Analysis

Wales adopts safe staffing laws while the rest of the UK watches

A law requiring health boards to provide sufficient numbers of nurses in medical and surgical wards will soon take effect in Wales, and Scotland is planning to follow suit, but there is no indication that England and Northern Ireland will have similar legislation

A law requiring health boards to provide sufficient numbers of nurses in medical and surgical wards will soon take effect in Wales, and Scotland is planning to follow suit, but there is no indication that England and Northern Ireland will have similar legislation

  • Safe staffing on wards is linked to reduced mortality
  • Welsh law will be extended to mental health, district nursing, paediatrics and care homes
  • It has enabled health boards to highlight areas where staffing needs to be reviewed


Picture: Pete Coburn

A law on safe nurse staffing levels in adult acute medical and surgical inpatient wards comes into force in Wales on 6 April.

The Nurse Staffing Levels (Wales) Act, the first law of its kind in Europe, places responsibility on health boards to calculate and provide sufficient numbers of nurses to care ‘sensitively’ for patients.

Joanna Doyle, manager of the All Wales Nurse Staffing Programme at Public Health Wales, said in early March that implementation of the law was going well.

26.9%

The new law requires established staffing levels to be increased by 26.9% to allow for holidays and sick leave.

Ms Doyle, who is helping NHS Wales prepare for and meet the new requirements, told the National Safe Staffing Summit in London: ‘The data we are using to drive this act are becoming more reliable and more robust. The staff have confidence in the data to provide an accurate picture of the ward where they work.’

Support and engagement

Health boards have to calculate the level of nursing staff by triangulating data on patient acuity, quality indicators and professional judgement. Statutory guidance on how this should be calculated was published in November, followed in December by new guidance on calculating acuity.

‘We have seen a change for the better in increasing commissions, recruitment, looking at workload, sustainability and commitment to staffing levels’

Tina Donnelly, RCN Wales director

Joanna Doyle
Joanna Doyle: Staff have
confidence in the data.

Using better data, which include acuity audits at least once every six months and information on patient flow and staff activity, has meant increasing levels of support and engagement from staff, Ms Doyle told the event.

It has also enabled health boards to make informed decisions about staff and highlight areas where staffing needs to be reviewed, she said.

Tina_Donnelly©JW
RCN’s Tina Donnelly: Positive
change so far. Picture: Jay Williams

RCN Wales director Tina Donnelly agrees that the legislation has already led to positive change. Student commissions have been increased from just over 900 in 2012 to nearly 1,500 places this year, and the Welsh government has launched initiatives on return to practice and flexible retirement, she says.

The new data and audits means that health boards have already spotted that they were sometimes struggling to meet the staffing requirement at weekends, and they have sought extra agency and bank staff.

So far it appears to have led to positive change, Ms Donnelly says.

Careful review

‘In the main, staffing levels have increased in term of both registered nurses and healthcare support workers,’ she says. ‘The whole reason we campaigned was to change behaviour, and we have seen a change for the better in increasing commissions, recruitment, looking at workload, sustainability and commitment to staffing levels.’

One concern that will need careful review is whether other wards and services are drained of staff to ensure that acute medical and surgical wards meet requirements.

‘We have been training our stewards and activists to ask questions locally as to whether the wards are ready from April to actually adhere to the staffing legislation, and we have had assurances from health boards that they are,’ Ms Donnelly says.

Seeking reassurance

 26%

Mortality was up to 26% higher in wards with the highest patient to nurse ratios compared with better staffed wards, according to research. 

‘However, there have been challenges over winter pressures and the snow. So the RCN Wales board asked me to write to chief executives seeking reassurance that they are able to meet the requirements, and that letter went out this week.’

There are plans to roll out the remit of the legislation further, to cover staffing in inpatient mental health, health visiting, district nursing, paediatrics and care homes. This is to happen before the end of the assembly government’s term in 2021, if sufficiently robust evidence can be compiled, Ms Donnelly says.

The law comes into force as concerns mount across the UK about insufficient numbers of nurses to fill vacancies. Last year the RCN said there were 40,000 unfilled vacancies in England alone.

‘Standards of patient care rise and fall along with the number of nurses on duty’

RCN associate director of policy Lara Carmona

Research has repeatedly shown that ward-based registered nurse staffing is significantly associated with reduced mortality.


Susan Osborne: Applauds progress
in Wales. Picture: Barney Newman

Safe Staffing Alliance chair Susan Osborne applauds the progress in Wales and says she hopes it will provide impetus for improvements elsewhere.

‘They are doing something, and being seen to do something,’ she says. ‘It is not perfect, but it is a standardised approach across all hospitals in Wales, using the same approach for determining what staffing levels should be. They are also linking it to clinical outcomes, which is the key to all of it.

Scotland follows suit

‘The problem that we have in England is that we have different trusts using different staffing levels, and we are trying to compare apples and pears.’

13%

Thirty-day mortality rates fell by up to 13% as a result of similar safe staffing legislation in California

Where Wales is leading the way in safe staffing, Scotland is following. A safe staffing bill is being developed, following a consultation last year on what it should include.

It will be introduced to the Scottish parliament in ‘the coming months’, according to the Scottish Government.

Scotland’s health secretary Shona Robison says it will ‘ensure safe and effective staffing, reflect patients’ care needs and promote a safe environment for service users and staff’.

The RCN is keen for legislation to follow in England and Northern Ireland, though the respective governments have not indicated that is likely. A campaign calling for safe staffing in all settings is due to be launched by the college later this year.


RCN’s Lara Carmona: Need to
ensure accountability.

Legislation is one piece of the safe staffing jigsaw, with other aspects such as robust data and a comprehensive workforce plan for England also essential, says RCN associate director of policy Lara Carmona.

Patient outcomes

The current approach in England, which includes guidance on safe and sustainable staffing in different settings by NHS Improvement, is insufficient, she says.

‘It is guidance, it isn’t enforceable in any way,’ Ms Carmona says. ‘A high proportion of the nursing workforce report they cannot do their job properly due to understaffing, so it is time for governments, policymakers and the NHS to listen.

‘Safe and effective staffing levels are vital. Standards of patient care rise and fall along with the number of nurses on duty. Patients can pay the very highest price when levels fall too low. Legislation is needed to ensure accountability.’

Five important responsibilities for health boards in Wales

  • Provide enough nurses to care sensitively for patients across services
  • Use a triangulated methodology to determine the nurse staffing levels in prescribed areas, currently medicine and surgery wards
  • Inform patients of nurse staffing levels
  • Take steps to maintain the nurse staffing level
  • Report to the Welsh Government compliance with maintaining the roster, actions taken in response to not maintaining the nurse staffing levels, and the impact on patient outcomes

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