The response of the Socialist Health Association (SHA) Cymru Wales
1. Purpose
This deliberately short paper responds to the invitation to submit comments on the forthcoming Bill proposed by Kirsty Williams AM to ensure safe nurse staffing levels within Wales. It draws upon consultation with the membership of SHA Cymru Wales which culminated with a meeting of members on September 3rd 2014 at which four speakers from different perspectives explained in detail some of the issues that need to be considered.
2. The SHA
SHA Cymru Wales is part of the UK Socialist Health Association which has over 700 individual members (and many affiliated organisations). Many members have some expertise in, or knowledge of, health care. It is affiliated to the Labour Party. It believes that health care systems should operate on the basis of meeting the needs of the population through a national, publicly owned, planned and delivered, system of care. SHA Cymru Wales has about 40 individual members, and several affiliated bodies that share its aims.
The response has two parts. The first offers comments upon aspects of the Bill. The second raises queries that arise from a reading of the Bill which it is hoped will be addressed as the Assembly undertakes its work upon the Bill.
3. Comments
3.1. SHA Cymru Wales understands the motivation for the Bill and has much sympathy with its aims. The best defence that the NHS can have against its detractors is that of offering consistently high quality care to its patients and their families who would be expected to be in the front line of defending the NHS from those who see it as an impediment to the relentless march of the alleged efficiency of profit- driven insurers and deliverers of health care. However, SHA Cymru Wales is not entirely clear how the precise legal vehicle chosen to ensure defined staffing levels will operate in practice.
3.2. Safe staffing levels must be a pre-requisite in ensuring that standards of care at all times meet all legal and professional requirements. Nurse staffing levels in particular have received much attention as a result of recent enquiries – notably the Francis Enquiry related to Mid Staffs. However, SHA Cymru Wales would see the need for safe levels of staff to apply across a range of care professionals. In this regard we would wish the Bill to be so crafted that other care professionals would be brought within it purview as evidence to underpin required staff ratios / levels becomes available.
3.3. Even if the Bill is confined to nursing levels, determining what a safe nurse staffing level is at any point in time in different care settings (an acute “on take” medical ward or award caring for elective surgery) has to take into account the severity of the patient load and the needs of those patients. Thus the nursing staff that ought to be available for a given setting have to be adequate both in quantity and in quality (skill). As ward setting become increasingly specialised it is important that staff have detailed knowledge of the care needs that arise from the precise clinical work being done. Nurses that have great experience of nursing patients recovering from major surgery may not be fully au fait with the needs of, say, elderly patients recovering from a stroke.
3.4. It is understood that there is some evidence base for different ratios of staff to patients in different settings, but some of that evidence is from outside the UK. It is not clear whether the evidence base being cited is totally transferable to the UK / Welsh context. If the research that underpins specific ratios comes from non UK care settings, these may, or may not, generate similar care needs and nursing requirements for similar numbers of patients. It It is requested that great care is taken to understand the extent of the transferability of research data from any overseas settings.
It is less clear whether the evidence base in regard to skill levels is sufficiently well developed in all nurse settings but it would be hoped that the Bill would prompt urgent research to identify appropriate levels across all hospital and community settings.
3.5. It is noted that the safe level would apply on a shift by shift basis. It is not clear how sudden surges in workloads are to be accommodated within this legislation. Three very different approaches might be intended.
a) Is it intended that such surges would be met by deploying a “reserve” of trained staff (with the inevitable implication that current total levels of staff would need to be increased to maintain such a reserve?
b) Is it intended that “manageable” workloads would be adjusted to allow for the surge in unmanageable demand – with the result that elective work would act as the safety valve in the system?
c) Is it intended that calculated “safe levels” would be explicitly relaxed when high levels of sudden demand are placed upon one part of the hospital system – and if so how would this be permitted?.
We would expect the Bill to recognise the possible reactions that the service would need to take.
3.6. The Bill is silent with regard to the financial implications. SHA has received some views that the measure may be “self funding” in that any higher staff costs arising from the Bill will be covered by shorter lengths of stay and better outcomes. SHA Cymru Wales would have major concerns if this is indeed the expectation for it is reported that the Welsh average nurse: patient staffing ratio is currently 1:10 and the intended ratio is 1:8. This represents an increase in staffing of about 20% and thus an increase in cost of about the same percentage for a large part of the total nursing budget. Worse, were the predicted reduced lengths of stay to occur, far from releasing funds to pay for the higher staffing levels, there is every probability that this would lead to an increase in workload, rather than a reduction in cost unless very tight controls over admissions were introduced and the “spare capacity” gathered together in such as way as to allow it to be closed.
3.7. Following on from 3.6. a major concern of SHA Cymru Wales is that the Bill will lead to unintended consequences if NHS funding remains tight. If legally binding staffing levels are established, these will be high on the agenda of Boards, professionals and managers. Such staffing levels will be protected at all costs. In straightened times, staff cost centres that are not so protected will inevitably become prey to cost reductions. Medical staffing levels have some protection – as do the services that are outsourced and are protected by commercial legally binding agreements.
There is thus concern that other staffing levels that are not well protected – for example ambulance services, community staff, rehabilitationists, and diagnostic staff – will bear the brunt of providing funding to support nursing areas to which legally binding levels of staff apply. This may, perversely, drain staff from the very support services that assist nursing staff, so that nurses then find themselves undertaking tasks that were once the preserve of others.
3.8. It has been noted that the evidence that links safe nurse staffing levels to good care (using reduced mortality and other measures as evidence of such care) has been interpreted as emphasising the staff : patient ratio as being the main feature. It is accepted that if good staff levels are maintained, then staff might feel more secure and settled, leading in turn to lower staff turnover and high team spirit.
However, members believe that great importance should be attached to the continuity of care that a settled ward staff can deliver. Merely ensuring a defined staff : patient ratio in itself will not automatically provide for the same nurses to care for patients throughout their stay. Indeed, if the impulse becomes one of staffing wards to a given level, then there is a risk that the use of transient agency staff and staff re-deployed from other areas will be increase.
We would wish further work to be undertaken to understand what impact continuity of staffing has on care outcomes.
4. Questions
4.1. The Bill is clearly titled so as to refer to “nurse” staffing levels. SHA Cymru Wales assumes that this wording intends specifically to apply to registered nurses only and not to staff sometimes seen as part of the nursing workforce at ward level, but who are not professionally qualified.
Is this understanding correct and if so, could this be made explicit within the Bill?
4.2. Again, in relation to the wording used, SHA Cymru Wales assumes that the Bill does not seek to bring midwifery staffing levels within the scope of the legislation. If so, SHA Cymru Wales is not persuaded that the omission of midwifery for any length of time can be justified. First, it is felt that the adequacy of staffing levels in this field can be predicted and assessed to a level similar to the (wider) range of nurse settings using an evidence base of comparable utility. Second, safe levels in this care area are just as important as in general nursing – especially given the nature of the care that is to be given to both mother and baby, the tragedies that arise from poor care, and the extremely high costs and that fall to be met by the NHS when avoidable harm arises from inadequate care. Third, workload in midwifery has some element of predictability that should aid the service in arranging adequate staff levels.
Could the Bill please allow for the inclusion of this service within its scope?
4.3. SHA Cymru Wales understands that much of the debate around the Bill has focussed on nursing care in acute hospital settings. SHA Cymru Wales however, would wish to see any “safe” level applying in all psychiatric care settings and would wish to be assured that this is so. In respect of 3.7. above SHA Cymru Wales would wish to see firm safeguards that protect investment in psychiatric settings and ensure that nursing levels here are set using appropriate metrics.
4.4. It is not clear whether the Bill intends that the safe staffing regime is to be applied to:
• NHS facilities operating in Wales only
• All health care facilities operating in Wales – public and private
• All health care facilities which provide services to Welsh patients as commissioned by the Welsh NHS.
SHA Cymru’s reading of the Bill as drafted is that Welsh health bodies would need to apply the provisions of the Bill both as providers of NHS care and as commissioners of NHS funded care. Further, the logic of the Bill should also apply to ensure that all privately provided nursing care operating in Wales is “safe”.
Clearly, if the Bill passes, NHS Wales should operate its own services in line with the Bill’s requirements. However, NHS Wales as a commissioner of services (whether from the English NHS or the private sector) will then be expected to ensure that any services it acquires for its patients also operate to safe standards. Further, for privately funded nursing care, it would seem unwise to allow a two tier level of staffing to operate within the public and private sector; if safe levels are required, they must be required in both.
Could the Bill please make clear the application of its provisions to health providers serving Welsh patients – whether publicly or privately funded?