Health and Social Care Committee

Bore da, colleagues. Gill Knight, nursing officer, working with the chief nursing officer in Welsh Government.

Bore da, good morning. Sue Tranka, chief nursing officer at Welsh Government.

Thank you, and thanks, both, for being with us as well today. Thank you. Well, if I could ask the first question: has the Nurse Staffing Levels (Wales) Act been successful?

I think, in parts, it's definitely been successful. I think a particular area that I think you can point to is empowering the voice of the nurse at the executive level. So, the fact that, within the Act, there's a designated person means that the nurse in that context of the executive has to be taken seriously when they need to determine what is a safe level of staffing. So, I think that has changed the culture within the organisation, and I think that was probably something you've heard from many of the people who've come before you.

And it was interesting that you said 'in parts'. So, in parts, it's not been successful; what are they?

Well, I think, it's not—. I don't think it's failed, but I think there have been some issues about unintended consequences and things that I think we probably need to look at. I can go into the details of some of those things—

Yes, go on, may as well. Let's have a look at them.

—if you'd like. So, I think part of the challenge around this is that it's all very well to write in law, 'This is what you have to do', but, actually, if those people don't exist—and let's remember that the World Health Organization has said that there is going to be a 10 million shortage of health workers by 2030—you can't just magic up those people just because it says so in a legal document. So, you've got to actually confront reality, and the Act itself didn't say anything around the training and the need for the development of nurses. Now—

So, should it have, do you think?

Well, we've got a whole area that works around that. I think putting those kinds of things in law would be unusual.

I know, Minister, in your paper to us—and thank you for that—you mentioned the lack of statutory mechanisms within the Act to ensure an increased supply of nursing staff. So, I'm just checking, because that could imply that there could be that mechanism within the Act, or there should be that mechanism within the Act.

I think what that wouldn't do for you is to give you the flexibility that you need to respond to different circumstances, but also, the key thing to remember is that, actually, the world has changed quite a lot since this Act was developed. And one of the key things is that, actually, we're very keen now to make sure that we have nurses working at the top of their licence, and where other people can do the work, where you have a mixed group that can support nurses, we should be looking at that. And that's certainly something, for example, in Scotland, where they developed their Act after ours, where they had that much more mixed approach to how you should staff wards, rather than just seeing it as the exclusive area for nursing. I don't know if Sue would like to come in there.

I'm happy to come in. So, I think, on the statutory mechanism in the Act for recruitment of staff—it's quite an interesting thing. I guess I would have to ask, 'What would that look like?' And if that was simply the solution, to put a statutory mechanism in for the recruitment of the workforce, well, then, surely, everyone across the globe would do that, given we have a 10, 20 million shortage that's expected. I do think there are other mechanisms that are non-statutory that need to be addressed first, and I think there is quite a lot of work that is ongoing within Health Education and Improvement Wales, and the Welsh Government, that is supporting the consistent and sustainable recruitment of not only domestic, but international recruitment as well, and we can give you some of those numbers in a moment.

I did want to come back, Chair, if that's all right, to the success of the Act. And to answer that question about the success of the Act, can I just revisit the explanatory memorandum that went into the Bill, that talked about the three aims? And the three aims of the Act—in order to understand its success or its impact, you need to understand what the aims were. And the aims were (1) to ensure safe and appropriate nurse staffing levels in any setting where NHS care is provided. But as suggested by the data that you've seen—you'll have seen our three-year report as well that has come through—this hasn't addressed the shortfall of nursing staff. So, therefore, creating the safe and appropriate levels has been somewhat challenging throughout the time. So, I think, when we say that there hasn't been full success, we mean that there's been limited success on that aim particularly.

The second aim that the Minister has talked about quite eloquently was on strengthening the accountability for safety and quality of workforce planning. I think that is arguably, clearly, where we've seen the most impact. The voice of the executive nurse director as the designated person has been really strengthened at health boards, with absolute authority on nurse staffing levels, and I think that has made the most significant difference.

The third aim has been about creating sustainability of workforce and, clearly, the Act has not been able to do so, so we come back round to, 'Is there a statutory mechanism to do so?' I think there are other mechanisms to support the sustainable workforce.

So, if I'm just summarising, what you're both saying to us this morning is that there are some areas where, perhaps, the Act hasn't been successful, or there are some challenges within the Act, but you don't think that there's a need for change to the Act, because you believe that those issues can be picked up through non-statutory processes. Is that a fair summary?

I think there are other aspects that can be done through other mechanisms besides statutory discipline. And I think that's—. I think, if you think about the kind of operational guidance and things that we can tweak, we can change—you don't have to put all of that stuff in law. You reach for law almost as a last resort. Okay? If you can do things before that, and provide more flexibility to respond—. And you think about—. We've had COVID since this Act came in—you have to adapt to circumstances. The law actually sometimes restricts you too much, and you just need to be able to respond to whatever's happening on the ground at the time. But also, in the face of that global challenge in terms of workforce, we do have to think much more broadly in terms of that mixed group around the nurse, so that the nurse can work at the top of their licence. These are highly skilled, highly trained people; there are other people who can do some of the work that would release nurses to work at the top of their licence.

I can see Gareth and Mabon both want to come in. I just want to try and get one thing clear in my mind, because I'm not completely clear, I suppose: do you think there should be a change in the Act? I think you're saying 'no', but, on the other hand, you're saying, 'Look, it's not perhaps worked as well as it could do.' So, I'm just trying to grapple with that.

Look, I haven't got an appetite to be making changes to Acts. If you go down the legislative route, if you think about all of the issues that are confronting the NHS today, this would not be top of my list of priorities of things to do.

Okay. I think that answers it. So, it could be, but there are perhaps other priorities that you would want to address.

But also, I think we can get there in other ways.

Okay. No problem. Gareth. Was it on these issues I've been raising?

Yes, absolutely.

Okay. Gareth, then Mabon.

I'm quite shocked this morning, actually, because the whole basis of our questions, and the reason for you coming this morning, is to talk about the Act. And in your first set of answers, you're saying that you don't believe the Act's fit for purpose, in a way—we seem to be alluding to that issue. But laws and rules and things are embedded in place to ensure that adequate and safe nurse staffing levels are there in place. So, what do we do? Where do we go from that, then? Do we just scrap it, and say, 'Well, it's not fit for purpose'? Or what do you do at a governmental level, to say, 'We recognise that the Act isn't maybe holding water here in a modern society, after COVID', as you say? Well, what do we do with that? Do we reform it, do we change it, do we adapt it for modern purposes, have another look at things to see how we can make it reflective of the modern society and modern health needs? So, where do we go from here, if you like?

Okay. Minister.

I didn't say the Act's not fit for purpose.

Well, you alluded to that, though.

Well, hang on. Please don't put words into my mouth that I haven't said. I did not say the Act is not fit for purpose. I think that the Act works well in the limited scope that it was meant to do, and we've set out very clearly the empowerment of the executive nurse, and how that has been a game changer. But the issue now is, 'Right, where do we go from here?' And I think that, actually, the way it's working in practice is dealing with—it's being flexible operationally. And so it is actually working, but it's not necessarily thanks to written words—it's because of the way that people are using it on the ground that it is managing to work. And what we can do, perhaps, is to just use that operational guidance in a more flexible way. Is that fair?

I think it's fair—

Shall I bring Mabon in, and then—? Mabon.

I'll be asking my question in Welsh. On what you said, you said that the concern was that there are unintended consequences emanating from the Act, and you said that there was nothing in written form in it talking about employment, about the workforce—

One moment—

Does it work? Okay.

Sorry. Yes.

Sorry.

There we are. You mentioned that there was nothing in the Act about employment and about the workforce. And the tone that I picked up was that, well, it's shame that there's nothing about that and that there's nothing that can be done. But don't you accept that there's a duty on the Government, therefore, to ensure that the workforce is there, that is, there is an Act that says that we need a workforce, so you have a duty to do everything that you can within your capability to get the students and to get the nurses to go through the system in order to live up to that duty? So, are you content that you as a Government have done everything within your ability, since we passed this Act, to ensure that there is an adequate workforce in place to comply with the Act?

Well, we are spending £0.25 billion a year on training people for the NHS in Wales, so that's a significant sum. We've seen an increase in the numbers that we are training, especially in terms of nursing, and we have maintained the nurse bursary. So, we have taken these issues seriously, but I don't think that legislation is the place for doing those things. We are doing them, but not because legislation demands that we have to. Sue.

May I come in—is that all right?

Yes, of course.

So, I did want to just bring to your attention that, on the nursing and midwifery professionals register, Wales has grown a record number of nurses, to over 40,127. And I'll just tell the committee, when I first joined Welsh Government, I met with the Minister, and she asked me what would success look like for our workforce, and I said, 'When we grow our workforce to over 40,000, we can really start to make some consistent and sustainable changes and improvement for patient care.'

We are doing a number of things, from recruitment—so, the numbers are growing year on year for the nursing training workforce places. We have increased our nurse training workforce places by 54.3 per cent, and midwifery training places increased by 41.8 per cent. The commission numbers are at the highest they've ever been. Of course, we have a fill rate that doesn't match those commission numbers, and there is good reason for that. It's post COVID and, given what's happened in the nursing profession over the last 18 months or so, the prevailing narrative has been particularly negative, and so we have more work to do around campaigning and making this profession attractive again.

We are doing—. Gill is doing a lot of work with Health Education and Improvement Wales around bringing in international nursing students. This is the first time this has been done in the United Kingdom. We are the first in Wales to bring over 140 international nursing students into training places within Wales, which we are very, very proud of, and we continue to support our retention. HEIW has only recently published their retention plan to support those who want to stay in the workforce and to be the very best they can be, but also to have conversations about flexibility of working, how do you retire and return.

So, there are a number of interventions that are in place currently to support the growth of our workforce. I think it would be remiss of us to say that this isn't a global challenge for workforce, and we are doing everything we can. We are constantly working with both our professional bodies and our unions, across the multiprofessional workforce, to consider what else can be done to strengthen our approaches.

I'm just checking, Sue—. Sorry, did you want to come in, Gill?

Just a little. I think it's really important to set some context here as well. So, if we look at the number of wards across Wales that are covered by section 25B of the Act, where there's a duty to calculate, it's about 180. Now, that fluctuates, depending on the primary purpose of a ward. So, the staffing that that covers is a small percentage of all registered nurses that we have working in the NHS. And in addition to what the Minister and the CNO have said, we've also increased training access across Wales to Aberystwyth—we've got flexible routes. In fact, both our Minister and CNO say there is no wrong door into the nursing profession in Wales. We've significantly increased the level 4 education with providers outside of the university, and that's a stepping stone into the profession; we have over 300 a year now who wouldn't have had an opportunity to enter, traditionally, into university, through to register as a nurse. So, we're doing much. We've expanded again, opened our Open University, so there's flexible, part-time local training to enhance and grow our workforce.

Given what you've both said, Sue and Gill—and you've talked about the challenges and response to the challenge about retention and recruitment—much of what you said, I would have thought, would have been—. That's what would have been carried out and done, whether the Act was there or not. Am I right in thinking that? Because, if the Act wasn't there, you would have still had those challenges with recruitment. So, to what extent is what you've just talked about in relation to the Act? Not that you're wrong to talk about that, because that was helpful background, but I'm just trying to understand some of the challenges and how they link to the Act.

So, what Mabon was saying is, 'Should we legislate for training?', and what we're saying is you don't need to legislate for training—we're doing all of these things without legislation. So, that's the relationship in terms of this particular conversation, I think.

I think what you're saying is that the Act is helpful in terms of knowing what levels—I'm trying to put words into your mouth, but I don't want to put words into your mouth—

Everyone is this morning.

—I want to be correctly putting them into your mouth. But I suppose on the one hand I'm still grappling a little bit—. The Act could be better. It could be better. The Act is helpful in many ways, but the areas where the Act has not been helpful you think you can address in other ways.

In other ways. There we go.

Okay, right. Gareth, did you want to come in on that?

Yes, thanks, Chair. It was just on the training response that you gave, Gill, about the Open University. I'm aware that there is a disparity in nurse training through the Open University between England and Wales, where it takes significantly longer to qualify as a nurse in Wales compared to England. So, in terms of getting a bit of parity of esteem between UK nations, how can we bridge that gap and get people trained up in an efficient way that's in sync with reality in the rest of the UK, really?

So, across the UK we will enable potential students to do their training in a way that suits them and meets their needs. So, some will choose to do it over three years, some over four and some over longer.

But they're not going to choose to do it over six, though, are they, really?

I don't know of any—

When somebody's on the border and their friend's doing it in three years, and they're doing it in six and don't want to do it six—

I don't know of any students in Wales that undertake their training—. Unless they have a suspension of study, of course, which some people may choose to do. But I would say that there are many routes in and the flexibility—. So, some it will not suit to do Open University training, some it will be through the band 4 route, or the level 4 education route. So, some will do NVQ 2, 3, 4, then feel ready to go on to level 5, 6 and graduate as a registered nurse, taking four to five years. So, it depends, and I would not say that there's a lack of parity; I'd say we're flexible in our approach. And if the Open University—. So, that's only 100 places that HEIW are commissioning for that; a lot more for the level 4 education.

But that could be seen as an informalised process compared to necessarily leaving your job, going to university for three years to study nursing, getting yourself into £27,000-worth of debt, whereas the Open University can be a bit of an 'earn as you learn', if you like. Obviously, I know the band 4 scheme—

Level 4, sorry—level 4.

—is a better route in, and it's a bit of a glass-ceiling-breaking exercise, but, still, it's seen as an informal way. But if we're—not intentionally, but—penalising people who choose that route, we could bridge a gap and make that path into nursing a little bit more streamlined with some of those systems.

Gill, I'll ask you to pause on that, because actually it's a really interesting discussion, but I'm just worried we might move off some of the issues around—

Can I say one—

Just briefly, yes.

One very last point on that. We're really fortunate that we've maintained our bursary in Wales, so students don't come out with a £27,000 debt on fees. So, we've not lost our bursary. So, we're really proud of that.

Whereas they have in England.

Whereas they have in England.

And, gosh, they've paid a price for it.

Sarah.

Thank you very much. Thank you all for being here this morning. I'm going to ask some questions now about the financial resources that have been required to implement the Act, and I would like to start by saying as well that, based on the evidence that we have gathered, we've found that the Act has raised the profile of nursing in Wales, there's a more systematic, joined-up approach to setting nurse staffing levels, and a stronger evidence base to support the workforce planning. And we've also heard evidence to say that investment in nursing has increased. Also, in the Welsh Government's evidence paper it states that funding of the general nursing workforce in areas where section 25B applies has increased since the Act came into force. Our question really would help us to understand as a committee where has this additional investment come from. Can you let us know how you have needed to maybe restructure your budget to ensure that the investment was there to implement the Act? Where has that money come from, essentially? Thank you.

Is that a question for me?

Yes, it was. Absolutely.

Thank you. So, I don't think that the money is coming from any different allocations other than the health boards' allocation. So, it's important to understand that the statutory guidance states that the maintenance of the nurse staffing levels should be funded from the local health boards' revenue allocation. How they then directly allocate that funding to increase their staffing and invest in their staffing or service delivery is entirely up to that health board. So, this isn't necessarily money that's coming from somewhere else, Sarah.

That's very helpful. Thank you very much. Also, we've had stakeholders describe culture change as a result of the Act. They've said that there is now corporate responsibility for nurse staffing and patient safety, combined with greater scrutiny and transparency. Our question is, though: does the Welsh Government have plans to carry out or commission a formal evaluation of the Act to ascertain whether it's delivering value for money, as well as the broader impact?

Yes, that's a really good question. I think that it's important to tell you that, when the Act was initially developed, there was no formal mechanism put in place for evaluation of the Act. I think that, at this point, one of the things that we would say is that, in order to fully evaluate the Act, we need a robust set of data, and you may hear something about our data quality challenges in a moment. But there have been a significant amount of data quality challenges in the last six years of implementing the 25B ward areas as part of the Act, and, in order to do that, I think that we are probably slightly challenged.

In terms of a value-for-money perspective, we've got to ask ourselves whether that is the right place, right now, at this point, to invest that money to do a formal evaluation, when we don't have a robust enough data set that will support a full and academic review of the Act. So, that's my sense, that's my opinion. But, certainly, I think that there is a place for research in the future.

Okay, thank you very much. Just my follow-up question on that, then, is that I've met with the Royal College of Nursing, I think that their 'Progress and Challenge in Delivering Safe and Effective Care 2023' report is really helpful, and really broken down by health board as well. I'm quite pleased because my own health board, Cwm Taf Morgannwg, they've said that there is clearly good work going on to help retain nursing staff, it has been a key pillar for the board's 2023 to 2026 plan, and it includes a workforce planning model and a recruitment and retention plan. So, that's wonderful to hear.

But the Royal College of Nursing is also calling on the Welsh Government to commission research also into the social, economic and patient safety impact of the Act. So, I know that you have just said that this is maybe not a priority for right now, but we have heard from other stakeholders that a formal evaluation of the Act should be carried out to inform the future development and use and incorporate those other metrics. So, what are your thoughts on that, please?

So, I think that, if we are going to undertake any further research on the Act, I might take you to a place of work where the Act has quite strongly been developed from a uniprofessional perspective. I think this creates a number of concerns in terms of how we clinically staff our ward settings and other settings to support care delivery. I would really be thinking about—. I think you heard in the October evidence from the nurse directors, who talked quite a lot about the practical, I suppose, implications for them in trying to staff up their wards without a multiprofessional perspective. So, if there was research that was going to really help this Act to move into a much more new world order, and a real-world—. Because this Act, really, when written—. Whilst we are very proud of it, if you look at it now, it has been written in a time that is of a different era, unfortunately. So, it has to modernise. So, the research needs to be in a place where we focus on the team around the patient, really understanding the application of this Act for the multiprofessional workforce, as the executive directors of nursing in the October evidence hearing told you. Then, I think that would be something that would be fully supportable. There is work ongoing already in Welsh Government looking at the team around the patient perspective. We have a policy group that has come together, and there is further work ongoing within the system. So, that I wouldn't rule out, Sarah, in terms of doing the research with that perspective in mind.

Okay, wonderful. Thank you very much and thank you, Chair.

Thank you, Sarah. Jack Sargeant.

Diolch, Cadeirydd. Bore da, bawb. Minister, if we can look at the 25B duty again—the duty to calculate—you referenced, in response to the Chair earlier, the operational guidance. But, perhaps, could we just, for the record—? Is it the Welsh Government's intention to keep the statutory and operational guidance under review to make sure it remains fit for purpose?

Well, to be honest, I'm more interested in the operational guidance, because I think that's the thing that makes a difference on the ground, and that is constantly under review. It's a live and dynamic document and it's consistently being tweaked. And I think that gives it more agility to respond to the circumstances within the ward, or at least the circumstances at the time, and I do think it's important. I'd be more interested in just making sure that we focus on that, rather than fundamentally altering the direction within the statutory guidance.

Would the operational guidance include a tweak, for example, the timing and frequency of the calculations?

So, there are already two mandatory biannual calculations that have to happen in terms of staffing levels anyway, so I'm not sure if we need to layer on top of that.

Okay. I won't press that further, Chair, because I think that's quite a good answer to the question. But just to note that we have heard that the biannual calculation might be a little onerous, and perhaps there's a need for an annual calculation, rather than a biannual. But I won't press you further, Minister, given the time we have in front of us.

The chief nursing officer, I think, in reference to my colleague Sarah, talked about the data quality 'challenges', I think you referred to them as. We've heard about some of those challenges as well, in particular the reporting from health boards. We heard the indicators are right, they're appropriate; the data coming from the health boards perhaps isn't too up to standard. You've mentioned it. What's your comment on that, really?

Can I come in?

Please.

Thank you very much. It's important to clarify, I think, that the quality indicators serve two functions within the Act. The first function is that it's used as part of a triangulated methodology to calculate the nurse staffing levels. In this context, the statutory guidance already sets out that the designated person may consider any indicator to be added, as they deem appropriate for their specific area. In practice, this would be things like infection control, missed care, delayed transfers of care, et cetera. Secondly, the quality indicators are also used for reporting under section 25E of the Act, where we report things like pressure ulcers, falls, medication errors, complaints.

I think the data, given the ICT systems, have been a problem in the past, and, up until April 2021, when we changed over to Datix Cymru, which is a standardised set of reporting in Wales, we have had very differing data coming through. And so that has been a persistent problem for quite a while. Those are the data quality issues that I referred to. Despite looking at that data and what's coming through currently, I think, in the next three-year reporting period, we will see a much more robust set of data, because we have a standardised approach to the collection of data through Datix Cymru. The utilisation of that data takes us to the next much more nuanced and sophisticated step. What you collect is important, and then understanding how you apply that to the safety and understanding the safety of care will be really necessary. So, the data is key. ICT has been a problem. We discussed this the last time I was at committee—

We did.

—and the data quality issues. We are working on them consistently, but they continue to be challenging.

If I remember rightly, I think that we spoke at some length about the IT system. So, I'm pleased to see that it's moving in a different direction to how it has been. It always stresses me out, Chair, talking about IT systems, but there you go. You said that there is the ability to include additional data if necessary, and that's welcome. Perhaps, Minister, turning to you with regard to extending it into different settings in the NHS, and particularly looking at mental health in-patient wards and community nursing. The RCN, I think, launched a petition a few years ago on this, which the Government responded to. Has the Government's position changed or is it still the same as it was then?

No, we haven't changed our position. I think writing a law that says 'You've got to staff in this way—'. If you haven't got the staff, you just can't meet the law. So, I just think you've got to be really practical about how this works, at a time when staffing is challenging. And, as Gill pointed out earlier, actually, the vast majority of nurses are not covered by this law. I think we've just got to understand, particularly—. Because I'm really keen to get into far more community nursing. How on earth do you start assessing what's appropriate in a community nursing setting? So, it's a very, very different calculation then, and I think, in the same way, in terms of mental health, it's this uniprofessional approach that I think we're concerned with, when the direction of travel is very different from what this particular approach in this law takes.

Thank you for that. Is there a concern then—? On the earlier questions around the training, I'm a big believer in that if we can get things done then we should do them; we don't necessarily need laws to do that. That's just where I come from on things. But there is a case where laws are needed to make sure that Governments do. It's great that you've got these ambitions and you're working towards those, but if there was a change of Government tomorrow, those priorities may be different and there could be a case where we don't train any more nurses. Is that a concern?

But if you write a law that says that you have to staff a particular ward at this level and those people don't exist, you are then getting into very difficult territory—

Haven't you done that? Isn't that what the staff nursing levels Act does?

But the kind of consequences that we're looking at, if you look at things like, for example, you know—. We haven't quite made the causal link, but the amount we spend on agency, for example, has gone up significantly, and if we have to comply with a law that says you have to have this many people on a ward, and you can't run that ward unless you've got that many people—

But that's what the Act is saying, isn't it?

Absolutely. But the consequence of that may be that you have to bring in far more agency workers, and that takes you into a very different set of problems. We're all very keen to reduce the use of agency workers, but if you can't get the substantive staff that we're all keen to get, then that's very difficult. I don't know if Sue would like to add to that.

Yes, of course. May I?

Yes, go for it.

Thank you. For me, I think it's really important that we move to a much more nuanced and productive conversation when it comes to the Act and the potential extension of this Act. I want to set up the process of systematically testing the workforce planning tools that we have to do in Wales, and I'm not sure if the committee fully grasps how long it can take to extend to any areas. If we were to do it in the way in which the Act currently sets it out, with systematically testing the workforce planning tools, they have to be developed in Wales firstly—that's what the Act says—or they need to be validated in Wales. We don't have any tools that we validate, currently; we develop them from scratch. That takes us about two years in development. And then we lay regulations in the Senedd to extend section 25B to each distinct care setting. If we were to do that, it would take us decades to ensure that we have nurse staffing levels at the appropriate level, and that's a cumbersome approach. It's taken already six years with the current extension.

So, I think there are different, more pragmatic and agile ways forward, that we could encourage the best use of tools, as we've done with the draft tools for mental health health visiting in the community already. They have been supplied to the system, the system is testing them currently, they are utilising them under section 25A of the Act, which is the broad overarching duty that enables you to utilise your tools in any other setting. And I think, as part of the refreshed work of the all-Wales nurse staffing programme going forward, we could commission a mapping of all such other tools that are available and develop the principles and guidance to ensure that there's a consistent approach across Wales, instead of calling for this long, protracted approach to extension through legislation.

I do want to very quickly give you an example in the community. I'm not sure if the committee is aware of the non-legislative progress that the community has made, which is incredible. So, as part of the budget compact with Plaid Cymru in 2018, you'll know we introduced a two-year pilot through the neighbourhood district nursing. They have done an incredible amount of work in considering what their workforce will look like and what's required. They've modernised and they've bolstered district nursing, including the roll-out of the model for Wales using e-scheduling, so an electronic scheduling system, and the ICT system is really agile. It enables nurses on the ground to practically come to a community setting, so a home, see a patient, determine that, 'We put in 15 minutes for your care. Actually, you're going to need an hour because you're sicker than we thought.' They go into their system online, they can put in the details. That system will reallocate their workload through the day to others or move it elsewhere and allow them the time, in an agile and dynamic way, to deliver that care. Community settings have done that, and they're applying that consistently. With that, they've also been able to increase the delegation of care to their healthcare support workers, which means they are truly utilising the team-around-the-patient approach. There is a non-legislative example that works incredibly well. So, we have to ask: if we have a consistent approach that is working without us taking this protracted approach, why would we choose that?

Examples are always very good, and it does help the committee, particularly when we're talking about technology like that, rather than fax machines, Chair. Chair, do I have time for one final question?

Yes. You ask the question. Gill, did you want to come in on this point?

The very final point on what the CNO was saying. Having worked as a ward manager for many years, I was in a position where I had to set our establishment. It was pre Act, but it would have been an area that would not have been covered by the Act. What I did then, and I know ward manager colleagues do now, was look at the needs, look at the holistic needs of the people that we're looking after, and recognise that it's not all about the registered nurse or the nursing workforce. So, having occupational therapy, physiotherapy, both registrants and assistants, pharmacy technicians and pharmacists supporting care delivery is fundamental. If I was back as a ward manager now, that is how I would plan and staff my wards safely to ensure that people have the best outcomes that they can in NHS Wales. Thanks.

Thank you for that. It brings us onto my final point and the provision of the information from the Act, but also the information you've just shared there that is available to the public. We've heard there could be improvements in terms of the staffing levels of nurses and what's available to the public. Does the Welsh Government recognise that, and what improvements would the Welsh Government like to see on that topic?

I think we recognise that—. Look, I think this is important, it's part of the Act, and it's important that the public know what to expect on their wards. The visibility of that is important, and that was working quite well until COVID came along and then all the paper had to be taken down from the walls and everything. So, we're in the process of trying to get back to what it was like pre COVID. This is an area where I think a lot of work is now going to be done to try and get back to what they were doing pre COVID. But that visibility for the public, for me, is crucial. Sue, would you like to add to that?

Yes. I couldn't agree more, Minister, and I think that the disruption through COVID has unfortunately interrupted what was a very normalised process in displaying visible information to the public. We are very grateful to the RCN, who have noted in their recent visits that there is a persistent variation to the extent that sites have returned to a pre-pandemic standard of reporting. I have met with the executive directors of nursing, I've also instructed the all-Wales nurse staffing group to have oversight and monitoring of this. It is absolutely key and necessary that the public are fully informed of who their nurses are on the day and how their area is staffed, and so we will be working with our nurse staffing group to oversee the improvements to this. We will be looking at their data as they supply it.

I'm really sorry, just to press: when will that process be normalised again?

'As soon as possible,' I want to say. It has started in terms of me asking and seeking the assurance that this is in place. We do have variation, and so it is the areas where I have the variations that I will be addressing, and so I want to be able to give some assurance to this committee that this is really important and it will be as soon as.

Okay, diolch.

Thank you, Jack. Did you want to come in, Gareth, before I bring Mabon in?

Thanks, Chair. I just wanted to come back on the response you gave about Datix forms and some of the quality of data. Unfortunately, I'm getting old enough now to remember using the IR1 forms, which predated the Datix forms.

I've no idea what you're talking about, but some people do, so—[Laughter.]

But the Datix forms are nothing new; they're 10, 15 years old at least now, so why is it still the case that we're trying to improve data, when there is seemingly an electronic and universal way to report incidents and things happening on wards, et cetera?

Yes, and I do sympathise with you for having to use IR1 forms in the past—I did as well.

So, on incidents of harm that are captured through Datix, one would think it's simple, but because we've had differing systems across Wales for a number of years, it has meant that the capability within Datix 1 or Datix versions 2 or 3 has not been upgraded in a standardised way, and that has caused historical and legacy issues with the data capture. We are through the other side of that; as of April 2021, Datix Cymru is a standardised mechanism that we have. Everyone has the same system, everyone has the same definition, the data standards comply, everyone is collecting the same level of data, which enables us to have high validity in comparability of that data as well, which is what makes the difference. I don't know if Gill wants to come in on anything additional to that.

Just to add that there is integration with others, like our patient administration system and our electronic staff record systems. So, there's integration with our other digital system, which Jack will be really pleased to hear about as well. So, all of that is progressing.

Thanks.

Thank you. Mabon.

Yes, just to correct the record, I wasn't saying, by the way, that we need an Act saying that we have to have a certain number of nurses. I was saying that if we have an Act in place that states that we need a specific number of nurses in order to be safe, then there is a duty on the Government to put those nurses in place. We're still 2,700 nurses short in Wales, and while it's good to hear about the steps that have been taken, we still need to recruit an additional 2,700 nurses in Wales.

I pick up on the tone, maybe rightly or wrongly, that the three of you aren't the greatest fans of this Act. Would you accept, in looking back and knowing about the scandal that happened in Mid Staffs, the scandal in Cwm Taf with maternity, and Tawel Fan, even, that we won't see those kinds of scandals again in Wales as a result of this Act? That is, one of the successes of this Act, perhaps, is ensuring that those kinds of scandals are avoided in the future.

Well, I think what's important is that we understand that we have a way now of ensuring if something isn't done, that there is escalation, that process is in place. That did happen in Cwm Taf where they weren't in compliance with the Act, and that was part of the reason why they did go into enhanced monitoring and targeted interventions. So, there was a consequence to the fact that they weren't in compliance with the Act, and I think that that has given us an extra tool to try to ensure that we won't see that kind of Mid Staffs situation here in Wales.

So, to return to the initial point, you'd say that that's another success of the Act.

I don't want you to think that we don't think that this Act is important; it has been helpful. I don't think that this is the magic bullet.

No, fine. In terms of the 25A duty, stakeholders that have appeared before us have called for more clarity and guidance about the implementation of the broader section 25A duty. Do you agree that further guidance would be helpful and would support a more consistent approach to implementing 25A across Wales?

Well, I think that it is fair to say, in terms of the guidance, I don't think that we need to have more statutory guidance, but I am interested in seeing operational guidance still being developed. And I think that's where we come back to that kind of flexibility that we all want to see to respond to what's happening on the ground.

I don't know if, Sue, you'd like to come in on that.

Thank you. I just want to be clear about the stakeholders that have called for guidance on section 25A. It was one stakeholder from all that you heard from in the committee—and not to diminish that voice at all; it is important that we hear the voices of all the stakeholders. I just want to go back to when the Act was passed. The statutory guidance was deemed unnecessary for such a broad overarching duty. So, 25A is the broad overarching duty. And, in the health boards' evidence session in October, the nurse executive directors did not call for statutory guidance. In fact, what they said was that they are fully aware and cognisant of how to go above and beyond what is written in that very broad duty. So, they were quite confident in the utilisation of section 25A.

And the intention of section 25A is to safeguard against the utilisation in the 25B areas, where you would deploy nurses from other areas to meet the needs under 25B. So, that is the safeguard and that was the purpose of it. However, as the Minister has said, I would fully support that there is a need for operational guidance to support a consistent approach to how 25A is used. I don't believe that there's a fundamental lack of understanding, but I do think operational guidance would strengthen that approach.

And how do you monitor compliance with section 25A?

So, compliance is monitored quite clearly through the three-year duty under the Act, and they report through that, but there is an annual mechanism through the Act, at health board level, where they report against their calculations for 25B—not only for the 25B areas, but their duty to keep all areas safe.FootnoteLink And I think, in the evidence to committee in October, the nurse directors reported about their application of 25A, where they utilised it consistently on a daily basis through all of their areas.

Any non-compliance with these areas is very clearly set out in the Act's operational guidance. And, as the Minister has said, we have seen one case in Wales, which has been tested in the real world, where non-compliance with the application of 25A [Correction: '25B'] has been escalated through the joint escalation and intervention arrangements that have been in place since 2014. Those arrangements are with the Welsh Government, and we meet with Audit Wales and Health Education and Improvement Wales twice a year to discuss any emerging information on a number of statutory and other patient safety areas.

We have seen a health board that hasn't been able to be compliant with section 25A [Correction: '25B']. This has gone through the escalation process. The chief nursing officer then wrote a letter setting out quite clearly the expectation on that health board to comply with this. They were then escalated to targeted intervention for monitoring and oversight, and they did rectify that situation. So, from a non-compliance picture, I feel confident that the reporting on compliance comes through the annual reporting to health boards, and then we pick that up in the three-year reporting as well.

Thank you.

Thank you. Gareth Davies.

Thank you, Chair. I just wanted to raise the future development of the Act—indeed, if we still believe in it after the evidence that we've heard this morning—and how that expands to other areas. We talk a lot about in-patient wards in hospital settings, but what about mental health in-patient wards, health visiting, district nursing, to make sure that staffing levels are adequate across the services? We often talk about waiting times and potential blocks in the system, so what work is being undertaken to make sure that adequate staffing levels are achieved across the nursing spectrum and not just in a certain area?

Well, I think it's probably worth reflecting on the fact that the Act has been in place for a number of years now, and what we don't have is the full complement of staff. So, it hasn't actually led to a situation where we have all the staff we need. So, if that's what you expected from the Act, that's not going to—. It hasn't worked so far and it's not likely to, because there's this hole, which doesn't address the issue of workforce—

Has the Act failed, then, in that case?

Well, it never addressed the issue of workforce, and, as we've rehearsed, would an Act be the best place to address the issue of workforce? I just think, just a simple—

So, what's the point in the Act, then? If a law in place to tackle nurse workforce recruitment levels and things like that—

No, but the Act doesn't do that. That's the point. The Act doesn't do that, and the Act never intended to do that. What the Act did was to say, 'We need you to comply with this level of nursing requirement,' but it didn't tell you what to do if it was difficult to recruit. That wasn't something that the Act addressed. So, on the issue of extending the Act further, you're still going to have that problem.

Excuse my ignorance, but I'm struggling to understand here. We've got a Welsh policy here, passed by the Welsh Government in only 2016, which is only seven years ago. I know we've had COVID, as we noted, since then, but we've got you here this morning as the health Minister saying that a Welsh Government Act—

Well, hang on. This was not a Welsh Government Act, was it?

—isn't having the efficacy that it should do. So, I'm struggling to understand where we're going here in terms of—

Hang on. It was not, and it's really important, this—

—your belief of the Act, because I don't get the—

Gareth, you finish your question and then I'll come to the Minister. Finish your question.

I just don't believe from what we've heard and what you're continuing to say this morning that you have faith in your own system. Obviously, I understand that you weren't health Minister at the time, but your predecessors—. You've inherited that, so, as Minister now, is that something that you don't believe in, necessarily?

Can I make it absolutely clear? This was not a Welsh Government Act. This was an individual Member's Bill.

Which was passed by the Government—

Hang on. Minister, finish your contribution.

It was an individual Member's Bill. This was not an initiative that was brought by the Welsh Government. We responded to what the individual Member Bill put on the table, but I guess we wouldn't have started from here.

Right, okay. So, in terms of the detail of the question about how we expand the Act across the nursing spectrum now, and not just in-patient settings but across community district nursing, how do we best achieve that?

We're just saying we've been through all of that. We just don't think that the Act is the most effective way of addressing the issue that you're trying to address, and I think some of the examples that Sue gave earlier were about how there has been a fundamental reform in the way that we are staffing and dealing with nursing in the community—we're doing it through technology, through flexibility, through a multiprofessional approach, and none of that has needed legislation.

Right. Okay. I'll leave it there because I don't think what I'm hearing is—

Gill, I think, would like to come in here.

—a good reflection, really, but there we go.

Just one really positive aspect of the Act is that there is 25C, which is the prescribed method of calculation. So, that's a triangulated approach, whereby we look at the nurse staffing levels at the centre and, to inform that, we look at patient acuity, based on holistic, person-centred needs. We look at quality indicators, so harm that may come to an individual, and then the professional judgment. So, that, as a triangulated approach, is a really valuable way to consider the staffing requirement, but, again, even more valuable if you can consider outside of the uniprofessional approach to inform that triangulated approach to calculate. So, there's some really valuable work from the Act.

Mabon, you wanted to come in.

Just to come in on that, you, Gill, have stated twice that you think it would be better to consider other jobs and roles to make the patient safe—occupational health, you mentioned, and pharmacists and so forth. So, would you adapt the Act in order to include or enforce the inclusion of those roles? Do you think that the Act needs to be adapted to those ends?

So, as a nurse, as I've spent most of my life as a cancer palliative care nurse, I would say that's definitely something for the Minister around legislation. If it was as simple as that, I think—I would hope—that we would have considered that some time ago, but, please, Minister.

Making law is very, very complicated. You've seen us go through this. We've just been through the Health Service Procurement (Wales) Bill. It's complicated, it takes a long time, it takes a long time to hit the ground. When we know we can do it in different ways, why wouldn't we reach for the easier ways, the more flexible ways, first, rather than go through that whole rigmarole of creating and adapting an Act? Adapting an Act—. So, we did add to this Act, didn't we, because we brought in the paediatric wards, but that took two years. And, at the moment, as health Minister, we're in a really difficult, challenging time. This is just not where I would set my priorities at the moment.

Thank you, Minister. Can I add? So, when I came into Government from practice—. It's the nurse staffing Act. Can I just reinforce that that's the title? It's the Nurse Staffing Levels (Wales) Act. So, based on my experience, having come in, I asked, 'Why is it not the workforce staffing Act? Why is it "the nurse"?' So, I was told, 'It is nurse staffing, so you can't amend, you can't change, because that's law.' So, I did ask that when I came in, and I was told, 'No, it's not.'

You can't change the scope of the Bill. You can't retrospectively change the scope of a Bill; you'd have to start again.

Sorry, Sue wants to come in.

Thank you. And, I think, revisiting the Act for the future would be looking to rectify some real fundamental issues that have been highlighted to the committee today, and from the executive nurse directors. They talked about it being really difficult to implement the Act in this current landscape in a uniprofessional way. So, they are the experts who are living and breathing this legislation on a daily basis. Therefore, I am inclined to listen to the experts who are trying to make this legislation work, and they are telling us that, from a uniprofessional perspective, if we were to expand it and extend it into areas where we maintain the uniprofessional focus, it is incredibly challenging for them to deliver safe patient care.

Therefore, I think, if we were to really review and refresh and revisit this Act, it's conceivable that we would come out with a very different Act for the future. And that's on the Minister's timetable if that were to be the case. And it's not that we're suggesting the Act is not fit for purpose; it has clearly had its successes to this point. What we're suggesting is, for the future, if we want to safeguard our communities—and we really do, we want to deliver the best possible care we can—then we've got to deliver it in a sense that looks practically at what the patient needs. It's not simply a registered nurse and an unregistered nurse. That is not the way the patients flow through our system any longer. They require very complex, very different levels and layers of care. Therefore, we should respond to that in that way, if we can. And that would mean that it would require a very different Act for the future, rather than simply registered nurses and unregistered nurses.

Vikki Howells.

Thank you, Chair, and good morning, Minister, and your officials as well. I've got some questions around ICT infrastructure. Firstly, I'd like to ask whether the Welsh Government's assessment—. I'd like to ask about whether the Welsh Government has made an assessment of whether and where any gaps in digital infrastructure remain in terms of effectively delivering the requirements of the Act.

Thanks. So, this all gets into very technical areas, so, if you don't mind, I'm going to call on my colleagues here to help me out.

Of course, no problem at all. So, the two main sets of data, as I've said before, Vikki, that are key to a health board effectively discharging their reporting duties under the Act are data on the nurse staffing, on a shift-by-shift basis, and data, then, on the incidents of harm, where not maintaining the nurse staffing levels has been deemed to be a factor.

I'll just take us back a moment, because it's a fact that when the Act came into force, health boards were not equipped with the necessary ICT systems to effectively capture and collate the shift data on a day-to-day basis, and this was a concern that was raised by the health boards and Welsh Government officials during the Bill’s scrutiny process. So, Welsh Government have since acted to remedy this by investing in a once-for-Wales contract so that all health boards are using the same e-rostering software, and you'll know that that's called SafeCare. You may know that. It's a powerful ward management module that provides health boards with the platform they need to put all the necessary data on staffing levels in a nationally consistent format and in a far less onerous way than they were doing before. Welsh Government have also funded operational leads for each health board to ensure the smooth and consistent roll-out of this new software. And as of this summer, SafeCare will have been rolled out at all health boards wherever section 25B of the Act applies.

So, we have made an assessment. We have noted the position from where we started, which has been, I would suggest, a less progressive one. We've moved much further forward. And then there's data on incidents, which I talked about, on Datix Cymru, which I won't rehearse again, but I think we're in a much better place in the 25B wards, although I would say the staffing system does not apply in all the other areas, so you won't find, in mental health settings or community settings, which have now got a slightly different system, that they all have the same software available, Vikki. So, I think, when we talk about application of workforce tools into other areas, there is a fundamental consideration of the ICT that is available to help enable that visibility of the key data, to then make the right decisions on appropriate nurse staffing.

Thank you very much for that, especially your comments on the e-rostering system. I've previously seen some really good work around that with the Buurtzorg model, with district nurses in my constituency. But looking at the issue of connectivity as well, I know that this committee and other committees in the past—the Public Accounts Committee that I was previously a member of—we've all heard that more could be done to maximise the use digital technology, not just for rostering purposes, but also to enable nurses to spend as much time as possible on patient care, rather than having to fill in paper work, chase referrals, et cetera. So, can I ask: how much of a priority is this for Welsh Government? Because it does seem as though it could play an important role in releasing our nurses to spend more time with their patients.

Well, thanks very much, Vikki. I can assure you that digital modernisation of the NHS has been one of my priorities since I became Minister. So, I have only picked on about four or five things that I absolutely drill down on, because you just can't do everything. But this is one of the areas. So, I do have monthly meetings with my digital team, and we have invested significantly in digital health, £286 million from the digital priorities fund, since 2019. We've now got a digital officer for health, and we meet very, very regularly.

Anything digital in the NHS seems to be difficult is the truth of it. I was reading something last week about the terrible, terrible trouble, and the immense sums that they've spent in England on trying to roll out, running into billions and billions of pounds, and then junking it. It's just shocking how much is spent. So, we try and do things a bit more carefully. So, you will have seen things like the fact that, actually, we've got the NHS app now, but you may have noticed that we're not really shouting about it too loudly yet, because we want to make sure that it works really well before we really push it with the public. Losing people's confidence in anything digital is absolutely fatal, so you've got to get it right, and this is why we're taking it one step at a time. We test things, test things, test things. We're being very, very careful in relation to digital. And when we get there, we hope what we'll have will be an all-singing-all-dancing network. So, we are slightly slower than they are in England, there's no question about that, but when we get to where we want to get to, because we've taken such a long time to build the infrastructure, so that all of these different systems will be able to speak to each other, that is absolutely critical.

One of the key things that I think we should be really proud of and that has worked really well is the Welsh nursing care record. That's already been rolled out to 80 per cent of adult in-patient wards in Wales, and we hope that all of them will come on board by March next year. We know, for example, from one health board, that that saved over 1.3 million pieces of paper documentation; it's resulted in an annual saving of £132,000, and it has saved a considerable amount of time for those nurses. It's released them to be able to spend time with patients. So, there's some really good things going on, and that nursing care record is one of the great, great things that I think that we should be really proud of.

Thank you, Chair.

Thank you, Vikki. Mabon, do you have any questions?

Yes. If I could return, as one does, to the workforce, which is the important element here. We know that there was industrial action last summer, or before last summer, and that you reached some kind of agreement with the nursing workforce. Getting a workforce that is content in its work is vital if we're going to increase the number of nurses. We know that nurses are leaving their profession because they don't feel that the agreements work for them. Could you give us some assurance that the agreement that you've come to with the workforce is going to be respected, and when will it be implemented? Are we going to see nurses going down to 36 hours a week? Are we going to see flexibility in the agreements for nurses? Are they going to get continuing professional development within their agreements?

Certainly, that's what we've promised to do, and that's what we will ensure does happen. So, things such as flexibility for nurses, I think that that will be a game changer—hopefully that will be a game changer—so that we can attract more nurses to work in the NHS rather than work for agencies. I hope that that will change. We've done a lot of work with the RCN on ensuring that that is in place. We know that that's starting to make a difference, and even this year we will see a reduction in how much money is spent on agency nurses of £50 million, so a 15 per cent reduction. That's as we start down this route of trying to make this change that we have agreed with the RCN and others.

So, when will the 36-hour week, for example, be coming in?

Details on that—. I don't know where we are on that.

Do you know where we're at on that?

So, what we've agreed to do is to look and to explore the 36-hour week as part of the non-pay element of the deal. So, those discussions are in progress, but there's no date or agreement to reduce to a 36-hour week. There are many concerns raised by colleagues, particularly around educational development and the flexibility with longer days and a couple of hours a week to enable the development of the workforce. But, as the Minister said, the commitment is to agree to discuss and explore options around a 36-hour week.

However, on the retention, you would be aware that HEIW published the retention plan recently, and there are key actions around flexible working within those, including—. So, organisations are currently working on guidance, standards, resources as to how the flexible working will look, metrics, reporting, how many people are asking, how many requests are being granted, how that looks. But I think, as we came to committee last time, we were talking about the CNO priorities; we talked about if a registered nurse wants to work whatever number of hours, we would welcome it, and we would want our organisation to explore how we could utilise those really valuable registered nurse hours.

That 36 hours is absolutely crucial to the nurses that I've spoken to as part of the agreement. So, they're looking for assurances on that. There are no assurances as yet.

That it will be explored and discussed.

It'll be looked at, but it's not going to be implemented, necessarily. Continuous professional development and the right for nurses to train during their working hours—is that something that is solid going to be in the agreement?

It is. And, in fact, the Welsh partnership forum, within the last two weeks—either last week or the week before—had a presentation on the draft CPD, continuing professional development, and there was really positive feedback in the room from what's being proposed, through HEIW. So, an absolute commitment on supporting. It's really important in post that you get the development opportunities to enable you to do your job as well as you can do.

So, are you confident that the new agreement, once it kicks in, will allow nurses to stay in their professions and attract more nurses in, so that we can reach the safe staffing levels that we all want?

So, I think we're confident that these are some of the things that will go quite a long way towards attracting and retaining our workforce in the profession. I think this is an ongoing piece of work; I think we have to keep listening to our workforce. As things change and move, as we lose our seasons and we become one big winter that we're addressing the NHS through, we have to understand what it is our nurses want differently, about what our clinical professions want differently, and work to try and support them to do that. So, I think this will go quite a long way towards it; I don't think it is completely the whole answer.

And let's not forget, we've just reached that target of 40,000 nurses, so something is working here. Something is working. We're going in the right direction. I'd like to think we've got a good relationship with our social partners here in Wales, and it's the fact that that constant dialogue means that we have got a relationship where we can just keep building and responding. But there are financial constraints at the moment, let's be absolutely honest about this. There are limits to what we can offer.

I think it's also important that, as we pursue some of this work, we really think about those career pathways as well for nurses. Nurses are looking—for those who are looking to climb the career ladder, go into enhanced practice or advanced practice, we've got quite a lot of work that's ongoing within the Nursing and Midwifery Council—and Wales is well represented within that—undertaking a review of what's required for advanced practice. I think it's supporting those career pathways as well, so that nurses know they are valued and that their competence and expertise are seen to come to bear in the right places, really. So, there is something about—. And we look at background, this team around the patient concept. If we're going to train our nurses—and we do, we train them to such a high standard. They're degree-trained nurses with huge numbers holding Master's degrees and some holding PhDs, and then we're asking them to do absolutely everything in the workplace rather than looking at complementing that high-level skill set that we have in our nursing, and that doesn't detract from the fact that a nurse won't do or supervise—someone else who's doing a piece of work will be able to support it. But it is truly understanding the value of this workforce and then utilising them in the best way. So, both ways need to come to bear, Mabon, and I would like to see that for the future.

And, Mabon, can I just add to that? So, you said about what nurses are saying to you. What nurses are saying to us—and we listen and meet them; we have a really close relationship with nurses, at all levels in organisations—what they say is what's really important is support across the career. So, back when we registered, you might not have had really good support. You might've been given the keys on day one, and the expectation of what you do is very different to now.

So, the CNO has been leading a significant piece of work, looking at career-spanning support. So, how do we support nurses at that point of registration? Because we know if nurses leave the profession, it's within those first two years. So, how do we support them to transition from students to competent practitioners? And then how do we support them throughout their year, through restorative clinical supervision? So, we're currently working with our education leads across Wales to develop the education for supervisors and supervisees, and next year we will be publishing something around that on how we support, throughout your career. I'm passionate about nursing. I'm passionate about doing the right thing for the nurses and supporting them, and I know the Minister is passionate about that too. So, we all want the right workforce to meet the needs of our population. That's really important to all of us.

Thank you. We're just coming to the end of the session. I just want to, Minister, get any final comments from yourself, particularly, perhaps, a reaction to what I'm going to say, because what I've picked up through this session is that you're not a great fan of the Act. You can tell me if I've got that right or wrong, but that's the tone that I've felt throughout the session. And you said that the Act has been helpful, so you've recognised that, but you've also gone on to say that you wouldn't have started from here, in response to Gareth Davies. And I totally recognise, of course, that this wasn't Government legislation. This was a private Member's Bill, but it was supported by the Government, and at the time, Mark Drakeford, who was the health Minister, put in amendments and supported the Bill at the time. So, the Government at the time, and the now First Minister at the time, supported the Act at that time. Have I summarised that right, in terms of that you wouldn't have started from here? So, where would you have started from?

Well, I think there have been some really positive things to come out of this Act, so I don't want it all to sound negative. I think it's enhanced the status of nurses, in particular, in the wards. It's given them status, it's given them clout, and it's empowered them in relation to other executives, and I think that's a great thing.

I think that—. I hope what you've heard today is that there are alternative mechanisms to achieve the outcome that we're all interested in. So, how do you achieve safe staffing levels, not safe nurse staffing levels, but how do you get that correct mix around the patient that releases the expertise of the nurses, but also allows others to contribute to support those nurses on those wards? I think the fact that we can tweak, we can be flexible, you can change operational guidance, the fact that we've seen how constructively nurses have responded within communities to what needs to be done—I think all of those things demonstrate that there are alternative models to legislation to achieve the outcome that we're all interested in.

It sounds, to a point, though, that you're saying the Act's had its day, and we've got a new day now, and now the Act is perhaps no longer the right Act to be in place going forward.

We will make this Act work.

Okay.

We will work with the Act and we will make it work. I think what we're not interested in doing is spending a whole lot of time adjusting the Act, changing the Act, enhancing the Act, because none of those things are simple. Those things take time, they're expensive, they're complicated, and at the moment I think there are other issues in the NHS that need our pressing attention. And if there are alternative mechanisms for us to get there, then I'd rather explore those.

Am I right to say you're not a fan of the Act, but you're going to make it work?

I think that would be fair.

Okay. That's a note to close on, of clarity. Thank you, Minister. Can I thank you for your time, Minister, and can I thank Sue as well, and Gill? Thank you for your attendance as well, and I hope you do have some time over Christmas to relax as well.

No, no, this is our busiest time now, isn't it?

Is it?

We're stepping up now. You all have a nice Christmas, we're just about to set off. [Laughter.]

Sorry, I do apologise, Sue and Gill, the Minister has said that you're going to be busy over Christmas. [Laughter.] But take care. Thank you very much. Diolch yn fawr iawn.

Thank you. Diolch.

Thank you.