Y Pwyllgor Iechyd a Gofal Cymdeithasol

Health and Social Care Committee

19/10/2023

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Gareth Davies
Joyce Watson
Mabon ap Gwynfor
Russell George Cadeirydd y Pwyllgor
Committee Chair
Sarah Murphy

Y rhai eraill a oedd yn bresennol

Others in Attendance

Gareth Howells Bwrdd Iechyd Prifysgol Bae Abertawe
Swansea Bay University Health Board
Helen Whyley Coleg Nyrsio Brenhinol Cymru
Royal College of Nursing Wales
Jackie Davies Coleg Nyrsio Brenhinol Cymru
Royal College of Nursing Wales
Jennifer Winslade Bwrdd Iechyd Prifysgol Aneurin Bevan
Aneurin Bevan University Health Board
Joanna Doyle Rhaglen Staff Nyrsio Cymru Gyfan
All Wales Nurse Staffing Programme
Julie Rogers Addysg a Gwella Iechyd Cymru
Health Education and Improvement Wales
Lisa Llewelyn Addysg a Gwella Iechyd Cymru
Health Education and Improvement Wales
Lisa Turnbull Coleg Nyrsio Brenhinol Cymru
Royal College of Nursing Wales
Nicola Williams Ymddiriedolaeth GIG Prifysgol Felindre
Velindre University NHS Trust
Ruth Walker Addysg a Gwella Iechyd Cymru
Health Education and Improvement Wales

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Morris Ail Glerc
Second Clerk
Philippa Watkins Ymchwilydd
Researcher
Rebekah James Ymchwilydd
Researcher
Sarah Beasley Clerc
Clerk
Sarah Hatherley Ymchwilydd
Researcher

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Cyfarfu’r pwyllgor yn y Senedd a thrwy gynhadledd fideo.

Dechreuodd y cyfarfod am 09:34.

The committee met in the Senedd and by video-conference.

The meeting began at 09:34.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions, and declarations of interest

Bore da, croeso i bawb. Welcome to the Health and Social Care Committee this morning. Just to say, this is a hybrid session this morning, so we have some Members and witnesses virtually and some here on the Senedd estate. As always, we operate bilingually, as well.

I'll move to item 1. We have no apologies this morning. I know Sarah Murphy has indicated she will be a little bit late joining us, at 10:00. Sorry, we do have an apology, from Jack Sargeant. If there are any declarations of interest, please do state that now.

I want to declare that a family member is a member of the Royal College of Nursing.

2. Deddf Lefelau Staff Nyrsio (Cymru) 2016: craffu ar ôl deddfu: sesiwn dystiolaeth gyda Choleg Nyrsio Brenhinol Cymru
2. Nurse Staffing Levels (Wales) Act 2016: post-legislative scrutiny: evidence session with the Royal College of Nursing Wales

We'll move to item 2. Item 2 is our first evidence session for the committee in its post-legislative enquiry into the Nurse Staffing Levels (Wales) Act 2016. We'll be hearing this morning from representatives of the Royal College of Nursing in Wales. Welcome to the three of you, thank you for being with us. Perhaps it would be useful if you just introduce yourselves and what you do for the public record. Shall I come to Helen?

09:35

I'm Helen Whyley, I'm the director of the Royal College of Nursing in Wales. Good morning.

I'm Jackie Davies, I am chair of the Royal College of Nursing Wales board, and I am a mental health nurse in Wales.

My name is Lisa Turnbull, I represent policy and public affairs within the Royal College of Nursing.

Thank you, and thank you all for joining us. And just to say, the mikes are all controlled virtually as well, so you don't need to press any buttons, they come on as if by magic. Thank you for being with us.

Has the Act delivered on its aims, do you think? I particularly ask that question in the context of outcomes for patients and staff safety.

I think there are many aims of the Act, but if we focus particularly on that patient safety angle, then what we've seen over the course of the duties being applied, in the public record in terms of health boards reporting, is that the serious incidents that they have had on wards, particularly where section 25B applies, are reduced, or appear to have less of a contributing factor around a staffing level. So, from a statistical perspective, we've got that data and it's in the public domain, but, of course, for the Royal College of Nursing, we've also got an anecdotal set of data from our members who have experienced this Act and who are champions of the Act, and are obviously the ones who ensure that it's delivered. So, we'll remember that we've got the duty of section 25A, which I'll come back to, but the duty in section 25B is where a triangulated method is used to determine the nurse staffing level, and the anecdotal response that we have back from members on a regular basis is that it has achieved its aims in terms of patient safety.

We are in a difficult environment, there is a worldwide shortage of nurses, but nonetheless, with the application of that duty, we've built the largest library of patient acuity—quite possibly in the world, certainly in the UK—so that we are understanding in a much more detailed manner the sort of staffing that we need on those wards. At the moment, that duty applies to medical, surgical, adult in-patients and paediatric in-patients. So, anecdotally, our members say it's made a difference to them, they say it's made a difference to the culture in which they're working as well, and it's made a difference to the way that the health boards take on board their professional judgement in terms of arriving at that staffing level. Over time, it's also meant—and we can see this in the public record—a significant increase into the amount of funds that health boards have put into nurse staffing in those particular areas. I'll just bring in my colleague Lisa—

I'll widen out my questions, rather than bring Lisa in. There's a couple of points you made there, Helen, which I know other Members have indicated they want to pick up on later, so I won't go into some of those. We'll hold fire on some of those points. Lisa, if you wanted to come in on the back of Helen's comments, but particularly perhaps widen out your reply to my question as well in terms of how Wales compares to other UK nations in terms of improved nurse staffing levels and patient safety. So, I'm asking the same question, but widening it out a little bit as well.

Thank you, Chair. I think, as Helen said, the central point is that we know that on section 25B wards, there are more nursing staff than there would otherwise have been. Because we know the correlation between not just the number but the skill level of the nursing staff and the risk of patient mortality and patient outcome, we know that patients are safer on those wards. So, that in itself is enough in terms of the beneficial impact of the Act.

But what I would say as well is that one of the impulses behind the Act is that where you know there is a danger to the public, legislation can act to prevent that danger and that risk of harm. And what we've seen is that there are a number of industries where safety legislation is commonplace, and has been for quite some time in law. Examples of that would be the care of children and nursery schools; other examples would be care of animals—dog kennels. Another example would be the aviation industry. So, many industries have a legal framework supporting their approach to public safety, but, for historical reasons, it's fascinating that the national health service in the UK didn't have that basis; there was no obligation or framework surrounding it.

I think one of the things that Wales has done—to answer the second part of your question on how it compares—is that we were very proud that we were able to see in Wales that first legal framework to say that there should be regard to patient safety in this manner, and that has very much changed corporate behaviour. We know this simply because if we examine health boards' papers, the publicly available board papers, from the period before the introduction of the Act and the period after the introduction of the Act, all of a sudden you see actual papers discussing the nursing workforce, and the workforce more broadly, and its relationship to patient safety. You see papers for the first time addressing nursing recruitment and retention at that senior level.

You can see that cultural shift, because one of the things, again, to go right back to the impetus for the legislation and why, as the Royal College of Nursing, we campaigned for it in the first place, is that very often—too often—we see a very tragic example of harm to the patients, there is an inquiry or some kind of investigation, and blame is apportioned or investigated as to the causes of that harm. But, very often, that centres around the individual incident, and that might be the individual nurse or member of nursing staff—that, perhaps, something should have been done and wasn't done. But it doesn't incorporate that wider corporate responsibility that we feel should be there. What is the responsibility of the finance director? What is the responsibility of the workforce director? What is the responsibility of the chief executive? I think that's one of the reasons for that legislation, and I think that wider culture change of corporate responsibility for safety has changed. I think that is the comparison to the other countries.

In terms of detailed statistics, if that's the question you're asking about patient harm—

09:40

Sorry, Lisa, I'm just conscious of time, actually, so—

I was just going to say, 'We don't have that information'—that's the simple answer. I think one of the things we've called for in this paper is some more detailed research on that. There is available data from the four countries that could be compared, so it is a project that could be done.

Okay. Is that something that you would consider doing, as a royal college?

I'd have to defer to my superiors as to whether we had the time and the capacity to do so, but certainly, I have to say, there is an opportunity for some good public policy research that, potentially, also, in fairness, the Welsh Government, perhaps, might want to look into. 

Okay, that's fair. Just a brief question: when the Act was introduced, or the Bill was introduced, I suppose, there was concern about unintended consequences. Have there been any unintended consequences? Were the concerns of unintended consequences mitigated, do you think?

One of the major unintended consequences that was a concern was about robbing Peter to pay Paul, really, so putting in a methodology in some parts of the hospital and then moving staff in order to fill that. I think, across time, what we've seen is that that sort of thing happens already. Before the Act came in, if there weren't enough staff, nurses were moved around in order to cover. That really big consequence of depleting other areas like community nursing didn't happen, but there is still a degree of needing to move staff around.

But the positive side of that unintended consequence is that we know what the gap looks like. So, because the staffing level is calculated on a regular basis, health boards can look and say, 'We know that we always need x number of nurses on these wards, so even for next week and next month, we haven't got them—we can look at bank and agency; we can look at other methods to mitigate that unintended consequence'. So, on balance, it was, but not to the degree that was anticipated. 

09:45

Diolch yn fawr iawn. Diolch i chi i gyd am fynychu y bore yma. Wrth gwrs, rydych chi fel y coleg brenhinol wedi sôn yn yr adroddiad cynnydd a her nôl ym mis Mai 2022 mai'r her fwyaf sy'n wynebu hyn ydy cynaliadwyedd y gweithlu nyrsio. Rydych chi'n sôn bod llawer iawn mwy o nyrsys yn gadael yr NHS na beth rydyn ni'n medru’u cynnal a'u cadw yma. Felly, pa gamau pellach ydych chi'n meddwl sydd angen eu cymryd er mwyn gwella'r elfen yna o recriwtio a chadw nyrsys er mwyn ein bod ni'n medru sicrhau bod pobl yn cadw at y Ddeddf?

Thank you very much. Thank you all for attending this morning. Of course, you, as the RCN, have mentioned in the progress and challenge report, which was published in May 2022, that the biggest challenge facing this is the sustainability of the nursing workforce. You mention that there are far more nurses leaving the NHS than can be retained here. So, what further action should be taken in order to improve that element of recruitment and retention of nurses so that we can ensure that people adhere to the Act?

In terms of the issue about recruiting and retaining nurses, I think you've seen, over the course of the last 12 months, a significant step up in terms of how nurses on the ground have felt about that particular issue. Some of the things that are needed are really not that complicated—so, a good approach to retention, giving people a job that they feel valued to do, allowing people to have time to prepare professionally with continuing professional development, allowing people to work flexibly, ensuring that they're not caring for patients in very challenging and inappropriate areas. All of those things absolutely add to retaining staff. And, of course, importantly, pay is in that too.

We still have a lot more work that we need to do. I would say that the recent NHS pay deal has some fantastic building blocks in it that we can now use in order to push that work forward. What we have to have is the delivery of that deal that was so hard fought for by nursing members. And it is so very important to have that, because a sustainable nursing workforce is central to the delivery of all of our NHS services. You will find nurses wherever you go in the NHS, with any type of care or treatment that's required. To move, as we currently are, to significantly relying on temporary work has significant impacts in terms of cost-effectiveness and outcomes for people. And we know that the evidence shows us that. A sustainable graduate nursing workforce saves people's lives. Lisa, did you want to come in?

If I may. I think the significant point in terms of the impact of the legislation is what the legislation can do and is intended to do and what it can't do. The legislation by itself is not a magic solution to the problem of the fact that we don't have enough nurses and we need to have more nurses working in the NHS. It's the same with any type of law. We have laws of safety on the road, we have laws around lots of different things, but public policy has to support that, whether that's in terms of education, resources, research, regulation, enforcement. There are lots of actions that need a support from public policy—law. So, what I would say is that the recommendations that we make as the Royal College of Nursing—. The Welsh Government, for example, has introduced a retention plan for the first time, which we've called for this year, which is good news for nursing. There's lots of work to be done around a sustainable workforce, and it isn't in the law—that's a different pattern of work.

But what the law has done, which goes back to Helen's earlier point, is it has allowed us to see what we need. So, instead of starting from the perspective of—. It may seem strange to say this, but it's a really important point to put on the table. If you were to say, prior to the introduction of this law, 'How many nurses does Wales need in the NHS?' the answer would've been guesswork, because we didn't have that kind of workforce planning; we've come on leaps and bounds in terms of workforce planning. Whereas at least this law allows us a framework of saying, 'Patients should be safe. In order for patients to be safe, how many nurses do we need? Oh, we haven't got them. Right. What steps do we need to take in public policy to ensure that we do have them?' So, it's that wider part of that culture that the legislation supports and helps with, rather than it, by itself, magically solving the problems.

Gaf i ddilyn hynny i fyny efo cwestiwn ychydig yn fwy pigog, hwyrach? Yn fy etholaeth i, mae yna ysbyty yn Nhywyn ac mae yna ward sydd wedi gorfod cau yn Nhywyn oherwydd bod yna ddim digon o nyrsys i gynnal y ward yna ar gyfer y cleifion. Felly, pam fyddech chi'n dweud bod y ward yna wedi cau? Ai oherwydd y Ddeddf yma, sydd yn golygu bod yn rhaid cael digon o nyrsys er mwyn cynnal y cleifion, ynteu methiant yr NHS a'r Llywodraeth i gael digon o nyrsys ydy'r methiant yn y fan honno? Am wn i, yr hyn dwi'n ei ofyn ydy: oes yna unintended consequences felly efo'r Ddeddf diogelu staffio?

Could I follow that up with a more contentious question, perhaps? In my constituency, there is a hospital in Tywyn and there is a ward that has had to close in Tywyn because there are not enough nurses to sustain that ward in relation to patients. So, why would you say that that ward has closed? Is it because of this Act, which states that enough nurses must be in place to sustain the patients, or is the failure of the NHS and the Government to recruit enough nurses the failure there? What I'm asking, I suppose, is: is that an unintended consequence of the Act?

09:50

Sorry, I couldn't hear you, because I had my—

I was just saying, just for time, if one person, perhaps, could lead on this. Helen.

I don't believe that the nurse staffing levels Act is responsible for the closure of hospital wards. It's a far wider, complicated system issue about why wards need to close. We certainly have a shortage of registered nurses; that's not a surprise, we've known about that for some time. But this individual piece of law doesn't make a ward close. We use temporary workers elsewhere, we can move staff around; we've done that before the legislation as well. That needs to be drilled into in terms of the operational delivery in that particular health board.

Diolch yn fawr iawn. Os caf i fynd ymlaen i adran arall o ran yr hyn sydd gennym ni, y syniad o ymestyn y Ddeddf, mi ydych chi fel coleg brenhinol wedi nodi pryderon ynghylch oedi rhaglen staffio nyrsio Cymru gyfan, ac yna mae yna oblygiadau posibl i hyn ar gyfer ymestyn y Ddeddf i leoliadau pellach, dŷch chi'n sôn. Felly, fedrwch chi ymhelaethu ar hynny, os gwelwch yn dda?

Thank you very much. If I could proceed now to another section in terms of what we've had in terms of the idea of extending the Act, you as the RCN have noted concerns about the pause of the all-Wales nurse staffing programme, and there are potential implications of that for extending the Act to further settings. So, could you expand on that, please?

Yes. So, our concerns are that the work to extend the Act does not seem to be gathering the pace that we would like it to. So, in terms of preparation before the Act came in, there were a set of principles applied in adult medical and surgical wards, and those principles then were the building blocks for working out the levels of dependency and applying the triangulated method. That work's been done in paediatrics, and we saw an extension in paediatrics back in 2021, but it's also been done in mental health and in some community settings. So, our concerns are that, whilst we've got those principles ready to roll, we're not doing the work of ensuring that they're being followed by the NHS and, therefore, extending 25B of the legislation into those areas. That was certainly the plan when the nurse staffing levels programme was set up. Health Education and Improvement Wales hosted it, and it was very clear from their website and their public documents that that work was in preparation for extension of the Act into mental health in-patient settings and then some community settings, including district nursing and health visiting.

I ddilyn hwnna i fyny, dwi'n deall yn iawn yr hyn dŷch chi'n ei alw amdano efo 25B, ond mae 25A yn eithaf penagored, ac felly sut nad ydy 25A yn medru cael ei ddehongli fel caniatâd i sicrhau diogelwch staffio ar gyfer pob ardal, boed yn iechyd meddwl, cymunedol ac yn y blaen?

Just to follow up on that, I understand what you're saying about 25B, but 25A is relatively open-ended, so how can 25A be used to secure safe staffing levels for mental health, community health et cetera?

Just to say, I think we're coming on to 25B in the next set of questions, so just—.

So, 25A is the overarching duty to have regard to sufficient nurses to care sensitively. Our view is that the Welsh Government should consider publishing statutory guidance on this duty, so that it's clearer in terms of what should be expected in there. For example, it might want to explore the commissioning arrangement between health boards and services that they commission, like care homes, and some tertiary areas as well. It may also want to explore the setting of more parameters or principles on the wider areas where it provides services that have registered nurses and nursing care in them. We believe that would be a good next step for this legislation, it would support workforce planning in those areas and allow us to continue to prepare for the extension of 25B, which is the more biting duty, right across all areas where nursing services are provided in the fullness of time. 

Gaf i orffen efo un cwestiwn olaf ar yr adran yma, felly? Diolch yn fawr iawn am yr ateb yna. Un thema cyson sydd wedi dod trwyddo yn ymatebion yr ymgynghoriad ydy bod natur proffesiwn benodol, uniprofessional, y Ddeddf yn cyfyngu ar y gallu i gefnogi ffyrdd newydd o weithio aml-broffesiynol, gyda'r tîm o amgylch y claf. Felly, beth ydy ymateb yr RCN i hynny? Pa fath o effaith dŷch chi'n meddwl mae'r Ddeddf wedi ei chael hyd yma ar weithio aml-broffesiynol?

Can I ask one final question in this section, then, please? Thank you very much for that response. One key theme that's come through in consultation responses is that the uniprofessional nature of the Act limits its ability to support new or evolving ways of multiprofessional working and the team around the patient. So, what is the RCN's response to this? What impact do you think the Act has had so far on multiprofessional working?

09:55

So, I don't believe that the Act is doing anything to stop that multiprofessional way of working. There are elements in the Act that can be used to embrace multiprofessional working. I don't see it as a hindrance in any way, and I don't see any reason why some of the aspects of the Act can't be rolled out across a multiprofessional team. I think there are already in the statutory guidance for the application of 25B elements around professional judgment, and, in that description of professional judgment, it talks about multiprofessional input into patient care—for example, physios attending wards to treat patients and others. So, there is capacity in the current methodology to allow for an adjustment to the nurse staffing level because of the impact of a more multiprofessional, team-around-the-patient type of approach. Some of that hasn't yet been tested, but there's no reason not to test that.

Any of the other panel members want to come in on any of the questions Mabon raised? Jackie Davies.

Yes, I think it's also important to remember that the nursing team are the only team that are there 24 hours a day. So, nursing care doesn't end, or clinical care doesn't end, at 5 o'clock. I echo what Helen has said, in terms of that it doesn't hinder multidisciplinary working, but it does ensure safe care during those 24 hours of the day. Because multidisciplinary working is the additional clinical expertise that comes in as well; each expert has their own role, but, in terms of keeping a ward safe, and outcomes for patients, that's what the safe staffing legislation does.

Okay, thank you. Would you like to come in, Lisa? You don't have to come in. We'll move on to the next set of questions. Did you want to come in, Lisa?

If I may, Chair.

I'll be brief. I just wanted to add to that point, because, as a lay person working in the Royal College of Nursing, I think there's a lot I've learnt over the years about nursing, and I think what I'd like to take that back to there, if I may, is the fundamental risk to the patient. So, it's obvious that you need a multiprofessional team to get the best outcomes for the patient; there's no doubt about that at all, and, as Helen has said, I think there is room within both the statutory and the operational guidance of the Act to explore that further if necessary. Certainly, when we gave evidence when the original Bill was passing through, for example, the British Medical Association was extremely supportive of this approach, and Scotland, I think, has had with its own legislation—although it's different—some experience perhaps to contribute here. But what I would say about the risk, going back to the issue of the risk to the patient, is, if you are talking about things like falls, if you're talking about infection, if you're talking about the damage that could be done by medication, the administering of medication, if you're talking about nutrition danger, swallowing issues, those kind of things, if you take it back to those kind of fundamentals of care that need to take place, as Jackie has said, over that 24/7 period, whoever is giving that care has historically been the business of nursing, and that's the definition of nursing.

So, I think what we would say is that it's nothing to do with one profession being more significant than another; it's simply the continuation of time and the risk to the patient, and the fact that we have the evidence base to show the direct correlation between the two. So, those were the reasons originally in the Act that this came forward in this way, but there is no reason why the Act can't evolve over time to reflect the changing patterns of care.

Thank you, Lisa. This probably moves us nicely on to Joyce's other questions. Joyce Watson.

Except for I want to ask first of all if there are any barriers to the extension of the Act, because there's been some evidence that suggests that informatics systems would need further development. Do you have a view on that?

Certainly, to extend 25B, you have to be able to apply the triangulated methodology, because that's the method set out on the face of the law. And to do that, you have to develop this database, really, of patient acuity, falls and professional judgment. And where there's a will, there's a way, I would say, and we've managed to see that in the NHS. There's some work they been doing on something called 'safe care', which is a kind of rota-ing system that talks to the acuity system. So, I would say that those barriers can be reduced and unblocked. And, again, it's about thinking around the investment in terms of quality outputs, and, actually, not only do we want quality outputs for patients, but that saves money too—it reduces length of stay, it improves outcomes et cetera. So, investing in a data or a digital service that allows you to do that seems to me to be a bit of a no-brainer. And we are doing it. As I've said, there’s been work in mental health, there’s been work in health visiting, there’s been work in district nursing. Some areas will be much more challenging, like care homes, because of the frameworks and the way that they provide care. But other areas we should be looking at putting into the pipeline of developing that acuity dataset and using the systems that we’ve got and learning from them, because measuring quality standards should be a fundamental thing of both the NHS and the Welsh Government in terms of holding the NHS to account. So, it’s part of the quality measurement suite that we could easily build in. So, as I say, for me, where there’s a will, there’s a way.

10:00

I'm going to go on now to 25B, which is why we were trying to hold back on those questions. You've talked already about skill mix. Are you confident that the 25B wards—that that produces the levels of skill mix that are required?

I would say that the evidence speaks for itself in that. So, the way that the staff measure patient acuity is through something called the Welsh levels of care. This country of Wales, this little country of Wales, has led the world in that. We haven’t shouted about it enough in my view.

We have a dataset there about patient acuity that, possibly, nobody else in the world has got. Now, that data and that information has been phenomenal in terms of understanding about patients, understanding about patient care, being able to move things forward. We should be hugely proud of how we’ve managed to do that, and I believe that building that into other areas, other clinical areas, is the right next step. I don’t know if you wanted to add anything, Jackie.

I just wanted to add, in terms of the staff experience there, because your workforce will tell you that, if they’re on a ward that comes under the legislation, they’re able to do the job they’re employed to do and deliver really good care. If you talk to the staff who are on the wards that don’t come under the legislation, they very much feel like second-class citizens and firefighters, because they don’t have the protection to be able to articulate the numbers they need to deliver that care.

Okay. So, you did start, Lisa, talking about those things that nurses do, with pressure ulcers, medication, falls and all of those things. But what I'm going to ask you is, whilst we acknowledge that is what nurses do, we've had some evidence questioning whether those indicators and the reporting arrangements are robust enough to demonstrate the link between nursing staff levels and the patient outcome.

I'm sure Lisa will want to come in. I think the reason why we see those indicators in the legislation is because there is an evidence base—there is a correlation between how many patients fall and the number of staff that you've got; how many infections there are, the number of registered nurses that you've got. So, that's why the legislation was built into those areas. Of course, things need to change and move forward, but we need to rely on evidence that's got the correlation and that correlation needs to be demonstrated. So, if we're to change the measurements, which is a sensible and helpful thing to do, because we're looking at quality—we have to ensure that we move to measurements that are also rigorous and robust and stand up to that critique about showing a correlation between nursing care and patent safety and patient outcomes, because that's what that section of the legislation has required us to do. I don't know if Lisa wanted—

Can I just further probe there? You're saying that, to move forward, those indicators also need to change.

There may be other indicators that come online. I don't think we should change the ones that we've currently got, because there's a good—.

But there may be other indicators that come online that are helpful and sensible to do and they could be around a number of different areas. If you think, particularly around mental health, it's quite challenging to look at things like falls, because, obviously, falls are not going to be the significant issue for people who have got an acute mental health illness. So, there may be other indicators in other areas that complement what we already have. But, those ones that we currently have—falls, safety indicators—they're on the face of the legislation, so it's very clear that they are a good data set with which to measure how the legislation's implemented. But, to bring along other indicators that help us to add value to that, I think would be very sensible to do.

10:05

If I may as well, I just think there are two separate issues here. One is: what are the indicators? That is, what does the scientific evidence tell us are the best indicators? And there is always a need for more research in that area, and there's no reason why Wales can't lead the way in that kind of international research. But the research when the Act was drawn up, the scientific research, told us that those were the best indicators. 

Now, there's a second issue, which is the data quality issue. Absolutely, I think everybody on this committee will be aware that there are issues with improving our systems of data collection and quality control. So, that's something we can also look at. But I think those are two related but different issues: what should be the indicator, and then is the data that we're receiving from the NHS as good as it possibly can be to inform policy?

Section 25A sets out an overarching duty on local health boards and NHS trusts to have regard to the importance of providing sufficient nurses in all settings, but it isn't explicitly covered by the Act's reporting requirements. Is there sufficient clarity and guidance about the implementation of this duty and what does compliance with 25A look like?

We would argue that—

Sorry, just to say, Joyce, I'll bring in Gareth after this as well, because I know Gareth had some questions on this as well, if that's all right.

Thank you. We would argue that there isn't sufficient guidance and clarity on the requirements of 25A. I think when the Act was introduced, it was a sensible wider duty to have, but now time has moved on and there are opportunities to build on that duty. As I mentioned before, I think health boards and the Government could think about what does that need to look like for different sections of where nursing care is provided. That would certainly help with workforce planning. That's one of the key things about this legislation, where there was multiparty support when the Act was going through, is the importance of having legislation that will help us with workforce planning, knowing what's needed into the future, how many nurses, et cetera.

So, for the Royal College of Nursing, we believe that statutory and potentially operational guidance for 25A would really strengthen the obligations that health boards might be able to develop that would allow them to workforce plan better, particularly outside of the NHS, because they commission that care, but the process of education commissioning can sometimes not take that in in its entirety, but also then to see how that might work for a more seamless journey for patients as well, so that people are able to stay in their communities, where care is being provided, because we've done the right workforce plans, because we've been clear about what is enough nurses and what is that duty to have regard to there being enough nurses to care sensitively. So, we think that's something that the Welsh Government could really look at and strengthen that would mean a positive outcome for patient improvement across many different services. 

Does anybody else want to come in on the back of that question? Jackie Davies.

Yes. I would just say that, for the areas that don't come under the legislation but the overarching 25A, our workforce would say that money comes before safety. I spent two hours on Tuesday evening talking to a very experienced ward manager who manages a ward that doesn't come under the legislation, close to tears, telling me she has been told that, absolutely, under no circumstances whatsoever can she use overtime. Regardless of the deficit she has that shift, she has to go to the cheapest option first, which is good business, I get that, but at the very point where she knows she's not going to have enough resource to give good care to those patients, she still cannot use overtime. And that for me is the difference between coming under the legislation and not coming under the legislation.

10:10

Thank you very much, Chair. Good morning, everybody—good to see you. I just wanted to expand a little bit more on 25A, if I may. We've already discussed what the compliance looks like with that, but what would be the main barriers or threats to compliance with 25A when considering issues such as recruitment and retention, which Mabon mentioned before?

I think the difficulty is that the requirements under 25A are so broad that it's difficult for health boards to operationalise them. The duty is to have regard for enough nurses to care sensitively in all settings. It's a very, very broad duty, so it can be interpreted differently by different health boards, and we believe that some firmer statutory guidance and operational guidance to really show health boards what that means and what it looks like would strengthen that part of the legislation. Do you want to come in, Lisa?

Yes, if I may. I'm just going to speculate here, because when we originally, as the Royal College of Nursing, gave evidence as the Bill was passing, we called for statutory guidance under section 25A, and obviously at the time the situation was different, it was all very new, so that didn't occur. But now might be a great opportunity to revisit it.

What could that look like? It might be the case that we can tie this in to existing obligations around, say, for example, quality statements. Again, when that piece of legislation was passing through the Welsh Parliament, ourselves and the BMA gave joint evidence on what we thought a quality statement, which health boards are obliged to produce, a meaningful quality statement, would look like. We both gave evidence at the time, saying that it needed to refer to, 'What actions are you taking to achieve a sustainable workforce?', to go back to your point. So, 'What actions are you taking on recruitment? What actions are you taking on retention?', for the sake of argument. So, potentially, we could be talking about that kind of approach. We could say, 'How do you demonstrate that you have due regard?' You do it by demonstrating that you have done these things. Or, you could be looking at an approach where you use, again, existing approaches. We have an inspection system of healthcare, Healthcare Inspectorate Wales. What could it usefully do? Could that be the role of saying, 'Yes, we have in our report, which we do regularly and normally of this healthcare, that we're going to look at section 25A and we're going to say, "Are we assured, as an inspection regime, that you are having due regard?"'

So, I'm not suggesting that's necessarily the right way or the best way forward, or the only way, but what I'm saying is I think it's worth having that conversation and exploring what that would look like, and I think it would be eminently achievable. Because, ultimately, what we want is we want a system whereby we and the Welsh Parliament, the public, the profession, are assured that there is regard to patient safety, and that is happening. So, I think putting some guidance under there is eminently doable, and could be something that the Welsh Government could usefully consult on.

I suppose there's that branch into the area of agency staff, because obviously to maintain safe nurse staffing levels and with the recruitment and retention issues that we all know too well about, does that then lend itself to the recruitment of more agency nurses, which arguably cost health boards and the Welsh Government more money than what nurses would be in an NHS setting? Sorry, I'll put my teeth back in.

I think, once again, we need to remember what legislation can do and what other things can do. We are in a shortage of nurses, that's right across the world, but what I believe we've seen as the benefit is understanding what the gap is, knowing what that gap is. We haven't worked out that gap sufficiently in the areas where 25B isn't covered. So, in the long term, if we also put in place the building blocks that we talked about outside of the legislation, which are good employment practices, et cetera, we'd actually have a healthier, more sustained, happier workforce, because we've taken the bold challenge of saying, 'This is what we need across the piece. This is what caring sensitively looks like.' So, agency fills gaps. If we close those gaps, we won't need to use agency, and in the long term, for doing that, for the Royal College of Nursing, that is about putting further and better guidance around 25A, which helps us to workforce plan, to identify what's needed into the future. And I'm not just talking five years; I'm probably talking 30 years plus in terms of the nursing workforce. So, I think I would go back to the point that Lisa made earlier, that legislation will do certain things, and other things need to be tackled through different methods. 

10:15

Thanks. So, do we have a clear picture of the extent to which health boards across Wales are managing to maintain nurse staffing levels in 25B wards? Because, as I mentioned, if the nurse staffing level is the standard to work to, then to what extent do health boards have to go to achieve that currently?

They have to make reports, which are in the public domain, and one of your colleagues referenced our previous 'Progress and Challenge'. That's coming up for publication very shortly, which, of course, we'll make sure the committee gets a copy of as you come to your conclusions. We know it's not always easy to maintain the level that the law requires. That was a challenge before the law came in. The difference now is we know what that level is, we can workforce plan in order to ensure that that supply is coming further forward. And we can look into the future more to say what agency, bank and other staff we need, because we now know the level where we're going to set it. 

What you see in other areas, which Jackie spoke about a little bit earlier, is that doesn't happen, and the staff become demoralised and they leave, and the problem becomes worse and worse, and you use more and more agency because you can't recruit a sustainable workforce into an environment where they can't give the care that they believe they were trained and educated to provide. So, the unintended consequences of that are significant and quite severe. 

What are the consequences of non-compliance, in terms of internally with health boards, NHS Wales, and then, indeed, Welsh Government as well?

So, on the face of the Act, there are no consequences written into the legislation. I think your question is probably best to be pointed towards the Welsh Government. From our members' perspective, they see the consequence of moving some people around, but you can't just wave a magic wand and have lots of nursing staff out there all of the time. That said, we believe there should be a further discussion about the consequences of non-compliance and how that could then focus the minds on ensuring compliance moving forward. But that's an area that we've certainly said in our evidence we would like to see strengthened, because it's not very strong at the current time. 

With, obviously, your professional background and your knowledge, what would you think would be reasonable and measured consequences to be included in that, then?

What I can say is that there have been consequences from non-compliance, because we have seen, in the escalation status of health boards, situations where part of the reason for escalating a health board's status has been non-compliance with the Act. Although it's not necessarily as systematic or as rigorous as we, the RCN, might wish, we know that Healthcare Inspectorate Wales do refer to compliance with the Act, and we also know that there are the public reports happening. 

What I would say is, by their very nature—and this is again the major reason for having a legal framework—organisations tend to focus on legal compliance. So, compliance is more usual than not, and that's the evidence we found in 'Progress and Challenge'. And the third report is due out next month, and I can tell you in advance that the findings are that there is compliance, more compliance—. Non-compliance is unusual, that's what I'm trying to say. And what I'm trying to say is that there have been consequences through the performance management of NHS Wales, and the Welsh Government, to non-compliance.

But, to echo Helen's point, could that be strengthened, could that be made clearer, could that be made more transparent? Yes, we think so. Public information is an area, actually, we haven't touched on, but we've touched on in our evidence. We do think there could be more public transparency about—. Public information is one thing, but making that information more accessible is another, about compliance.

10:20

Just to hone in a bit on the question a bit more, I suppose what I'm looking for is: what would the consequences look like? Would they be punitive, as such? What would be an example of a consequence in your mind?

I think it's difficult to be in a punitive setting because, ultimately, that can have its own unintended consequences, and we've got lessons to learn, haven't we, from things like waiting targets and various other things. I think there needs to be a more rounded discussion about what consequences could look like, which is a solutions-focused one for me. So, the consequences of over-relying on agency work is an area that we could have a further discussion. So, not so much a punitive consequence, but a solution-focused consequence would be more helpful, I believe.

So, for example, health boards, if they can't meet the section 25B requirement, have to demonstrate that they've taken all possible steps to address that situation. So, part of that would be actions to improve retention. So, support in an escalation process could look like, 'Have you tried these actions? The evidence is clear that these actions impact beneficially on retention. We want you to do them.' So, it could be part of the support and escalation process, but very specific.

Joyce wants to ask a question, but I just wanted to come back on one myself. Just to understand, do we know the extent of where there is non-compliance?

Because it's reported in the board reports. There are regular reports on each health board to the board, which advise the boards of their corporate responsibilities and their compliance and non-compliance, and if there is a danger—. For example, in one health board, I can recollect in the last five years—. Again, part of the benefits of this legislation has been that it's very much strengthened the role that the nurse director has, and it's strengthened the seriousness with which that role is taken in the organisation, because they are now reporting regularly to board around an issue of serious compliance. So, I can think of one example where the nurses director was saying to the board, 'We have a danger here. There is a danger that this is not compliant. I need support to address this issue', and indeed received support to address that issue. And you can simply see the progress of that in the board reports. So, we have that information available, and it's really very positive to be able to see that, because, previously, we had no way of knowing. And to go back to the earlier point that you made about the importance of technology, I recall, not that long ago, just before the introduction of the Act, being with the director in a meeting where the nurse director was appalled to discover the state of nurse staffing on the wards because the system she had at that time only told her what was rostered. It didn’t tell her the staff that were actually real-time available. And that, in fact, that situation, has improved, which is fantastic.

We are out of time, and I won't come to Joyce, but the one case I wanted to raise, which helps me to understand how I can help a constituent, is the context of one constituent, not particularly elderly, who moved from a district general hospital and steps down to a community hospital setting, and was talking to me about her experience, good and bad. And I think the worst experience for her, which she felt was incredibly undignified, was in the evenings, because she wasn't able to go to the bathroom herself—she needed support. She referred to them as adult nappies—I'm sorry I don't know the correct terminology—which were placed on her in the evening because there weren't sufficient staff to take her to the bathroom. Is that a case of that ward not being compliant with the Act, and how would anyone know about that? How would that be reported back? Or is that another situation that you think I should be taking up with the health board?

Firstly, that's quite shocking for me.

I'm very sorry to hear that your constituent has had that. One of the fundamental principles about nursing care is fostering independence and dignity and respect and, quite honestly, I find that very, very shocking. Again, I don't think that's about a legislation—I honestly don't. You shouldn't need a law to say there are enough people to take somebody to the bathroom. That's a basic human right—to be treated with dignity and respect. So, I don't think you can blame or associate that with compliance or non-compliance with this piece of legislation. In terms of a quality standard, for me, that's a fundamental breach and absolutely something that should be taken up with the health board. This level of care that we're prescribing in the legislation is based on good methodology and good theory. And that shouldn't happen in those wards, with 25B, but, quite honestly, it shouldn't happen on any ward at all.

10:25

Okay. So, you're suspecting that there probably were sufficient staff on the ward and there was another reason for the incident.

I think that's something you need to talk to the health board about, because if the staff are saying, 'There aren't enough of us to help you go to the bathroom', then there are issues there, aren't there, about whistleblowing, escalation, patient safety, vulnerable patients and safeguarding.

My final question was to tie in the recruitment—. Is the recruitment and retention policy that's been worked on, to provide flexible working, et cetera, et cetera, to retain people, is it tied in enough and does it cross-over enough with this legislation in mind, because the two obviously fit together?

I'm going to let Lisa answer that one, because it's quite a technical one in terms of law. Before Lisa answers, though, what I would say is you can't do one without the other. You can't apply a methodology and arrive at a nurse staffing level if you don't have the right staff to do that. So, building blocks like the retention plan are absolutely key and essential. For us, that's a first step and I welcome it—absolutely welcome it—but, no, it's got a journey to go on. But I'm going to let Lisa answer the more technical point.

I was just going to say, we are out of time and I can see Mabon's got a question as well. If I ask Mabon to come in now, then perhaps I can ask you to incorporate Mabon and Joyce's point. Mabon.

Diolch, Gadeirydd. Yn sydyn iawn, mae Lisa a Helen wedi cyffwrdd â hyn yn yr atebion pellach, ond roeddwn i eisiau gweld os medrwn ni gael mwy o wybodaeth. Rydych chi'ch dwy wedi sôn bod posib esblygu'r Ddeddf yma dros amser, ac roeddwn i eisiau gweld sut ydych chi'n meddwl y gellir esblygu’r Ddeddf yma, i'w chryfhau hi er mwyn iddi fod yn fwy addas i'r dyfodol.

Thank you, Chair. Very quickly, Lisa and Helen have touched on this previously, but I wanted to see whether we can have more information. You've both mentioned that it would be possible to evolve the Act over time, and I want to see how you think this Act could be evolved over time, to strengthen it in order for it to be more appropriate for the future.

So, we are out of time and I was going to say, 'Can you give a brief answer?', but it's very difficult to give a brief answer, but if I could ask you to incorporate Joyce and Mabon's comments in some final comments from you, Lisa.

I shall answer, Chair. The retention plan from the Welsh Government is very welcome. We've been calling for that for a long time, and I have to say, its commitment to implementing time flexing, for example, which we know is the second most critical issue—if not, perhaps, the first most critical issue—that sits alongside pay as something that's important, is really very good. The question is: how are we going to implement it and make sure it's implemented? So, I think it is critical to this Act, and it needs to be implemented, basically. So, I think the answer to that question is that we just need to keep an eye on it. I think our report 'Nursing in Numbers 2023' contains a range of workforce recommendations that address the sustainability issue, and I would recommend to the committee that perhaps we can put that publication in as evidence, to answer some of the related questions, because the two are hand in hand.

In answer to the question of how it could evolve, I would say section 25B is, I think, a proven effective method and has had great results, and we would like to see that extended to areas such as mental health in-patient wards and community, where those things have been developed. Where section 25B isn't perhaps the most appropriate method to achieve safe and effective care, let's look at some other mechanisms. Let's look at strengthening the Health Education and Improvement Wales role, for example. Let's put some statutory guidance under section 25A, to explain how the health boards—. In fairness, how can they answer that question, that they're having due regard? And I would think the final thing that we would suggest is that section 25B, the Act, is statutory guidance and operational guidance. And that's the beauty of that approach to legislation, that that can be more flexible and can be reviewed and changed, and is done so. So, I think that should be, and is, a regular process of reviewing that, to make sure it's fit for purpose.

10:30

Thank you. Sorry, we'd better draw this session to an end. I know we've gone over just a little bit, but can I thank you all very much for being with us this morning? And, of course, if there's further evidence that you want to submit, and following the other sessions as well, then that would be very welcome indeed. Diolch yn fawr iawn. Thank you very much. We'll have to take a short five-minute break just to facilitate the changeover of the witness panel. So, back in five minutes.

Gohiriwyd y cyfarfod rhwng 10:30 a 10:38.

The meeting adjourned between 10:30 and 10:38.

10:35
3. Deddf Lefelau Staff Nyrsio (Cymru) 2016: craffu ar ôl deddfu: sesiwn dystiolaeth gyda chyfarwyddwyr nyrsio
3. Nurse Staffing Levels (Wales) Act 2016: post-legislative scrutiny: evidence session with nursing directors

Croeso, bawb. Welcome back to the Health and Social Care Committee. I move to our next item, which is item 3, in regard to our second session today on the Nurse Staffing Levels (Wales) Act 2016 and our post-legislative scrutiny. We've got some evidence, and this next panel, from nursing directors. So, thank you very much for being with us today. I'd be very grateful if you could just introduce yourselves for the public record.

Hello. I'm Nicola Williams. I'm the executive director of nursing, allied health professionals and health science at Velindre University NHS Trust.

And I'm Jennifer Winslade. I'm executive director of nursing at Aneurin Bevan University Health Board.

Good morning, everyone. I'm Gareth Howells. I'm the executive director of nursing in Swansea Bay University Health Board.

Right. Thank you for being with us. So, to what extent has the Act delivered on its aims?

If you think the ultimate aim was to improve patient care, it's been a positive development on the whole, because we can evidence improvements in care, not solely related to numbers of nurses on wards, but the process over the last five years. I know in some of our wards we've seen a reduction in falls, seen a reduction in patient pressure damage, seen a reduction in medication incidents, and the like there. Now, the real challenge, I think, with that is is that while we're seeing those reductions on our nurse staffing Act wards, we're also seeing reductions on our non-nurse staffing Act wards. So, the harm work that we've been implementing across our health board has had that impact. So, then you go back to—staffing is just one component of this, I think it's fair to say. I think the other thing it's done is supported investment. If you look at Swansea bay, we've invested about £5 million over the last five years in nurse staffing Act areas, and it's provided a focus on paediatrics, obviously, because the second part of the roll-out included paeds.

So, for me, I think it's improved our board's understanding. It's been a positive development. But I think we're at a bit of juncture, and that juncture is part of the review today, that would be my assessment, in terms of 'Where do we go next and what does this look like moving forward?' And I think it will be good to have that conversation as well, reflecting on the benefits but seeing how we can maintain those benefits moving forward. 

10:40

Thank you. I'll widen my question out, and perhaps bring you in as well, Jennifer, but a number of the consultation responses provided to us said that there's now a greater corporate responsibility for nurse staffing, and I wonder if you agree with that. By all means, respond to the first question and incorporate that as well in your answer. 

So, I came to Wales 13 months ago from England, and there is no doubt to me, having worked in the English NHS for a very long time, that the Act has had an extremely positive impact on patient outcomes, but also on the sense of well-being and, certainly, the impact on our staff who are nursing on the wards every day. One of the things that I've noticed, in particular, with the band 7s and the free-to-lead concept that has come with the Act—that's definitely had a very positive impact on quality and safety for our patients and our citizens on the wards. 

In terms of the corporate ownership, I think it has been pivotal to the success of the Act and the positive impact, because there is a sense, when there is reporting through the executive committee to the health board, of everybody understanding the impact of the Act, of the staffing levels, and therefore what that means for the quality of care. So, across finance, workforce, through to the whole health board. So, I think it's had a very positive impact in terms of that corporate ownership and accountability, and I can definitely see that mirrored very differently in the context I've come from. 

That's really interesting to have that evidence from working in Wales for 13 months. So, that's powerful to hear that, so perhaps some Members might want to dive into some of that a bit later on as well. You mentioned finance in your response as well. There's obviously significant financial resource required in terms of ensuring that the Act is implemented correctly. Does the Act deliver value for money? I think you're going to say 'yes' from your earlier answer, but I'm just trying to draw that out as well.

Yes, the Act does deliver value for money. I think, as Gareth said, we're at a juncture. We know that the needs of the Welsh population are changing. The recent report that NHS Wales commissioned into the 10 years hence I think identifies that there will be a change to the needs of the population from a healthcare and social care perspective over the next 10 years. And I think it does deliver value for money, but I think we do need to think differently about the future. 

Okay. I'll just bring in Sarah Murphy at this point. Sarah Murphy. 

Thank you very much, Chair, and thank you all for being here today. I'm just going to ask some further questions, really, and dig down into the implementation challenges that you've faced. We have consistently heard that a shortage of nurses is the biggest challenge to the implementation of the Act. Have health boards had difficulty recruiting sufficient nurses to the required establishment to fill planned rosters? And, crucially, to what extent have health boards had to rely on agency and bank staff to maintain staffing levels? 

Who would like to address that point? Nicola Williams. 

I'll make a start, if that's okay. Yes, I think the supply of nurses has been a challenge, as you quite rightly outlined, and therefore we do need to look at what our patients require, and of course they will require nursing staff, but they also require staff of different disciplines, and the team that our patients require is very different today, maybe, than when the Act first came into force. As Jenny just outlined, the 10-plus years document that's just been produced—that outlines very different challenges going forward.

So, we have to, firstly, retain our nurses. I think that's really, really important, and the experience our nurses are having in the workplace is part of that retention. But also, how do we ensure they have time to develop and clinically skill up and update? How do we make sure they have supervision, that they have mentorship and support within the workplace? So, we've just published a nurse retention plan, albeit it's focusing on nurses. And, again, one thing I'm really keen to look at is how we develop the multiprofessional workforce, and not just concentrate on nurses. We have had an increase in numbers of pre-registration trainees coming into nurse training this year, and what we have to do is retain those nurses and give them as positive a work experience as possible so that we keep them within the NHS. But we also think about where we need to be deploying our nurses, and that is across the whole spectrum of care delivery. So, the 25B part of the ward focuses very much on paediatrics, in-patient medical and surgical areas, but, actually, we need to be shifting our care delivery into the community, and we need to make sure that we’ve got staff that are deployed where our patients actually require that. And when we’ve got 3,200-plus vacancy positions, as we had in December, we have to ensure that we are allowing our nurses to do what only nurses can do, and make sure that we’ve got the right support in place, through clerical support, through healthcare support workers, but also through therapists and other disciplines of staff who can provide the care for the patients.

The other enabler is digital. So, we really need to be looking at how we use proper digital infrastructure, how we have digital at the bedside, and at the virtual bedside through mobile devices, which really maximises the time our nurses can spend with patients, rather than with paperwork and trying to follow things through and chase referrals et cetera, which could all be digitally enabled to happen. But that in itself would also help to reduce patient harm and ensure safety.

10:45

Thank you very much. You've actually answered my second question as well, which is extremely helpful. 

There we are. Does anybody else want to come in on the back of that? Gareth Howells and then Jennifer. 

You know, nursing is a wonderful profession. I'm exceptionally proud to be a nurse. I love being a nurse. I'm in my forty-second year of being a nurse. So, there’s something about how we make nursing attractive again. We know that our universities and the like are struggling to fill cohorts of students coming through, so I think there is something there that goes with the retention work—just being really clear about the real benefits of nursing, the benefits of care, the wonderful interactions you can have and what it can do to support you as an individual and, obviously, as a professional.

And I think, post COVID, we’ve got to get our mojo back. It does feel like we’ve been through an exceptionally challenging couple of years on the back of an exceptionally challenging couple of years. So, I think the work we need to do now isn’t just about numbers on wards, in my view; it’s about culture, it’s about really making nursing attractive, and then living up to what we offer. For us in Swansea, we’ve done quite a bit of work on ethical overseas recruitment. We’ve reduced our vacancy levels by about two thirds in the last 18 months. The difference that’s making on the wards is enormous—one, financially, because we’re not using the banking agency that we were using previously. But then being in a position whereby we have fully established wards enables your ward manager to be supervised, it enables you to train, to support and all that goes with it there. So, there’s a cycle in terms of the profession and getting to a point whereby we’re fully established. 

Absolutely. If I could just ask, though—and thank you ever so much; all of that is extremely helpful and relevant—it would be helpful just to know to what extent, though, health boards are having to rely on agency and bank nurse staff to maintain those staffing levels. 

I'll bring Jennifer in, if that's all right, Gareth, just to finish on this point. 

Like Gareth, I've been a nurse for a very long time, and I'm extremely proud to be a nurse. From the day I first met a patient you could cut me in half and find 'nurse' written through me. And I'm very proud to work in Wales. I think it is an incredibly supportive and positive system in the NHS in Wales. One of the things that—. So, there is a reliance on bank and agency at the moment, as you know, and that's precipitated in some ways by the pandemic and the need for additional staff during that very awful, awful period of time. And one of the things that we've been focused on is really trying to think how we think differently about recruitment and retention into nursing. So, some of the work we've been doing in Aneurin Bevan is thinking differently about how we work with young people, communities, how we work with the new generation—are we on generation Z—in terms of what they want from a career in nursing, and what that looks and feels like. So, you know, starting to think about non-traditional routes, and the opportunity to enter as a band 2 and become a nurse consultant. So, those opportunities to say, 'We know you don't want to work five shifts a week any more; we know you want a flexible route and you don't necessarily want to go to university', but really working with our communities to say, 'Let's have a different pathway that enables us to really support people to have a lifetime career in the NHS in Wales.' And I think people can, and that can be really, really fulfilling.

And I think that's the way we tackle the bank and agency use. And I would say that, actually, to some extent we will always want bank use, because, actually, there are recruited and retained staff who do work flexibly, but that meets their need. But, actually, you know, how do we encourage the good agency staff to come back? How do we support those staff to work in our systems again? And how do we work with our population to say, 'Nursing is where it's at, nursing is the future.'

The other thing I just wanted to add was around the digital, so just leading on from what Nicola has said. I think it's not just the systems, it's the connectivity of those systems. So, wouldn't it be great to have single opportunities to draw the data together in a way that enables us to think intelligently around workforce planning, around meeting the needs of the patient. So, I think there are some opportunities in Wales that we really, really need to grab hold of. 

10:50

Thank you very much. And, Chair, I believe Mabon would like to come in as well. Thank you. 

Oh, sorry, I didn't see you have a hand there, Mabon. Mabon. 

Diolch, Gadeirydd. Mi fyddaf i'n siarad yn Gymraeg yn sydyn. Jest ar y pwynt yna, yn dilyn fyny ar yr hyn yr oedd Sarah yn ei ddweud—rydych chi'n dweud mai un o'r heriau mwyaf ydi recriwtio a chadw staff. Felly, ydych chi'n meddwl bod yna bwynt i'r ddeddfwriaeth hon, i'r Ddeddf yma os nad ydyn ni'n medru recriwtio a chynnal a chadw'n staff? Os nad oes digon o nyrsys gennym ni, oes yna bwynt i'r Ddeddf? Oes yna bwynt, y tu hwnt i ddim ond niferoedd y nyrsys, i'r Ddeddf, sydd yn gwneud y Ddeddf yn werth chweil, beth bynnag?

Thank you, Chair. I'll be speaking Welsh, quickly. Just on the point, following up on what you were saying, Sarah—you were saying that one of the biggest challenges is recruitment and retention of staff. So, do you think there's a point to this Act if we can't recruit and retain our staff? If there aren't enough nurses, is there really a point to the Act? Is there a point, beyond just the number of nurses, to the Act, which makes the Act worth while, anyway?

I'll make a start. Thank you. I think for the reasons that Gareth outlined in relation to the difference that this Act has made, yes, there is a point to this Act and it has made a difference. I was in more of an operational role when the Act first came into place, and I've seen that first-hand, as part of the hospital-level work to implement the Act and now in an executive role. What we need to do is broaden out beyond nursing and nurses play a pivotal role, and always will play a pivotal role in the care for patients. But it's not only about nursing, and therefore the Act narrows that focus. Although, 25A does give us an opportunity to look beyond that, but we have to look at the multiprofessional approach and what is that team that that patient requires. 

So, just yesterday the National Institute for Health and Care Excellence published revised guidance for stroke care, and, really, referred to intense walking within the first 24-hours of a stroke, and quantified in hours the amount of therapy patients required post strokes. Therefore, a stroke ward should have an establishment that includes therapists at a number that meets those requirements. So, it is much broader than nursing. And if we also looked differently, if we did have integrated digital enablement, if we did have, you know, the wider support, clerical support, that would release nurses' time, and I think the recruitment and retention gap would lessen. So, it's how we look at this in a much broader perspective rather than just the numbers, and really look at what our patients require and what other support mechanisms we can put in place that will transform the lives of our nurses, but also release their time, and maybe reduce the amount of hours that we need from a nursing perspective and offset that with some other things.

10:55

Thank you. I'd better move onto the next section just for time, unless there's any pressing point. No. That's fine. Thank you. Joyce Watson.

I'm going to go onto the triangulated approach, but before I do that, I want to ask for your views about the messages around nursing—the positive messages, that is, around nursing, rather than the headlines about where things go wrong, which they do sometimes, let's be honest. In your view, does that have an impact—those negative headlines about various settings—on recruitment? Are you having any feedback in that regard?

I haven't got any evidence, but I think anecdotally, I would say 'yes'. And I agree with you so much; the vast majority of what we do, we do really well. And I say that to our teams all the time when we are under the pressure that we're under. But the NHS generally, as we know, is quite politicised, and we know we have a lot of views about how it should and shouldn't be ordered and managed there—notwithstanding the fact things have gone wrong. But it isn't just nursing; and I think while nurses haven't got a monopoly on caring, nursing is always seen at the centre of everything—when it's good, when it's bad and the like. For recruitment, we're quite lucky, I think. Our staff tend to live in our communities and don't tend to move. So, you know, we can't take that for granted, but we know that we can attract people because there's a loyalty to our organisations and a locality to where they can work there; but logic would profess that if it's continually negative about the NHS, then people would see that and it may impact their decision to apply for jobs with any of us.

Thank you. I'm going to move on now to the triangulated approach, and whether you can talk us through the approach to calculating nurse staffing levels in 25B settings—that's what I'm particularly going to be talking about. Do you think that the timing and frequency of calculations as they currently stand are appropriate?

A personal view is that the Act was set up in what feels like a very different time. And for us, it tends to be a really time-inclusive process: the twice-yearly review of acuity, the discussions with teams and the debate around how we got to that decision, the professional judgement that comes in there, that we need to take it through our meeting structure and then to board. To do that twice a year is quite a challenge. So, my thoughts moving forward are that it would be great to have that annually and to do it just the once over every year.

It does provide assurance, though, and it does provide that oversight in terms of making that link between staff required, acuity and what the outcomes are. But I would argue that there's an art and a science to roster management. There's the science around, 'This is what the acuity is telling us, this is what the outcome is', but there's professional judgement in that, in saying, 'Well, yes, we should have eight, but we've got seven staff on duty; we'll manage, we'll be okay'. We escalate and advise when we're in that position. So, I think we can't take the professional judgment component away from it as well there. But that process, I think, probably going back 30 years, we've always used: number of staff, acuity and what the outcomes are.

I think the frequency is important, but what is also important is that the Act and the statutory guidance do require that to be revisited in between the timelines should anything change; and wards change, the types of patients on the ward change. So we do the establishment reviews in between those time periods if they require it. My personal view is that six months is a reasonable timescale, and, you know, we've got some variation there, but the organisation I'm responsible for is much smaller than the organisation that my colleagues work in. But regardless of what time period the calculations are required to be done in, there are escalation points should acuity change, should the profile of the patients change or should something else change—that that is revisited in between the periods of time.

11:00

From my perspective, it has been incredibly helpful to have the six-monthly reviews, although, as Gareth says, because the systems aren't necessarily connected, it comes back to the information technology and digital point—there is a burden to that. However, I think it does give the ward managers the opportunity, the accountability and the responsibility to influence the ward establishment. That has to be balanced with the acuity, the quality metrics and the professional judgement, but, as Nicola says, what's most important is that we don't just use those touch points to ensure we're providing safe care. That's a continual and ongoing basis through our internal mechanisms to make sure that our staff are supported, that our wards are safe and that our patients receive high-quality care.

Thank you. We've had some evidence that questions whether the quality indicators used as part of the triangulated approach and their reporting arrangements are robust enough to demonstrate a link between the nurse staffing levels and the patient outcomes, because that's, clearly, what this Act is all about. Do you have any comments on that yourselves?

If I make a start, my observation, as someone who is new to Wales and to the Act, is that the issue we have is that patients never follow a linear pathway. So, many of the metrics will be influenced by other professionals and through, potentially, other parts of the service. Assessing it on a ward basis against the metrics that do have an evidence base in some ways doesn't, perhaps, give you the true picture on outcomes. I think it would be valuable to do further work, as the Act progresses, on, actually, how you demonstrate that move from measurement to outcome, because if you take a complaint, for example, around nurse staffing, very rarely is it purely around nurse staffing; it will be multifaceted in approach.

I think the other issue is that we have multiple causes and effects. So, for example, with pressure ulcers, there has been a huge amount of work done in the quality and safety space around improvement through pressure ulcer collaborations. We've had a very successful one in Aneurin Bevan. Therefore, again, what is the impact of the Act? What is the impact of that collaborative? How, therefore, do we ensure that we have that integrity of reporting, but also that we're able to look at what that means in terms of outcomes? So, my personal view would be that there is further work to be done.

I'd support Jennifer with that. I think, for me, there is something as well about how we pull together workforce-type information like sickness levels, retention levels, throughput and the like, operational information—how many discharges, how many admissions and the like there—and then using the quality outcomes and the quality metrics in line with workforce, in line with operations. I think that, then, gives you, probably, a more rounded view of what the ward is like, what the outcomes are like and what care is like. 

But there are specific parameters around, you know, what you're measuring, whether it's falls—we've mentioned the pressure sores and other things that fit within that. We've heard from the previous witnesses that those specifics within the Act do show improvement, and they would say as a consequence of higher nurse staffing levels. Would you agree with that analysis and observation?

My personal view is that I think it's one component. I think we couldn't say that just by increasing the number of nurses it's the only thing that has caused reduction in harm. Because, as Jennifer said, there's so much other work ongoing around the fact that we're focusing on falls reduction and pressure ulcer reduction. There's no doubt that it's a component, in my view, but I think it's one component.

11:05

Okay. We've got statutory guidance and we've got operational guidance on implementing section 25B of the Act. Are they clear enough? Would you want to see any difference?

It's clear for what it covers. If we're looking at general acute ward areas and paediatrics, if I were to look at my worry list, it's as much those areas that are not covered by the Act, and I think that's where we need to focus, moving forward. We've got a lot of work ongoing around principles in areas like district nursing, mental health nursing and the like, but our nurse staffing Act wards are really quite clear; we know what they are, we know what they do, we know what we review and we know what they should be. We've got the same degree of scrutiny in our other areas, but without the leverage that an Act gives you in terms of being sure you're at a level of staffing.

That's exactly what we are being told; it's the leverage, it's the fact that you have to report on it—

It's powerful.

—making it, as you say, powerful. Since you're all nodding your heads, I won't reask the question, but I'm going to ask about the ability for people to have their care, if they require it, through the medium of Welsh. How confident are you that that skill level amongst staff is being reflected in delivery?

Again, a personal view, I don't think we always get it right. We have a focus on training our staff in conversational Welsh at various levels. It's interesting, we had a story at our board two weeks ago from one of our nurse specialists who was caring for somebody at the end of their life, and the difference that speaking Welsh made to that gentleman, and the assessment of his care changed, obviously by being able to converse in Welsh. So, as I say, I don't think we've got it right. We know it's a priority for us and we know where our Welsh speakers are, and we know who we can call upon if we require that degree of input there. And just recognising that English isn't the only medium. And while we've got a legal responsibility around Welsh, there are other languages as well. In Swansea, I think there are 90 different languages that people speak. So, it's being able to assess care appropriately in the language of choice, and being sure that we can do that either with our own staff, or using things like LanguageLine and the like. But for Welsh in particular, we're having a major focus at the moment.

Absolutely.

Yes, absolutely.

Thank you very much, Chair. Good morning, everybody. It's good to see you. I just want to start with a remark if I may, Chair, just to say that I find it really nice and quite refreshing to see a passion for nursing. Obviously, you highlighted the positives and benefits of working in Wales, and I can really feel your passion for the sector in the evidence that you're giving, so it's just really nice and refreshing to see that this morning.

I'm going to focus on reporting and compliance with the Act, if I may. It stipulates that health boards and trusts must take all reasonable steps to maintain the nurse staffing level. Is there sufficient clarity about what constitutes 'all reasonable steps' in that term, and is there a consistent approach across the health boards and trusts in Wales? 

For myself, I think it's very clear to me and to my teams what the steps are that are required, and they are multifactorial, depending on the situation that results in the roster not being the roster that we had agreed. Therefore, within organisations across Wales, there's a very similar approach, I think. Certainly, I've worked in a couple of organisations and there is a very similar approach to that. There is an escalation process that works in usual hours, but also out of hours, to try and do the best we can to make sure that we have sufficient staff within any clinical area at any time. And I think that is wider than just the 25B wards, because it's really, really important that we have the right staff wherever we have patients, and that may be in theatres, or it may be within the emergency department. So, there is a very clear process in place that may slightly differ across organisations, but, essentially, most of them will end up in an agency request at the highest level.

But, prior to us getting to there, we would have done all sorts of other things like looking at are there areas where there are lower acuity patients at this point, so that we can make sure that we use a risk-based approach to deploy the staff that we have, as well as using our own staff that are keen to do extra shifts, from part-time up to extra hours or working on the bank.

11:10

Could I just add—?

From my perspective, I think it is very clear, and the all-Wales staffing group has done a huge amount of work to ensure the consistency in the way in which this is monitored. Again, I think there is a point around the digital connectivity of systems and the way in which that can help us to have a more fleet-of-foot way of monitoring and reporting. As Nicola says, we don't just focus on the 25B wards as directors of nursing, we focus on all of our clinical environments to ensure that staffing is safe. Clearly, the parameters under the Act are very clear for 25B, but I think it is absolutely implicit that we continue to focus on the establishment and the safety of all of our services, no matter whether they're in the community or the hospital.

So, am I, obviously, detecting a sense that 'all reasonable steps' can produce a degree of ambiguity into how that nurse staffing level is achieved? Because I mentioned to previous witnesses, or guests, I should say, this morning, that, with the recruitment of agency staff—. Is that something that's a common theme across health boards? Because, obviously, we're all too aware of the costs of that and the cost implications for health boards, so is that something that's included in that 'reasonable steps' scope, if you like?

Yes, absolutely it is. The other thing, just to add to my response as well, is taking reasonable steps also includes taking reasonable steps to actively recruit, and using different ways to recruit and retain your workforce. So, it's not just at the time where your roster is short, but, actually, how are we as executive directors and our board colleagues doing everything we can do to make sure that we are recruiting and retaining as many nurses and unregistered staff as we can to maintain safe rosters. And the work that Gareth, I think, outlined earlier around international recruitment, the work that HEIW have been leading on about increasing our pre-registration places, the part-time pipelines from apprentice healthcare support worker through to registrant, these are the types of things that, as organisations, we're also doing that will help us with those reasonable steps, I think, as well as just the times when our rosters may be short. But, yes, agency is definitely—. And I don't think there's any ambiguity there, just to respond to that.

The only thing I would add is that, again, if it comes back to how do you design a service around the needs of the patient. And the 25B is clearly very prescriptive in terms of how registered nurses are deployed, but I would bring it back to that wider multidisciplinary team working and the opportunity to create new and alternative roles that meet the needs of the patient. So, for example, in Aneurin Bevan, we're currently piloting recreational support workers to work with patients who have dementia, and it has been incredibly successful in terms of providing that high quality of care. 

Thank you. I want to focus on cases of non-compliance with the Act. Are there clear escalation arrangements, and what are the potential consequences of non-compliance with it?

There are escalation processes. For us, we have a monthly oversight group where all breaches are reported to. We provide assurance via our workforce and organisational development committees on a biannual basis, and, obviously, to board then, when we don't achieve the Act. But I think there's an important point there, and it's the 'all reasonable steps' can almost be seen as—. It's quite a blasé phrase—you know, 'Well, we're taking all reasonable steps, so we're okay.' We really don't work like that, so being really clear about what the establishment needs to be, where the gaps are, what the acuity is, and, on a daily basis, I know our teams meet three times a day to go through staffing within the areas there. But I’m satisfied that there is a process for informing our board around where we are with the nurse staffing Act, and any challenges that we have within that, and it's stipulated quite clearly within the Act, the expectations, also.

11:15

Thanks, Gareth. Is it necessarily—? The consequences, are they punitive, or do they tend to be constructive, in terms of non-compliance? I'm just trying to understand an example of a consequence in terms of non-compliance with the Act, and who and what administers that, and then what's the sort of scenario in the case of non-compliance?

In terms of a punitive approach to our clinical areas, there's no punitive approach. So, it's really important that that point is made, that our teams don't get a hard time if they're struggling to staff their wards.

In terms of oversight, obviously, we provide a three-yearly review in that cycle as well, and that is reviewed centrally, and again areas of non-compliance have been identified within there, and it tends to be about, 'Okay, right, okay, what do we need to do to improve that, moving forward?', rather than any sort of punitive oversight.

Okay, thanks. I understand. And just finally, in terms of communication with patients on the nurse staffing level on 25B wards, how is that done in practice, and how is it done to patients in a way that is understandable in terms of staffing and making sure that if there are any undue waiting times, or not being seen for care in a timely manner—how is that then communicated with the patient?

Personally, I still think we've got some more work to do there. Within the Act, the expectation is that our staffing levels are displayed, and displayed within our clinical areas to say the number of staff we expect to have on duty and the number of staff we have on duty. I know in our organisation that that isn't consistent, and I think—and not to look for excuses—it's coming out of COVID, and really re-emphasising what we need to do in our clinical areas, and that part of the Act in particular. Pre COVID, we used to do it consistently, but my personal view is that we've still got some more work to do there.

I would agree with that. I think there is further work to do. Clearly, our reports are in the public domain through our reporting through to the health board. I think one of the opportunities we have is how we are much more transparent with the public around things like our quality indicators as well. So, under the duty of quality, ensuring we have that always on reporting, and we're really clear around staffing, not just in the 25B wards, but in all of our clinical areas, around the impact of staffing and our clinical quality metrics and what that means. There's been a huge amount of work done globally in terms of how you might do that, and it's one of the things I think that gives us an opportunity for staff to be really proud of their environment and to celebrate the success, but also be honest about the areas that perhaps they're struggling with. And where that's been done, and the publication has worked in that way, there's been really positive patient feedback—really positive patient feedback.

I suppose unless a patient is a nursing professional themselves or a professional in a health setting, they're not going to necessarily know what a 25B ward is, or, indeed, the nurse staffing levels. So, in terms of getting that message across in a lay perspective, if you like, how would that be achieved?

I think on a patient-by-patient basis, it probably doesn't happen, in the main. We publish—as Gareth said, at the entrance of the ward usually, but it may vary—the number of staff that the funded nursing establishment is, and the actual, but that in itself could cause concern, because, actually, you could have people on duty that are fewer than what the nurse roster should be; however, given the acuity at the time, that may be perfectly reasonable and would not have a detriment to the care that's being delivered to those patients at that time.

So, I think we do need to do a little bit of work there. I don't think we explain to patients routinely. I think our staff are very good, in the event of us having shortages of staff on a shift that we cannot cover or having temporary staff, that we do explain to patients at that point, and relatives, in relation to what the situation is, what we've tried to do to mitigate it and what the consequence of that is, but that—

11:20

Just in terms of the work that you're doing, are we over-complicating it in saying—? It could just be a simple case of saying, 'Look, we're understaffed today', and saying it in an informal way. Can that necessarily be frameworked or legislated for, or are we just over-egging the omelette in that sense then?

My personal view is that open and transparent communication with the public is really important, but that needs to be in a way in which it's understandable to all. And I think, as Gareth says, there is further work to do. But my personal view is that I want to do that in a way that I share with patients all of what we understand to be the quality of the care environment in a way that is really, really transparent. And I think there is an opportunity for us to be doing more of that in Wales in terms of how we do that collaboratively, so that it doesn't matter which hospital you go to in Wales, actually, you are really clear, if you're a patient on a ward, about what it means. And how we do that is going to be incredibly important. But I'll come back again—and I might be a little bit like a broken record again—digitally how we can make that easy for our staff, how we can create an opportunity to have that single version of the truth, is really important.

Can I just ask some questions now around the non-25B elements as well? So, is there sufficient clarity or guidance about the implementation of 25A, do you think?

In respect of 25A, I think this is probably an area where there may be some variation across organisations in relation to what reporting actually takes place. So, within Velindre, we're a much smaller organisation, I do an establishment review across all of my areas where I deploy nurses and those are my 25B and 25A areas. There isn't a great deal of detail around that, but I use exactly the same methodology as I do for the 25B ward for those other areas, and that's really useful because what that does pick up is where you may have areas such as headroom. So, headroom is one of the positive features of the Act that's ensuring that we've got time for annual leave, study leave and sick leave built into rosters—that you're not having a shortage every time such events occur. But that is not equitable across all areas in all organisations where nurses may be deployed. So, for myself, I've been able to use the 25A part of the Act to have those discussions at an executive and a board level within my organisation, but there is a variation in the detail, yes.

If I think of Swansea bay, we do deep-dives into those areas that are not covered by the Act and that's taken via our workforce and organisational development committee and ultimately on to board. So, we would do a deep-dive into mental health nursing, we would do a deep-dive into maternity, into A&E and the like there. So, while we haven't got the same sort of legislative reporting mechanism around those areas not covered by the Act, we do give them a heck of a lot of scrutiny, because, again, they're challenged areas, and, if I think about emergency care areas, our intensive therapy units, our paediatric ITUs—all the areas where we have people who are unwell, which is probably everywhere at the moment—we have to maintain that focus there. And it's a worry, really, in as much as, if we just concentrate on the Act and concentrate on those areas, then that probably covers just over a third of my organisation. So, we've got lots of areas where people are being cared for that don't come under the Act, which we have to scrutinise, have to oversee and have to report upon in terms of safety and outcomes for our patients.

Could I just add?

Because I'm in a very similar place to Gareth in terms of that we have a nursing workforce group that meets regularly that considers all areas of nursing work where our nursing workforce is deployed. I think there's an opportunity with 25A and I think the opportunity, again, comes to what I'll call the team around the patient—how we work in that multiprofessional way to meet the needs of patients and our citizens in our care settings.

I think the other area where I think we could bring greater clarity is our commissioned services—so, an understanding of the services we commission as well as those services we provide.

11:25

Okay. Thank you. We've had some evidence provided to us ahead of the session today that highlights that some areas, including critical care and emergency units, are not currently covered by section 25B. Do you have any concerns about some wards or some settings potentially being left behind? I wonder if you could expand on that view at all.

From my perspective, they aren't left behind in my organisation. We have focus on those areas and our community settings, which, as Gareth said, are the areas where sometimes we have the greatest concern because we don't have line of sight necessarily to those areas every minute of every day. But, from my perspective, it is very much inclusive of our areas that aren't covered by 25B.

It was Cardiff and Vale that highlighted that in their response to us. But that's not an observation in your organisation.

If you think about ITU, there are national ITU staffing guidelines. If you think of district nursing, there's quite a bit of information out there about what safe staffing looks like. If you look at maternity, we've got Birthrate Plus, which again is a framework within which we should staff. So, while we haven't got the legal wraparound of the Act in these areas, there's a heck of a lot of information out there that enables us to see what safe staffing looks like in these areas that's evidenced as well. As, I'm sure, with everyone, we use those types of frameworks and that type of information to then set what we need moving forward in terms of safety of our services.

Okay. That's fine. Mabon ap Gwynfor for the last section in today's session.

Diolch yn fawr, Gadeirydd. Mae'r dystiolaeth rydych chi wedi ei rhoi yn ysgrifenedig a'r hyn rydych chi wedi ei roi ar lafar fan hyn yn dangos cefnogaeth glir i'r ddeddfwriaeth. Rydych chi'n meddwl ei bod wedi gwneud gwahaniaeth cadarnhaol, yn ôl tôn a chynnwys yr hyn rydych chi wedi ei ddweud. Fel man cychwyn, gaf i ofyn a ydych chi'n meddwl bod y ddeddfwriaeth wedi eich dal chi yn ôl mewn unrhyw ffordd neu wedi eich atal chi rhag gwneud rhywbeth o ran nyrsio neu ar wardiau? Oes yna elfen negyddol iddi hi?

Thank you, Chair. The evidence that you've given in written form and also orally this morning shows clear support for the Act. You think it's made a positive difference, according to the tone and content of what you say. As a starting point, could I ask, do you think that this legislation has held you back in any way or prevented you from doing something within nursing or on wards? Is there any kind of negative aspect to this legislation? 

Shall I make a start?

Okay. I don't think it's held—. Well, from a personal perspective, in my various roles since the Act has come into force, I don't think it's held us back; I think it's had a significantly positive impact, as we've already outlined. I think the area that is at risk, going forward, is that multiprofessional area. I think it is professionally siloed, and of course nursing is really, really important and will always be important in that patient's care journey, but we have to think broader than nursing in relation to the care that our patients require. So, I think the designated professional currently is the nurse executive, and that's right and proper, but should we expand, particularly using 25A, we would need to look at that covering the directors of therapies and others as well. So, personally, I don't think it has, but I think we now need to look at this very differently and it needs to be a multiprofessional model, and therefore the Act as it is may make that difficult. I'm sure my colleagues will wish to add—.

I would support completely what Nicola has said. I think that the Act has had an extremely positive impact, certainly on the outcomes for nursing and also for the quality of care. I think, as I said earlier, the evidence is the population of Wales is changing, the needs of the population of Wales are changing, and therefore what we need moving forward, really, is to focus on how we have a rounded approach to multiprofessional care and support for nursing from those alternative roles that we know will release registered nurses to do the job that's intended through their licence and their registration. So, creating the opportunity for us to have the team around the patient, to make sure that we're meeting the needs of the patient with the right professional or the right alternative non-registered role to support that registered nurse in her duties and responsibilities.

11:30

Wel, mae yna ddau beth yn codi. Yr hyn ddaru Jennifer ei ddweud yn fanna o ran datblygu'r tîm o amgylch y claf ac yn y blaen, sut mae gwneud hynny, felly? A oes angen cryfhau'r Ddeddf, ynteu ai rhywbeth y tu allan i'r Ddeddf ydy hynny?

Well, there are two matters that arise. What Jennifer said there in terms of developing the team around the patient, how do you do that, therefore? Do we need to strengthen the Act, or is it something outwith the Act that's relevant to that?

I think it can be done within the Act. It wouldn't be for me to advise how that's done, but I think there are opportunities to review elements of the Act to ensure that we keep the integrity of what has been positive and good with the Act. We respond to the needs of patients, so I think very much that it can be done within the Act. There would need to be clear lines of sight from a professional accountability perspective, as Nicola has said, but we need to think about how we meet the needs of the population, and actually how we meet the needs of our workforce moving forward, because again the young people coming through the system want different careers. They don't necessarily want to do the same role for the whole of their career, and we should provide those opportunities for them. We've had, as I said, some success with working very differently with our patient population, looking at different roles and opportunities.

For me, I don't think this is at the expense of nursing. If I use the example, you know—. We have to look at multiprofessional workforce planning would be my view. We have to really be clear about how many therapists and the like we need to support our wards and our in-patient areas. But I've got wards where I know I've got a full establishment, but if I haven't got an occupational therapist, I can't discharge anyone. So, the skills that they bring to the patient pathway are really important, and I think we don't operate as uniprofessional staffing groups within clinical areas; we act as a team, from our medics, our physios, our nurses, our unregistered staff, and the like, there. So, it's how we really bring all that together, and we do it informally in many ways, but I think if we're at a juncture where we're reviewing where we are, looking at what our services need moving forward, that isn't just about nursing but can support nursing, would be where I would be at.

I can see Joyce wants to come in. Do you have any other final questions, Mabon?

Yn sydyn iawn. Rydych chi wedi cyffwrdd â hyn, ond un o'r pethau cyntaf ddaru Gareth ei ddweud oedd ein bod ni ar groesffordd ar hyn o bryd, a 'Lle ydyn ni'n mynd nesaf?' oedd y cwestiwn ddaru Gareth ofyn reit ar gychwyn ei gyfraniad. A dyna'r cwestiwn roeddwn i am ei luchio nôl atoch chi'ch tri, felly. Rydych chi wedi rhoi ambell i syniad, ond lle ydyn ni'n mynd nesaf efo'r ddeddfwriaeth yma, felly? Rydych chi wedi cyflwyno ambell i syniad ac wedi dangos lle mae'n bosib i'w chryfhau hi, ond oes gennych chi unrhyw syniadau pellach ar sut rydyn ni'n edrych i gryfhau'r Ddeddf neu newid elfennau ohoni er mwyn ei gwneud hi'n haws i gael y multiprofessionals yna yn rhan o'r prosesau nyrsio?

Very quickly. You've touched on this already, but one of the first things that Gareth said was that we're at a crossroads at present, and 'Where do we go next?' is the question that Gareth asked at the start of his contribution. And that's the question I wanted to throw back to you three, then. You've given us some ideas, but where do we go next with this legislation? You've presented some ideas and shown where it's possible to strengthen it, but do you have any further ideas on how we should look to strengthen the Act or to change elements of it in order to make it easier to get those multiprofessionals part of the nursing process?

Just while you're thinking of that response, Joyce, did you want to come in with your question, and then I can ask you all to—

Well, this follows on, and it links a few things—the digitalisation of healthcare. But the care of the patient beyond the hospital setting isn't covered here. You highlighted stroke particularly, and the demographic that's changing. So, in terms of the staffing level in the ward, which is right and proper, there's also the need for the staffing levels in the community, and you've both mentioned it in different ways. How could we look at that in terms of improving the patient outcome for those groups that we know are going to be of major critical need, now and in the very near future? It's the very near future.

Okay. There are two quite big questions there, but we're over time, unfortunately. I wonder if I could ask each of you to make some final comments, taking into account Mabon's question and Joyce's question as well. Who would like to go first?

If it's a reflection of where we are, I think, for me, I welcome the Act and we've worked really hard to make sure it's embedded and recognised the impact on patient care as a positive there. I still think there's a focus—and linking into Mabon's question—about what multiprofessional workforce planning looks like moving forward, but not just the planning, but about how we operate within that. In our community areas, we have virtual wards. We have a structure whereby we have that cohesive, multiprofessional working process, so there are ways to do this moving forward.

But I think we've got to look back to move forward. I think it's the opportunity to review where we've been, scope where we've been, and really take a fresh look at what services should look like moving forward. We need to take stock and review its impact, and not lose the true essence of it, but build on what we've got, to ensure we've got that sort of multiprofessional approach moving forward. 

11:35

Focusing on the looking back really would—. We haven't done a formal evaluation of the Act. And we don't want to take years to do that, but I really feel it's important for us to look back and do a formal evaluation of the Act. That will help us with that question about what is next, therefore, and how we may best develop the Act further to address that multiprofessional approach, and make sure that it's broadened into areas such as community, which we all know are so very important for patients and the population going forward.

The other area where I think the Act could be looked at and be strengthened is the enablers. So, it's not just about numbers. That is really important. We've had a huge discussion on digital today, but I think there are other enablers, and environment and cultural things, that we also need to look at, rather than just the numbers.

I will try and keep it succinct so as not to repeat what my colleagues have said. I think there is an opportunity to evaluate the Act, as Nicola has said, to focus on how we can use the learning from the Act to marry that with the needs of the population moving forward, the workforce planning, to make sure that we can meet those needs, and being very clear about the distinct contribution of nursing, from a whole-system perspective. So, when I talk around nursing, I talk in care homes, I talk in primary care, I talk in hospitals, how across the breadth do we have the right nursing workforce, complemented and working multiprofessionally with a number of roles and areas of work, but also how we take that into the prevention space. I'm a health visitor as well by background. We haven't talked about health visiting, but the opportunity that exists for our children and young people by focusing on the prevention aspect of the value that nurses can bring to that, I think is going to be absolutely pivotal. 

Thank you. And, for the record, Gareth said he agrees, so—

Did you? [Laughter.]

I do agree, yes. [Laughter.]

Well, I should ask: is there anything any of you have just said where you don't agree with each other? I don't think there was; I think you were all nodding away. So, thank you; that's really helpful and clear. So, thank you so much for your time today. It's been really, really helpful to us as we undertake our inquiry. And we'll send you a transcript of what's been said this morning, and if you think there's anything you want to add to what you've said, then, by all means, come back to us at any point as well. But, diolch yn fawr iawn. Thank you very much for being with us today. 

Thank you. 

Thank you. 

We'll take a small break, just so we can change the panel over for our next session. So, we'll be back in about six or seven minutes. 

Gohiriwyd y cyfarfod rhwng 11:38 ac 11:48.

The meeting adjourned between 11:38 and 11:48.

11:45
4. Deddf Lefelau Staff Nyrsio (Cymru) 2016: craffu ar ôl deddfu: sesiwn dystiolaeth gyda Rhaglen Staff Nyrsio Cymru Gyfan
4. Nurse Staffing Levels (Wales) Act 2016: post-legislative scrutiny: evidence session with the All Wales Nurse Staffing Programme

Welcome back to the Health and Social Care Committee. I move to our fourth item today with regard to our inquiry into the Nurse Staffing Levels (Wales) Act 2016 post-legislative scrutiny. This session is with regard to a session with the all-Wales nurse staffing programme. So, thank you ever so much for being with us this morning. I appreciate your time, and I wonder if you could just introduce yourselves, just for the public record.

Hello, my name is Joanna Doyle. I'm associate director and head of the all-Wales nurse staffing programme in Health Education and Improvement Wales.

Bore da. Good morning. My name is Ruth Walker. I'm currently the associate director for nursing and midwifery leadership at HEIW, but I'm here today as a previous chair of the all-Wales working group, prior to my retirement from the role of executive nurse director in Cardiff and the Vale in May 2022.

Bore da, pawb. My name is Lisa Llewelyn. I'm the director of nurse and health professional education at Health Education Improvement Wales. I'm here today, actually, because, obviously, we oversee the programme, and also this is about how we actually take this forward.

11:50