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 Minister for Health and Social Services - SNSL AI
19 / Tystiolaeth gan y Gweinidog Iechyd a Gofal Cymdeithasol- SNSL
AI 19
Safe Nurse Staffing
Levels (Wales) Bill
Further evidence
from the Welsh Government in respect of using existing Ministerial
powers to achieve the aims in the Bill
Background
- The Bill’s stated aim is to achieve
safe nurse staffing levels in “adult inpatient wards in
acute hospitals" by creating a legal requirement for local
health boards “to take all reasonable steps to maintain
minimum registered nurse: patient ratios and minimum registered
nurse:healthcare support workers ratios.” There are
no ratios on the face of the Bill, as it is intended that the
ratios be set in guidance to be issued by the Welsh
Ministers. The Bill also sets out a very prescriptive list of
matters which must be included in the guidance.
- During the Health and Social Care (HSC)
Committee’s evidence session on 5 March 2015, Assembly
Members sought clarification on the acuity tool and its potential
use to produce an appropriate number or ratio for the purposes of
the Bill.
- It is not possible to take the raw figure
generated by the acuity tool for a defined period of time and use
it unquestioningly as a minimum staffing figure from then on,
because the situation in an acute ward changes so frequently.
Local Health Boards (LHBs) therefore use the acuity tool as well as
professional judgement and nurse-sensitive indicators (the
triangulated approach) to determine nurse staffing levels.
- When the acuity tool has completed its
development and validation phase, the Minister will be in a
position to mandate its use by LHBs in Wales. It is
anticipated that this phase will be completed by summer 2015.
Relevant Ministerial
powers
- Section 12 of the National Health Service
(Wales) Act 2006 (the 2006 Act) allows the Welsh Ministers to issue
directions to local health boards about the exercise of any of
their functions. Under section 204 of that Act, such directions may
either be given in writing or may be prescribed in
regulations.
- The Minister may mandate the use of the
acuity tool under these existing powers. In this case, the
Minister considers that issuing directions in writing (for example,
in the form of guidance) would be effective, as opposed to having
to make regulations, given that all LHBs have already actively
engaged with the acuity tool since its introduction in Wales.
Any directions which the Minister issues to LHBs about the
exercise of their functions must be met in full by each LHB, and
they are not able to use their own discretion to decide whether or
not they wish to follow these.
- The delivery of NHS functions is performance
managed against the NHS Delivery Framework. If an LHB is ever
considered to not be performing in one or more areas of service
delivery, then the escalation arrangements contained within the NHS
Delivery Framework will be instigated. If there is continued
failure by an LHB to deliver, then the framework sets out that
Welsh Ministers may make an intervention order under section 26 of
the 2006 Act and remove any or all of the members of the applicable
LHB board.
- At the HSC Committee on 12 February, Lynne
Neagle AM asked what LHBs would consider to be mandatory
guidance. Paul Roberts, representing Abertawe Bro Morgannwg
University LHB, said
“We
account, as health boards, to Welsh Government, and, if Welsh
Government tell us something is mandatory, then it is. That is what
I would see as mandatory.”
Anne Phillimore, representing Aneurin
Bevan LHB, agreed.
- The Scottish Government has mandated the use
of their acuity tool without resorting to legislation. In
October 2013, NHS Scotland revised its workforce planning guidance
and mandated that, from April 2014, all health boards must apply
nursing and midwifery workforce planning tools, where available. To
date, the Nursing and Midwifery Workforce Workload Planning
Programme has facilitated local implementation within boards
thereby assuring that the tools are applied systematically across
the whole of the healthcare system in Scotland. This has been
supported with the development of a Nursing and Midwifery Workload
and Workforce Planning Toolkit. Their acuity tool is similar
to that used in Wales:
“The Adult
Inpatient tool determines nursing staffing levels using an
acuity-dependency approach and is based on a staff to bed ratio and
average bed occupancy (ABO) level, including a 22.5% predictable
absence allowance.
‘The staff
to bed ratio has been developed from specialty specific
observational studies conducted in NHS England and validated in NHS
Scotland. These studies monitor patient dependence and the
volume of nursing resource allocated to a range of tasks including
patient hygiene, vital signs, reporting, cleaning etc. Data
from these studies is used to calculate the specialty specific
staff to bed ratio.”
(Source: NHS
Scotland Workforce Planning website)