National Assembly for Wales

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.

Thank you, Joyce Watson.

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?

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—

I won't go into it too much—

Oh, sorry.

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. 

Thank you. Mabon ap Gwynfor.

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.

[Inaudible.]—back in on this? [Inaudible.]

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.

Mabon.

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.

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. 

Mabon.

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.

Yes, absolutely. Absolutely, yes.

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.

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.

No, we haven't.

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—.

No, but add.

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.

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?

Okay. Thank you, Lisa.

Okay. Am I going on?

Yes, please.

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.

Okay. Yes, fine.

Sorry to interrupt, Helen.

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. 

Okay.

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.

Thank you.

Thank you. Gareth Davies. Last section, I think.

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. 

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.

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?

Yes.

How do we know that?

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.

Is it really? Okay.

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.

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.

Okay, thank you. Joyce, you wanted to come in.

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.

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.

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.

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.

Thank you.

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. 

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.

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. 

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. 

Would you like to address that, Nicola?

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.

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.

What are your views?

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.

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.

Anything further to add, anybody? 

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.

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.

Are all of you agreed, yes?

Absolutely.

Yes, absolutely.

There we are. Thank you. Gareth Davies.

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.

Could I just add—?

Yes, absolutely, yes.

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.

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.

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—

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?

Who wants to come in last on this point?

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.

Okay.

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?

Yes, certainly.

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.

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.

Shall I make a start?

Yes, please. Thank you, Nicola.

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.

Mabon, do you want to come back in?

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?

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. 

Thank you, Gareth. And Nicola.

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.

Okay. Thank you. And Jennifer.

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. 

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.

Thank you.

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.

Lovely. Well, thank you for being with us. Perhaps the first question is to give us a bit of background about the establishment of the all-Wales nurse staffing programme, perhaps tell us about its role, the description of its role in supporting the implementation of the nurse staffing levels Act.

So, if I start, and you two can come in. So, in 2012 the chief nursing officer issued some guidance in relation to a set of principles for staffing across Wales. It became clear as part of that work that there was a requirement to have an all-Wales nurse staffing group, run by a particular programme of work. That programme of work evolved, with the implementation of the Act in 2016, although quite a considerable amount of work had already commenced prior to that. So, the role of the all-Wales nurse staffing group was to pull together the programme of work in order to be able to implement the Act, but to set up steering groups that were involving staff that were on the ground, that actually were part of the particular area that we were focusing on—so acute medical wards or surgical wards or paediatrics—and actually to work alongside them to design, to test and retest, because a lot of that went on, to educate and to implement the recommendations. Once we were clear about what they were, they were then—. As chair of that group, I would report into the all-Wales nurse directors group, the executive nurse directors group, where the final sign-off would be in relation to the recommendations of how the Act could be implemented. That was taken back to each organisation and discussed in details as part of a consultation process before formal sign-off. So, those were the governance arrangements. Jo, did you want to add to that?

As part of that work, we also set up three developmental work streams. So, we started off with five—adult acute medical and surgical, paediatrics, health visiting, district nursing and mental health—and we worked across the organisations, engaging with many stakeholders, to put together a programme of work under a once-for-Wales approach that enabled us to develop a range of evidence-based workforce planning tools for those areas of speciality.

And has the programme been paused at all, or is it paused now?

Lisa, do you want to take this?

I ask the question because the Royal College of Nursing, in their paper, noted that the programme had been paused.

The programme has not been paused. I can honestly say the all-Wales nurse staffing group is continuing, actually, to function. What's happened is that it has actually gone into a transition phase of reviewing where we were. There came a point, actually, whereby many of the work streams were being implemented. And it was, in a way, actually, a time for reflection of what we were learning and how we could take that forward, going into the next stage. And that is a piece of work that we're doing now, recognising the multiprofessional aspects that we need to consider as well. So, the programme is not paused.

Right. Okay. Thank you for that clarity. Great. Okay, I'll come to Sarah Murphy to ask her set of questions.

Thank you very much, and thank you very much for being here today as well. I'm sorry, Chair, I'm just trying to find the next section of questions.

No problem at all. Are you all okay? Yes.

Right. So, I'm going to ask some questions now about the programme work streams. So, each work stream is working towards developing and testing an evidence-based workforce planning tool specific to their area. Could you provide an update on progress in each of the different work streams, but we're particularly looking at mental health in-patient, health visiting and district nursing? Thank you.

Up to 2022 we had implemented acute medical surgical and paediatrics, and we'd undertaken the testing in mental health, health visiting and district nursing. So, I'll hand over to Lisa to update you on where we are with those.

So, in relation to mental health, district nursing and health visiting, as we indicated previously, those work streams actually continued and developed those particular tools. It was as a result of that that there was a decision made to review where we were with those. But, nevertheless, the vast amount of work and the engagement in developing those tools was something that we didn't actually want to lose. And as a result of that, working with some of the existing national professional groups that we have in Wales, which is an asset, we've actually then worked with them and, in a way, asked them to continue to take that work forward within their health boards as well. And, of course, one of the key elements that we've been very fortunate to have is that Welsh Government did invest in having all-Wales nurse staffing leads being employed in each organisation as well. So, the all-Wales nurse staffing group is continuing, but those national groups are now feeding in on how they are progressing and implementing those tools within that health board arena, and that continues today.

Thank you. Does that mean that it's still the intention to extend the Act to these settings?

That is something that, obviously, Welsh Government is considering.

Thank you very much.

What would—

Okay. And—

I was going to say, Sarah—what would be your view on that?

My view would be the work has already commenced. The staff have been amazing in their contribution that they have given to establishing the work. They have done some of the testing. I think that can continue. I do think that it is necessary, particularly post pandemic, to consider the work that we have already done and whether that is still fit for purpose. So, in health visiting and district nursing, it may very well be, in the sense of it's quite unique around those particular professions. But in areas such as mental health in-patient areas, we've seen a significant change, a change in demand, but also, one of the pieces of work that came out of that initial work around mental health was that, actually, this is quite difficult to do. Because, as a group, we work very closely with our multidisciplinary colleagues, and therefore deciding which bit of the job is for nursing only, and which bit may be for a psychologist, for example, isn't quite as easy. And that's why the testing is so very important, and revisiting that post pandemic, in mental health particularly. Jo, I don't know if you wanted to add to that.

As so much work has already gone on, I think it's important that we keep that momentum going. There is still a lot of work to be done around testing the tools and finding the informatics systems and digital solutions we need in order to enable health boards and staff within them to be able to collect the data, extract it, analyse it, and use it to inform day-to-day deployment of nursing staff, as well as workforce planning. I think there's no shortage of commitment and enthusiasm to continue the work, and we've done so much that I think people feel that it has great value, and we're already seeing that being embedded day-to-day within teams across health boards.

Thank you. Sarah.

Thank you. We’ve received some evidence as well that describes a loss of central control in respect of the work streams, resulting in different-paced approaches across Wales, depending on each health board's priorities. From the research, though, from the evidence that we've received, obviously I think that it has been raised that there are pros and cons to this, because you do want it to be able to be localised, whilst also having that broad, all-Wales approach. So, what are your thoughts on this, please?

So, I think this comes down to, and if you look at those particular work streams—they were there to do those dedicated pieces of work, and as Jo has described, that work was commendable and is being taken forward. I think you're absolutely right, in that each area does need to consider that in a different way. And obviously, the 10 years plus plan that's recently been published really describes how our population health needs are changing. And if you are going to apply those in a different setting, you do need to identify what those population health needs are. You then design your services to meet those particular needs. But also what we heard was the importance of preventative health. So, our population is changing, the demographics of our population are changing, they're living longer, there's more morbidity, so our needs are changing in terms of how we deliver services going forward as well. So, these need to be taken into account, and that can only be done on a local level. So, it's important to take the good standards and the ideas that we've developed and help them to be implemented and applied into health board populations.

Thank you.

Thank you very much. And just my last question—

Hold on, Sarah. Oh, you go ahead, Sarah; I'll bring Ruth in after. Go ahead, Sarah.

Okay. Just to tag it on, really, as we're limited on time, but just also an insight into what lessons were learnt from the process of extending section 25B to paediatric in-patient wards as well would be extremely helpful. Thank you.

There we are. Did you want to address both, Ruth? 

I'll try and address both, yes. I think Lisa's absolutely right. We know that the governance arrangements and the way in which we ran the programme were very productive, and actually delivered the programme as we'd been asked to do. I think understanding what the design of the workforce around the patient is going to look like locally can feed into what it might look like nationally. And what we know is that having a national approach to how we implement this to allow us to have digital solutions, to allow us to have a national reporting arrangement, to have that level of transparency and ownership and accountability at board level, as well as feeding into the accountability that comes nationally from Welsh Government, I think is going to be very important. So, it feels to me as if a hybrid of where we've been before and what the future might look like would give us that opportunity. 

In relation to paediatrics, without any doubt, the needs of children were changing pre pandemic; the needs of children have changed significantly post pandemic. So, we would have seen in a hospital setting typically children that were acutely ill with physical health conditions, or chronic long-term conditions. We weren't necessarily seeing children with those conditions plus longer mental health conditions. And now we're often seeing young children with mental health needs, who are in a crisis and require admission, are often having to be admitted into an acute paediatric setting. So, actually, the tools have assisted us in understanding how that change is required to ensure we've got the right care for those patients. It's also helped us understand what are the needs for education and training, and how those teams might pull on or work with colleagues in the NHS that they haven't worked with before. So, that was an unintended consequence, but it was a positive unintended consequence in relation to paediatrics.   

Thank you. 

Thank you very much. Thank you, Chair. 

Thank you. Mabon ap Gwynfor. 

I'll start and then bring colleagues in. So, 25B is very clear in relation to what is required, because we have the triangulated methodology. And the key to that triangulated methodology was designing an acuity tool that was specific for a medical surgical ward or a paediatric ward, and then being able to test that acuity tool. It doesn't take away the professional judgment or the measurement of the outcomes. They would be the same in all clinical areas. As you heard from the executive nurse directors who gave evidence previously, there is a requirement of the Act to report biannually to the board, and therefore the executive nurse directors would be reporting on the professional judgment and outcomes in those areas where 25A applies. So, that applies to all other areas where you have deployed nursing staff. So, it gives an opportunity for the executive nurse directors to advise their boards, as the designated professionals, of what the establishment should be in all of those clinical areas. What they don't have is the work that's been undertaken to design an acuity tool. 

Now, you heard them talk a little bit about the fact that there are standards in places like A&E, critical care, that are set nationally—and, in some cases, internationally—around the ratios of nurses to patients. Those were some of the evidence base that was provided to assist those executive nurse directors to provide the 25A assurance to their board, or not to provide it when it wasn't there and they didn't feel that, actually, the funding—the financial allocation—was there to give the establishments that were required. Because, remember, executive nurse directors have to work very closely with their finance directors and their workforce directors to provide the board with assurance that the establishments are set, but, actually, the money and the workforce is aligned to that to be able to deliver the care that is required for our patients. Jo, did you want to add anything to that? 

No, nothing to add. Thank you. 

I think it also—

Go ahead, Lisa. 

I think it also adds to that as well in terms of recognising—. Ruth has described to you the critical care standards. We've also got standards at midwifery practice, so there are—. It's not as if those 25B wards are the only wards that we look at in terms of standards. Actually, Health Education and Improvement Wales did a key piece of work following the pandemic into critical care, and it looked at the opportunities for all those other professionals who actually contribute to the care of that patient in that arena—how could we utilise their skills and their expertise in the most efficient and productive way. And that's where we actually suggested, not actually dictated, but actually sort of transformation opportunities whereby—. And I'm talking about pharmacists, I'm talking about others actually taking that patient from the critical care arena onto the other wards as well. It explored what the skill sets were of all those individuals, including healthcare scientists, who came onto a critical care unit—much-needed, actually, expertise, but was that sufficient and could we do it better?

So, I think what you've got at junior wards currently is they are looking at the skill sets of all the other professionals and how we all work together to deliver that care for that particular patient. It might vary in different settings, and actually, if you look at the child agenda, really there's a lot of preventative work that we need to do in that relation as well. So, the whole model of the workforce is changing because of the demography of our population and their health needs.

Thank you. I'll just check: no further questions, Mabon? No. Joyce Watson. [Interruption.] Thank you, Mabon. Joyce Watson. 

I'm going on to look at the triangulated approach that you've all been alluding to, and it has applied to paediatric wards now for two years—adult and acute medical surgical wards for over five years—so we’ve got an understanding. In your view, is there evidence of the effectiveness of that approach to calculating the nurse staffing levels for those settings, including reference to each of those elements of a triangulated approach workforce planning tool? Because that was obviously what it was designed to do. 

I think it has. We've got a huge data set of evidence, probably some of the biggest in the UK, if not wider than that. Unfortunately, that data doesn’t talk to the roster, doesn’t talk to the patient record. I think if we had a system where these did talk to one another, I would be able to sit here today and provide you with the evidence that, actually, these do correlate. At the moment, it’s very, very difficult to do that, and I think that’s very unfortunate. It would be really helpful, I think, to undertake some research in this area, but also to look at the digital systems and how they connect.

It's really important also because every nurse will assess the patient when they come in contact with them. They’ll make a record of that. If that record is electronic, and it allows them to assess the acuity of the patient at the same time, which then goes into the rostering system, and then measures outcomes for that particular patient when they come to be discharged, or during their care, you have one system that allows that nurse to understand where she is with her patient, and that patient to understand, because they can have the conversation; the sister charge nurse, the senior nurse, right up to the executive nurse director who can look across a large area by having a digital system that talks to one another. But it can bring attention when there’s concern and it can also allow praise when things are going really well, and people can learn from areas that are going really well. So, I think we believe there is, but I don’t think we’ve got the evidence.

I think some of the really positive evidence that we have got is the level of engagement of front-line staff to the board, where they can actually articulate, ‘This is what I require, this is what I need, and this is what a difference it will make.’ I think we cannot underestimate how powerful that has been. Often, when I talk to nurses at the front line, they talk about, ‘We know we don’t have as many nurses as we need, but actually being able to have a system that reports that makes us feel more valid and actually gives us hope that our workforces will be more informed as we go forward and we start to really, really look at the number of nurses that we require.’

So, I think those are some of the positive unintended consequences of what we do, but to give real evidence we have to do that research, and we have to have systems that talk to one another.

I'd extend that, actually. We need to make that available to our other multiprofessional colleagues as well, because the opportunity is there, because I actually oversee other health professionals as well, and they want to actually see and input into the same system so that we are not having different systems with different professions inputting into them in a different arena. It's about actually that patient care record and the system to keep that patient safe as well. So, there is real opportunity, but I agree with Ruth, we need to do the evaluation, and there's an opportunity to take this forward.

Joanna, you had your—

I was just going to mention how beneficial the triangulated approach has been and how well received it's been by our operational teams. We acknowledge that all our patients are different, they all have different needs, and being able to use a national tool that's been co-produced and tested by thousands of front-line nursing teams to prove how patients' needs differ and change over time, and being able to evidence and articulate that, gives us such a wide range of data, which my colleagues have referred to, that gives that real value to why we need to change our staffing levels or our skill mix or bring in additional colleagues, because we now have more granular detail around the staffing, the patient's needs, based on the use of this tool. And also I think the professional judgment section of the triangle is incredibly powerful, because a nurse's professional judgment is very important; we use it day in, day out to keep our patients safe and to make informed decisions, and I think recognising that that's an important element when calculating the nurse staffing level and all those factors that need to be taken into account helps to give weight and credibility to the decisions we make about what the staffing level should be on those wards.

I think the other interesting point is that we are now at a place where we've done this so often, our front-line staff, that actually they can measure the acuity of a patient exactly the same in any part of Wales, which wasn't the case when we began. So, the testing bit was really important, because what we found was, if you were used to seeing very sick children, you would often mark their acuity at a lesser level than if you were in a different part of Wales, where you saw less acutely ill. What we've learnt as we've tested the tool over and over again and people have worked together and moved around in Wales and tested it in different places on behalf of one another, is that, actually, we've got consistency. So, it's not just about professional judgment and the measurement of acuity, it's about how there's consistency in that, which, again, is really important in the context of a piece of research.

And can't be underestimated.

No.

That's really good news. We keep coming back to this digitalisation that needs to happen, so we'll obviously explore that further, but we've also had people who gave evidence question whether the quality indicators and the reporting arrangements are both robust enough to demonstrate the link between—because this is a nurse staffing level piece of legislation—and patient outcome. What are your views on those?

I think there was an evidence base to choose those, and, actually, there was a system in place that we could measure those, and they were the drivers to why we chose those. I think it is absolutely fair to say that the world has moved on; we now have the duty of quality, the duty of candour. The type of investigations we undertake now, for example, in pressure damage, where there's an evaluation based on the risk assessment, are actually multifactorial, and have begun, from the learning from that, to identify that, actually, we might measure pressure damage in a ward area, but it may have occurred in an accident and emergency department or in the back of an ambulance, where somebody has waited for longer than they should have. So, I think they are tools that are very helpful to measuring patient outcome; they don't always measure patient outcome in that particular clinical area, and they don't always take into consideration that it is not just nursing care that will have had an impact in relation to that outcome for the patient. So, I think this is an area where we need to do more work, and we also need to recognise that what is important in an acute medical and surgical ward will be very different in mental health, district nursing or health visiting. So, the outcome measures will be very different in those areas, and, as the Act evolves, then they will be different in the other areas that we move into. So, I think it's helpful as we are at the moment, but there's more work to be done. I don't know what my colleagues think.

I think the duty of quality, actually, is the key, and, therefore, this being implemented across the whole of Wales is obviously really embedding it right across the system. So, it doesn't matter whether we are talking about those 25B wards or any other particular arena, basically, those quality outcomes and those domains are something that we implemented right across the board. And as a result of doing that, the most important aspect out of that is what the lessons are to be learned. Once again, it could be in a different setting. Ruth is absolutely right that when it comes to a pressure ulcer, that pressure ulcer could have started in a care home, and, therefore, how can you actually then say it was the nurse staffing Act that did or didn't actually create harm. That's where we need to see the patient journey, rather than actually one focused arena where we're actually measuring that. It's really important to take that. And that does happen, actually, when we look at things like incident reporting; you do look at the breadth of that patient journey. So we've now got the duty of quality, we're going to apply those standards right across Wales, which is really welcomed, and as a result of that I'm sure that will enhance the quality of care being delivered to our patients, definitely. 

I'd just like to say that this whole process has been iterative. We're very proud to be the first country in the UK to legislate on nurse staffing levels. This is groundbreaking work. And one of the really important things is that throughout the process of preparing for and, now, implementing the Act, we have learnt along the way. We have learnt lessons, we have learnt from experience and we have used those in terms of how we then move forward with developing those tools and learning the lessons—good, bad and indifferent—from our journey. But one of the things we have done in terms of the reporting metrics is that off the first three-yearly report that was presented to the Welsh Government, we've reviewed those reports and we've worked collectively. We've set up a group that has representatives from across NHS Wales and looked at those reports and how we can refine and develop the reporting metrics. So, we have now revised the reporting metrics in line with the duty of candour to include level 3 incidents of moderate harm, and we'll be looking to implement those new reporting metrics, which have now been agreed by the executive nurse directors for Wales and the chief nursing officer, from April 2024. So, in the next reporting cycle we will have a lot more data with a more granular level to be able to look at the impact it's had on nurse staffing levels.  

So, it's put a focus on where that focus might not have been before. 

Yes. 

Okay. Thank you. 

Thank you. Gareth Davies. 

Thank you very much, Chair, and good afternoon, everybody. I would like to focus on working with others, if I may, and how the programme has gone about engaging with stakeholders, including front-line staff, patients and the public, and keeping them informed about the programme and its work streams' progress.

I'm very proud to say that we have worked collaboratively and incredibly hard with a wide range of stakeholders. And the best part of my job has been going out, meeting and working with very passionate, committed front-line nursing teams to be able to develop the national workforce planning tools that we're very proud to call ours here in Wales. We've done a lot of stakeholder engagement. We have a website where we share information about the great work that we've done. We've also held two highly successful large national conferences, which were attended by colleagues from across the UK. So, we're doing everything we can to raise the profile not just of this exciting legislation, but also the great work that's been undertaken by a wide number of colleagues.

I think the fact that we have such commitment from front-line nursing teams at such a busy and pressured time with the services is testament to the fact that people welcome the legislation. It's certainly raised the profile of nursing. But, also, also nurses welcome the opportunity to be involved and co-produce these national tools that mean something to them, that support them in their practice and help evidence the need for the staffing levels that they require, but also can evidence where improvements can be made, and I think that's a very positive move. So, I would like to take the opportunity to thank all those staff who've helped us make the programme as successful as it's been, because without their commitment and ongoing support it would have been very difficult to complete this piece of work with the key achievements that we've already achieved. 

Thank you. In terms of how that message is tailored to different stakeholders, whether that be the public, patients or staff, is there different messaging to get that across? Because I can only assume that the messaging would be different to professionals than what it would be to patients and the public. How is that message tailored across those different stakeholders?

Ruth, do you want to come in?

Yes, it is. And just before I answer that, I wanted to just expand the stakeholders a little bit, because the Royal College of Nursing has been very significant in relation to stakeholders. They have really challenged us as part of this process and we have welcomed that. It's not been easy at times, trying to work through how we're going to implement the Act.

So, yes, I agree with Jo completely, our front-line staff have been fantastic and we need to thank them. The CNO's office has made a huge contribution in helping us navigate through the legislation and giving us that advice about how some of this works in Government. But also, the engagement with the public and the community health councils, as was, Llais as it is now, has been really important in helping us understand, and when they do their inspections understand, what the public might be looking for. So, the ability to share with the public what staffing should be and share with the public what staffing actually is, where we positioned that in a clinical area was really important. We were advised that, actually, we needed to do that where the nursing staff were, because if you were a patient in a bed and saw that you should have seven staff on duty and actually there were only four or five, then actually, that could be quite worrying. So, ensuring that we had staff near who could actually articulate what the difference was and what that meant to them was really helpful to us.

So, there's been stakeholder engagement, stakeholder advice and stakeholder direction, all of which we've welcomed a great deal. In fact, it helped us design a tool to give to patients so that, actually, they understand the nurse staffing Act a little bit more. As my executive nurse director colleagues alluded to, there's probably much more work to do there on how we inspect and check our wards internally in organisations, but also for external bodies, I think. That would be quite helpful in reinforcing the Act.

Yes, that certainly seems to be a common theme coming across during our evidence this morning, as I've asked a similar question to our previous two panels over a similar thing. Just finally, I want to focus on ICT and how the programme is working with Digital Health and Care Wales to ensure that the appropriate ICT solutions are in place to support health boards to meet their duties under the Act.

This is quite challenging, but I'm going to ask Jo to talk about some of the detail.

Thank you. As we've mentioned, prior to the Act coming into force, we didn't have a really robust national IT infrastructure in place, and this has impacted on the health boards' ability to be able to capture all the information that they need to be able to demonstrate their position in relation to the reporting requirements of the Act. However, we were sighted on this and have worked really hard with our partners and colleagues across Digital Health and Care Wales and the private sector to identify ways though which we can inform and enhance a national informatics system to be able to enable health boards to collect, analyse and utilise the data that we collect, day in, day out.

We have managed to put this system in place. I can confirm that I've had assurance that it's implemented across all section 25B wards within all of the health boards, and it's working very effectively. We recognise that there are still some developments that we need to take forward and we also need to look at ways in which we can have a similar robust system for other areas, such as health visiting, district nursing and mental health. Some of those are already in train and are in place, but they do need some refinement.

We are continuing to work with Digital Health and Care Wales and our partners to explore all possible options to improve data analytical support, digital solutions and informatics systems and processes. We've made significant progress, but there still is some work to do.

I'd just like to add there that we need to remember as well that DHCW did not exist when the Act was introduced. So, that's something where it is, as Jo describes, the ongoing development of this. And this is exactly what we're looking at now in terms of reviewing where we are and what we need to do to take this forward. We're actually quite encouraged, because as part of the all-Wales—. You asked the question, 'Is the all-Wales nurse staffing group still continuing?' Yes, it is, and DHCW is a key member on that particular group. But we recognise the other systems and it is about how we get the outcomes from all that data to say what it is that we're looking at and what's the good out of that, as well. But we need to remember it's been an evolving journey, and DHCW was not born then.

Thank you very much.

Thank you, Gareth. Mabon ap Gwynfor.

I don't think we can underestimate how powerful the nurse staffing Act has been in raising the profile of nursing at all levels of an organisation. Nurses are present in all of our services, and we're predominately talking about the NHS, but we commission services from the private sector and care homes. Therefore, we have a responsibility to ensure that we can, as the Act says, sensitively care for patients, so we need to understand what is required.

What's happened by introducing the nurse staffing Act is it's helped us focus on actually what is it that we need around the patient in order to care for them. We know we need nurses and we know we need registered nurses and unregistered nurses. The Act currently talks about registered nurses and unregistered, it doesn't talk about those nurses that are in development roles that, actually, may be doing some of the work that registered nurses have done in the past. We haven't talked about some of the models we've implemented on the back of the pandemic, where we're delivering care differently, and we haven't talked about, and we could talk about much more, what our patients want from the NHS and the care that they receive. That's particularly important when you think about prevention and independence, and that's really, really important when we talk about and we start to look at community services more closely.

So, I think the Act has been very successful in looking at the core element of care delivery, which is around nurse staffing. I do believe that 25A gives us opportunity to broaden that so that we can actually look more at the team around the patient and how we work together to deliver what the patient needs. There's a bit more co-production as part of that process. I don't know what my colleagues think.

To add to that, I'm pleased to say that is why we are currently looking at this, working with the chief nursing officer's office, in order to understand how we take that forward, because that team around the patient is becoming such a key factor in delivering that care. I'm pleased to say that, on the back of that, and this is the evidence, the chief nursing officer has now actually scheduled a specific task and finish group, due to start looking at that team around the patient. The first meeting is at the end of this month. That will involve all the different professional groups to see how we can take this forward. It's been a real great learning curve, and this provides us with a great opportunity. We've come to a point where we need to look at this differently. It's important that we look at it differently for the reasons that we've spelt out earlier, but, really, this is showing and demonstrating that we're serious in looking at that issue and we are taking that forward. So, it's about understanding how multiprofessional working impacts on the Act. That's the question.

Thank you, and you were here—

Can I ask a final question?

Yes, absolutely, Joyce.

I think it's a question in the room, actually. If we hadn't had the Act—. Or the fact that we've had the Act; let's be positive. Has that driven all those things that have come out of it, all those things that you've talked about?

Just a brief answer.

I'd like to think it has. I think the pandemic has made us look at it to some extent, but we were certainly ahead of that and starting to have some of these conversations beforehand.

Yes, I think it has. It has demonstrated standards, it has demonstrated consistency across the whole of Wales. We know we don't want that variation of wherever you live you have a different type of service. So, we've had those consistent standards, had the testing, we've had good implementation of those standards, and as a result of that, we can build on that. Yes, we need to do that evaluation, we need to do that research, but it's a really good focal point of where we can take it forward. I think it's really successful in that way.

Thank you.

You were here for the earlier session. Was there any disagreement with what was said earlier on?

No.

No?

[Inaudible.]—extremely well.

There we are. Jo, did you want—? Did you want to answer the last question?

I was just going to say that I made a list of how do you do this. We've got to utilise the workforce data effectively to workforce plan. We need a digital system that talks to one another and we can measure patient outcomes on the patient journey. We need to talk to our finance colleagues and understand what this is going to cost, so we can actually predict what the future workforce looks like financially, as well as operationally, to deliver. We need to evaluate, because it would be lovely to be able to sit in front of you and give you the evidence. So, therefore, some research needs to be undertaken, and there may be some learning coming out of that research that will shape the future.

Measuring the key indicators is really important, therefore keeping our minds open to how we might be able to do that with new ways of working, such as the duty of quality and the duty of candour. Consistency in application of 24A is something that is challenging, but actually, until we evolve the Act and we're clear about what the acuity tools are going to be, it's going to be quite difficult to have that consistency, I feel, although we need to value the executive nurse directors and their teams in understanding their professional judgment as they move forward. And of course, we have to futureproof for what our team around the patient is going to look like.

They were the things that came to my head. I don't know if colleagues have got anything else to add.

I think the most important thing is valuing our staff, because valuing our staff is going to contribute to the retention of our staff in order to deliver these outcomes that we want to deliver to our patients. So, valuing our staff, taking them along this journey is so important as well.

Thank you.

I think the journey and the Act has given us so many opportunities. It's given us an opportunity to look at things differently. It's also raised the profile of nursing, but highlighted areas where there are improvements that are needed, and I think that's really important, and the opportunity for us to be able to do that is still here, so I think we need to seize that opportunity, maximise those opportunities to be able to collect the data once and use it multiple times, with as few systems as possible, but use all the data we've got. We've collected so much data, and this data, I think, is incredibly powerful when you look at demand, capacity, changing in-patient acuity, and it gives us a real indication of how we need to change our workforce models going forward to meet the needs of those patients and the population.

Thank you for that summary at the end. That's really helpful as well. So, thank you for your time today. We'll send you a transcript of the proceedings of today, and if you want to add to anything you've said that you think is important for us in our inquiry, then please do let us know, but diolch yn fawr iawn. Thank you very much for being with us today.

Diolch.

Thank you.

Thank you.

I move to item 5, and I propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public from items 6, 9, and 10 of today's meeting, if we all agree. That's it, we all agree, so we'll be back in public session at 2 o'clock today.

Welcome back to the Health and Social Care Committee. I move to item 7 and this is our continued scrutiny of the Nurse Staffing Levels (Wales) Act 2016, and this final session of today is with representatives of Health Education and Improvement Wales. So, I'd be very grateful if you could just introduce yourselves for the public record.

Thank you. My name is Julie Rogers. I'm the director of workforce and organisational development at HEIW and I'm also the deputy chief executive.

Prynhawn da, bawb. I'm Lisa Llewelyn. I'm the director of nurse and health professional education at Health Education and Improvement Wales.

You look very familiar.

Yes?

You look very familiar.

Why do you say that? [Laughter.]

If anyone is just watching this session, it's because you were in with us in the last session as well, weren't you, this morning, Lisa? So, welcome back.

Yes, of course. I'm now coming to you with a different responsibility.

With your different hat on, absolutely. So, thank you. So, perhaps I could ask you first of all to give a general view or observation about the extent to which the Act has delivered on its aims.

Yes, for sure. So, I think you've heard quite a lot of evidence today from various colleagues around the impact of the Act, and I would say that there's nothing that's been said today that we would disagree with. So, we do think there have been positive benefits to the Act and we think it has made a real difference, certainly in terms of staff perspective of the Act, raising the profile of nursing and the stuff that you've talked about around governance and accountability and the transparency.

I think, looking at it through the HEIW lens and the national workforce body, we wouldn't actually be able to say to you that we've got absolute evidence that it's made a difference at a strategic, national level, so I think that's where we'd be coming from in terms of the impact. So, I think in terms of the way that it has landed locally and the way that it has helped all of the things we've heard about today, we would agree that it has delivered its aims. But from a national perspective, that evidence isn't there in terms of things like sustainable workforce, attraction, recruitment, retention. There's some anecdotal evidence, but not hard evidence that it's made a difference.

Okay, and then in terms of patient outcomes as well.

Yes, so, I don't know, Lisa, if you'd want to take that.

Yes, so as far as patient outcomes are concerned, obviously, we did hear this morning in terms of outcomes for patients who are on the specific wards where you have got the Act and, obviously, you can start to identify some patient outcomes, but as we described previously, that patient journey doesn't always actually stay on one particular ward. But, obviously, as far as patients are concerned, what we've been able to give is a consistent standard of nursing services right across where it does apply, and that's where we come from.

And part of the Act's stated purpose was to strengthen accountability for safety, equality and to support the workforce planning and management. So, is there anything further you can say in terms of how you think the Act has delivered on its stated intentions in that regard?

In regard to, obviously, patient safety and everything, that is something that comes through the health boards. So, that's where we work with them in order to understand where there are developments needed, et cetera. But, obviously, what we've got in Wales are very good processes for managing safety incidents, et cetera, reviewing them and, more importantly, learning the lessons and then putting improvements in place for how we can improve that. At times, that could be educational elements as well, and that's where through our integrated working with both health boards and our universities we review the education that may or may not be needed to enhance and improve that patient safety outcome as well.  

Thank you. I'll bring Sarah Murphy in at this point. Sarah.

Thank you very much, Chair, and thank you all for being here today. So, I'm just going to look a little bit more at the nurse education and training. Some evidence we've received has described recent low fill rates on nursing degree programmes as extremely concerning. So, have fill rates improved for the September 2023 intake, and what action is being taken and in what settings to promote nursing as an attractive career?

Okay, so I'll take that one. In terms of the education and training, we're really pleased, as far as HEIW is concerned, that obviously we have got a key responsibility for planning and commissioning that pre-registration programme for nurses. Now, over the last 10 years, we've seen a vast increase in the number of pre-reg applications being enrolled onto our programmes, which is very, very much welcomed. Last year, we did see the fill rate drop in a September focus, but that happened nationally. It wasn't just in Wales, it was across the whole of the UK; everybody saw that. I can say that we are collating the final numbers as we speak, because obviously the programmes for this year started this particular month, and we get the final programmes when they join those courses. So, bearing that in mind, I can say that now, at this point, our pre-reg nurse recruitment is the highest ever that it has been in Wales. So, basically, I'm looking at it and we will have over 1,600 new pre-reg nurses starting on our programmes this September. Bearing in mind that I'm still waiting on those final numbers, that is a significant increase from last year. We saw a dip last year from our previous years, but as a result of the efforts that we've put in place, and we can describe these to you, basically we've increased that. So, that's really good to know. 

Now, that is based on—. We commission a number of places with our universities, but what we did last year was that, when we saw that that fill rate dropped, we took initiatives to say, 'We need to do something more.' So, we looked at what we could do to enhance those numbers going through. So, as well as the commissioned places, there are a number of interventions that we've put in place to enhance those numbers. So, if I give you an example, pre-registration international students: we are the first country in the UK to offer that programme to our students, and I've currently got a number of those on these programmes, which started in July/August this year. And, as a result of that, we've worked extensively with not just the UK Government but Welsh Government to make sure that we are attracting people from an international arena to come to train to be nurses in Wales. 

We believe that's a good thing, because by training in Wales, you start to learn about the culture, we learn about their culture, and hopefully as a result of that, they will stay. That complements the post-registration international students that we've got as well. But there are a number of other elements that we've done as well in order to enhance that. We've looked at different programmes that we've got in place and introduced various initiatives to change those. So, making them much more practical. We've listened to a number of our health boards, who have said that they want a work-based learning culture, so that we've got the workforce currently learning to become registered nurses as well. So, in short, it's good news. 

I have to say that all sounds tremendous. My second question, which I can combine, actually, because you answered a lot of what I was going to ask—