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 Royal College of Speech and Language Therapists – SNSL(Org) 13 / Tystiolaeth gan Coleg Brenhinol y Therapyddion Iaith a Lleferydd – SNSL(Org) 13

Wales Policy Office

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Health and Social Care Committee,

National Assembly for Wales

Cardiff Bay,

CF99 1NA

21^st January, 2015

Dear Committee Member

Safe Nurse Staffing Levels (Wales) Bill – Written Evidence from the Royal College of Speech and Language Therapists

The Royal College of Speech and Language Therapists (RCSLT) welcomes the opportunity to provide written evidence to the Health and Social Care Committee on the above Bill. In providing evidence, we wish to reiterate our commitment to provide the highest standards of patient care and to the best outcomes for patients.  However, we are firmly of the view that this can only be achieved through a holistic, multi-disciplinary approach based on the individual needs of the patient.  We are also concerned that if resources are diverted to increase nurse staffing levels following legislation then this may have a detrimental impact on other essential services.

We also question whether legislation for minimum nurse staffing levels will hinder or enhance the Welsh Government’s Prudent Healthcare Policy for Wales.  Prudent Healthcare has not yet had sufficient time to become properly embedded in the delivery of healthcare in Wales and is likely to have an impact, not only on staffing levels, but also on the development of a more diverse workforce and mix of skills required in the future.  We are of the view that the proposed legislation will fetter the ability of NHS Health Boards and Trusts to respond to the Prudent Healthcare principles – particularly in terms of workforce planning, promoting equity and co-production.

For these reasons we do not support a legislative approach that is entirely focused on nurse staffing levels. 

Response to consultation questions

1. General

1.1       Is there a need for legislation to make provision about safe nurse staffing levels?

We are committed to ensuring the highest quality patient care based on a   person-centred approach that is safe, compassionate and effective.  We are firmly of the view that delivering the best outcomes for patients can best be achieved through a multi-disciplinary approach based on the needs of the patient.  Legislation for mandatory staffing levels will not guarantee patient care.

We are concerned that a focus on nurse staffing levels in isolation risks overlooking other important factors that affect outcomes and experience for patients.

1.2       Are the provisions in the Bill the best way to achieve the Bill’s overall purpose (as set out in section 1 of the Bill?)

We have concerns over clarity in terms of terminology used.  For example, the Bill states that nurses should be deployed in ‘sufficient numbers’, to enable ‘safe nursing care’.  However, it is unclear as to what ‘sufficient numbers’ or what ‘safe nursing care’ should be in relation to staffing levels.

We support the view of the NHS Nurse Director in Wales that there needs to be clear professional judgement to ensure that flexibility in staffing remains a critical part of meeting patient needs.  In the wake of the Francis Report, there is already an assessment process to determine staffing levels on wards based on the severity of patients’ conditions rather than on patient numbers. 

1.3       What, if any, are the potential barriers to implementing the provisions of the Bill?  Does the Bill take sufficient account of them?

The focus of the Bill is on nurse staffing levels but does not address wider workforce planning issues.  We believe that nurse staffing levels should be planned as part of wider workforce planning for a healthcare system that is designed to meet the needs of its service users and is responsive to the major demographic changes and challenges it faces over the coming years - particularly the challenge of an ageing population and high rates of chronic conditions.  We do not believe that minimum nurse staffing levels will be sufficient to meet those challenges if planned in isolation.

1.4       Are there any unintended consequences arising from the Bill?

Yes.  We believe there are a number of unintended consequences.

• There are many factors contributing to patient safety and high quality care which may be overlooked if the focus is solely on nurse staffing levels;

• Diverting resources to meet minimum nurse staffing levels could mean the diversion of resources away from other essential services which would impact on patient outcomes;

• There is likely to be increased bureaucracy as hospitals and services will have to demonstrate that they are compliant with minimum nurse staffing levels;

• Legislation may limit the ability of NHS hospitals and services to plan care in a way that best meets the needs and demands of patients in the areas they serve and also stifle innovation;

• Minimum standards may be set too low to achieve the standards of care we are striving for.

2. Provisions in the Bill

2.1       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?

Health Boards and Trusts are responsible for the quality and safety of care provided to patients and should be accountable to the Welsh Government for safe and effective staffing across all disciplines.  We believe that a prescriptive legislative approach to nursing in isolation from other factors could impact adversely on accountability. We support a holistic approach which encompasses all factors contributing to the best outcomes for patients. 

2.2       The 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 worker ratios, which will apply initially in adult inpatient wards in acute hospitals?         

There would need to be a clear definition of what ‘all reasonable steps’ are considered to be.  It is assumed that there will be clarification on the processes that would be put in place to ensure compliance with minimum nurse staffing levels and the consequences of non compliance.

2.3       The fact that, in the first instance, the duty applies to adult inpatients wards   

in acute hospitals only?

While we do not support legislation on nurse staffing levels, we are concerned that the proposed legislation applies only to adult in-patient wards in acute hospitals.  An unintended consequence may be that resources are diverted to these settings which would create imbalances in provision and have an adverse impact on other staff groups and healthcare settings. This would be to the detriment of patients in other healthcare settings in terms of patient care, experience and outcomes. This is also contrary to policy direction to strengthen community services in order to reduce demand on acute services.  Within community hospital settings, the recent benchmarking UK audit showed that better patient outcomes correlated to diversity of professions around the patient.

2.4        The requirement of the Welsh Government to issue guidance in respect

of the duty set out in section 10A(1)(b) inserted by section 2(1) of the Bill.

We believe that each hospital and service should exercise their professional

judgement in determining how services should be organised to meet demands.  We are concerned that guidance specifying minimum nurse to patient ratios would restrict the ability of hospitals and services to respond flexibly to changing demands and patient needs. 

2.5 The requirement for the Welsh Government to consult

before issuing guidance. 

It would be essential for the Welsh Government to conduct an extensive and wide-ranging consultation to ensure that the intentions of the legislation are fully understood and that the implications, risks and unintended consequences are thoroughly scrutinised and evaluated.

2.6        The monitoring requirements set out in the Bill?

The monitoring process should encompass all issues that impact on patient experience and outcomes and collect information relating to other professions and staffing as well as nursing.

2.7       The requirement for each health service body to publish an annual report?

· While we support the need for clear transparency and accountability, we are concerned that production of annual reports may place additional bureaucratic burdens on service providers;  

· Reviews of the impact of the planned legislation should cover quality of patient care, experience and outcomes including impact on other service areas.

2.8        The requirement for Welsh Ministers to review the operation and   

effectiveness of the Act as set out in section 3?

We recognise that review of the operation and effectiveness of the Act is an integral part of implementing the legislation.  We would want to ensure that

measures included in the review process are meaningful and  cover factors across the range of services where impact of the legislation may have unintended consequences.  Also, that indicators should encompass quality of care and patient outcomes.

3. Impact of existing guidance

Does the RCSLT have a view on the effectiveness of the existing guidance?

We believe that the existing All Wales Nurse Staffing Principles Guidance should be properly implemented to ensure adherence to its recommendations and form part of the Tier 1 indicators.  We would wish to see staffing principles guidance introduced across the whole NHS workforce.

4.          Powers to make subordinate legislation

We believe that legislation premised on only one health care setting would be flawed. We are concerned that powers for Welsh Ministers to amend settings to which minimum staffing levels would be conferred through subordinate legislation and not on the face of the Bill.  We are concerned about the narrow focus of the Bill as currently proposed.

5. Financial implications

We reiterate our concerns that focus on nurse staffing levels could divert resources away from other essential services that play a vital role in patient care.  Similarly, we are concerned that the proposed legislation could divert resources from community services and that financial implications of the Bill will not include consideration of the unintended consequences of its implementation. 

The Royal College of Speech and Language Therapists

The Royal College of Speech and Language Therapists (RCSLT) is the professional body for speech and language therapists (SLTs), SLT students and support workers working in the UK.  The RCSLT has 15,000 members in the UK  (600 in Wales) representing approximately 95% of SLTs working in the UK (who are registered with the Health & Care Professions Council.  We promote excellence in practice and influence health, education, care and justice policies.

Submitted by Dr Alison Stroud

Wales Country Policy Officer,

Royal College of Speech and Language Therapists.