National Assembly for Wales

This is the Health and Social Care Committee. I'd like to welcome any stakeholders and others watching in this morning to committee. Welcome back to Members. Before we go any further, if there are any declarations of interest that want to be highlighted in the public session, I'd be grateful for that. Sarah.

I'm a Member of Unison, Unite the Union and GMB.

Joyce Watson.

I'm a member of Unite, and a close family member is a member of the Royal College of Nursing.

Jack Sargeant.

Thank you, Chair. I'm a member of Community union and Unite the Union.

Thank you all. We move to item 5, and this is in regard to scrutiny of the chief nursing officer. This session today will provide us with an opportunity to hear about the chief nursing officer's priorities and nursing and midwifery professions in Wales, and to discuss challenges as well. Can I thank you both for being with us today and just ask you to introduce yourselves for the public record?

Thank you, Chair. Good morning. My name is Sue Tranka, I am the Chief Nursing Officer for Wales, working at the Welsh Government. I'm also the nurse director for NHS Wales.

Good morning, committee and Chair. My name is Gillian Knight. I'm a nursing officer working in the Welsh Government, working with the chief nursing officer.FootnoteLink

Thank you. Members will have various questions this morning, but if I can kick off with the first: is the nursing workforce in crisis?

Thank you, Chair. Good question, 'Is the nursing workforce in crisis?' I think you have to look across the globe to understand whether Wales's nursing workforce is in crisis. We are not unique within Wales. The World Health Organization has set out very clearly that the vacancies are over 50 per cent for the nursing and midwifery workforce across the globe, and that's of all the healthcare workers.FootnoteLink Within Wales, we have—and you will have seen—the RCN's report, 'Nursing in Numbers' from last year, and we are very grateful to the RCN for the work that they have done. But you will have seen a growing number of vacancies within the workforce.

We have pieces of work that are ongoing to address the current vacancies. I think, if we are to continue along the path that the workforce is on, then we are certainly not going to be able to recoup what is becoming increasingly difficult challenges. I think there is a lot of work for us to do around the right recruitment, training the right numbers of staff, retaining the ones we have—because we have incredible staff who are doing an exceptional job under very challenging, very difficult circumstances—and then, we have to continue to attract the right people into the profession.

So, is the nursing workforce in crisis?

I think it's really challenged. I think it's really very difficult currently. We have a growing number of vacancies, and I think there is work to be done. I'm not sure I would necessarily label it as 'crisis', but I think I would certainly say it is perhaps the most challenged position I have seen in my 31 years as a nurse.

Thank you, Sue, for that. You've listed some of the challenges already, but in terms of setting the context for the rest of the session, perhaps just bullet-point what you think the challenges are, not just for the workforce within the community, but also in public health roles as well. So, what would you bullet-point are the specific challenges?

I don't think you can carve off challenges for community or challenges for public health nurses or challenges for the acute sector nurses. I think the entirety of the workforce is experiencing the same set of challenges, just in different levels of severity, I suspect. The challenges I think first and foremost are retention. I think we have a workforce who are making decisions about where else they would like to work, making decisions about the working conditions they are currently under, and making decisions to choose not to stay in nursing. So, retention is clearly one of the biggest issues we have within the nursing workforce.

Second to that is that the Minister has invested a huge amount of money. I will ask Gill to confirm, but I think it's £260 million in 2023-24 in terms of training numbers and commissions and the training in education plan.FootnoteLink We have the highest number of nurses within Wales that we have had. Since 2016 I think it's 55 per cent that the commissions have grown. So, in terms of the recruitment of numbers, and the training numbers coming through, that's not necessarily the biggest problem, but you will be aware that we don't necessarily recruit to a 100 per cent of the training numbers we require and we need in Wales. So, I think recruitment in Wales is an issue. I think recruitment in Wales, in certain specialties as well, continues to be an issue.

I think the health and well-being of our workforce is one that cannot be underestimated. Since the pandemic, since 2020, our workforce have been experiencing significant mental health, physical health and general health conditions. I think that is post-traumatic stress, moral injury and distress, and current circumstances will only lead you to have a look and see that nurses have made decisions about their own health in the workplace. 

So, I think, retention, recruitment, attraction are those big factors within the workforce. And working conditions cannot be underestimated. The working conditions have to be right to enable our workforce to stay, to have joy in their work, to want to continue to give of their very best in this very difficult landscape. So, I think those have to be considered as the top issues. 

A lot of what you've mentioned I think Members have got some specific questions on, so they'll pick those up later in the session. Are there any specific challenges in terms of the midwifery workforce that you would like to highlight?

I think I would start by saying that our midwifery workforce has grown by something like 97 per cent in the last five years, and that is really positive.FootnoteLink We continue to see our midwives stay with us, and we do retain our midwives. However, we have an emerging challenge in midwifery, which is not dissimilar to what we're seeing in nursing. I think what we are seeing in midwifery is a greater requirement on care. It's a greater demand on services. And I think that is reflected in whether our workforce continue to stay with us, if we can recruit the right numbers of midwives, and that we can care for those midwives in the services where they provide care, particularly over the community and acute sectors.

I don't think the issues or the concerns that midwives experience are dissimilar to that which nurses experience. And I would go further to say that I don't think that these are unique to the nursing profession. I would say that healthcare workers across the sector, post-pandemic, in the last three years, have had the most challenged time that cannot be underestimated, from both a physical impact and mental health impact, and a general provision of services. I think it has been exceptional for them. 

Yes, I quite understand. Thank you. Jack Sargeant. 

Thank you, Chair. Good morning, both; yes, it's still morning. The Minister is in negotiations at the moment with a number of trade unions, and I refer the Chair to my interest before as a trade union member. Can I ask what role you play as chief nursing officer in advising the Minister and the Welsh Government on nurses' pay in particular?

My role as an official does not extend into any pay negotiations; that is a matter for the Minister. The Minister is advised by the policy officials for workforce, the workforce director. My role is to offer any advice on any packages that are being put together, in order to understand, and, I suppose, assess, how that plays through to the nursing workforce. I think that is my entire role in terms of the professional advice that I would bring to the Minister. I do not engage in any of the further discussions on pay outside of the offer. 

Thank you. I think that clears my question up very well. 

Joyce, do you want to come in?

I would ask if you have an opinion about the recent Welsh Government advice to health boards that lower risk patients could be discharged without a care package.

Thank you for that. I think, first, I'd like to clear up any misinterpretations of that letter. Contextually, it's really important to set out why that letter was sent. Currently, in our healthcare provision across Wales, we have anything between 1,700 to 2,000 patients who should not be in our acute beds because they do not require emergency, urgent or acute care. I think having patients in acute beds is fundamentally wrong for those patients—they become more unwell, they tend to deteriorate, they decondition significantly and then we go into a cycle of requiring further care. So, these patients should certainly not be there.

The letter that we sent out during a very difficult period was not that patients should go home without a package of care—that would be irresponsible, and that goes against my professional values and that of the Welsh Government. What we have asked is that those who do not have a perfect package of care—. And let me give you an example of what that means: a patient waiting to go home for support in the home for something like a two or three-times-a-day package of care. Whilst waiting for that full package to be put in place, the request was whether a conversation could be had with the patient, family members, loved ones, if somebody could support that patient with that extra requirement in the day until that full package could come into effect.

I think that is a fair request, at a time when the harm in the community is so high, when patients can’t be seen, when they cannot be conveyed to hospital, when they are having really severe and significant conditions awaiting care—that we ask a question of that nature. And I think that was the responsible thing to do. I think the key here is that we wanted it to be a safe discharge and that is really an important thing to understand. There is a set of assessments and procedures that take place at a health board level prior to a patient being discharged. By no means does a letter leave the Welsh Government and a health board chooses to discharge a patient simply without applying any type of professional judgment.

How would we monitor? Is there a capacity in place to monitor? Whilst it might be safe medically, there's the social aspect to that and the pressures on the wider workforce that you previously mentioned in trying to deliver that. How do we monitor the need for care, which might not be medical, but nonetheless is there, and the pressure that that might then in turn put on those delivering it without that full care package and ensuring their well-being?

There is a mechanism currently by which we review that. For example, where community nurses need to step into that space temporarily to support a package of care that is not a full package of care currently, we will record that through what we have in the community system currently, which is a digital system that monitors demand and capacity and scheduling. So, we would look at what is the additional demand that is coming into the community, how they’ve managed to reschedule and move their work around to manage within the community provision, and then understand that gap and then do some work to understand what needs to be done to close that gap. It is quite a new system. It’s been in place only a couple of months. We are waiting for a full read-out of that data, which will probably be in the next six months or so, where we can understand it. Currently, it is there, it is being assessed on a daily basis by those who are using it, but the Welsh Government hasn’t had a full report yet and we won’t have one for a few months yet.

Thank you.

Thank you. Just to follow up on Jack Sargeant's question, I suppose, and to understand more about your role—. I ask the question in the context of the current negotiations and views in terms of nurses' pay and conditions. I'm just trying to understand how you balance perhaps potentially two different elements of your role. One is providing recommendations and guidance to the Welsh Government, as you've set out to Jack, and the other is being the voice of the nursing profession and standing up for the nursing profession, who clearly have a different view at the moment in terms of pay and conditions to the Government. So, how do you balance those two positions?

Thank you; interesting question. I'm a professional at heart—that’s first and foremost. I am a civil servant and I am here to discharge my duties accordingly. My role within this I don’t see as two different things. I think my professional advice to the Minister is based very much on the views of the profession, and maybe not only the views but also what the profession needs. It is really important that that professional advice is evidence based, that it is tested, that we understand the needs of the profession and then that advice put forward to the Minister.

I would say that as the head of profession, I absolutely acknowledge and understand where nurses and midwives are coming from currently, and it is really disappointing to see that they have been pushed to this point. I do think that they need to use their voices and as I put my head-of-profession hat on, it is important for me to encourage nurses to use their voices for what they require. It is equally important for me to be able to hear those voices, and I spend a lot of time out in the system—not just now during industrial action; I have spent hours and hours out in the system since I have arrived in post. I continue to do that on a monthly system. I am out in service; I have a uniform on, I visit the service. I ask staff, 'What do you want? What do you need? What can we do for you?' And then that comes back to inform policy positions. It comes back to inform what we can do together. It comes back in terms of how I can offer that advice to the Minister. And we have a Minister who is very opening open to listening and really open to supporting many, many of the CNO priorities so far in terms of—and we can go through those priorities in terms of understanding what we've put into place.

So, that is, I think, how I balance my role currently. But it mustn't be underestimated that these are two different roles, but I am one person, and I am a professional at heart, and I think I want to remind the committee that that does guide me in my professional advice to the Minister.

Thank you. Sarah Murphy.

Thank you very much, Chair. Hello. Thank you for being here. So, you talked earlier on about attracting nurses to the profession, but I'm going to ask some questions about their retention. So, we're seeing trends in nurses leaving the profession, so my question is: do we know what areas they're leaving from? So, for example, are there parts of the NHS that are particularly at risk, in your opinion? And also, the Nursing and Midwifery Council register data doesn't provide this information, so that's why we're asking. And what work is being done to understand why nurses are leaving? Thank you.

Okay. So, let me start with what work is being done to understand why nurses are leaving. So, there have been a number of surveys undertaken with the workforce and our stakeholders, of course, by HEIW—Health Education and Improvement Wales. They are our national education body in Wales, and they have undertaken some work with stakeholders to really ask and understand, 'Why are you leaving the profession currently? What would make you stay?' I think that is the question we have to ask.

Predominantly, I think the answers have been around exactly what our nurses are asking for currently, and better working conditions. Recognition as well does come up regularly; recognition of the contribution that they have made.

So, as a result of those surveys and the intelligence that has been received, HEIW have set out to undertake what is called a 'national nursing workforce plan'. Within the national nursing workforce plan, one of the elements that they are delivering on is the retention plan. And we have asked our union colleagues to sit alongside us, Welsh Government, HEIW, the system, the service and our colleagues, to advise and pull together what will be essentially a retention toolkit.

Okay.

And a guide, which will be published shortly. I think it's March—do correct me, Gill—I think it's March, and that guide will be, in essence, for the workforce, but also for employers to undertake self-assessment and to understand exactly what they need to do in their organisation to ensure that they have support in place.

But my expectation is that health boards have early supported discussions with the workforce, that they are undertaking to signpost their workforce to the right places for support and help, that we identify quite early on when nurses require additional support from a mental health perspective or a different perspective, and that we are signposting our workforce to those places.

So, that's the retention piece of work. That doesn't mean to say that there has been no retention work that has been ongoing at health board level. Health boards have all been individually undertaking some of this work, through either exit interviews or pre-exit interviews, to understand what will make their workforce stay. Flexible working is one of the other things that staff ask for quite a bit, and we've got quite a lot of work that is ongoing around flexible working currently.

The NMC register doesn't, unfortunately, give us retention data in the way in which you are asking for, but what it does highlight is whether or not our register grows year on year. We get a six-monthly report from the NMC. The NMC is the Nursing and Midwifery Council, they are the regulator for nurses and midwives, and they provide a readout of whether or not the register has grown. In the last period up to September 2022, the register in Wales has grown by 1.7 per cent of our nursing workforce, and I think, if I'm not mistaken, that that is the biggest growth across the UK that we saw in Wales.FootnoteLink So, that is positive, but they don't necessarily hold retention data. That is for health boards and country-specific to hold their own retention data. I hope that answers your question.

Okay. Thank you, yes. But, essentially, though, it does mean that we're not able, really, to identify if nurses are leaving from particular areas more than others—or are you aware just from anecdotes, I suppose.

I may pass on to Gill for that, if that's all right. Gill.

Okay, thank you.

No, we don't have specific data across—do you mean across services?

Yes—it says here, 'Are there parts of the NHS that are particularly at risk that nurses are leaving from?' Is it mental health, is it accident and emergency? We don't know that.

We don't have specific data about that, but we do have priorities, so we have health and care priorities, mental health being one. So, there is a focus and an increase in the commission of training and nurses required to work in those service areas.

The CNO mentioned flexible working, and another key ask from the nurses on the ground is time to develop, time to learn, time to have a break. What I've witnessed the CNO do and say is that it's really important that you work together, that you're kind as a workforce, that you look after each other, you take the breaks, you hear what the pressures are, daily, weekly, particularly now. So, that flexible working, that ensuring people have time, have a break, have the right facilities within the services and the environments to enable that to happen, and to let people know it's okay if you're not well. Another thing that came from Public Health Wales's survey of our nurses was that people felt they had to come to work if they weren't feeling well, and it's really important that if people aren't well they know they're not expected to come into the workplace. We have to look after the nursing and midwifery workforce to help retain them and to attract people in.

Wonderful. You've answered quite a few of my follow-up questions, so I'm just going to ask one more, if that's okay, Chair. You said in your priorities document about generational incentives to work for the NHS, so would some of the things that you've just said then around flexible working, time to develop, and so on, would those come under it? And also, just to say, at the moment, though, is there scope to offer more flexible working and training opportunities, so maybe with nursing students, helping them with childcare? Is that already in place? What can be done and is there anything that can be done to do more?

So, from a generational incentive perspective, I think it's really important to understand that somebody at the end of their nursing career will want a very different type of flexibility than somebody at the start of their career. What we are seeing in terms of the differences in generations is the younger generation that are coming through are very different to those of us that started in nursing 30, 40 years ago. They want something completely different. Their flexible working has a different meaning, and we have to be able to work with our newer generations to understand what they require. They want digital technology at their fingertips, and they want it in the workplace, and I will talk a little bit in a moment about what we've done to enable some of that.

Our older workforce want something different again, but we don't want to lose—and when I talk about generational incentives, I don't want to lose the older workforce because they go with such memories, such richness of experience and expertise. So, we have set out to work with HEIW to develop what's called a—I'm calling it a retired nurse network, but I'm sure there'll be a better word for that in the future. But that's to retain that expertise in the system. When they want to retire they can, but we bring them back to help us, on their terms and their conditions, and they can help the newer generations to settle in, to bed in to the new way of working, and to support them through either a mentor or a coach system. So, I'm really pleased to say that we've done some of that, and the network is clearly under way and under development currently.

Sorry, your second question, Sarah?

My second question was around childcare. What is the scope like at the moment in terms of being able to offer that flexibility for people? And childcare is an example of, maybe, the need for that.

I'm not sure I have to hand any examples of that, so apologies for that. But certainly that's one that is worth discussing. Gill, do you want to come in on that?

Yes, thank you. I want to go back one point as well. The CNO has an excellent example of working with our retired, experienced executive directors of nursing, where we have a secondee who recently started with us who's doing some scoping work around a particular piece of work, looking at the band 4 workforce, doing the scoping to inform a policy position. This retired nurse has excellent experience—well, there are two—to help inform what we're doing whilst also supporting some of the other newly appointed executive directors of nursing.FootnoteLink

Around childcare, yes, I would have to say that I heard it last week from a colleague in practice who said, 'If a nurse came forward and said, "I could work three hours a day", I would say, "Yes, please come in and let's see how we can make that work for you."' Now, that's difficult—some services may say that's difficult—when you've got services to cover. But we're really keen to have and to work with any time that registered nurses can give us across the system.

That's very interesting also. Thank you very much. Thank you, Chair.

Jack, you wanted to come in on this.

Yes, thanks, Chair. Just going back a couple of questions, really, Gill, you said you don't have the specific data—from Sarah's question—that shows you whether parts of the NHS are at risk, for example, but you have priorities. Would that data not be useful to have, and is there a way of collecting it to help plan your priorities, if they're changing, or actually to help fulfil what you need to achieve?

We, centrally, in Welsh Government, don't hold that data. But our organisations will use that data to inform their workforce planning at this time. We don't have it centrally.

So, at this time, would you then be saying it would be welcome if Welsh Government had that data? Because it's there, isn't it?

Data is really valuable to help inform priorities and what we do, yes.

Thank you.

That was a good question, Jack. Is there any reason why Welsh Government wouldn't have that data? I would have thought it's information that is—. There's no secret in the information. It needs to be shared to help Welsh Government plan. Is there a reason why that data wouldn't be available to Welsh Government?

Do you want me to answer? Thank you, Chair. So, I agree; there is no reason why that data is not available other than we currently have a technological issue with getting that data through to us, and that is where the Minister has been really clear, and so have I, that not having transparency of data from a health board level on vacancies and retention in the way in which we would like to see it is not an acceptable position for us in Wales. We have to be able to address that, and we are currently working with HEIW to understand how we can get that data through on an all-Wales level. 

Lovely. Jack.

Thank you, Chair. It's interesting, this, because there is a solution out there, it's just a technological—some people would say 'barrier', but I don't believe in barriers. It's a technological opportunity here, and it's great that you're doing the work. Is there a time frame around that solution? When would you expect—? Maybe not 'when would you expect', but when would you like it? Because it would help your role. When would you like to see it?

And what is the technological issue?

I can't go into the detail because I don't understand the technological issue, to be frank. I'm not sure if it's software or hardware or an interface—I'm really not sure. We can certainly come back to you, Chair, with what that issue currently is. But, yes, what is the timeline and how soon would I like it? Look, I think if we work in an evidence-based profession—and we do—data is the thing that drives us all forward, data is what we base our improvements on and data is what we're looking for. So, absolutely, I would like the data tomorrow, really, and I think that is how soon we should have it. The Minister would probably say a similar thing. She has been asking for a while for this data, and for us to find a way through the barriers that have been to this technological solution. We are working to understand what we can do with that.

I'm just trying to simplify it a bit more. Each organisation and health board will have that data. Can't you just write that down on a bit of paper and pass it to the Government and say, 'This is it' and add it all together? Or is that simplistic?

I suppose it's not too simplistic; it is a way of doing it. In data management you will appreciate that you need data control, you need data validation, and there is a bit of work that needs to be done. So, I'm not sure accepting data on a piece of paper is the way I would suggest we do things, just for validity and reliability. But I certainly see your point, Chair.

The point I'm making is that each organisation and health board has that information—there it is, drop it in an e-mail to the Government and the Welsh Government puts it together and it's easily available. It's much better to have a technological solution for that, but if it's not available, it doesn't seem too hard to do that. And that's really important information that's needed to plan. 

We do have some data through StatsWales. Maybe Gill can come in just to advise what StatsWales does currently publish for the Welsh Government's use, but actually for public use as well.

I'll just ask Jack to come in first. 

I don't actually think we need to know what StatsWales do. The data's there, this clearly needs to happen. I think you've answered it well. I think this is a question for the Minister, actually, because technological solutions are made every day. It doesn't seem particularly difficult. I look at my role as an engineer—it's not difficult to just move data; it's when that's going to happen. I think if the Minister wants this to happen, then it could happen pretty quickly, in my view. And I think that's a question for the Minister.

I think you've answered the question as is needed, unless there's anything you want to add.

Just that we know this work is under way and we expect it any day.

All right. Thank you. That's great. Rhun ap Iorwerth.

Just in case you missed the first part of that as you were putting on your earsets, Rhun was asking if there's any part of the UK where this data isn't available. 

That is correct. Wales is the only place in the UK that currently doesn't hold this data.

That's a good point. It's not so much a model as a technological solution. I think it is quite simple: the data is collected at health board level, the data is available. The data needs mining into a central space where there can be transparency of that data. I think it is simply for our colleagues at Health Education and Improvement Wales to help us to work out how that data can come to the fore. Like Gill says, we are working with them, and it has been a bit of discussion in the last few months to get us to where we are. I don't think it's far off having it done. I want to be really clear that I don't think this is a matter of 'if' it will be published; for me, it is a matter of 'when' it will be published. It is one of the things in my priorities, but also clearly up on Minister's list of things that need to be done.

Thank you for that. We are very grateful, as I said before, to the RCN for publishing their report, 'Nursing in Numbers'. I don't think that's far away. I think the vacancies have grown. I think we are more or less around that number of 2,900. What it doesn't account for—and I will be really clear, because I don't think it makes that correlation within the report—is the numbers that are coming through on the commissioned and the training numbers. So, this year, I think we have something like 2,300 in commissioned. It doesn't account for that, nor does it account for the retention numbers. So, I think, if you take that into consideration, we are more or less probably just around those numbers, or just under those numbers. But, yes, it is a growing problem around vacancies, and we have to continue to do more around domestic recruitment, international recruitment, and attraction and retention. 

Absolutely; you are correct. The Nursing and Midwifery Council holds a register of all nurses with an address in Wales. That doesn't necessarily mean that that growth translates into those numbers within the workforce, as we know. They may also not equate to full-time equivalents in the workforce; people choose to work part-time, people choose to work outside of the health sector, as you can appreciate. They may work in the independent sector, and those numbers don't account for that. So, you are correct. 

Thank you. There are a number of questions within that. I think, to be clear, when the Minister has said there are more nurses than ever, she is correct. That is correct. In its entirety, and compositely, there are more nurses than ever within the Welsh nursing workforce. How that translates into the service, and how that translates into full-time equivalents, is something different, and we have to be able to delineate one from the other in order to fully understand and have a conversation that is more meaningful, I think. 

When it comes down to nurses choosing to work in other sectors, particularly the agency sector, we have intelligence that tells us that nurses choose to work in those sectors for different reasons, as you can appreciate. Some will have very significant caring responsibilities. Some will choose to work there because it offers a different type of flexibility that the NHS is not yet able to offer. Some will choose to work there from a monetary perspective, and that is their choice entirely.

What that means for us is—. Am I worried in terms of the amount that we are spending on agency within the workforce? Of course. That bill that you just mentioned a minute ago is exceptional. It's possibly the highest we have seen in Wales. Prior to the pandemic, the Welsh Government officials had done an incredible amount of work in reducing the agency bill. I don't have the numbers to hand—apologies—but they had done quite an incredible amount of work. I want to say it was around £50 million, but I will double-check that for you and come back.FootnoteLink Post pandemic, those numbers have—

I'm saying that, prior to the pandemic, in 2019, Welsh Government officials had done an exceptional amount of work of ensuring that agency costs were reduced. What we have seen since the pandemic is the numbers grow. We have seen the bill increase, and we are now at, I think you quoted the number of nearly £140 million. What the director general at the Welsh Government, taking an instruction from the Minister, has done is set up a group called 'the effective use of resources', and that group is overseeing efficiency and productivity work around agency, bank usage, looking at enhanced rates for our workforce, looking at the use of an all-Wales bank, and many, many other productivity measures. I think this is a really important one for us to consider and to also work out from the intelligence how we can bring those agency nurses back into the workforce. Because there is a way, and I think we have to be able to have some conversations that are open, honest, but also perhaps a little difficult in understanding what is it that will encourage our agency nurses back into our workforce.

I think that's a really interesting question in adapting contracts. I don't think it even has to go that far, if I'm entirely honest with you. I think with health boards, this is within their gift to enable flexibility within the provision of service. And there comes the balance, I think. There is a provision of service for patients that must be sustainable and has to be available, and I think in making those very difficult decisions, flexibility has to be built into that. I don't think it requires a contract change, Rhun. I think really what it needs is for health boards to understand what their workforce is asking for, how we can enable our agency workers to come back, how they can pick up the work on the all-Wales bank where the rates are far more attractive—not that they are comparative to agency rates, because I don’t think that is really good fiscal management for us as country. But I do think it is important that we have rates that are attractive—somewhere between an agency and bank. But equally I think the working conditions must be considered. It is important that nurses get their breaks, it is important that they have a place to take their break, and health boards are working on a number of things to ensure that nurses’ health and well-being are being focused on.

I think, given the premise on which the NHS has been established, of course what we want to see is any efficiencies and productivity that are gained through NHS reabsorbed into the NHS in order to make services better, in order to continue to offer provision for patients, in order to transform and innovate. I think that is the basis on which I would like to see efficiencies and productivity being reabsorbed. I may have a personal view. I'm not sure the committee necessarily would want to hear that. But as a civil servant, I think it is really important that we spend time working out how we can really generate the best outcomes for our patients through our workforce, with our workforce, via something that they believe in and they work through, and I think that is potentially something like the all-Wales nurse bank, where the money is staying within the system. I hope I've answered that.

I'd very much like a personal view. 

I think it's more of a case of whether you feel comfortable giving it to us, but I understand your reasons why you wouldn't want to do that, of course. Thank you for that. Joyce Watson, did you have a question on this?

I'm going to ask one last one on vacancies and agency nursing, and that is the age profile, you know, when you collect the data and if it gets disaggregated, it would be useful to know two things: the age profile of agency nurses and the areas in which they predominate. Because that will definitely inform workforce planning going forward. I just ask that question, because you haven't got the data yet—

We haven't.

—but that is a consideration. But I'm going on to workforce planning, in terms of education and training, and, of course, there have been concerns raised by the RCN about the 22 per cent drop in the number of nurses entering education in Wales in 2022. So, first of all, your reaction to that, and secondly, your response.

Thank you. I will ask Gill, if that's okay, if we have any information on age profile for our agency nurses. I suspect I know the answer to that, but let me offer Gill an opportunity.

We don't. What I must say is that our agency nurses contribute huge amounts to our health and social care system across Wales. We know and have worked with many of our agency nurses, so it's really important that, when the CNO talked about working with the agency nurses to bring them into the fold, because these nurses—we wouldn't be able to provide the services that we do without them. But no, we don't have—. We contract directly with the agencies, so we don't have profiles on ages of agency nurses.

Joyce, do you mind if I just come in? Is it that you don't know, but the relevant organisations and health boards do know?

They don't collect age—

They don't collect it either.

They don't collect age. So, many will know, because they will know the nurses and they will get to—. Many of these agency nurses are not temporary, as in, one day here or there; many of them will know the services that they're working within and will know the staff and be really core, key members of teams. So, they will know, but it's not something that's published.

Sure. The question was about—going back to the other question, where the health boards know and the Welsh Government doesn't, but no, you've answered the question now. Sorry, Joyce.

You're going on to the response about the 22 per cent drop in training.

We actually—out of our commissioned rates, in 2021-22, we've had the highest ever recruitment into Wales into nurse-commissioned places. So, we had 1,995 out of the 2202 commissioned places, and that's across nursing and midwifery. If we looked at just nursing, our fill rate was over 93 per cent, so the highest number that we've ever recruited into our training places in Wales was in 2021-22.

Okay. So, the RCN have raised concerns about this too, and they've written here, and they state the UCAS figures as—

So, that's different. UCAS figures are different to fill rates.

That's why I was asking the point: is that what's going on here—different figures being used?

Yes. Fundamentally, those are two different figures. UCAS figures are—as you can appreciate—that is the clearing system through which we get the numbers through, but that's not the only way in which we would collect that data. We offer different types of training, so for example, there will be online training mechanisms that are in place as well, which HEIW have opened an additional number of places to in the last period, and that will increase the number of trainees and commissions that take up those places. So, there is a difference in what we're talking about. They're two different things, I think.

Currently, what we're seeing in 2023, we have got an increase, I think a 12.7 per cent increase, in our training planned numbers, so they go up to about 2,701 numbers for—is that 2023-24? So, we have increased the commissions again. I think, then, there's a lot of work for us to do in terms of attracting people to take up those places. What I will say is that this is not unique to Wales, either—that we are seeing UCAS numbers on a decrease. In 2020 during the pandemic, what we saw was that the population really wanted to come into nursing, and they wanted to take up a job with us. What we have seen subsequently to that, last year and in this year particularly, is a real drop-off in that interest for various reasons, really, across—and I'm happy to go into those reasons if you would like. But I think we all can understand, and we're seeing it daily in the media, for financial reasons, cost of living, other economic issues, people are not choosing to come into this profession. This is a UK-wide problem that we're experiencing.

But I don't recognise the 22 per cent number. We have a different number around our commissions. What I think we will hit this year, where we're are in terms of our planning, is currently, for 2022-23, we are somewhere between 75 per cent and 80 per cent of our commissions, but that is set to change and rise, given the additional work that we have done around that. So, I hope that answers it.

It does, and the other thing—because we took evidence from students, we went out and they were talking about, some of them, either suspending or completely leaving their training places. So, again, it's a retention issue, isn't it, about students? What work have you put in place to try and help with that?

I do spend quite a lot of time with students. I've taken the time to meet a number of students regularly over the last 18 months. I have asked what would make it better for them. I think I also want to say health and social care programmes or nursing and midwifery are some of the most difficult and really—I think it's quite a draw being a student during this. It's an incredible profession to come into, but it is quite tough. It's tough to study and to be on placement, it's tough to travel when you have a cost-of-living crisis. All of those things don't always enable our students to make it through successfully out of their programme. It is a really difficult programme to come through in any event.

So, I think anything that we can do to support our students to stay is a good thing. Students have given me feedback that has said, firstly, the streamlining process that we have, they've asked—streamlining is the process by which, when a student finishes their training, they have their last placement in a particular area, say that's their management placement, and then they are streamed into an area of work of their choice. We think that's a much neater and more robust process, but students have told us that it doesn't actually work. So, we've put that feedback back to our teams that are running the process, and, actually, we have done quite a lot of work in terms of streamlining that streamlining process—forgive the pun there. But that's some of the feedback we've had.

We've had feedback around how students are supported on the ward, what are the learning placement environments, what does that look like. I regularly ask for HEIs', that's the health education institutions, feedback on student surveys. I want to understand what their learning placements are like, are they getting enough support, do they have enough supervision, do they have enough time to do what they need to do and to learn? So, we are seeking out that feedback. I am interested in understanding how our future leaders, our future nurses, our future generations can be really robustly supported to come out of their training as well equipped as they can be. And so, I think we are taking that feedback and trying to work on that. I don't know that I can give you any further data on the students, but we are keeping this as an active, open communication with our HEIs and our students. Gill.

Just to add to that—thank you, CNO—Health Education and Improvement Wales work very closely with all of the HEIs that they commission education programmes with. They identify early when the attrition rates among students are going up, so they have been in active communications with universities looking at what they could do to help with early triggers to prevent—early identification of students who are failing. So, triggers might be not getting assignments in on time, having some sickness off placements. So, trying to identify early triggers and do something then, rather than wait until it's too late. And I know that our colleagues in HEIW were looking at purchasing or exploring a national programme, but that hasn't progressed, because the HEIs each have their own early identification—. And I know that that's something that's being monitored. A tool—sorry, Jack, I saw your eyes there—a tool to help you have triggers, to have a red flag when a student isn't engaging, in any small way, to see how you can work with them to prevent them leaving the programme.

Jack, did you want to come in?

Thanks, Chair. I need to work on my poker face a bit. [Laughter.] The information that we've just discussed there—it's really good that you're doing that, and gathering that experience from the students. It's clear that those conversations will go back to the Minister for health, for example, but do you have those conversations with the Minister for education or the education department in Welsh Government, because that department needs to be aware as well? Do you have those links? Could they be strengthened?

We do have those links, of course, across our education department. I think it's slightly different for our nursing students, and I suppose we have those discussions directly through HEIW instead, directly into the HEIs rather than through the education department, per se. I'm very open to those discussions if I think that the levers are there, Jack; they're certainly going to seek them out and find them. But I think, currently, we have been working through our national organisation. Gill, do you want to come in?

We are. We're also aware and looking at the student packages. So, there's a review at the moment on the students—. As you will be aware, we've maintained and retained the student bursary in Wales for NHS students. But there is a review under way to ensure that what we offer in Wales is comparable and attractive for students to study in Wales. And the CNO mentioned the streamlining, where we support students into roles. We do that because we train students in Wales; we want them to stay here. So, if we sign them off as competent in elements of their—. We want them to get jobs, we want them to stay here, so that's part of the student support package into supporting them as registrants in the services that they trained in.

Thank you. Gareth Davies.

Thank you, Chair, and good afternoon, everyone. I want to talk about the Nurse Staffing Levels (Wales) Act 2016 and the health boards' compliance with the Act so far, and what have been the main challenges around that. Could you also set out as well whether there's been any regional variance in that, for example, maybe the differences between north Wales and health boards in the south, just to see if there are any varying levels of compliance there?

Absolutely, thank you. So, the nurse staffing levels Act, for the committee, is the legislation around staffing our 25B wards, and those are the wards that are acute medical and surgical wards. And what the Act essentially does is it gives a set of tools that are available to set establishments—establishments being the number of nurses required to keep a ward functional. How is the Act working? Currently, in its current format, we've had the three-year report through last year, and you'll know that that report was laid, I think. We are seeing a consistent approach across health boards where the 25B part of the Act is implemented. We're seeing a consistent approach in terms of acuity levels, so, how they assess their acuity, how sick their patients are, how dependent their patients are, and what staff they require against that. We are seeing a consistent approach of professional judgment being applied, and also the measures that are required to test out, for example, the number of falls based on the number of nurses you have in a ward, or any other harm that comes to patients. 

Hospitals have all been compliant with their reporting to their board. They report to their board twice yearly. One is board reporting only, the other is a bigger report that we will see, and then Welsh Government does a three-year report. In terms of variation, what we are seeing is that there is a greater number of vacancies in some parts of the country than others, and north Wales is one of those organisations with a greater number of vacancies, not necessarily within the 25B wards, but across the entire organisation. There is certainly, I think, scope to continue to monitor and get health boards as compliant with the Act as possible. I think it important also to say at this point that the Act, when developed nine years ago or so, I think was developed for a time and place and point in time, perhaps. I think the landscape is so very different now. Nobody could have foreseen the very different landscape we have, and somehow—. I'm not entirely convinced, I think, that compliance with the Act is the sole thing we require. We always need compliance with legislation, but I think we need to think bigger and broader around how we actually use the Act to staff our wards in a way that is smart, that is different, that is multiprofessional in nature, because the Act is quite uniprofessional, as you can appreciate, and that is not how patients use our services nor how their care is delivered. So, I think there is a bit of work for us to do to consider the 'what next' with the Act. I'm not sure, as it stands right now—. Whilst compliance remains high, I think that variation that is coming through tells a different story—not necessarily a lack of compliance; I think it tells a story of a different type of workforce that is required.

When you talk about some of the vacancies, how is that reflected on the ward as such? So, when there is evidence of vacancies, how are those wards staffed so that health boards are still compliant? Is that done through agency work, or is that done through other methods, maybe just moving staff around, making sure that the wards are safely nursed? How does that reflect on the shop floor, if you like?

I think all of those things that you've just mentioned. So, there is a deployment strategy in most organisations around staffing, which means an assessment is made on a daily basis, sometimes on an hourly basis, depending on what the activity that is coming through the organisation looks and feels like. Staff are deployed with the right skills and the right requirements into different areas. Of course, usage of temporary staffing, as we've just heard around the agency staff usage—temporary staff bank, agency and additional staff from other ward areas are deployed into those areas to maintain safety and to maintain the staffing levels at which we require it. Do I think that that has been consistently achieved? I think it is very, very challenging, and I think it is very difficult, and professional judgments and decisions have to be made on a daily basis to deliver care in the safest way possible.

In terms of the Act, can you provide an update on the current work to extend the Act to other settings? It was 25B you mentioned, so is there the scope to extend the Act to other care settings so that we can ensure safe nursing staff levels in all care facilities and not just specific wards?

Yes. Thank you. The Minister set a very clear position on this in September, during the debate on the RCN's petition, and I'm certainly not going to deviate from that position here. The Nurse Staffing Levels (Wales) Act 2016 is very clear, I think, about what would be required to extend the Act, and I don't want to give you the impression that simply extending the Act equals safer care, equals more workforce, because that is not the case. As we have been talking for the last 45 minutes or so, we must appreciate that the global workforce challenge, which we are feeling quite significantly here, does not automatically guarantee us the number of nurses that the Act will therefore require us to have.

What I think needs to happen—and I've been clear about this since I have come into post—. There are a set of conditions that have to be in place for the Act to be implemented and be effective, and the Act is really clear about what it requires: it requires an acuity assessment tool, which isn't available for the areas of extension that are under discussion currently. It requires the professional judgment tool, and it requires a set of measures—the harm-free care measures—to be in place. All of those take time to develop, and they need to be tested. They are not simply developed and given to the NHS. They are developed. They are then under testing, for 18 months sometimes, to ensure we get it right. And then they are applied to those ward areas. 

In the meantime, I don't want to leave you with the impression that, where the Act is not in place, we do not have a system by which establishments are curated and determined. We do have a system. What we may not have is a system that is the same as the Act, but there is a method in place that determines a set of staffing requirements. So, I—[Interruption.] Go on. 

But would that be your—[Inaudible.] As chief nursing officer, would that be your ambition, to see the extension of the Act? Obviously, we're not in the ideal situation. I suppose, in an ideal world, you'd be saying, 'Well, we'd like to extend the Act into all care settings so that nobody misses out, and every care setting has adequate nursing staff levels.' So, as chief nursing officer, would that be your professional and personal ambition, to see the extension of the Act, so that we can ensure the same care for everybody in that aspect?

Yes, thank you. So, my ambition, as chief nursing officer, is to ensure that we have the right people in the right place to deliver the absolutely excellent care that our workforce want to deliver, that the people of Wales deserve. And I am absolutely clear that that is not delivered only through a uniprofessional perspective. I have been clear since I've come into post that we have to take a view around a team around the patient—concept and philosophy—because patients will require that.

If we are to extend the Act in its current format, what that means is we continue to focus through a uniprofessional lens, and that is not to the benefit of our patients. What I would like to see done is to develop a way in which team around the patient principles can intersect with the Act, such that we can offer a team around the patient that is fully multiprofessional in nature, supports the patient through their journey, helps them to return to their place of origin faster than they are currently, and to deliver the safest care. That is my ambition as the chief nursing officer. 

And is that ambition then conveyed to the Welsh Government and the health Minister in order to inform policy, from your remit anyway?

Absolutely. I have conveyed that and discussed it with the health Minister, who has been very supportive, and has supported us to fund secondees, which Jo was talking about earlier, to look at the band 4 role—the band 4 role is the healthcare support worker role in Wales—and to consider whether what England has done in 2017, with a regulated, registered role in band 4, is necessary and one that would help support us in the way in which we deliver care. So, the Minister is incredibly supportive, and she's equally supportive of the concept of a team around the patient to understand how that will translate into the delivery of care for patients. So, the short answer is 'yes'.

I appreciate your responses there. Thank you. I just want to move on to tackling inequality in my next line of questioning, and the actions that are being taken to build a diverse and inclusive nursing and midwifery workforce that's more representative of the communities it serves. So, what sort of steps or work is going on from your remit and department to increase diversity and inclusivity in the nursing profession?

Thank you very much. 

[Inaudible.]—because we've got—. Just a brief answer, if you can. 

Yes, of course. So, quite a lot of work, as you can imagine. It's one of my CNO priorities. We have set out to do a number of things, one of which is that we've sponsored something called the equity sponsor programme for a number of our workforce in Wales who are in a position of a sponsoree, being sponsored by somebody not from an ethnic minority background, to really act as a sponsor and an ally to support the workforce.

I have also set up a national CNO network for the black and Asian minority ethnic workforce, to understand what we need to do better for not only them, but the communities as well that we serve. And there is a tonne of other work that's ongoing. This is a really important one to me, really, personally, professionally, but also for the diverse communities that we are seen to be growing in Wales, which is incredible—it brings a lot of rich diversity and I think it is really important. So, there is a lot of work that we are undertaking currently, but I'm really mindful of time and I don't want to list and reel off all of the things we're doing, but clearly a focus on that.

We appreciate that. Gareth.

Back to you; back to the Chair.

Did you have a final question, Gareth, or are you—?

No, no, I'll leave it there.

That's fine. Thank you, Gareth, thank you. Jack Sargeant.

Thank you, Chair. We've spoken a lot about data and I'm going to move away from that, but stay with a focus on digital technology. Reflecting on my poker face—you should have seen it when we spoke for half an hour about fax machines, which I cannot cope with today. Again, I'm conscious of time—perhaps in bullet points, titles, headline answers, where else can digital technology be introduced to deliver effective nursing care?

Oh, I think in so many places. I'd start with artificial intelligence for a start. I'd start with virtual wards. I would really talk about our Welsh nursing care record that is currently in place to support our nursing workforce to be productive. I would think about additional mobile technology to enable them to really do what they need to do. 

So, that's a very good answer. Where are we in the process of seeing that happen? So, something like AI might be a way away, but the Welsh nursing record might be—.

Yes, of course. Look, I think AI and machine learning and that kind of stuff, we are a little way off, but where are we with the rest of it? So, let me just give you two examples, if that's okay. The Welsh nursing care record has been in place for a number of months now—nearly two years I think. We have it in—. And I'm going to give you the data, so if you just bear with me a second. So, it's being used in 204 wards currently across 33 hospital sites, and this accounts for 54 per cent of the eligible wards. I'm just going to give you the data in terms of what we've actually seen in terms of output. We have over 1.9 million digital risk assessments completed for patients, which is incredible. We have captured over 2.3 million in-patient nursing notes—this equates to huge amounts of assessments: pressure ulcer risk assessments, nutritional risk assessments—and also a huge number of our workforce have been trained and are digitally capable of utilising this record. That's one.

And the second one, if I may just tell you very quickly: Digital Maternity Cymru is the piece of work that the Minister has just supported, and I think it's a £7.4 million investment over the next few years—I think it's the next five years—to look at what the Digital Maternity Cymru system is going to look like. And this is a digital system that joins up care across maternity and neonatal. I am really keen that we improve the service for maternity and neonatal, that we bring it together to streamline and have a seamless service, and the one way that we can start to do that is through a digital system that joins up the data.

That's really good—

Can I—?

Yes, sorry. Gill.

Can I just say that those numbers of the Welsh nursing care assessments are going up every day? So, there's one health board that's had problems with Wi-Fi and enabling the system and that's nearly ready. So, by March, we're hoping that significantly more than 54 per cent of eligible wards will be using the Welsh nursing care record.

So, it just proves it can be done—that these technical solutions are out there.

Oh, it's not been straightforward either, Jack. It's taken—

I can imagine it's not been straightforward, but there are ways around certain things and it is pleasing. In your role as chief nursing officer—and I'm really conscious of time now—what would be the next—? In fairness to the Minister, she's quite clear that this is one of her priorities and I think, as a committee, we need to press her on that. What would your request to the Minister be next or what should we request or recommend to the Minister that the next step of digital technology or digital enhancement in nursing should be?

So, I don't think it's for nursing. I would even go further and say that, for the patient, it should be a digital patient record that is accessible across primary care, primary care into secondary care and on to tertiary care. I think that enables the workforce as a whole, and nurses ultimately, to be more productive and really streamline care and see better outcomes for patients.

Excellent. Thank you.

We also know that's a priority for our Digital Health and Care Wales colleagues and we know that that is something that we're all working towards.

Thank you. I'm just looking at other Members, either virtually or in person. Any other final questions from Members at all? Joyce Watson, yes.

Yes, there is one we missed out. We were talking about training the workforce—and if you haven't got time now, just send it to us—but the need to train individuals, or for individuals to be trained bilingually.

Yes, absolutely. So, we can pick that up. It is part of my priorities under professional equity. You'll be pleased to hear that I am really clear that this is not only about—this is all the inequities, and Cymraeg, I believe, belongs to all, and I'm really quite clear that the strategy around Welsh language is an important one for us.

I want to tell you very quickly the universities that we've been working with to ensure that we have the delivery of education through the Welsh medium. So, we offer all nursing and midwifery students an opportunity to complete the Welsh language skills certificate. There is a main scholarship of £3,000 over three years for students studying at least 66 per cent of their course—that's 80 credits a year—through the medium of Welsh. Bangor University's currently the only higher education institute that offers a main scholarship across the four fields of nursing practice, but that is something that I want to do more work on. And we have other universities, from Bangor, Cardiff, Aberystwyth and Swansea that offer a 33 per cent grant for those that study through the medium of Welsh. There are a number of support research development programmes at postgrad level as well—and I can't say the name in Welsh, so forgive me—I think it's 'coleg Cymraeg'.

That's it. Very good.

Is that it? Yes? And we have additional Higher Education Statistics Agency figures [Correction: 'data for 2020-21'] that show that 488 of our students studied some of their course in Welsh. So, this is really quite important to me for our Welsh population. We have seen examples of care where, when care workers are unable to communicate in Welsh, it results in poor outcomes for those families. It is a terrible experience, and I have seen some recent ones. But I've also seen a lovely one where one of our Welsh patients went over to England and the nurses there chose to speak Welsh, and I think we've got to do better on our side.

Thank you. I know we're pressed for time, but I've got a quick question. And Gareth Davies, have you got a quick question as well, Gareth?

Yes. Thanks, Chair. It's just more of a comment, really. Because we mentioned the band 4s and training opportunities, it's the extension of that roll-out and internalising the training opportunities to get people into nursing. And I did it myself, back in 2017, so I can certainly see the benefits of doing that from an internal perspective, to get people into the nursing profession, so I'd just like to say how much it is appreciated, tackling some of the staffing problems in health boards. Thank you.

Thank you.

Thank you, Gareth. And my final question was: to what extent is there an increasing reliance on the international recruitment of nurses?

I think there is a greater amount of international recruitment that is occurring in Wales, but also across the globe. I don't think that is a sustainable solution for us in Wales, and I've always been really clear about this. Since I've been in post, for the last 18 months, this is a solution for us for now; we have to be self-reliant; we have to have our own domestic trainees trained.

I think for the problem we have currently, it works. Speaking as an internationally educated nurse, I don't think that this is the sustainable solution. We have had a phase 1 of international recruitment and I'm really, really proud to say we did it on an all-Wales basis for the very first time, and we've seen that nearly 90 per cent of those recruited have been on-boarded into health boards, so that's excellent. I don't think that's enough; I think there is a real piece of work and responsibility on our part to ensure that we give good pastoral support, that there is good integration and support for people that are coming from abroad into our communities, to enable them to work and to live here.

We do have plans for a phase 2, but this does not mean that we will continue to do international recruitment at a rate at which it has been done elsewhere, because I'm really highly mindful of the ethical impact as well that this has on developing countries. We are really keen to create some reciprocal approaches and I have been speaking with Health Education and Improvement Wales and HEIs to consider the training and supporting education training for international students, rather than simply just clutching them and picking them out of their countries of origin.

Thank you for that answer. Is there any question today that you think we should have asked you that we haven't?

No, I think I'm surprised at the focus on workforce, and I would have liked to have brought my workforce director had I known there was going to be this much focus on the data, so perhaps, for the next time, we would have liked to have done that.

Well, this is your first time to committee, and we know we'd be very pleased to have you back. We'll make sure that, next time, we give a good steer on what we're planning to ask you about in order that you can bring appropriate officials with you. So, thank you very much.

Thank you very much.

We were very much looking forward to talking to you more about the priorities, the plans and their work that we have under way, but next time.

Right. We will invite you back. But thank you ever so much for being with us today.

Thank you for having us. We really, really appreciate it.

We really appreciate it, and we'll give you a transcript of the proceedings for you to have a look over. If you think there's something to add after you've received that, by all means, let us know.

We will do. Thank you so much.

Diolch yn fawr iawn. Thank you very much.

I move to item 6. There are a number of papers to note this afternoon. There's correspondence with Care Inspectorate Wales about the issues facing social care; and with the Public Accounts and Public Administration Committee regarding the inquiry into public appointments. There's correspondence between the Royal College of Nursing and the First Minister regarding strike action; and various bits of correspondence between the Welsh Government and ourselves, including correspondence around the health service procurement Bill. Are Members content to note those papers?

Yes.

Thank you very much. And that brings our public session to an end. Our next session will be taking place next Thursday.