Kirsty's Law to set minimum nursing levels?

Wednesday saw the introduction of the fifth Member's Bill this Assembly term on behalf of Welsh Liberal Democrat Leader, Kirsty Williams (Lib Dem, Brecon & Radnor) – the Safe Nurse Staffing Levels Bill.

The Bill's available here (pdf), explanatory memorandum here (pdf).

The need for a Bill

Few local health boards currently meet the recommended minimum ratios
of registered nurses to patients and support workers.
(Pic : NHS Wales)

Safe staffing levels – defined as the minimum number of staff needed to provide a safe service – have been raised in numerous critical reports of the Welsh NHS. This is especially important with regard nurses on hospital wards and in situations where close one-to-one care is important, like care for the elderly.

The number of qualified nurses are falling - the result of recruitment freezes and an ageing workforce which will soon start to retire in greater numbers.

Research published in The Lancet showed that for every extra patient a nurse has to treat, the chances of a patient dying within 30 days of admission rise by 7%. It's the same with a lower ratio of qualified registered nurses (i.e those with a nursing degree) to health care support workers.

Increasing pressures on the workforce also reduce job satisfaction amongst staff and put, ironically, the long-term health of nurses themselves at risk.

In 2012, the Chief Nursing Officer laid down minimum nurse-to-patient ratios of 1:7 during daytime and 1:11 during nights, with a mix of 60:40 of registered nurses to support workers.

A year later, although most local health boards (LHBs) were meeting or narrowly exceeding the daytime ratio, most had 1 nurse to every 13-14 patients at night. Meanwhile, the registered to non-registered nursing staff ratios varied wildly depending on local health board and the hospital ward.

Some US and Australian states now have mandated minimum nursing requirements. In Victoria state, mandated minimum staffing ratios brought 5,000 nurses out of retirement and many now wouldn't consider working if the staffing ratios were abolished. California's similar law also works along the same lines.

What does the Safe Nurse Staffing Levels Bill propose?

As you can tell for yourselves, the Bill itself is very short. The main thrust of the proposed legislation is a series of amendments to the NHS Wales Act 2006.

The Bill :

• Places a duty on health authorities (Welsh Government, LHBs, NHS Trusts) to have regard for, and take all reasonable steps to ensure, the levels of staffing needed to provide safe nursing care, and to comply with minimum registered nurse:patient and minimum registered nurse:support worker ratios.
• Places a duty on the Welsh Government to issue guidance on safe staffing ratios. The ratios themselves aren't included in the Bill to ensure flexibility, and must be adjusted to ensure local needs. Protections will be included for student nursing staff, professional development, training, leave etc.
• Places a duty on health bodies to to publish nursing numbers and their skill levels, as set out by guidance; and also places a duty on them to publish an annual report outlining how they are complying with the provisions of the Act.
• Places a duty on the Welsh Government to review the effectiveness of the Act within a year of the Act coming into force, and no later than ever two years after that. The report must include data relating to safe nursing levels, which includes things like : mortality rates, hospital acquired infections, falls, bed sores, patient satisfaction levels, nurses' overtime and sickness, use of agency staff etc.

How much would the Safe Nurse Staffing Levels Act cost?

In short, an additional £83,000 over 5 years.

Kirsty and her team came to that conclusion based on the costs of reviewing the effectiveness of the legislation (£37,500 over 5 years) and the annual report requirement (just over £45,300 over 5 years).

Nursing acute patients itself costs around £275million per year; so although the costs of the Bill itself are small, it's likely to direct spending of a much bigger budget.

Kirsty's Law : Likely to struggle?

Politics might be a bigger stumbling block here than principle.
(Pic : Wales Online)

It's quite obvious from the outset that the Welsh Government aren't fans of this law, though they'll no doubt say they support the principle of having the right number of nurses, with the Health Minister himself saying on Wednesday that the government will "work constructively" on the Bill.

This looks as though it's trapped in a similar situation to the (withdrawn) Financial Education & Inclusion Bill : if there's little to no government support, Labour AMs will be whipped (or threatened to be whipped) into voting the Bill down and some sort of off-the-statute-book compromise will be made. That's a government's prerogative I suppose, but it's no good for opposition legislation however well-intentioned that legislation might be.

Having said that, it's clear Kirsty Williams and the Lib Dems have a better working relationship with the Welsh Government than Plaid or the Conservatives. The NHS is, however, seen as something of a Labour golden goose and I suspect they won't take kindly to anyone threatening their party's God-given right to exclusive tinkering privileges with the health service.

I suspect that one of the main arguments the Welsh Government will use against this law is that having a minimum staffing level could set a floor for, rather than increase, the number of nurses. Though the Bill specifically says that any Welsh Government guidance must ensure the ratios "are not regarded as an upper-limit in practice", how that would be done is a different question.

Then there's questions over whether there's a need for legislation on this (there probably is based on the information provided by Kirsty), and a point raised during the debate on why nursing in particular should be picked for this when health care is multi-disciplinary.

Too few cleaners and caretakers will play as big a role in hospital infections, for example, while pretty much every single politician ignores the contribution scientific (i.e. clinical & biomedical scientists) and diagnostic staff (i.e. radiologists) make to patient care because they're not seen by the public (you'll never see a lab technician or speech and language therapist on Casualty), they don't have an RCN or BMA to lobby for them in the Senedd and are therefore "politically unsexy".

But I'm willing to bet a large chunk of the problems in the Welsh NHS in terms of waiting times are down to understaffing and underinvestment in allied health professionals.

Doctors are, first and foremost, scientists who can't practice medicine without someone to do scientific tests for them, while nurses are not much use on their own. Therefore everyone should be careful to ensure the NHS isn't reduced to a infant school view of the world where hospitals are full of doctorsandnurses.

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Bridgend's Deprivation Mapped

The Caerau Park and Tudor estates are placed near the top of the most
relatively deprived areas in Wales. What about the rest of the county?
(Pic : zoopla.com)

Last week, the latest figures from the triennial Welsh Index of Multiple Deprivation (WIMD) were released by the Welsh Government and Office of National Statistics. Deprivation itself is defined, statistically, as a "lack of access to opportunities or resources".

The WIMD collects data from each of Wales' 1,909 Lower Super Output Areas (LSOAs) – there's roughly one for every 1,000-1,500 people – and compares them to each other, giving policy makers and the general public an idea how relatively deprived neighbourhoods are compared to the rest of Wales (not the rest of the local authority).

So it's important to point out from the start that ranking lowly doesn't mean a community is "affluent" and it doesn't measure precisely how deprived a community is – only how deprived a community is compared to every other community in Wales.

The WIMD has an overall ranking, but it also has 8 separate types of deprivation each LSOA is measured against, with some indicators weighing more heavily in the final ranking than others :

• Income – Proportions of people with an income below a certain level and claiming income-based benefits and tax credits.
• Employment – A general lack of employment, based on claims for out-of-work benefits.
• Health – Lack of good health, including : long-term disabilities, low birth weights, cancer incidences and death rates.
• Education – Numbers of people with no qualifications, truancy levels, university admissions and GCSE pass rates.
• Access to Services – The ability to access everyday services essential for day-to-day living (food, GP appointments, after school clubs), and the travel times to reach such services.
• Community Safety – Overall crime levels, based on police and fire service statistics.
• Physical Environment – Proximity to big polluters, flood risk and air quality.
• Housing – Lack of adequate housing, including overcrowding and no access to central heating.

In terms of the all-Wales figures, St James' in Caerphilly is now ranked as the most relatively deprived community in Wales, though many of the names towards the top are all too familiar – Rhyl West, Splott, Queensway 1 in Wrexham (Caia Park), Twyn Carno (Fochriw, I think), Penydarren 1 (Galon Uchaf area of Merthyr) and Caerau 1 in Bridgend (Caerau Park and Tudor Estates).

With the number crunching done, it's worth taking a look at the picture in Bridgend in some more detail.

Overall Ranking & Changes Compared to 2011

(Click to enlarge)

The 2014 listings aren't really all that different to those in 2011.

The areas you would expect to be more deprived were, including : Caerau, Morfa ward (which includes Wildmill), Bettws, and at a more local level the Brackla Meadows estate, Bryntirion (the area around the Labour club), the Marlas estate in North Cornelly and the Queens Avenue area of Sarn.

As you would also expect, the valleys are relatively more deprived than the coastal/Vale areas, and the suburbs of Bridgend (including Litchard, Broadlands and the Coity end of Brackla), as well as Porthcawl, come out of it rather well.

In terms of how the rankings have changed since 2011, very few areas have dramatically become relatively less deprived than they were, though Sarn 2 (the southern half of the village) fell the most places along with the Hendre area of Pencoed, Nottage in Porthcawl and Cornelly 2 (South Cornelly and Kenfig village). It looks like – despite their overall poor ranking – levels of deprivation in Caerau, Bettws and Morfa have stalled or have even improved slightly compared to the rest of Wales.

In terms of areas which have moved up the rankings, then Brackla comes off particularly badly, especially Brackla 1 (the area around Tremains Primary) and Brackla 4 (Priory Oak, Trem-y-Mor). All Garw Valley wards have slipped – and weren't in a great position in the first place – but it's Pyle 1 (a large chunk of Kenfig Hill) and Pendre – Carwyn Jones' old council ward – which have risen the sharpest in the rankings compared to 2011.

Income & Employment

(Click to enlarge)

These are perhaps two of the more important measures of deprivation as low incomes and lack of high quality employment will limit opportunities by themselves.

In terms of income, the picture perhaps isn't quite as bad as many would believe. Even in parts of the valleys – especially Pontycymer, Maesteg, Nantyfyllon (Caerau 5), Ynysawdre and Bryncethin – incomes are near enough in the middle compared to the rest of Wales, or even slightly exceeding this. These areas have lots of cheap housing and might be attractive for younger working families priced out of other areas, while Maesteg has always had a settled middle class.

Unsurprisingly, Porthcawl and the villages and suburbs of Bridgend and Pencoed do well. You need to remember though that Welsh income levels aren't great compared to the UK anyway.

With employment, however, the differences are more stark, with pronounced problems in the valleys and urban centres (Morfa, Pyle, Porthcawl East & West Central) as you might expect – Caerau 1 ranks as the 4^th most deprived area in terms of employment in the whole of Wales. Bridgend doesn't do too great overall, but clearly employment opportunities are much better south of the M4 and around Pencoed than elsewhere in the county.

Health & Education

(Click to enlarge)

There are five big pockets of areas where people are more deprived in terms of health compared to the rest of Wales – Caerau & Maesteg, Nantymoel, the central Garw Valley (Bettws, Llangeinor, Ynysawdre), North Cornelly & Pyle and the big estates in and around Bridgend town centre (Wildmill, Brackla Meadows, Ystrad Fawr). Again, this shouldn't be a surprise.

As you might expect the areas with good health are Broadlands, Laleston, Litchard and Brackla. These areas are not only generally wealthier than the average, but some areas - like Brackla - are generally younger than the rest of the county.

The north-south split is starker in education than any other measure. Pretty much all of the areas with low-ranking wards in terms of educational deprivation are located in and around Porthcawl, Pencoed and Bridgend, while the valleys have numerous areas that rank in the top 20% most deprived in Wales. The M4 almost matches the boundary perfectly as even Cornelly and Pyle fit in "the north".

That doesn't mean everywhere south of the M4 is doing well (Wildmill & Brackla Meadows) or that everywhere north of the M4 is doing badly (Llangynwyd & Aberkenfig).

Access to Services & Community Safety

(Click to enlarge)

Access to services is as much an infrastructure problem as one of the facilities being in close proximity. Blaengarw and Nantymoel have quite a few shops and services close at hand, ditto the upper Llynfi valley, so these areas do well. More rural areas like Cefn Cribwr and Coychurch, as well as "overheated" areas like Broadlands, will do badly. If you're close to a town centre you're going to rank well on this, so it doesn't really tell us much.

Community safety doesn't really tell us much either, as the closer you are to a town centre, the more crime will be committed. This means urban wards like Morfa and Porthcawl West & East Central will score worse than leafy suburbs like Broadlands, Litchard, Penyfai and Newton.

Caerau, Aberkenfig and Bettws don't really count as either so their poor scores on community safety probably indicate problems other than population density - presumably high levels of anti-social behavior.

Environment & Housing

(Click to enlarge)

You would expect areas close to Bridgend and Maesteg town centres to suffer from pollution problems, but there's a strip of particularly poor-scoring areas stretching from Aberkenfig to Pencoed. I think the culprits are the M4, traffic problems caused by the awkward road layout around Bryncethin, Tondu and Sarn, the Brynmenyn industrial estate and the fact the three main tributaries of the River Ogmore confluence in this area, which is prone to floods.

Ogmore Vale stands out and I have absolutely no idea why other than the polluting industries – like car scrappage and recycling firms - on the Penllwyngwent industrial estate.

On the flipside, you would expect rural wards and Porthcawl – with its seafront and access to the sand dunes - to score well, so no real surprise there.

Housing is the category where Bridgend county on a whole does very well compared to the rest of Wales, so this is clearly one of Bridgend's core strengths. It's probably because large amounts of housing have been built since the 1970s, like Brackla, or more recently, like Broadlands and Tondu, meaning they're often of a higher spec than the terraced houses of old. It's generally the areas where Edwardian and Victorian terraced houses are the only option – like the Garw Valley, Morfa 1 & 3 and Oldcastle 1 (the area around Nolton Street and Cowbridge Road) – which score poorly.

What can we learn from WIMD 2014?

Is enough being done in Bridgend's relatively deprived neighbourhoods?
(Pic : Wildmill Communities First)

Things haven't changed dramatically – As I've said, the areas of Bridgend you would've expected to rank towards the top and bottom have done so. Although these figures are relative, it's hard to tell if Welsh Government and local authority schemes like Communities First are really targeting the core issues that result in higher deprivation : unemployment, poor education and low incomes.

A better environment doesn't mean better life chances – The Bridgend valleys boast some of the finest scenery in south Wales, and since the end of mining, the environment of these areas has improved. The people there are still broadly worse off than those living in and around the M4 though. It makes you wonder if "sustainable development" is really going to improve people's well being or not, and whether local communities are being assisted to make the most of the natural environment.

Sarn and Pencoed are on the up; Brackla and Pendre are on the way down – Again, you have to remember that these figures are relative, but what's clear is that Sarn and Pencoed are becoming relatively less deprived compared to the surrounding areas, while Brackla and Pendre are starting to slip. Brackla is also, arguably, the most diverse council ward in Bridgend, as you can go from some of Wales' most grinding deprivation to some of its swankiest postcodes in a 20 minute walk.

Something needs to be done with "the usual suspects" – Marlas, Caerau, Bettws, Wildmill, Brackla Meadows - yet again they're mentioned for the wrong reasons. I could probably write fifty blogs on the state of Bridgend, but the question remains - what can be done to turn these areas around? With regard Caerau, in the last fortnight I mentioned there were plans for a holiday resort in the Afan Valley, which might generate much needed employment in the area and make use of Caerau's strengths – but those plans have stalled. Valleys 2 Coast had/have plans for housing renewal programmes in Wildmill (pdf) and Careau Park (pdf) too, but again presumably nothing will happen without the funding. New houses won't necessarily solve problems relating to crime, unemployment and low incomes either.

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