The pivotal role of nurses in delivering care and saving lives has never been more evident than during the COVID-19 pandemic.
In 2016, Wales passed the Nurse Staffing Levels (Wales) Act. It was the first country in Europe to recognise – in legislation – the link between numbers and skill mix of nursing staff and patient outcomes. Scotland followed with the Health and Care (Staffing) (Scotland) Act in 2019, which sets out safe staffing requirements across health and social care services. The Royal College of Nursing (RCN) continues to campaign for nurse staffing laws in England and Northern Ireland.
The Nurse Staffing Levels (Wales) Act initially required health boards in Wales to calculate and maintain appropriate nurse staffing levels in adult acute hospital wards. Throughout the development and passage of the legislation, there was a clear intention to extend this to other healthcare settings in the future.
This article provides a recap of the main provisions of the Nurse Staffing Levels (Wales) Act 2016, and an update on work to extend the legislation in the context of COVID-19.
About the Act
- require health service bodies to make provision for safe nurse staffing levels, and to ensure that nurses are deployed in sufficient numbers to:
- enable the provision of safe nursing care to patients at all times;
- improve working conditions for nursing and other staff; and
- strengthen accountability for the safety, quality and efficacy of workforce planning and management.
A Welsh Government amendment removed the word ‘safe’ from the Bill’s title during stage 2 consideration. The Bill was passed by the Assembly in February 2016. Full details of the legislation’s passage through the Assembly can be found on the Senedd website.
The Act inserted the following new sections into the NHS (Wales) Act 2006 (the key duties are often referred to by these section numbers):
25A An overarching duty on local health boards and NHS trusts to have regard to the importance of providing sufficient nurses in all settings. This also applies where health boards are commissioning services from a third party. This duty came into force in April 2017.
25B A duty to calculate and maintain nurse staffing levels in specified settings (the ‘nurse staffing level’ is defined as “the number of nurses appropriate to provide care to patients that meets all reasonable requirements in that situation”). For adult acute medical and surgical wards, this came into force in April 2018. From October 2021, it will also apply to paediatric inpatient wards. This section also makes provision for extending the duty to further settings.
25C Sets out the method of calculation for nurse staffing levels.
25D Requires the Welsh Government to issue statutory guidance to health boards/trusts about their duties under 25B and 25C.
25E Health boards (and trusts where applicable) are required to report to Welsh Government on their compliance with section 25B after a three year period. The Welsh Government must subsequently publish a summary report. The first of these summary reports, for the period April 2018-April 2021, is expected to be published in autumn 2021.
Extending the Act
At the start of the Fifth Senedd, the Welsh Government made a commitment to “more nurses in more settings, through an extended nurse staffing levels law”. The All Wales nurse staffing programme has five workstreams:
- adult acute medical and surgical inpatient - the duty to calculate/maintain nurse staffing levels has applied to adult acute wards since April 2018;
- paediatric inpatient - the duty to calculate/maintain nurse staffing levels will apply to paediatric wards from October 2021;
- mental health inpatient – work ongoing;
- health visiting – work ongoing; and
- district nursing – work ongoing.
The Fifth Senedd Health Committee’s 2019 inquiry into community nursing called on the Welsh Government to publish a strategy for extending the Act to all settings. The Welsh Government rejected this, saying:
There are significant and numerous fundamental differences to the various settings in which nurses provide care in Wales. (…). It is far too early to begin to understand the level of complexity around that variability across all settings, a substantial piece of mapping work will need to be undertaken by the All Wales Nurse Staffing Programme before a national strategy could be contemplated. The Programme Manager has begun the early stages of that work.
The Royal College of Nursing (RCN) in Wales surveyed its members ahead of the Senedd election in May 2021. More than three quarters of respondents identified care homes and community settings as priority areas for extending the legislation. In a letter to the First Minister (June 2021), a ‘safe nurse staffing levels coalition’ of health organisations (headed by RCN Wales) called for extension of the Act to cover community nursing and mental health inpatient wards during this parliamentary term.
Capacity of the nursing workforce
During scrutiny of the Bill, the lack of existing workforce capacity was overwhelmingly cited as the most significant barrier to the legislation’s implementation.
In 2017, the then Health Minister wrote “It is well known that the Act is being implemented at a time of global shortage in nurse staff”. He explained that the Nurse Staffing Levels (Wales) Act was designed with a long lead-in time to enable Health Boards to prepare for the workforce planning implications, and highlighted work being done to address nurse recruitment challenges (e.g. the Train Work Live campaign), and how the Welsh Government was investing in nurse education and training.
RCN Wales published a progress report on implementation of the Nurse Staffing Levels (Wales) Act in November 2019, identifying key questions for individual health boards and also making a number of recommendations to the Welsh Government. These included continued investment in nursing education and action to improve nurse recruitment and retention.
In September 2020, the then Health Minister noted that the COVID-19 pandemic has placed significant additional pressures on the nursing workforce, and has also had an impact on the programme of work to extend the Nurse Staffing Levels Act. Giving evidence to the Fifth Senedd Health Committee’s inquiry into the impact of COVID-19, RCN Wales reiterated its call for action to address the shortage of nurses, and maximise opportunities to improve nurse retention:
In the first wave, we saw so many nurses returning to the workforce to try and help out. (…). What work has been done to actually bring that group in permanently, and what work has been done to ask that group of people what would make them come back? That would be a really valuable lesson in terms of going forward.
The Welsh Government’s first three year report on health boards’ implementation of the Act (expected autumn 2021) should give us an idea about how well the Act is working. But it’s clear that key to realising the ambitions of the legislation will be ensuring a sustainable supply of nurses, and developing the evidence base to support extending the Act to further settings. As highlighted in the Explanatory Memorandum:
Nurses provide 24 hour care for patients, work in every type of healthcare setting and area of clinical practice, and care for people from before birth through to death. As such, nurses are uniquely positioned to have a significant impact on the health and wellbeing of all members of the population.
Article by Philippa Watkins, Senedd Research, Welsh Parliament