central manchester university …. agenda item 9.2 - bod...central manchester university hospitals...

Agenda Item 9.2

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

Report of: Chief Nurse - Cheryl Lenney

Paper prepared by: Director of Nursing - Dawn Pike, Head of Nursing (Workforce) - Anne-Marie Varney

Date of paper: August 2017

Subject: Safer Staffing – To provide the Board of Directors with the bi annual Nursing and Midwifery Safer Staffing report

Purpose of Report:

Indicate which by • Information to note

• Support

• Resolution

• Approval

Consideration of Risk against Key Priorities

(Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust’s strategy in a risk aware manner) 1. Patient Safety 2. Patient Experience 3. Productivity and Efficiency

Recommendations:

To note the work that is being undertaken to ensure provision of a nursing and midwifery workforce to support evidence based nursing and midwifery establishments.

Contact:

Dawn Pike Director of Nursing 0161 276 8862

of 21

Agenda Item 9.2 Executive Summary 1. Introduction

1.1 This paper provides the bi annual comprehensive report to the Board of Directors on Nursing

and Midwifery staffing, which is mandated by the National Quality Board (NQB) guidance issued in November 2013.

1.2 The Board of Directors received a paper in March 2017 outlining the Trust’s position at the end of January 2017, against the NQB standards, detailing the analysis and associated recommendations from the triangulation of the acuity and dependency census data to current nursing and midwifery establishments.

1.3 The paper also describes the numbers of Registered Nurse and Registered Midwife vacancies across the Trust and the continued efforts made to retain staff whilst actively recruiting both in the UK and international market.

1.4 Nurse staffing is currently detailed as a risk on the Trust risk register with a score of 9, having been reviewed in May 2017 from the original high level risk score of 16. The risk is reviewed on a monthly basis as part of the governance and monitoring processes.

2. Current Position

2.1 At the end of June 2017, there were a total of 442.2wte (9.9%) qualified Nursing and Midwifery vacancies within the Trust compared to 350.95wte (7.9%) in January 2017. The majority of vacancies are within the staff nurse (band 5) workforce. At the end of June 2017 there were 346.3wte (14.9%) staff nurse (band 5) vacancies across the Trust compared to 227.5wte (9.9%) at the end of January 2017.

2.2 There has been an overall increase in the establishments in April 2017 of 41.01wte to support additional capacity requirements planned in the Divisional capacity plans in 2016/17 in the Division of Surgery and Royal Manchester Children’s Hospital. Taking this increase into consideration the actual number of nurse and midwifery vacancies has increased by 1.1% (50.24 wte) since January 2017.

2.3 Since April 2015 as a result of investment from business cases to support service

development and additional activity, the overall nursing and midwifery establishment has increased by 163.86 which is a 4.1% increase.

2.4 In the January 2017 paper, it was predicted that vacancies would rise during June – August

2017. This predicted rise is as a result of workforce supply during these months, whilst providers await graduates completing programmes of training in September/October, as well as the reduction in EU nursing staffing applying to work in the UK.

2.5 Further investigation of the rise in vacancies demonstrates that since April 2017, the overall number of qualified nursing and midwifery staff in post has remained unchanged, which is a positive indication that staff have gained promotions from Staff Nurse (band 5) roles, rather than leaving the Trust.

of 21

Agenda Item 9.2 2.6 Trust wide recruitment campaigns continue to attract newly qualified nurses and midwives

who will graduate in September/October 2017. There are a total of 285 nursing and midwifery staff with job offers with a confirmed start date September – October 2017. The band 5 staff nurse vacancy rate is predicted to be 9.7% following the intake of newly qualified starters in October 2017, taking into account predicted attrition of 10%.

2.7 Based on the analysis of previous years it is anticipated that will be approximately 10%

attrition from this cohort of staff. Whilst these staff are progressing through the pre-employment recruitment process managers are keeping in touch with candidates to reduce the likelihood of them withdrawing from the process or accepting an offer with another healthcare provider.

2.8 A total of 32 International nurses have commenced in post since January 2017, with a further 20 nurses predicted to arrive before the end of November 2017.

2.9 The workforce modelling undertaken in April 2016 and reported in March 2017 predicted that by June 2017 the band 5 vacancies to be 243.3 wte. The workforce modelling has been revised due to a reduction in band 5 nurses commencing in post between January and March 2017. The reduction in nurse starters is due to reduction in the supply of EU nurses post Brexit and following the NMC introduction of language testing for EU citizens in January 2017. Prior to these changes the Trust recruited an average of 5-6 EU nurses per month, since January no nurses have been recruited by NHSP as part of our EU recruitment programme.

2.10 In line with recommendations from NHS Improvement the Trust triangulates the staffing levels, with nurse sensitive clinical outcome indicators and patient experience indicators. These reports are provided to the Quality Committee and Board scrutiny is provided through the Quality and Performance Scrutiny Committee.

2.11 The Board of Directors is asked to receive this paper, which provides an update on the Nursing and midwifery workforce position and to note the actions taken to recruit and retain the appropriate number of staff to provide safe care to patients and service users.

of 21

Agenda Item 9.2 1. Introduction 1.1 This is the bi-annual, comprehensive report provided to the Board of Directors on Nursing

and Midwifery staffing detailing the Trust’s position against the requirements of the National Quality Board (NQB) Safer Staffing Guidance 20131, NQB Guidance 20162 and the National Institute of Health and Care Excellence (NICE) guidance issued in July 20143, for adult wards.

1.2 This paper provides the outcome of the analysis of the Safer Nursing Care Tool (SCNT)4

acuity and dependency data collected daily and the actions taken to address any areas highlighted which is as a result of an analysis of this data.

1.3 The paper also provides the nursing and midwifery workforce position as of the end of June

20175 and the continued efforts made to retain staff whilst actively recruiting both in the UK and international market.

2. National Context 2.1 Since the publication of the Francis Report and reviews undertaken by The National Institute

for Health and Care Excellence (NICE) and National Quality Board (NQB) guidance there has been; an increased demand for Registered Nurses in the UK resulting in a requirement of an additional 24,000 full time equivalent (FTE) new nursing posts between 2012 and 2015, an increased demand of 8.1% for Registered Nurses (Health Education England (HEE) Workforce Plan 2016)6.

2.2 This increased demand is against a background of a reduction in national commissions for

nurse training places since 2013 and therefore makes maintaining safe staffing levels a challenge for all healthcare providers.

2.3 The number of Nursing and Midwifery staff within the UK, joining the NHS since 2012 has

increased from 6.7% to 9.7%7, which is mainly as a result of organisations increasing staffing levels in response to the Francis Report and the subsequent Safer Staffing Guidance issued following this report. During this same period the number of leavers from the NHS rose, from 7.7% in 2012 to 8.6% in 2015, mainly due to retirements and staff leaving the profession due to competitive agency rates and limited job satisfaction. Growth to the NHS nursing and midwifery workforce over the last 5 years has therefore been unremarkable with a marginal increase of 1.1%. The number of nurses leaving the NMC register has for the first time in many years exceeded the number of nurses joining the register resulting in an overall drop in the number of nurses able to practice8.

2.4 Graph 1, taken from the HEE Workforce Plan 2016, illustrates how NHS funded demand for nursing staff increased year on year between 2012 and 2015 and the widening gap between

1 How to ensure the right people, with the right skills, are in the right place at the right time. National Quality Board November 2013 2 Supporting NHS Providers to deliver the right staff, with the right skills in the right place at the right time. National Quality Board, July 2016 3 Safe staffing for nursing in adult in patient wards in acute hospitals July 2014 4 The Safer Nursing Care Tool. The Shelford Group/AUKUH. (2014) 5 June 2017 position provided as this is the most up to date position at time of writing report 6 HEE Workforce Plan 2016 7 The labour market for nurses in the UK and its relationship to the demand for, and supply of, international nurses in the NHS. Institute for Employment Studies. 2016 8 NMC and Chief Nursing Officer for England Briefing July 2017

of 21

Agenda Item 9.2 2015 workforce planning submissions to HEE will continue to rise and there will continue to be a predicted tension between supply and demand.

Graph 1: Increased demand for nursing staff 2012 to 2015

2.5 The consequence of this rapid growth in demand for Registered Nurses has resulted in a

national workforce shortage across the UK, which is estimated to currently be circa 26,000 nursing vacancies, which represents 8.5% of the overall NHS funded establishment for nurses and midwives.

2.6 In 2014 HEE increased the number of annual nurse training commissions nationally by 4%.

Whilst this will provide a supply of additional Registered Nurses from autumn 2017 onwards, Graph 1 demonstrates that this will not address the current and predicted 3 year workforce supply deficit up to 20199.

2.7 In April 2016 following a review by the Migration Advisory Committee the Home Office

confirmed that nursing would be added to the ‘shortage occupation’ list for a period of 3 years. As a result this enables the Trust to obtain Certificates of Sponsorship for non EU migrant nurses to support the workforce requirements. The Trust has undertaken a further recruitment campaign in India in November 2016, appointing 100 nurses who, following Nursing and Midwifery Council and UKVI approval will commence in the Trust during quarters 3 and 4. The first of these nurses are expected to arrive from September 2017 with cohorts of 5-10 nurses arriving each month thereafter.

2.8 The Carter productivity and efficiency report10 and the NHS Five Year Forward View11

planning guidance report identified significant and unwarranted variation in cost and practice

9 HEE Workforce Plan 10 Lord Carter final report Feb 2016 11 Five Year Forward View. NHS England. October 2014

of 21

Agenda Item 9.2 within workforce budgets recommending workforce and financial plans must be aligned to optimise clinical quality and the use of resources. The report highlights the need to address the variation in how acute Trusts currently manage staff, from annual leave allocation, shift patterns and flexible working through to using technology such as e-rostering systems to enable the productive use of staff resources, care quality, and financial control.

3. Trust Workforce Position 3.1 The previous report to the Board of Directors in March 2017 detailed the Nursing and

Midwifery workforce position as at the end of January 2017, showing an overall qualified Nursing and Midwifery vacancy rate of 9.9% (350.95wte), with a staff nurse (band 5) vacancy rate of 14.5% (227.5wte).

3.2 At the end of June 2017, there were a total of 442.2wte (9.9%) qualified Nursing and

Midwifery vacancies within the Trust compared to 350.95wte (7.9%) in January 2017. The majority of vacancies are within the staff nurse (band 5) workforce. At the end of June 2017 there were 346.3wte (14.9%) staff nurse (band 5) vacancies across the Trust compared to 227.5wte (9.9%) at the end of January 2017. Appendix 1 provides a detailed breakdown of the workforce position by ward/clinical area, as at the end of June 2017. This breakdown does not take into account candidates with job offers who are due to commence in post over the next few months.

3.3 The majority of vacancies within Nursing and Midwifery are within the staff nurse (band 5)

role. At the end of June 2017 there were 346.29wte staff nurse (band 5) vacancies across the Trust compared to 227.5wte at the end of January 2017. This is an increase of 118.8wte since January 2017 staff nurse vacancies across the Trust and a vacancy rate of 14.9%.

3.4 There has been an overall increase from April-June 2017 to the Nursing and Midwifery

establishments of 41.01wte to support additional capacity in the Division of Surgery and Royal Manchester Children’s Hospital. Taking this increase into consideration the actual number of nurse and midwifery vacancies has increased by 1.1% (50.24 wte) since January 2017.

3.4 As a result of investment from business cases to due to increasing acuity and dependency,

service expansion and additional activity, since April 2015 the overall nursing and midwifery establishment has increased by 163.86 wte, which is a 4.1% increase.

3.5 Whilst there has been an increase in line with predictions, in the vacancy position since

January 2017, it was identified in the previous paper that vacancies were predicted to rise between June-August 2017. This predicted rise is as a result of workforce supply during these months, whilst providers await graduates completing programmes of training in September/October each year.

3.6 Further investigation or the rise in vacancies demonstrates that since April 2017, the overall

number of qualified nursing and midwifery staff in post has remained unchanged, which is a positive indication that staff have gained promotions from band 5 roles, rather than leaving the Trust.

3.7 Trust wide recruitment campaigns continue to attract newly qualified nurses and midwives

who will graduate in September/October 2017. There are a total of 285 nursing and midwifery staff with job offers with a confirmed start date September – October 2017. The

of 21

Agenda Item 9.2 band 5 staff nurse vacancy rate is predicted to be 9.7% following the intake of newly qualified starters in October 2017.

3.8 Based on the analysis of previous years attrition, it is predicted that approximately 10%

attrition from this cohort of staff. Whilst these staff are progressing through the pre-employment recruitment process managers are keeping in touch with candidates to reduce the likelihood of them withdrawing from the process or accepting an offer with another healthcare provider.

3.9 Taking into account attrition in terms of new starters, the band 5 vacancy is predicted to reduce from the current 14.9% to 9.7% in October 2017.

3.6 A total of 32 International nurses have commenced in post since January 2017, with a further 20 nurses predicted to arrive before the end of November 2017.

3.5 The workforce modelling undertaken in April 2016 and reported in March 2017 predicted that by June 2017 the band 5 vacancies to be 243.3 wte. The workforce modelling has been revised due to a reduction in band 5 nurses commencing in post between January and March 2017. This reduction in nurse starters is owing to the poor uptake of substantive posts by EU nurses initially recruited through the NHSP recruitment campaign, the significant reduction in applications from the EU post Brexit and following the NMC introduction of language testing for EU citizens in January 2017.

3.6 Graph 2 demonstrates the actual and predicted workforce position for band 5 roles until December 2017. This modelling has been adjusted to remove the supply of nurses from the EU, which has resulted in the change in the predicted position when compared with the position reported in the previous report. It had been predicted in the modelling presented in January 2017 that there would be an EU workforce supply of approximately 10 nurses per month. Post Brexit and the NMC introduction of language testing for EU citizen this workforce supply has completely ceased.

3.7 Members of the Board should note that the number of band 5 staff in post in 2017/18 is

significantly improved when compared with the same period in 2015/16 and has not deteriorated given the increase in funded establishments during the period.

Graph 2: Actual vs. predicted workforce position (band 5) until December 2017

of 21

Agenda Item 9.2 3.7 Graph 2 shows the predicted decrease in the number of band 5 vacancies over Quarter 3

2017, with the predicted position at the end of December 2017 being 273.3wte vacancies, which equates to a 11.7% vacancy rate.

3.8 Retaining staff is a key element of addressing the workforce position. At the end of June

2017 the rolling 12 month turnover rate for staff nurses (band 5) has reduced further to 18.8%, which is a 1% reduction since January 2017.

3.9 A revised Nursing and Midwifery Retention Strategy was launched in July 2017. The

strategy continues to focus on continuing to reduce the Nursing and Midwifery turnover during the next 12 months in order to achieve a maximum of a 15% turnover rate.

4 Midwifery Workforce Position

4.1 The successful recruitment program from 2016 has generated a much reduced vacancy

position at the end of May 2017. The WTE for midwifery is current set at 341.47 against which there is an actual vacancy position of 5.37 wte

4.2 The SMH has therefore adopted the same approach for the 2017 recruitment plan. The open

day held in May was extremely successful with over 100 interested applicants for midwifery positions against which currently 50 offers have been made. The aim is to attract Midwifery students who qualify in September 2017 and to enable recruitment to turnover to take place. The Division has data which suggests turnover of 3wte midwives per month and as such a total of 46 wte candidates have been offered posts to maintain full establishment by March 2018.

4.3 In April 2017, work was commissioned by the Chief Nurse to develop a maternity workforce

strategy for the next 2 years, incorporating new roles and ways of working to support an integrated service model across Manchester. The first phase of this work has commenced to review the midwifery workforce in relation to activity across SMH along with partnership working to support the stabilization plan at North and the planning of the new workforce for the new organisation following merger with UHSM.

5. Planned versus Actual Staff on Duty 5.1 In line with the NQB requirements the Trust publishes Nursing and Midwifery staffing data on

a daily basis at entrances to wards, using ‘data at the door’ poster boards. Staffing data is also submitted on a monthly basis through a Unify submission to the NHS Choices site and published on the Trust’s website.

5.2 Graphs 3 and 4, illustrate the number of wards achieving 90% planned staffing levels for the

January 2017 to June 2017 period.

of 21

Agenda Item 9.2 Graph 3: Number of wards achieving 90% planned vs. actual - Registered Nurses and Midwives (n=53 ward areas)

Graph 4: Number of wards achieving 90% planned vs. actual Nursing Assistants (n= 53 ward areas)

5.3 Over the six month period since January 2017, the number of wards achieving registered

staffing levels above 90% has reduced marginally for both the Day and Night shifts. In January 51 areas achieved above 90% staffing levels during the day, whereas in June 2017 it was 47, with 39 areas achieving above 90% staffing on nights compared to 34 units achieved the 90% target in June 2017. This slight decrease has been seen across Divisions where there has been additional nursing demand to support winter escalation capacity or additional elective activity (i.e. DMACS, SMS and Surgery).

5.4 Whilst there has been a minor reduction in the number of areas achieving the 90% target

over the past 6 months, for planned staffing for day shifts demonstrates a significantly improved compliance with the target when compared to 12 months ago with an increase of 20 wards/units achieving above 90% staffing levels during the day shift.

5.5 There has been a slight improvement in the unregistered staffing levels with the number of

units achieving above 90% staffing levels since January 17 increasing marginally from 46 (Jan-17) to 47 (Jun-17) on the days. There was a more significant improvement on night shifts with an increase from 31 (Jan-17) to 37 (Jun-17) wards meeting the 90% position.

0

20

40

60

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

Number of units above 90% for actual staffing levels vs planned for registered staff

Reg Day > 90% Reg Day < 90%

0

20

40

60

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

Number of units above 90% for actual staffing levels vs planned for unregistered staff

Unreg Day > 90% Unreg Day < 90%

of 21

Agenda Item 9.2

5.6 Established daily reviews of staffing requirements by senior Nursing and Midwifery staff and escalation processes are in place to mitigate the impact of when planned staffing levels are not achieved and ensure the safe delivery of care. These processes are currently subject to a review by the Directors of Nursing on a weekly basis.

6. NICE Requirements 6.1 The following are core requirements to be reported in the Safer Staffing Bi Annual report,

stipulated by the NQB and the NICE guidance for adult in-patient areas.

Red Flags 6.2 NICE guidance recommends Trusts have a mechanism to capture ‘red flag’ events. Red flag

events can be defined as events that prompt an immediate response by the Registered Nurse in charge of the ward on a given shift to ensure there is sufficient staff to meet the needs of the patients on the ward.

6.3 Since January 2017 to date 244 red flag events have been raised. Of the 244, 97% (239)

were recorded as a ‘shortfall in RN time’, which is consistent with the data captured in relation to planned staffing levels. The remaining red flags were recorded across a number of other reasons:

Delay in Providing Pain Relief 3 Missed ‘intentional rounding’ 2

6.4 These events were mitigated in real time through interventions by senior nurses in line with

the Nursing Staffing Escalation Process to enable the delivery of safe and effective patient care.

6.5 Work is planned during quarter ¾ 2017/18 to review and refine the red flag reporting

process, aligning this across the Single Hospital Service. This work will include the introduction the functionality within the system to capture the actions taken in real time when a red flag is raised by the ward team. This will provide further assurance that the staffing escalation processes in place mitigate the impact of any red flag events.

Acuity and Dependency

6.6 In line with NQB and NICE requirements, the Trust has used the Safer Nurse Care Tool

(SNCT) since 2012 bi-annually, with data collected daily since May 2015 through the Allocate E-Rostering tool.

6.7 The SNCT tool does not differentiate between qualified and unqualified staff hours; therefore

the analysis requires a very good understanding of the patient population and nursing requirements. Professional judgment is acknowledged as an important factor to be considered when making decisions about staffing establishments.

6.8 Evidence suggests that a minimum of 4 census periods across both winter and summer

periods to identify any seasonal variation, are required before adjustments to establishments are made based on the SCNT recommendation.

of 21

Agenda Item 9.2 6.9 The tool also requires that between census periods there are no significant changes in ward

environment or patient case mix as both of these factors impact on the validity of the census information.

6.10 It should be noted that the tool is not designed to capture acuity and dependency data from

wards with less than 16 beds, day case areas, maternity areas or departments such as emergency departments and critical care units, therefore these areas are excluded from the data collection process.

6.11 The Shelford Chief Nurse group commissioned a programme of work in June 2016 to

support the benchmarking of acuity and dependency across Adult Emergency Departments. The Trust has engaged in this work stream submitting data collected in November 2016 and the Trust received the initial data for review in February 2017. Analysis of this initial data demonstrates that in terms of quality of care provided in the Adult ED the Trust is above the national average and is in the top three when compared to the Shelford Group. In terms of staffing, the data identifies a high level of direct care time (60.4%) and staff to patient ratios which sit at the medium position. The Trust is currently waiting for the final report from this work which is expected at the end of 2017.

6.12 In the absence of NICE validated tools for use in the community setting, the Shelford Chief

Nurse Group is currently developing a programme of work to review and pilot community workforce tools within adult care settings. The Trust is involved in this programme of work to

explore how the lessons learned at Sheffield Teaching Hospital NHS Foundation Trust to implement a caseload tool into their IT system (System one) can be utilised in developing a similar tool with the introduction/phasing of an Electronic Patient Record using EMIS within Adult Community Services at CMFT. This is a complex programme of work, which it is anticipated will take 12 months to develop and implement.

6.13 NICE guidance[1] was produced in January 2015 which suggested that maternity wards

should be utilising an acuity and dependency tool to assess staffing requirements when caring for post-natal women. The Royal College of Midwives (RCM), who support the project for Birth Rate Plus, which assesses acuity and dependency during intrapartum care developed a tool for assessing the acuity of women receiving inpatient care in wards. St Mary’s Hospital was involved in the pilot of this tool on the two post natal wards in early 2017 and has been participating in the finalisation of the tool. The tool is planned to be launched at the Royal College Midwives conference at the end of October 2017.

6.14 The lead for the development of Safer Staffing Guidance moved to NHS Improvement from April 2016 from NICE. In the past 6 months NHSI have consulted on guidance for District Nursing Services and Maternity Services. The Trust responded to the consultation on the guidance for District Nursing services in April 2017 and the Maternity consultation in August 2017. As yet NHSI have not provided any indication as to the timescale or the next steps for providing this guidance.

Analysis of Acuity and Dependency Data

6.15 The SNCT data collected provides information for 36 inpatient areas, based on the current

configuration of wards, all of which have been monitored monthly since May 2016.

[1] NICE Maternity guidance 2015 of 21

Agenda Item 9.2 6.16 There are 16 areas which have been excluded, as these have a mixed day case and

inpatient case mix, are less than 16 beds or are new ward environments (i.e. previous CPE isolation ward).

6.17 Within DAMCS the newly opened Manchester Ward has been excluded as the acuity and

dependency tool is not validated for use within this patient care setting. The establishment for this area has been agreed with the Chief Nurse and informed by professional judgement.

6.18 Since May 2016, the acuity and dependency data is analysed on a monthly basis, which will

ensure that the required four census periods to validate the establishment is available at the end of each quarter. It will also be possible to review trends in terms of the acuity and dependency recommendations provided by the SNCT to understand the impact of seasonal variation or changes to patient case mix.

6.19 An analysis of acuity and dependency profiles against establishments for wards has been

undertaken by the Directors of Nursing with the Divisional Heads of Nursing for any ward areas with four or more valid census periods.

6.20 Within the Division of Medicine and Community Services, there are eight wards where

SCNT data is collected. Of these the census data for 5 ward areas confirms that the current establishment are appropriate to meet the requirements of the patients.

6.21 The acuity and dependency data for Wards 7 (previously Ward 5), 45 and 46 provides

evidence that there is a case for an increase in establishments for these ward areas. A staffing requirement supported by the Chief Nurse and developed by Divisional Management Team, has been approved in principle by the Director of Finance to uplift the nursing assistant establishment by 29.90 wte across the 3 wards. A recruitment campaign to support this uplift has focused on attracting support staff interested in working with frail elderly patients with dementia and it is anticipated that these additional staff will commenced in post in the autumn. Following appointment to these posts, the current run rate pressure in these wards due to use of temporary staffing will cease.

6.22 Whilst the process of recruiting to the required staffing needs, patient care has not been

compromised in the above wards as the wards have used temporary staff to provide additional nursing support as identified for patient need. However, this additional staffing requirement to deliver patient care needs, impacts negatively on the pay spend within these ward areas and the overall Nursing and Midwifery run rate.

6.23 There are eight wards within the Division of Specialist Medical Services where SNCT data

is collected and available for review. The SNCT data for Wards 36 and 37 validates the establishment as being appropriate for the patients’ needs. The census data for the remaining ward areas within the division have been affected by changes made to patient case mix and reconfiguration of services, with establishments in these areas being agreed with the Chief Nurse, informed by professional judgment.

6.24 Changes to the AM3 bed base in December 2016 resulted in this area increasing the number

of gastroenterology beds by 10. Work has been undertaken to reconfigure the establishment for AM3 and AM4 as a result of this change as part of annual budget setting process. The changes to the establishment will be validated on an on-going basis through the acuity and dependency census data.

of 21

Agenda Item 9.2 6.25 The SNCT data for wards 44 (Haematology) and the Acute Cardiac Unit does not reflect the

complexities of these clinical areas or the fact that the Acute Cardiac Unit is a mixed critical care and inpatient area. The data is valuable in terms of providing details of patient dependency on a daily basis, but cannot be used to inform decisions in terms of establishment levels. Wards 3 and 4 have had changes to patient case mix and are now managed as two separate units, therefore further analysis of the monthly acuity and dependency data over four census periods (summer and winter months) will be undertaken by the Head of Nursing and Director of Nursing, and these establishments will be validated with the Chief Nurse in quarter 4.

6.26 There are seven wards within the Division of Surgery where the SNCT census data is

available. The SNCT data for wards 9/10, 11/12 (double lobby wards) and 8 validates the establishment as being appropriate for the patients’ needs.

6.27 Following a change in case mix a review of the ESTU establishment requirements was

commissioned by the Chief Nurse. To support this review the acuity and dependency census data was reviewed including incidents and nurse sensitive indicators. As ESTU is currently a combined orthopaedic inpatient area and Surgical Receiving Unit the SNCT data only identifies the requirements for the orthopaedic in patient area, and does not provide validated data for the receiving unit requirements due to the high volumes of patient activity which takes place through the Surgical Receiving Units. The review has recommended an increase to the nursing establishment for ESTU as a result of patient dependency, and a statement of need is currently being considered by the Director of Finance to support this requirement. In the interim, the care needs of the patients are being supported by the use of temporary staffing, maintaining safety, but has an impact on the financial position within the Division.

6.28 The Head of Nursing and Director of Nursing have also undertaken a review of the staffing

requirements for the Head and Neck Surgical unit, due to an increase in the acuity of the patients cared for within this area. Until May 2017 the acuity and dependency census for this area was amalgamated with the Vascular Unit as these two areas had been managed as one ward. This has meant this data could not be used to support the review and professional judgement, supported by evidence has been used as the basis for the review. The review has recommended an increase to the nursing establishment due to the acuity and dependency of the patients, which is currently being considered by the Director of Finance. In the interim, the care needs of the patients are being supported by the use of temporary staffing, maintaining safety, but has an impact on the financial position within the Division.

6.29 The remaining ward (ETC/Urology ward) has undergone significant changes over the last 18

months in regards to service configuration and case mix to support the Divisional work on reducing length of stay. This has included the move of the urology patients from ward 9 & 10 to ETC and the transfer of Hepatobiliary Services to the Division.

6.30 A review undertaken by the Director of Nursing and Head of Nursing to reconfigure

establishments based on the service changes and additional beds required to delivery elective activity targets, has resulted in the budgets being aligned with the required staffing resource. In June 2017 an additional 20 wte nursing posts were added to the establishments to enable recruitment of staff to support capacity increase which had been made to manage the activity without the corresponding adjustment to the nursing establishments.

of 21

Agenda Item 9.2 6.31 Within the Trafford Division there are seven ward areas where SCNT data is collected to

inform daily staffing requirements and validate establishments. The data to date demonstrates that the establishments for 4 areas can be validated from the SNCT censuses (Wards 1, 2, 4, and AMU). The SCNT data for the INRU unit does not capture the dependency and complexity of the patient group resulting in inconsistent results. The current establishment has been agreed with the Chief Nurse using professional judgement and benchmarking with other similar units to meet the needs of the patients. It is planned over the next 6 months to undertake further work with the Head of Nursing to ensure that as this service expands the SCNT tool can be used effectively to capture the acuity and dependency of this patient group.

6.31 The acuity and dependency data demonstrates that the establishment for ward 6 does not

currently meet the recommendations. Analysis of the 12 months data for this area indicates that a recommended establishment of 45.22 wte is required, which is 8.2 wte above that currently agreed establishment for the ward. This is mainly due to the complexity of the patient group cared for in this area, with a number of these patients requiring enhanced supervision to maintain their safety and the safety of other patients. As a result the Director of Nursing has reviewed the acuity and dependency data and a statement of need, recommending an increase in the nursing assistant establishment to enable an increase in nursing assistants on late, night and weekend shifts has been developed and is currently being considered by the Director of Finance. In the interim, the care needs of the patients are being supported by the use of temporary staffing, maintaining safety, but has an impact on the financial position within the Division.

6.32 The Manchester Orthopaedic Centre (MOC) establishment supports both day case and

inpatients and therefore the SCNT data can be used on a daily basis to inform staffing decisions, but not to inform the establishment requirements. The establishment for this agree has been agreed with the Chief Nurse and is based on professional judgement

6.33 The acuity and dependency data collection and analysis using specific paediatric acuity and

dependency multipliers, is within five wards areas (Wards 75, 77, 78, 84IP and 85) in the Royal Manchester Children’s Hospital. Analysis of the data demonstrates that the SNCT data recommendation continues to differ from the current establishment, with recommendations being above current establishments. The Head of Nursing for RMCH has undertaken a benchmarking exercise with four other Children’s Hospital which has identified that there are currently three acuity and dependency tools utilised. As there are currently no NICE or Safer Staffing guidance related to Children’s services, a programme of work will commence to undertake an in depth review of the three tools available in order to identify the most appropriate tool to provide the information required to support evidence based staffing establishments. Staffing establishment within RMCH are currently based on professional judgement, agreed with the Chief Nurse.

6.34 The use of the SNCT tool within the Saint Mary’s Division is limited to the speciality of

gynaecology. The SNCT tool is not validated for use in midwifery services; the recommended birth rate plus tool12 is used for midwifery services and Saint Mary’s Hospital establishment is at the appropriate ratio of 1:28. Provision of care on the gynaecology ward (62) includes care of day case, emergency and in patients, which invalidates the data collected via the SNCT tool. The establishment is therefore based on professional judgement, agreed with the Chief Nurse.

12 Birthrate Plus (2010). ‘Birthrate Plus: Workforce planning for midwifery services’. Birthrate Plus website. Available at: www.birthrateplus.co.uk (accessed on 21 February (2011)

of 21

Agenda Item 9.2 7. Care Contact Time 7.1 The NQB require that care contact time is collected twice a year and reported annually to the

Board of Directors. The Trust collects this information in January and July to report to the Board in September. The data is collected by ward areas as part of their local improvement work.

7.2 There are no targets set nationally for care contact time although it is widely assumed that

more Registered Nurse direct care results in better outcomes for patients. The results for 2017 will be shared with members for the Board through the Quality Committee report in September 2017.

8.0 Care Hours Per Patient Day (CHPPD) 8.1 Since May 2016, all acute Trusts began reporting occupancy data alongside planned and

actual staffing via the Unify monthly report in order to enable NHS Improvement (NHSI) to calculate CHPPD benchmarking data. As there are currently no national benchmarks for CHPPD, it is anticipated that CHPPD will be used locally alongside other patient outcome measures, to identify changes that might be made to staffing establishment to improve outcomes for patients.

8.2 CHPPD is a simple measure of nursing input and must be considered alongside acuity and

skill mix. CHPPD is calculated by taking all the shift hours worked over the 24 hours period by Registered Nurses and Nursing Assistants and dividing this by the number of patients occupying a bed at midnight.

8,3 It is important to note that the use of the CHPPD metric will only capture the care hours

provided to each ‘bed’, and does not capture all the activity on a ward such as the turnover of patients through that bed within the 24 hour period or recognise the acuity of the patient receiving the care.

8.4 Reviewing the Trust CHPPD data with the national data, demonstrates significant variance in

the range for this measure from 6.2-12.3, with the Trust position in June 2017 being 7.2. The lack of national benchmarks limits the validity and use of this data to inform safer staffing decisions at present.

9. Workforce Efficiency 9.1 A key recommendation in the Lord Carter Report on workforce efficiency in the NHS is the

use of an electronic rostering system to improve the productive use of staff resources. The Trust has utilised the Allocate Health Roster system to manage nursing and midwifery rosters and payroll since 2013.

9.2 Key Performance Indicators are in place, supported by monthly performance data, to include

the management of annual leave and sickness within Trust target, management of under-rostered hours and additional bank and agency shift requests above establishment. The Key Performance Indicators are monitored as part of the Nursing and Midwifery Turnaround Controls process meetings chaired by the Chief Nurse.

of 21

Agenda Item 9.2 9.3 As part of the 2017/18 nursing and midwifery efficiency schemes, a programme of work to

reduce staff absence and promote staff well-being was launched in April 2017. The aim of this programme is to reduce absence levels for registered nurses/midwives and nursing assistants to between 3-3.9% by April 2017. It should be noted that these targets are ambitious and are aimed at driving a positive culture of continuous improvement in attendance.

9.4 Divisional absence reduction trajectories have been set with key milestones in the WAVE

system to enable monitoring and oversight of this programme of work. The Heads of Nursing are working with HR Business Partners to ensure delivery of the milestones.

9.5 The June data demonstrates that for registered staff that four divisions have achieved or

exceeded the monthly trajectory, with the remaining divisions between above the trajectory. For unregistered staff six divisions have achieved the trajectory or below, with the remaining divisions exceeding the trajectory. These reductions in absence levels have delivered £19K of savings on temporary staffing spend since April 2017.

9.5 The Directors of Nursing meet with Heads of Nursing weekly to review bank and agency

spend, and as part of these meetings and monthly one-to-one management of absence is discussed to ensure delivery of the trajectories.

10. Recruitment and Retention

Domestic Recruitment 10.1 A number of recruitment events have been held to attract newly qualified Nurses and

Midwives who are due to graduate in September and November 2017. There are a total of 285 nursing and midwifery staff with job offers progressing through the pre-employment recruitment process with an expected start date before November 2017.

10.2 The Divisional recruitment lead and Heads of Nursing have implemented a series of

interventions to keep appointed staff engaged with the Trust in order to increase the likelihood of them commencing in post.

10.3 There is a schedule of further recruitment events are planned for the next 12 months and

work has commenced with UHSM to identify opportunities, the nursing and midwifery recruitment identify and the processes for recruitment post the pending merger.

International Nurse Recruitment

10.4 The Trust continues to source staff through international recruitment from India as part of the

International Recruitment Programme and support their progression through United Kingdom Visa and Immigration (UKVI) and the Nursing and Midwifery Council (NMC) requirements.

10.5 Since April 2016 the UK Home Office added nursing to the shortage occupation for a period

of three years. This change has addressed the challenges previously faced of obtaining Certificates of Sponsorship (CoS) for staff. It should be noted that the process through the UKVI and NMC requirements remains long, being on average a minimum of 6-9 months to complete the International English Language Test (IELT) and part 1 of the NMC process (CBT) to support their application to UKVI.

of 21

Agenda Item 9.2 10.6 Whilst the Trust is committed to continuing to recruit from the EU the supply of staff ceased

as a result of the NMC English language requirements and the post EU referendum results creating uncertainty for this group of workers.

10.7 Following approval from the Trust Management Board in June 2016 the Trust recruited a

further cohort of 128 nurses from India in November 2016. In view of our experiences to date, the recruitment process for these staff now includes a support package and online coaching to prepare candidates in advance of sitting their International English Language Test (IELTs). There are 59 nurses who are still required to pass IELTs with 21 nurses withdrawing from the process.

10.8 A total of 32 International nurses have commenced in post since January 2017. This brings

the total number of international recruits who have commenced in post in the last 20 months to 126. There are a further 48 candidates who have completed their IELT and are currently at the NMC stage of the process. It is predicted that 20 nurses from India will arrive before November 2017 with a further 5 nurses arriving each subsequent month.

10.9 The Trust continues to interview candidates in India who have achieved the required ILET’s

score through Skype, which provides a further source of staff into the workforce. 10.10 The NMC is currently reviewing the level of the ILET’s required of international and EU

nurses as part of their on-going quality review process. It is unlikely that the NMC will reduce the overall level of the score, but they may consider reducing from 7 to 6.5 one element of the test related to written English. It is not known when the NMC will conclude this process, but any change would require consultation and is therefore unlikely to take place within the next 9 months.

Retention

10.11 At the end of June 2017 the rolling 12 month turnover rate for staff nurse (band 5) 18.8%

which has reduced from the July 2016 position of 19.9%. The aspiration when the Nursing and Midwifery Retention Strategy was launched in September 2015 was to achieve a turnover rate of 15% by March 2017. The level was set based on national benchmarking across the NHS, as the retention levels within individual Trust and regions varies significantly. Across the Shelford group retention levels within the London Trust exceed 20% with the position at other Trust ranging between 14-18%.

10.12 A number of actions have been implemented to achieve the current reduction in turnover,

and a revised Nursing and Midwifery Retention Strategy was launched in July 2017. The strategy focuses on actions to reduce the Nursing and Midwifery turnover rate of 15% by March 2017. The key principles of the strategy are:-

• Supporting staff • Listening and responding • Workforce development • Developing career pathways for staff • Effective use of resources

10.13 A number of corporate work streams have been developed to support this strategy and are

monitored through the Nursing and Midwifery Workforce Forum and include: • Focus on staff ‘wellbeing’ and plans to promote a take a break initiative to ensure staff

are supported to take adequate rest time whilst on shift during Quarter 3. of 21

Agenda Item 9.2 • Director of Nursing listening events with newly qualified nurses and midwives have

been established to provide feedback. • Plan to launch ‘itchy feet’ web account to capture staff feedback when staff thinking of

leaving allowing senior nursing and midwifery staff to meet with the individual prior to them handing in their notice and understand what actions could be taken to retain them at the Trust.

• Implementation of 12.5 hour shift patterns across Trust for nursing and midwifery staff who wish to condense their hours over a shorter working week.

• Further development of the BME Nursing and Midwifery Forum to enable peer support and career progression for BME staff

• Theatre workforce modelling in MRI and TGH theatres to create a career framework and support retention of staff, which has included the development and implementation of Band 3 Scrub Assistant role

• Development of band 3 senior nursing assistant roles in cardiology and renal to support registered nurses and revised workforce plans

• Implementation of Pharmacy Technician role administering medications across further wards.

10.14 In September 2016, the Trust as part of a GM partnership became a pilot site to develop and train the Nursing Associate (NA). This will be the first nationally developed new nursing role within the workforce for a significant period of time and will be regulated by the Nursing and Midwifery Council from 2019.

10.15 The NMC are expected to consult on the NA practice standards later this year. The

agreement to regulate will clarify the lines of accountability for NAs, set out the education and training requirements to achieve NA status and support the training and development of roles traditionally taken on by registered practitioners e.g. administration of medicines.

10.16 The Trainee Nursing Associates (TNA) programme is a 2 year work based learning

programme. Trainees form part of the nursing establishment within their clinical placement. TNA’s will be paid band 3 salary during their training as per national agreement. The TNA’s are released from their post for 1 day per week to attend university.

10.17 The Trust has 65 Nursing Associates in training across adult, community and children’s areas. The trainees have successfully completed their first 6 month placement and initial feedback reflects positively on this role within the nursing workforce.

11. Workforce Supply verses Demand – Summary 11.1 This paper has described the current position in terms of the number of Registered Nurse

and Registered Midwife vacancies across the Trust alongside the continued efforts made to retain staff whilst actively recruiting both in the UK and international market. Significant work has been undertaken and continues to ensure that the Trust has a sustainable nursing and midwifery workforce. Despite the increase in the nursing and midwifery establishment, the overall percentage qualified vacancy rate has remained static since January 2017 and will reduce to the predicted position of 9.7% in September 2017 as a result of this work, with an average of 250 vacant posts.

11.2 The national workforce model suggests that there will continue to be a supply and demand

mismatch beyond 2020. The delivery and organisation of services in the future creates workforce challenges and opportunities and is significantly dependant on the development of

of 21

Agenda Item 9.2 an appropriately trained and competent workforce. There is therefore a need for the profession to embrace new roles, such as the NA role as well as considering new career pathways and new models of working which will challenge traditional thinking. The Trust remains committed to the delivery of safer staffing levels, and is working with strategic partners to ensure that the changes to nurse education and the introduction of new roles is aligned to this objective.

11.3 In line with recommendations from NHS Improvement1314 the Trust triangulates the staffing

levels, with nurse sensitive clinical outcome indicators and patient experience. These reports are provided to the Quality Committee and Board scrutiny is provided by the Quality and Performance Scrutiny Committee.

12. Key Risks 12.1 The information outlined in this paper sets out the numerous actions being undertaken to

enable the Trust to continue to reduce the number of vacancies within the Nursing and Midwifery workforce and respond to service developments which require additional nursing or midwifery staff. This risk had been registered on the Trust Risk Register as a high risk and was reviewed in February 2017 has resulted in the risk being revised to a medium risk. As the strategies in this paper impact on reducing vacancy rates the risk will be continually reviewed and revised as appropriate.

13. Conclusion 13.1 The Board is asked to receive this paper, which highlights that the Nursing and Midwifery

staffing position is on trajectory to achieve a continued reduction in vacancies (noting the seasonal rise in vacancies from June to August 2017) and to note the actions taken to recruit and retain the correct number of staff to provide safe care to patients and service users.

13 NHSI letter to NHS Foundation Trusts and NHS Trust Directors and Medical Directors 14th July 2016 14 Supporting NHS Providers to deliver the right staff, with the right skills in the right place at the right time – Safe sustainable and productive staffing. NQB July 2016

of 21

Agenda Item 9.2

Appendix 1

of 21

Agenda Item 9.2

of 21

central manchester university …. agenda item 9.2 - bod...central manchester university hospitals...

Documents