Unite the Union Response to:

Safe Nurse Staffing Levels (Wales) Bill

This response is submitted by Unite. Unite is the UK’s largest trade union with 1.5 million members across the private and public sectors. The union’s members work in a range of industries including manufacturing, financial services, print, media, construction, transport, local government, education, health and not for profit sectors.

Unite represents in excess of 100,000 health sector workers. This includes eight professional associations - British Veterinary Union (BVU), College of Health Care Chaplains (CHCC), Community Practitioners and Health Visitors’ Association (CPHVA), Guild of Healthcare Pharmacists (GHP), Hospital Physicists Association (HPA), Medical Practitioners Union (MPU), Mental Health Nurses Association (MNHA), Society of Sexual Health Advisors (SSHA).

Unite also represents members in occupations such as allied health professions, healthcare science, applied psychology, counselling and psychotherapy, dental professions, audiology, optometry, building trades, estates, craft and maintenance, administration, ICT, support services and ambulance services.

1. Introduction

1.1. Unite welcomes the opportunity to respond to the Consultation on the Safe Nurse Staffing (Wales) Bill (3).

1.2. As part of this response, Unite has used its ongoing routes throughout the organisation to hear back the views of members in Wales and these have informed our response.

2. Is there a need for legislation?

2.1. There have been several highly publicised reports over recent years which have, to a lesser or greater degree, implicated both registered nurse staffing levels and skill mix in producing adverse outcomes for patients. The two most high profile reports are the Mid Staffordshire NHS Foundation Trust Public Inquiry, more commonly known as the Francis Report (2013) and the more local Trusted to Care Report, more commonly known as the Andrews Report (2014) which looked at standards of care in the Princess of Wales Hospital, Bridgend. Both of these evidenced not only individual failures of care, but also the failure of management to understand the importance of appropriate staffing levels for registered nursing staff.

2.2. There is a large body of available evidence which links registered nurse staffing levels to better patient outcomes in terms of speedier admission to discharge and reduced morbidity and mortality. Large scale studies have been undertaken in the United States and elsewhere which further demonstrate this (Shekelle, 2013, Spetz et al 2013 and Wallace 2013). However it is important to note that not all studies conducted to date agree that legislation is required, with some suggesting instead that empowering professionals is the key to getting the skill mix and staffing levels right.

2.3. NICE in England have reemphasised the role played by the registered nurse in patient care and have published guidance in England which is designed to alert both ward and general managers to trigger points which could indicate that patients might be at increased risk. The threshold is one registered nurse to eight patients. However, Unite supports the 4:1 campaign for a ratio of one registered nurse to four patients (http://4to1.org.uk/campaign-statement/). In Wales the current ratio is 10.5 patients per nurse, despite guidance from the CNO that the ratio should be 7 patients per registered nurse. This clearly demonstrates that guidance alone is not effective and consequently Unite would support the introduction of legislation around minimum staffing levels.

3. Are the provisions in the Bill the best way of achieving the Bill’s overall purpose (set out in Section 1 of the Bill)?

3.1. Unite considers that the provisions in the Bill do not support the overall purpose as set out in Section 1.

3.2. Numbers alone do not guarantee safe patient care, and there is no clarity around how working conditions are to be improved for other staff, nor indeed, any definition of who the “other staff” are.

4. What, if any, are the potential barriers to implementing the provisions of the Bill? Does the Bill take sufficient account of them?

4.1. Unite considers that the potential barriers include;

4.1.1. The financial circumstances that Health Boards in Wales find themselves in due to the impact of austerity.

4.1.2. The restriction of these provisions to Acute wards only could lead to reduced registered nurse levels in satellite hospitals as services seek to shore up the Acute sector.

4.1.3. The monitoring arrangements include data already provided to the Welsh Government. Some of which are not wholly indicative of poor care but could in fact relate to the level of patient need with those who are more seriously ill requiring a higher nurse/patient ratio.

4.1.4. The monitoring arrangements suggested have the potential to add a new layer of management to oversee progress in each Health Board.

4.1.5. Workforce planning tools, in the context of staffing, are generally retrospective, which means that by the time the data is received, the shift is completed.

4.2. The Bill, as is, does not address these potential consequences.

5. Are there any unintended consequences arising from the Bill?

5.1.The Bill could lead to additional expenditure being used to support the rostering of registered nurses, with expenditure removed from other front line clinical services.

5.2.In addition as care is increasingly undertaken in the community there is a risk that a focus on staffing levels in the acute will deplete nurse staffing levels in this setting.

5.3.A third area concerns the ethics of using incentives to meet statutory requirements. If RRPs are used to recruit to ensure that hospitals meet their statutory requirements this could leave other services with a worsening skill mix/staffing levels. I also think that we should argue against overseas recruitment as we are moving staff from, for example, Spain and Portugal, where there is a weaker economy, to the UK. This will create skill mix issues there – where there is even more challenge on the cost of training staff. Ultimately we need to do more on workforce planning and training here.

5.4.There may be some transition issues as the pool of trained staff will take time to emerge.

6. Provisions in the Bill

6.1. There is, as yet, no clarity around the phrase “all reasonable steps” in the context of maintaining minimum staffing levels. We would be concerned that this could include for example, staff being asked to give up annual leave/study leave to support the ward rota. We would expect all staff to be rewarded according to Agenda for Change terms and conditions.

6.2. There is no evidence that there will be consequences for any Health Body which fails to comply.

6.3. Restricting the legislation to Acute wards is disappointing for our members working in satellite hospitals who are caring for patients who, only a couple of years ago would have been regarded as being acute. Indeed, this seems to imply that the service provided for these frequently very vulnerable patients, is not as important.

6.4. Guidance and consultation on such guidance poses difficulties. Definitive guidance, likely to come from the CNO office, is already available, so it is unclear how reinforcing this will add to patient protection. The guidance is already there. With this in mind it is hard to see how we can expect an effective consultation on guidance which has already been issued and, unfortunately, not adhered to.

6.5. The monitoring requirements, as stated above, include information which is already available for the most part. Relating this to staffing levels/skill mix will not be straightforward unless a retrospective study is also undertaken to establish a baseline of previous practice.

6.6. The requirement to produce an annual report need not be an onerous as the Health Boards already produce annual quality statements, and a report on staffing levels could be part of this. It would be hard to justify a separate document.

7. Impact of existing guidance

7.1. As stated earlier the guidance is already there – it would seem to be reasonable to make this a duty on Health Boards to comply, rather than create another piece of legislation which only addresses a small amount of the staffing constraints in the NHS in Wales.

7.2. The guidance at the moment is ineffective as Health Boards do not choose to make Registered Nurse staffing levels a priority.

22 January 2015

This response is submitted on behalf of Unite the Union by:

Rachael Maskell

Head of Health

Unite the Union

For further information about this response please contact;

Richard Munn

Lead Officer for Health

Unite the Union

1, Cathedral Road

Cardiff CF11 9SD

Submitted to: SeneddHealth@Assembly.Wales

References

Shekelle, P. (2013). Nursepatient ratios as a patient safety strategy.Annals of Internal Medicine, 158, (5), 404–410.

Spetz, J., Harless, D., Herrera, C., & Mark, B. (2013).Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care.Medical Care Research and Review, 70(4),380–399.

Wallace, B., (2013). Nurse staffing and patient safety: What’s your perspective? Nursing Management, 44(6), 49-51.doi: 10.1097/01.NUMA.0000430406.50335.51