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 Welsh Independent Healthcare Association - SNSL AI 11 / Tystiolaeth gan Cymdeithas Gofal Iechyd Annibynnol Cymru - SNSL AI 11


Safe Nurse Staffing Levels (Wales) Bill

WIHA’s second written submission to the Health and Social Care Committee



1.      Further to the Welsh Independent Healthcare Association’s (WIHA) response to the Call for Evidence on this Bill, WIHA is pleased to submit this further response to two questions posed by the Health and Social Care Committee.


2.      WIHA is the representative association of the majority of independent acute and mental health hospitals in Wales. Please find attached the latest WIHA Credentials document which provides an overview of the independent healthcare sector in Wales.

Applying the provisions of the Bill to independent healthcare settings

3.      Question 1 - Why, in your view, the Bill should include provisions that apply to independent healthcare settings - the WIHA’s written evidence states: “The WIHA is very pleased to have had the opportunity to comment on a possible amendment for the Safe Nurse Staffing Levels Bill to include the independent healthcare sector and it is important that should the Bill be extended that is will include all of the Independent Sector not just NHS funded care within the Sector.”


4.      The independent healthcare sector serves to provide safe quality healthcare to patients who choose to self-pay or use private medical insurance. The sector also provides some additional capacity to the NHS in periods of extreme pressure on NHS services. Safe staffing is a key aspect of independent healthcare quality standards in order to protect all patients (whether NHS or privately-funded) and to supply safe care in a dignified manner. Therefore inclusion in the Bill allows the independent sector to reflect their support of safe staffing for all the patients they treat.


5.      The independent healthcare sector is, of course, already reviewed for safe practise by Healthcare Inspectorate Wales. However the additional provision of standards via this Bill would support this function and provide clear guidance to the regulator and providers.


6.      WIHA members treat a mixture of NHS and privately-funded (private medical insurance and self-pay) patients alongside each other; there is no distinction between patients on the basis of their funding source. Indeed nursing staff would not necessarily know the funding means of a particular patient. Were the Bill to only apply to NHS-funded patients it could lead to a discriminatory system between the two groups of patients which may cause confusion and care lapses.

Nurse staffing ratios in the independent healthcare sector

7.      Question 2 - Whether the industry adheres to any staffing ratios at the moment and, if so, what those ratios are, to what extent compliance is monitored and by whom, and what the rates of compliance are.


8.      Does the sector adhere to any staffing ratios at the moment?


9.      Staffing ratios are assessed using the clinical judgement and expertise of the clinical leaders as a recognised tool. Acuity of patients, skill mix of staff, category of surgery and local factors are all used to establish safe staffing. Staffing ratios are assessed as a minimum 24 hours in advance, and as a continuous measure. The aim is to meet patient need at the time and in order to do so the system requires flexibility. The actual ratios may be slightly different dependant on the WIHA member and indicate minimum safe staffing levels rather than a maximum.


10.  WIHA members also take cognisance of relevant guidance in this area, for example:

·         NICE guideline Safe staffing for nurses on adult inpatient wards in acute hospitals, which has application in Wales.

·         Royal College of Nursing publications such as Guidance on Safe Nurse Staffing Levels in the UK.


11.  WIHA values the bi-annual meetings held with Chief Nursing Officer (CNO) for Wales, Dr Jean White, and her inclusive approach to WIHA members. The CNO communicates developments in this area to WIHA members.


12.  If so, what are these ratios?


13.  As per paragraph 9 above, nursing staff ratios vary for a number of reasons. It is essential that professional judgement is used throughout the planning process.


14.  Ratios in WIHA member hospitals also reflect the abilities of our Healthcare Assistants (HCAs) who having gained an NVQ Level Three are able to participate more fully in providing care.




15.  To what extent is compliance monitored?


16.  Any unsafe levels of staffing are escalated via clinical leaders to senior nursing management under the WIHA member’s clinical governance structures. Compliance is also monitored via audit at clinical reviews, and is part of the complaints and any adverse incident investigations. Comprehensive Whistleblowing policies are in place to protect the staff member should there be an issue which an individual feels is necessary to escalate.


17.  Healthcare Inspectorate Wales have also discussed safe staffing at recent inspection visits of certain WIHA member hospitals.


18.  By whom is compliance monitored?


19.  Compliance is monitored by clinical leaders and shift coordinators within the organisation. As stated above this is also monitored periodically through the internal clinical audit process and externally by Healthcare Inspectorate Wales.


20.  What are the rates of compliance?


21.  WIHA members achieve 100% compliance as there is a zero tolerance approach to unsafe staffing. Bank and agency staff are used to fill any staffing shortages.

Particular points to consider in the independent healthcare sector context

22.  Should this Bill be enacted, robust workforce planning strategies will be needed to ensure that there are sufficient nursing staff numbers to ensure compliance. WIHA members are beginning to be included in formal workforce planning structures for Wales and this would need to be continued. Nursing staff can and do work across the NHS and independent sector and it is therefore helpful to consider workforce planning in the widest sense to encompass the entire healthcare sector.


23.  The proposed Bill makes mention of registered nurse ratios and the ratio of healthcare support workers to registered nurses but makes no specific recommendation on the HCA role nor on minimum numbers for these important members of staff.  WIHA members have invested in the training of their HCA staff who consequently play a significant role in the provision of essential nursing care. It would seem prudent that their role is recognised within this Bill.



24.  Independent healthcare providers tend to deliver care using a holistic approach based on a multi-disciplinary team. Different professions have more scope to deliver care that might not traditionally be delivered by their profession in a different setting. For example, the boundaries between nurses and occupational therapists may be more blurred in parts - focusing solely on nurse staffing ratios could have adverse effects on such allied health professions.


25.  Models of effective healthcare delivery are continually evolving and due to their nature independent healthcare providers are able to respond quickly to such changes. There is a real danger that any inflexible legislation could become outdated as care delivery models change and new evidence bases develop.


26.  The independent healthcare sector has a significant provision of the mental health and learning disabilities services in Wales and WIHA would be interested to know whether such settings would also be brought under the auspices of the Bill.


27.  Nurse staffing ratios are a highly complex issue. Should the Bill’s remit be extended beyond the NHS, sufficient flexibility would need to be built into its provisions to ensure that it allows the differing structures within the independent sector to meet the terms.


28.  In order for Committee members to gain a broader understanding of the independent healthcare sector, WIHA would like to formally invite them to visit their local WIHA member hospital. This will enable members to see the hospital in operation and speak directly to the lead nurse on the issue of safe staffing levels.


11 March 2015