National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee/ Y Pwyllgor Iechyd a Gofal Cymdeithasol

Safe Nurse Staffing Levels (Wales) Bill / Bil Lefelau Diogel Staff Nyrsio (Cymru)

Evidence from Care Forum Wales – SNSL(Org) 24 / Tystiolaeth gan Fforwm Gofal Cymru – SNSL(Org) 24

Care Forum Wales would like to thank the Health and Social Care Committee for the opportunity to provide written evidence on the Safe Nurse Staffing (Wales) Bill.  In our evidence, we seek to respond to some of the general matters raised in the consultation and more specifically to the question of whether similar provisions should be applied in settings relevant to our members.

Care Forum Wales is the main professional representative organisation for independent providers of health and social care services in Wales.  Our 450 plus members include a large percentage of private and third sector nursing homes who provide services that are vital in underpinning the NHS in Wales.  Whereas Welsh hospitals provided 11,495 beds in 2013, the independent sector provides over 11,500 beds for people with long term nursing needs who would otherwise have to be cared for in hospital settings at a much greater cost to the tax payer.  Welsh Government conservatively estimates the cost of an overnight stay in hospital at £300 per night, or £2,100 per week.  Yet the weekly Continuing Health Care payment by local health boards to independent care homes providing long term nursing for people with complex needs is less than £800 per week in most areas.   We have long campaigned for the independent sector to be treated as a genuine and equal partner, recognised and valued for its contribution to compassionate care, to employment and to local economies, and resourced at a level that will ensure stability and viability.

In our original response to the bill, Care Forum Wales confirmed its support for the ambition to promote safe nursing levels in NHS acute in-patient settings, but we raised concerns about possible unintended consequences for people using and providing services in the independent sector.  Put simply, there is a risk that the requirement to maintain safe nursing levels in acute wards will increase movement of nurses away from the independent sector, exacerbating the existing crisis facing care homes which has seen nursing homes close or de-register to provide personal care only. The net result will be staff shortages and further closures, placing residents at risk; threatening local employment; undermining stability and incoming investment in the sector; and diverting NHS resources from acute care. 

In November 2013, BBC Wales reported as a result of a Freedom of Information Request that 800 Welsh nursing home beds had disappeared in the previous four years. Shortly before the original consultation we saw a number of nursing homes closing due to recruitment difficulties, some of which was attributable to recruitment exercises by some Health Boards in response to high profile reports that highlighted the correlation of nursing levels with the ability to provide compassionate care.  Care Forum Wales conducted a survey in August 2014, to which 38 members responded, which showed there were 75 nurse vacancies in care homes at that time, 15 of which were attributed to transfer to the NHS.  Extrapolating across the 240 settings registered with CSSIW would suggest a national figure of 480 vacancies in that single snapshot in time. 

There is no reason to think that this situation has improved since.  Indeed, concerns about nurse levels in care homes are now beginning to permeate public consciousness.  In her review of residential care for older people, “A Place to Call Home”, Sarah Rochira, the Older People’s Commissioner (OPC) acknowledged concerns raised by a number of respondents, including Care Forum Wales and the Royal College of Nursing, stating “a shortage of appropriately skilled nursing staff are risk factors to both the quality of care being provided and the ability for a provider to continue provision”. 

 A key factor in nurse shortages is that responsibility for commissioning pre-registration education places falls to the Local Health Boards and Trusts.  At the time of the original consultation nurse training was not being commissioned on a partnership basis and with regard for the number of qualified nurses required to safely staff nursing homes.  Care Forum Wales has since met with Dr Andrew Goodall, Chief Executive of NHS Wales, and other representatives of Welsh Government and obtained broad support in encouraging Health Boards to recruit for independent sector needs.  Options discussed include retraining for former nurses; fast tracking of social care practitioners and uncapped training.  However, there is obviously a time lag and these are very much long term solutions that do not address the immediate crisis.  Nor has it proved straightforward to identify the numbers of nurses needed and there remain a number of unknown factors, such as the impact of revalidation that has been introduced by the Nursing and Midwifery Council.  Further, the OPC has set a requirement that “NHS workforce planning projections identify the current and future levels of nursing required within the residential and nursing care sector”.  An increased reliance on social care practitioners is also a potential concern at a time when government funding for apprenticeships has been removed for those aged 25 and above, who represent by far the largest part of the workforce.

Nor does this address the wider issue of retention and ability to compete with NHS on an even playing field for high quality nurses.  Independent sector providers are simply not able to compete on pay, terms and conditions, with NHS providing sick pay, more annual leave and a better career path.  NHS nurses have greater opportunities both to specialise and to experience variety.  Our members report that nurses from abroad quickly move on the NHS because hospital working is considered more “exciting”.  Rural areas in particular seem to be a less popular working destination for nurses, especially for those with families or lacking personal transport. The independent sector is additionally hampered by the perception of care homes as being somehow inferior and less secure. As a result, providers report falling standards in new recruits with most being either newly qualified or having been out of work for some time.  Meanwhile, morale and wellbeing within the sector continue to decline as a result of the current shortages, with members reporting that it is common for nurses to work in excess of 60 hours per week.  The issues for the independent sector go beyond recruitment and training: we need support to raise the profile of the sector; we need to promote the idea of one workforce; we need genuine partnership and we need fair commissioning.

There is an unfortunate myth that care providers are only interested in profit.  This simply is not true, as can be readily seen from the difference between the cost of care provided by NHS and the cost of care commissioned by the NHS.  Providers cannot rely on “self-funded” care to remain viable as the vast majority of care is NHS funded and “top ups” are not legal.  The sector cannot rely on injections of capital from Welsh Government as can the NHS which, for instance, was recently awarded additional funding to cope with winter pressures. There are also issues with funding for Funded Nursing Care (FNC) which was established in response to section 49 of the Health and Social Care Act 2001 which stated that “no local authority, after 1 April 2004, may arrange, provide or (by implication) pay for care by a registered nurse for instance in a care home”.  It applies to a category of residents where some, but not all of their needs, were nursing: their other needs were deemed social care, which fell within the remit of the local authority, on a means tested basis. For many years care homes have absorbed the loss arising from what is commonly known as the “gap costs” between the funding provided by the Local Authorities and the Local Health Boards, despite government guidance that there should be no gap. The Health Boards appointed Laing and Buisson to review FNC in 2013 but rejected their findings as regards direct nursing costs which the Boards maintain should not include time spent on breaks, supervision and aspects of personal care, for all of which NHS nurses are rightly paid. 

Our experience is that Health Boards are likely to interpret guidance as purely discretionary, rather than something that should only be departed from with compelling reason.  We fear that the general wording on the face of the bill is therefore not in itself sufficiently proscriptive or transparent to ensure that local Health Boards will recruit or commission services at an adequate level in nursing homes.  Whilst we continue to support the aims of the Bill, we remain concerned that the requirement to provide minimum nursing levels only in adult inpatient wards will result in a further drain on staffing levels in nursing homes.  We would like the Bill to make clear that there is a duty upon the NHS to commission care in nursing homes at a rate that enables both adequate nursing levels and improved working conditions. 

In summary, Care Forum Wales supports the Bill in principle, but we are concerned that if it does not apply to nursing homes it will adversely affect them and their ability to recruit and retain nurses.  However, if it were to apply to care homes, funding would not automatically follow and we would want to see some commissioning responsibility clearly included.

Melanie Minty

Policy Adviser

11 February 2015