Under Scrutiny? Nurse staffing levels in Wales

15th May 2024

The Welsh Parliament Health and Social Care Committee (“HSCC”), which scrutinises policy and legislation on specific issues in Wales, recently published its report on the Nurse Staffing Levels (Wales) Act 2016.


In 2016, prompted by concerns about failings in nursing care in the UK, the Nurse Staffing Levels (Wales) Act 2016 (“the Act”) was passed. It was the first piece of legislation in Europe to recognise the link between patient outcomes and the numbers and skill mix of nursing staff. The Act was brought in to ensure that health service bodies provided safe nurse staffing levels, and to ensure that nurses were deployed in sufficient numbers.

The Act inserted a number of key provisions into the NHS (Wales) Act 2006:

Section 25AA non-statutory duty on local health boards and NHS trusts to provide sufficient nurses in all settings.
Section 25BA statutory duty to calculate and maintain nurse staffing levels in specified settings. This includes adult acute medical and surgical wards and, as of October 2021, paediatric inpatient wards.
Section 25CThe method of calculation for nurse staffing levels.
Section 25DA requirement on the Welsh Government to issue statutory guidance to health boards and trusts about their duties under 25B and 25C.

The Report

In February 2023 the HSCC began their post-legislative scrutiny of the Act.

Overall, the HSCC found that many respondents to their call for evidence were supportive of the Act, with praise including that the Act had:

  • driven an increase in investment in nursing;
  • created a change in culture, with corporate responsibility for nurse staffing and patient safety;
  • supported workforce planning;
  • raised the profile of the nursing profession with senior NHS management, and empowered senior nursing teams; and
  • increased transparency and accountability within health boards.

However, the inquiry found that several respondents felt there was little to no evidence of the Act positively impacting patient outcomes, particularly as other improvements had been implemented during this time, making it difficult to attribute positive changes solely to the Act.

The report further set out that some respondents felt that the lack of statutory guidance on the implementation of section 25A made it difficult to ensure compliance and that, where health boards did not comply with section 25A, they faced few consequences.

Many respondents also shared their concerns about the lack of formal research and evaluation undertaken on the benefits and impact of the Act. Research-based quality indicators were also raised as something to be considered, particularly if the Act is to be extended into further settings.


The inquiry made a number of recommendations of the Minister for Health and Social Services, including:

aThe consequences of non-compliance with sections 25B and C of the Act should be clarified, and the Minister should consider including provision for this in the NHS Wales Escalation and Intervention Arrangements.
bWithin six months of publication of the report, the Minister should write to the HSCC to provide an update on progress by health boards in consistently displaying information about nurse staffing levels on section 25B wards.
cClear operational guidance should be implemented to ensure section 25A is consistently applied across health boards in Wales. Progress on developing this should be reported to the HSCC within six months of publication of the report.
dA mapping of the digital systems involved in complying with the requirements of the Act should be commissioned, to enable an honest appraisal of the work that needs to be done to improve these systems.
eA full and academic review of the Act should be taken, as soon as the data to support this is available.
fResearch into the use of the Welsh Levels of Care workforce planning tool to date should be commissioned, including how Wales compares with other UK nations in terms of improved nurse staffing levels and patient safety.
gWithin six months of publication of the report, the Minister should provide a written update on the success of actions to improve nurse recruitment and retention and ensure a sustainable supply of nurses.
hThe Minister should provide further information on registered nursing associate roles (including whether these positions will be fully funded and, if so, where that funding will come from, assurance that these positions will be an addition to the current workforce and not a substitute for registered nurses, how to requirements of the Act will apply to the role and details of any risk assessments to patient safety that has been or will be done in areas where registered nursing associates will be employed.
iThe Minister should report back to the HSCC within nine months of publication of this report on the use of the draft Welsh Levels of Care Tools for mental health and health visiting by health boards, with an evaluation of how they contribute to a sustainable workforce and improved patient care.
jThe All-Wales Nurse Staffing Programme should be used to commission a mapping of other workforce planning tools, to develop the guidance to ensure a consistent approach across Wales.
kThe Minister should share with the HSCC the findings of the All-Wales Nurse Staffing Group’s assessment of the impact of the Act on multi-professional working.

Responses to the Report

The Royal College of Nursing, which has repeatedly called for the Act to be widened, welcomed the recommendations of the HSCC. Helen Whyley, RCN Wales Executive Director, also called on the First Minister to further extend the legislation to cover both mental health and community settings.

The Welsh NHS Confederation have also praised the findings of the report, whilst also calling for the Act to be supported with “the provision of a long-term, sustainable funding plan to recruit and train both NHS and social care staff”, to tackle the challenges around recruitment and retention.

You can read the full report of the HSCC here.

For more information about the Act, this report as well as Welsh health and care legislation, please contact Eve Piffaretti.

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