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Vaughan Gething, Cabinet Secretary for Health and Social Services

First published:
7 June 2018
Last updated:

This was published under the 2016 to 2021 administration of the Welsh Government


In February 2016, the National Assembly passed the Nurse Staffing Levels (Wales) Bill into law, making Wales the first country in Europe to legislate on nurse staffing levels. The Act came fully into force within adult acute medical and surgical wards in April of this year.

The Government remains committed to extending the Act into additional settings by the end of this Assembly term. The wording of the Act is quite clear about what is required to enable the extension of section 25B into other healthcare settings. As set out in the Act, an evidence-based workforce planning tool must be used as part of a triangulated method of calculating nurse staffing levels. Paragraph 41 of the statutory guidance states that the Chief Nursing Officer would determine which tool is to be used in Wales based on its fulfilment of the following definition: “an established theoretical tool or a tool developed for use in NHS Wales that has been validated for use by establishing an evidence base of its applicability in Welsh clinical settings.”

For adult acute medical and surgical wards, the Welsh Levels of Care (WLOC) is deemed to be the sole tool that meets the definition in Wales at this time and was therefore prescribed to all health boards for use as part of the staffing calculation process from 6 April 2018 onwards. The WLOC tool was developed over a two year iterative process with thousands of Welsh nurses collecting data across the entire country to create the necessary evidence base in a Welsh clinical setting. The testing and development the WLOC tool in Wales was possible within a relatively short time period because there was a tool with a well-tested algorithm already in place in many parts of the UK that we were able to use as a foundation to build on – The Safer Nursing Care Tool.

Currently, there are no similarly established workforce planning tools in use for other care settings which is why – through the All Wales Nurse Staffing Levels Group (AWNSLG) - we are building new tools and plan to undertake the testing across NHS Wales to develop the necessary evidence base. Inevitably, this process and the necessary engagement with teams throughout the country is not something that can be achieved overnight, but it is vital to allow the working groups the time they need to scope, undertake, pilot, review and complete the development work thoroughly. If we rush to produce these tools and get them wrong, they could either result in inappropriately high staffing levels which would be too costly with no added patient benefit, or more importantly, they could lead to patient harm due to staffing levels being too low.

There are five work streams overseen by the AWNSLG that are exploring extension of the Act into their respective nurse settings. These are:

- adult mental health inpatient wards; 

- district nursing; 

- health visitors; 

- care homes; and 

- paediatric inpatient wards.

The working groups are following a similar methodology to meeting the requirements of the Act and are at varying stages of developing the necessary evidence-based workforce planning tools akin to the WLOC. The five settings vary greatly in the nature of their delivery of nursing care; therefore the working groups are pursuing different types of workforce planning tools that will be suitable for their respective areas. The setting that most closely resembles the adult acute medical and surgical setting is paediatric inpatients. This is due to both being based in an inpatient ward setting where physical health descriptors are the primary factor in determining a patient’s level of acuity.

The work already undertaken to develop the WLOC tool for adult medical and surgical wards forms a solid foundation upon which the paediatrics working group can build and develop a tool fit for their speciality area. The lessons learned along that iterative journey are proving invaluable in the development of the paediatrics version of the WLOC tool which has been underway since 2017.

Due to the advanced stage of the paediatrics working group, in April last year I agreed to fund a two-year post for a project lead to help accelerate the progress of the paediatrics work stream. This project lead has been in post within Public Health Wales since January and is leading the development of a paediatric WLOC tool. This is expected to take approximately the same amount of time (2 years) as the development of the adult WLOC. My view is that paediatrics is the most likely additional setting that will be ready for extension of the Act by the end of this government term. An additional benefit of this project lead being in place has been the release of resource capacity within the All Wales Nurse Staffing Programme to focus energy on the development of the other 4 work-streams.

In the years leading up to the passing of the Nurse Staffing Levels (Wales) Act, the Chief Nursing Officer and Executive Nurse Directors agreed a series of staffing principles for adult acute medical and surgical wards which provided a valuable picture of the nurse staffing landscape in Wales and helped to prepare the ground in the NHS for the Act’s introduction.

In November of 2017, the CNO agreed a similar set of staffing principles for district nursing. Further to that, the remaining 4 working-streams are contemplating principles suitable for their respective settings. It is conceivable that by the end of this government term, there will be staffing principles in place for each of the 5 nurse settings as a preparatory step towards extension of the Act.

Section 25A of the Act came into force in April 2017 and sets out the overarching responsibility for health boards and trusts to ensure there are sufficient nurses to care for patients sensitively, and NHS Wales is committed to meeting this duty. The duty applies to all settings where nursing care is provided or commissioned in Wales.

As outlined in section 25E of the Act, the first NHS report on compliance with the Act to Welsh Ministers will be submitted in April 2021, three years after the implementation of the second duty. This report will then be submitted to the National Assembly early in its sixth term.