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.