Devolution and health in Wales part 2: mental health, organ donation and nurse staffing

Published 06/07/2023   |   Last Updated 06/07/2023   |   Reading Time minutes

This is the second of our articles exploring the impact of devolution on health and health services in Wales.

Our first article, published earlier this week, looked at legislation with a public health focus.

In this second part we look at: the Mental Health (Wales) Measure, the move to an opt-out system for organ donation, and how Wales has sought to enshrine safe nurse staffing levels in law.

Improving access to mental health care

The Mental Health (Wales) Measure 2010 was the first piece of mental health legislation focused on Wales. The Measure aimed to improve the provision of mental health assessment, treatment and support across the country.

The Mental Health Measure has four main objectives

An infographic detailing the four objectives of the Mental Health Measure which are to: improve provision of primary care support services for mental health, to introduce specialist, coordinated care plans in secondary care, to allow people who have previously accessed secondary mental health services the ability to self-refer back to these and to provide independent advocates for people receiving mental health care.

Source: Mental Health (Wales) Measure 2010: leaflet. Welsh Government, 2017.

Statistics measuring the progress of the Measure are released quarterly. The most recent figures, covering January to March 2023, show that progress against the objectives is variable. During this period, 69% of people began treatment within 28 days of their assessment, falling short of the 80% target. However, 84% of patients in secondary care had an established Care and Treatment Plan, exceeding the target of 80%.

In an evaluation of the Measure’s impact 10 years on from its inception, the mental health charity Mind Cymru concluded that some objectives had been very successful. The legislation has improved access to assessment and treatment through primary care, with around 40,000 people assessed each year in Wales.

The Measure also expanded the number of people receiving inpatient treatment who were eligible for an expert to advocate for them and their care. 80% of people receiving this advocacy service rated it as good or excellent.

Yet, the report noted that the system works better for some people than others, with waiting times for assessing and treating children and young people falling short of targets. Only 58% of children and young people were assessed within 28 days of their referral, well below the Welsh Government’s target of 80%, compared to 83% of adults.

Tackling the problem of organ supply and demand

Organ transplants save the lives of patients with organ failure and chronic disease. However, the demand for organs for transplants has long outstripped the supply.

In a move intended to tackle this problem, Wales became the first country in the UK to move to an opt-out system for organ donation in 2015. The legislation means that everyone is presumed to have consented to donate their organs unless they have specified otherwise.

Prior to the change, in 2013/14, 211 people in Wales were waiting for a transplant but only 159 received an organ. It was hoped that the new approach would expand the number of organs available for transplants, in turn increasing the number of people who benefit from this life-saving procedure.

NHS Blood and Transplant reported that the number of transplants in Wales was increasing year on year after the legislation passed, from 135 in 2016/17 to 171 in 2018/19, a 27% increase. During the pandemic, there was a drop in the number of transplants, although an increase in figures in 2021/22 suggests the situation is recovering.

One of the concerns about the change to an opt-out system was that it would drive large numbers of people to opt out of the donor register, having the opposite effect of that intended. But this doesn’t seem to have come to fruition. Whilst the number of people opting out of the register has increased since the change in 2015 this has been very gradual and the overall number on the register has increased.

The opt-out strategy was later adopted by England and Scotland, but not until 2020 and 2021, respectively. A related Act has also received Royal Assent in Northern Ireland.

Ensuring safe levels of nursing staff

The Senedd passed the Nurse Staffing Levels (Wales) Act in 2016, making it the first country in Europe to recognise, in legislation, the link between numbers and skill mix of nursing staff and patient outcomes. The legislation was introduced by a Member of the Senedd rather than the Welsh Government, and was one of only two pieces of Member legislation to have passed into law.

It was introduced to respond to concerns about issues with nursing care across the UK. Scotland followed suit in 2019 with similar legislation.

The Act initially required health boards in Wales to calculate and maintain appropriate nurse staffing levels in adult acute hospital wards, with the aim of this eventually being applied to other settings. Subsequently, it has applied in paediatric wards since October 2021.

As required by the Act, the Welsh Government published its first summary report on the compliance of health boards in 2021. This highlighted the limitations in capturing data to facilitate effective monitoring of progress.

The Royal College of Nursing (RCN) released two reports, in 2019 and 2022, assessing the progress of the implementation of the Act. These praised the Act, with the 2022 report finding that the Act has:

improved patient care, with less patient falls and hospital acquired pressure ulcers being reported as a result of a failure to maintain nurse staffing levels.

The RCN’s reports recommended the extension of the Act to more healthcare settings, including mental health inpatient wards and care homes.

When the Bill was being considered, the then Health and Social Care Committee highlighted issues with workforce capacity as a potential barrier to the implementation of the act. This issue is still relevant eight years on. In the RCN’s evaluation of the Act, they highlighted the need for focused efforts to improve workforce recruitment and retention to support the implementation of the Act.

In a separate report on nursing staff levels in Wales, the RCN stated that “[…] there are not enough registered nurses or nursing staff employed by NHS Wales and this is having a devastating impact on nursing morale.” Further information on this topic can be found in our article ‘Is nursing a workforce in crisis?’.

The Health and Social Care Committee is currently carrying out post-legislative scrutiny on the Nurse Staffing Levels Act.

Article by Ailish McCafferty, Senedd Research, Welsh Parliament

Senedd Research acknowledges the parliamentary fellowship provided to Ailish McCafferty by the Medical Research Council which enabled this research article to be completed.