funding issued to Local Health Boards to enhance medical and surgical hospital nurse staffing introduced in July 2013 on a recurrent basis.  The funding was allocated based on the needs of the population, using the Townsend formula. This is exactly how safe staffing needs to be determined, by the Local Health Boards and NHS Trusts, in order that they can take into account of changing circumstances when and as the arise.


43. The Explanatory Memorandum sets out some of the impact of the CNO principles on nurse staffing levels. Paragraph 174 on page 40 states “The introduction of the national principles has led to an improving picture for nurse staffing levels across adult acute in-patient wards in NHS Wales. The principles included a requirement of 1:7 registered nurse to patient ratio by day; the majority of areas now comply with this.”  The CNO’s principles are an interim measure to be used until the acuity and dependency tool can be fully implemented and do not mandate a staffing ratio.


44.  The CNO and Nurse Directors principles agreed in May 2012 have had a significant impact on nurse staffing levels. They have embraced best evidence in this area and allowed an approach to be formulated at local level to inform the allocation of nurse staffing establishments. While progress to achieve such principles has been monitored, it has always been considered as requiring a time frame in which movement towards compliance would be incremental. The additional monies announced to support work in the area of hospital nurse staffing levels has aided that journey. The NHS in Wales can demonstrate where progress has been made, even in the difficult current market for registered nurses.

45.The latest NICE guidance entitled safe staffing for nursing in adult inpatient wards in acute hospitals informs the Chief Nursing Officer’s work.  This guidance does not prescribe a fixed staffing ratio.  In the accompanying Frequently Asked Questions document, NICE states

““The Safe Staffing Advisory Committee reviewed the best available evidence and concluded there is no single nursing staff to patient ratio that can be safely applied across the wide range of acute adult in-patient wards in the NHS.”

The existing guidance issued with the Wales acuity tool already incorporates much of the advice from NICE. 

46.  It is too early to tell what the impact has been of the NICE guidance in NHS England.

Powers to make subordinate legislation and guidance


47.  The Welsh Government considers that the affirmative procedure is appropriate for the powers to make subordinate legislation at section 10A (3) to extend the application of the duty to maintain minimum staff ratios to other settings.  Extending this duty could have a substantial impact upon the NHS in terms of staff resources and administration/operational costs, and thorough consideration would need to be given as to how any such duty could work in practical terms within the particular characteristics of the NHS in Wales. 


48.  The Welsh Government has no plans to bring forward any subordinate legislation under these powers for the foreseeable future and would want to review how effective the Bill was in acute medical and surgical settings before applying it to other settings, if evidence supported the need.


Financial Implications


Start up costs


New guidance or the revision of guidance to reflect the provisions in the Bill


49. The estimated one off cost in the Explanatory Memoran

of guidance over a three month period is £45,000.  The information to support this amount draws on an estimated amount used for the NHS Finance (Wales) Act 2014, whereby guidance was updated to reflect moving from a one-year financial duty to a three-year rolling financial duty, and was issued to Local Health Boards only. 


50. However, the guidance proposed under the Bill would be far more complex to produce.  There would be a need to draw together guidance based on best practice and robust evidence. The Explanatory Memorandum states that the “Welsh Government must issue guidance, which must be consulted upon with experts and those organisations that will be impacted upon by this guidance”. Therefore the guidance will need to be developed with stakeholder, lay and expert input. This is a significant change from the current guidance that supports the adult acute in-patient acuity tool, which is a ‘how to’ guide.


51. The Explanatory Memorandum states that “the intention of this Bill is that the statutory guidance will be based on the guidance issued by the Chief Nursing Officer, involving the use of existing validated acuity and dependency workforce planning tools and also professional judgement”. However, this triangulated approach does not allow for the setting of a minimum ratio. The current triangulated approach allows for a local contextual flexibility.  It is not described in the Fundamentals of Care System User Guide Adult Acute Nursing Acuity & Dependency Tool as this does not set a minimum ratio for staff numbers. If a fixed staffing ratio is set, the guidance would require more detail and explanation than the current documents. For this reason, the model adopted by NICE seems appropriate, where the literature is reviewed and a panel determines the content of the guidance. Such guidance could include recommendations on safe staffing for nursing in adult inpatient wards in acute hospitals, based on the best available evidence. It would also identify the organisational and managerial factors necessary to support safe staffing for nursing, and appropriate methods to measure compliance with the guidance.


52.  The requirement for the guidance to “include provision for ensuring that the recommended minimum ratios are not applied as an upper limit in practice” introduces a new concept that is not included in the existing guidance. There is no evidence base in the literature of a method or approach to do this, and therefore this aspect of the guidance would require further work. It is not possible to cost this without significant analysis.



Changes to IT systems for the purpose of reporting


53. The Explanatory Memorandum does not recognise any additional costs associated with the reporting requirement against the list of indicators described in section 3(5) (a) – (i) of the Bill.  It suggests that there will be no additional costs in terms of ICT administration for the implementation of this section. 


54. Many of the indicators in section 3(5) (a-i) are available at hospital or Local Health Board level.  They are Local Health Board management information, held by the NHS Wales Informatics Service (NWIS). 


55. An initial consultation with the NHS in Wales about the availability of the indicators at ward-level shows the differences in how each organisation collects and processes the data that would needed to provide these indicators. 


·           One Local Health Board collects all of the indicator data at ward-level, although their data about patient and public satisfaction with services are collected using a paper-based system.

·           Two Local Health Boards collect most of the indicator data at ward-level, but not mortality rates, readmission rates or hospital-acquired infections. 

·           One Local Health Board collects most of the indicator data at ward-level, but not mortality rates or readmission rates. 

·           One Local Health Board collects data at ward level for readmission rates, hospital-acquired infections and number and severity of hospital-acquired pressure ulcers, but not the other indicators.   The Local Health Board commented that such information “isn't all available at ward level.  Some is, some is only available by service area and is collected in different ways and with different systems.” 


56. Collecting all of the indicators at ward-level would impose a considerable burden on the NHS in Wales in terms of staff resource to adapt NWIS systems to receive ward-level data, to input the additional data and to generate and analyse reports based on these data. 


Data Collection


57. The Explanatory Memorandum (paragraph 218) states that Local Health Boards have data management systems at ward level, but this is not the case for all of the indicators, as discussed above in paragraph 57.


58. Local Health Board staff have also confirmed that the existing IT systems cannot produce a report which integrates the indicators listed in section 3(5) (a) – (i) of the Bill into a single report.


ICT changes


59. Currently there is no single information solution that has been specified to collect all the data required for the indicators listed in section 3(5) (a-i) of the Bill at ward-level and collate them into a single report.  It would therefore be necessary to carry out scoping and development work to create any new information sources.  This could involve the design and construction of a dedicated database to hold these data; the modification of existing NHS IT systems, and processes to quality assure the data fed into any new solutions by Local Health Boards.  An analysis would need to be undertaken to consider the information requirements and the best way of meeting them.    Without such an analysis, it is very difficult to estimate the costs of establishing a solution that will generate the information required to monitor the indicators. 


60. Also, it will be important to consider any other factors that may affect progress against the indicators, not just nurse staffing levels.


Impact on the workforce


61. A mandatory ratio is likely to have an impact on the nursing workforce; however, it is not possible to estimate the cost of this impact.  Local Health Boards put forward the number of nurses to be trained every year, based on their requirements to fulfil the health needs of their population.  The Welsh Government can not anticipate the nursing levels required by Local Health Board nor the numbers of registered nurses available to the Welsh NHS.  It is therefore not possible to estimate a cost.


On-going costs


Review of guidance after the first year and every two years thereafter


62. The Welsh Government agrees with the estimated review costs set out in the Explanatory Memorandum of £37,500 over a five year period.  However, even though the guidance will be reviewed every two years, in light of the current fast -changing environment in the NHS in Wales, is likely that a major review of the guidance would be required after the first five years. This change environment includes the implementation of the regional service reconfiguration plans, the adoption of prudent healthcare principles, developing new advance practice roles and the introduction of a new Primary Care Plan as well as change in other areas. Therefore the workforce and roles of today’s staffing requirements are likely to look very different in the next five years. This guidance must prescribe set ratios that need to ensure they consider these changes as well as reflecting the ever increasing evidence base in this area. A major review is considered likely. Again the method proposed to undertake would be the model used by NICE, which draws on additional expertise and utilises the most recent evidence from a Welsh NHS context.  Further expenditure would be incurred if the Welsh Government followed this anticipated approach.


Welsh Ministers to publish a report of the operation and effectiveness of the Act


63. The Explanatory Memorandum does not recognise a cost for Welsh Government in terms of reporting.  It assumes that the NHS Delivery Framework or Annual Quality Statement can be used as a mechanism for reporting in paragraphs 223 and 224.


64. The Welsh Government is preparing to launch the NHS Outcome Framework supported by the Annual Quality Delivery Framework in March 2015.  The purpose of both the NHS Outcomes Framework and the Quality Delivery Framework is to measure delivery across a wider area than just the acute hospitals to reflect the structure and accountability of the Local Health Boards. It starts to focus on health and well being across the whole of the NHS and wider partners.  The NHS will work to the Outcomes and Quality Delivery Framework from April 2015.  The NHS Delivery Framework includes reporting on some of the indicators listed in section 3(5) (a) – (i) of the Bill to some extent namely mortality indicators, readmission rates for chronic conditions, healthcare acquired infections, pressure ulcers (just the number), patient and public satisfaction, and sickness absence .  It may be possible to modify the NHS Outcomes Framework to publish information about the other indicators, but quality-assuring the data and generating a report in the required format will still require extra investment and resource.


65. As already explained in this evidence paper, there are a number of planning and reporting mechanisms that could potentially be used to report on the operation and effectiveness of the Bill.  However, each mechanism does not reflect entirely the requirements in section 3(5).  Costs would need to be identified to either modify an existing reporting mechanism or create a new reporting platform to meet the duty to report as currently drafted.  The ongoing costs would further increase if the reporting mechanism was modified to take into account new settings prescribed by regulation in section 10A (3).