2.1 That the Board approve an investment in nurse staffing levels in 2010/11 of 516.5k and a further investment of 427.1k in 2011/12.

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1 HEREFORD HOSPITALS NHS TRUST PUBLIC BOARD MEETING 29 TH MARCH 2010 Agenda Item 6 (iv) (c) AUTHOR OF REPORT AND REPORT NO. Catherine Davies-Head of Nursing CONTACT AND TELEPHONE NUMBER: Catherine.Davies@hhtr.nhs.uk Ext: 2936 REPORT SPONSOR: DIRECTOR OF NURSING & OPERATIONS INVESTMENT IN NURSING WORKFORCE 1.0 INTRODUCTION 1.1 This report identifies the need for further investment in nurse staffing levels on the acute medical and surgical wards in the County Hospital. This is in addition to the 2009/10 investment of 242K previously agreed. 1.2 Nurse staffing levels in 2009/10 were identified as being high risk on the Board Assurance Framework and this was also highlighted at assurance visits undertaken by the West Midlands Strategic Health Authority and Herefordshire PCT as a result of media coverage arising from the publication of the Dr Foster Good Hospital Guide. 2.0 RECOMMENDATION 2.1 That the Board approve an investment in nurse staffing levels in 2010/11 of 516.5k and a further investment of 427.1k in 2011/ The 2011/12 investment will be subject to continuing evidence on patient acuity and the transfer of skills which will be required as Primary and Secondary Care integrate (see Option2). 3.0 MAIN BODY OF REPORT 3.1 Background The West Midlands Strategic Health Authority (WMSHA) recommends nurse staffing levels on acute medical and surgical wards as 1.2 Whole Time Equivalent (WTE) nurses per bed with a skill mix ratio of 60% registered nurses to 40% non registered nurses and a 24% allocation of time for personal development/training. The 2009/10 Hereford County Hospital Nursing Budget delivered 1.1WTE with a skill mix ratio of 50% registered nurses to 50% non registered nurses and 18% for personal development and training. Describing a nurse to bed ratio is not the only indicator of nurse workforce requirements. The Trust has seen over the last 12 months an 8.6% increase in emergency care with a high proportion of these patients being frail elderly with acute and chronic conditions. Elective surgery increases of 16% from 2008/09 have been maintained and with length of stay reducing this has increased the intensity of care required from the nursing workforce.. CD Page 1 of 8 V8

2 3.2 Workload Intensity To assess the nursing requirements against the dependency of patients in the hospital the Association of United Kingdom University Hospitals (AUKUH) Nursing Acuity and Dependency Tool was implemented throughout the Trust in November This tool is recommended and supported by the WMSHA and provides the following: Criteria to assess nursing requirements for each patient based on their care needs. Utilisation of nursing quality/risk assessment data to identify patients with relatively higher dependency needs A process to continuously monitor nursing demands. The results from using this assessment tool across the acute wards over a 4 month period further support the requirements for the investment already identified. 3.3 Clinical Quality Indicators In addition to nurse to bed and dependency a range of nursing indicators are used as measures of care standards provided to patients. These include: number of patient falls, acquired pressure ulcers, infection control rates, number of medication errors and complaints. Nursing in the Trust has responded to the challenge of improving nursing outcomes through the systematic implementation of the Productive Ward which will, coupled with other initiatives such Energising for Excellence and with the support of the WMSHA continue to improve service delivery in nursing. Since April WTE nurses have been released back to care for patients by reorganising the way wards work around the patient journey rather than the continued use of out dated practice. This process empowers ward sisters to manage and ward nurses to innovate. The example below shows patient falls data which is reported on each ward from July 2009 December This data is reported to and reviewed by the Patient Safety Group (PSG). Although there has been an improvement the rate is still above that of the NPSA standard rate. It is expected that with the further investment requested there will be a sustained improvement in quality of care for patients and increased morale in the nursing workforce. July 09 Aug 9 Sept 09 Oct09 Nov09 Dec 09 Total bed days No. of falls per month Rate (NPSA Standard rate 4.8) CD Page 2 of 8 V8

3 3.4 Financial Appraisal This proposal is intended to build on and update the previous budget investment paper put forward in 2008/09 which resulted in a 224k budget increase (of the 1.2m bid value). The following financial section of the report is divided into two parts: Section 1 Identifies recent efficiencies which have provided financial benefit and have been developed over the two years and are now built into the base budgets and business plan. Section 2 Focuses on the proposed investment change required to secure the benefits and mitigate the present levels of risk to patient care This forms the investment decision for the Board to consider, beyond the present base case business plan. Section 1 In built and continuous efficiency The arguments for investment (patient acuity, staff to bed ratio and workforce training) are all made within the earlier sections of this report. The purpose of this section is to highlight initiatives and working practice which are already delivering cash and efficiency benefits through the appropriate management of the nursing workforce. 1. Unbudgeted use of commercial agency there is a significant advantage to be gained by keeping an element of the workforce able to flex up and down through the year. This is achieved by an appropriate split between temporary and substantive contracts. However financially this can only be delivered in affordable terms through the use of bank and fixed term contracts. The use of commercial agency, although providing flexibility, comes at a financial cost to the Trust which represents poor value for money. During the course of the last three years agency use has been significantly reduced from previous levels. It is still running at 370k per annum and without further investment in the substantive element of the nursing workforce it is unlikely to be reduced further. The value of this potential further step change (eliminating use of agency) is in the region of 200k in terms of unbudgeted expenditure and cost reduction. The average cost for an agency nurse being 86k per wte (compared with 39k substantive). 2. Productive Ward: Releasing Time to Care This initiative was implemented in 2008 and uses service improvement tools to improve the amount of time spent providing direct patient care. This has included applying lean methodology to procedures and processes such as altering where stores are located, improving handovers between clinical teams and reducing interruptions to clinical staff. It has been assessed this has resulted in the release of time to care as previously described. 3. Absence Management The investment proposal described in this paper is quantified through a nurse to bed ratio. Sickness levels are presently unacceptably high but are likely to be a symptom of the present shortfalls in substantive staff. Initiatives are in place to reduce present levels of 4.5% (registered) and 8.2% (non registered). The Heads of Nursing are presently targeting 3% ( registered) and initially an improvement to 5% (non registered). Achieving the above would not reduce the investment value identified in this paper. However if these reduced sickness levels were not achieved, the desired ratio of nurses to beds would also not be achieved. CD Page 3 of 8 V8

4 Section 2 Currently the Trust invests 23.8m annually in nursing resource. Board members will note there has been an under spend against this resource ( 259k at month 10) but this is entirely attributable to the midwife vacancies now being proactively recruited to. For this reason the base position should be considered to be a full recurrent commitment against the current base budget. Of the existing 23.8m (total nursing investment) this is broken down as follows: m (09/10) WTE Ward Based Nurse management Registered Unregistered Other areas CNS senior nurses Maternity Theatres & Daycase A&E ITU/HDU Children s Ward SCBU CCU All other nursing Total There are three distinct financial aspects in this years planning round concerning nursing budgets. These need to be recognised so that they may be understood fully and separated out appropriately:: Full year impact of 09/10 QPP this was designed to promote minimising the use of high cost agency and reducing sickness levels. It was phased to cover the last 6 months of the year and has been demonstrated to have been delivered in Qrt. 3 (although winter pressures are now likely to impact on the agency element of this in Qrt. 4). The step change built into the Business Plan (and already applied to budgets) is to increase this value from 130k to 260k full year effect. Although on face value appearing to be directly opposite to the argument for further investment, this expectation does continue to promote the best practice ideals of low sickness and a low reliance on agency. For these reasons it is appropriate to be within the base position. High Dependency Unit investment This is covered in a separate paper with appropriate adjustments made to ensure no overlap or double counts. The reason why it is appropriate to treat the HDU separately is that the improved caring and nursing for HDU patients should attract an appropriately uplifted PBR tariff, providing this initiative gains the approval and backing of HPCT. This tariff would be expected to be at least neutral, or possibly slightly above direct costs. It should also be recognised that this group of patients already exist in the patient population in the hospital and focus on these individual patients aims to improve their outcome and reduce the overall length of stay. HDU should therefore be considered as a freestanding issue from this general ward based nursing investment. CD Page 4 of 8 V8

5 Ward Nursing Provision The focus of this paper and one targeted at mitigating risks through the provision of an evidenced based standard of care, secured through appropriate bed to nursing ratio. The investment There are several elements to this investment as follows: To achieve a ratio of 1.2 nurses to each ward bed (1.5 Admissions). To achieve a ratio between registered and unregistered nurses of 6:4 To increase the Time Out Allowance (used in calculating ward shift patterns and including statutory leave) to 24% (presently 18% and failing to allow adequate training provision). There are two options for achieving this which both deliver the benefit by year 2. Option 1 is to move directly to the recommended level of 24%, Option 2 is to phase this change over two years (increase to 21% in year 1). Both options include the base principle of establishing the above nurse to bed ratio and equally both options have a part year effect (from July) in the Business Planning round 2010/11 to allow recruitment of nurses. The full benefit and financial impact of the proposal will impact in 2011/12. Appendix 1 shows a simple table which establishes the need for WTE additional nurses to achieve the nurse to bed ratio. The table then identifies a further WTE required to achieved the full Time Out allowance of 24%. 000 s Timing in 2010/11 (Time Out) Total Investment value Option 1 Option 2 Sources of funding (in Business Planning and Budget Setting terms) A recurrent reserve set up against additional capacity in 2009/10 and already included in base figures for 2010/ Further budget funded against increased QPP Total Financial Conclusion and Phasing Options This will deliver the improved bed to nurse ratio and the improved Time Out Allowance in the rotas, over a time period of two years. The common principle running through both options is the need to establish both the nurse to bed and also the registered to unregistered ratios described above. Equally there is a natural lead in time of 3 months resulting in 9 months impact in 2010/11. The options described below merely concern the speed of achieving the improved Time Out to be built into establishment across the ward areas of the hospital and the decision of whether to increase these by 3% in 2010/11 or immediately target the 6% growth to 24%. Option nurses to each general ward bed (1.5 Admissions) and 6% increase to present level of Time Out Allowance built into establishments and rotas All figures in 000 s 2010/11 (from month 4) 2011/12 (from month 1) Total investment by CD Page 5 of 8 V8

6 year 2 Agenda Item 6 (iv) (c) Total Option nurses to each general ward bed (1.5 Admissions) and 3% increase to present level of Time Out Allowance built into establishments and rotas in 2010/11 with further increase of 3% in 2011/12. All figures in 000 s 2010/11 (from month 4) 2011/12 (from month 1) Total investment by year 2 Total POLICY AND BUSINESS PLAN CONSIDERATIONS 4.1 Integration As indicated earlier, future delivery of service in an integrated care organisation will require changing models of care. This will present a significant workforce development challenge for nursing. The investment recommended here in nursing particularly in terms of increased focus on training time out, will facilitate transition of acute nursing skills into the community base required in the future state Herefordshire Health Economy. 5.0 RISK ASSESSMENT 5.1 This is described in the Board Assurance Framework 2009/10 as a high risk and encompasses: Likely increased incidents of patients falls; Likely increase in pressure sore prevalence; Infection control failures; Mandatory training not achieved; Lack of capacity to train nursing staff for integrated organisation Decline in moral already reflected in the national staff survey VALUE FOR MONEY 6.1 Investment in the Nursing workforce will: Enable development of skills and competencies to deliver safe care Ensure sustained level of quality care is delivered by monitoring quality indicators. Reduce use of temporary staff Support reduction of Sickness and Absence 7.0 HEALTHCARE / NATIONAL POLICY 7.1 Recent changes in health policy have focused on improving quality and safety of services. To achieve this, a motivated, skilled nursing workforce is essential. In addition CD Page 6 of 8 V8

7 future. development of the local Healthcare Community requires a nursing workforce skilled to deliver care in a variety of settings. 8.0 CONCLUSIONS 8.1 The paper describes the requirements to invest in the Nursing workforce at HHT with phasing over two years to provide the safe quality service expected by the local population and taking into account 2010/2011 integration agenda with Primary and Secondary care. This investment will meet the following requirements: a. Demonstrate improved safety through appropriate staffing levels in General Adult wards b. Ensures move towards WMSHA recommended ratio and skill mix of registered and non registered nursing staff c. Ensures an increase in time out allowance to meet nursing workforce development needs. d. Introduces the use of an acuity/dependency tool to monitor trends in acuity and dependency within ward areas. e. Supports a model to describe future provision of a nursing workforce to meet operational and strategic challenges. References: Recommendations for Nurse Staffing on Acute Medicine/Medical assessment Units (AMU) Society for Acute Medicine 2004 AUKUH Acuity/Dependency Tool Implementation Resource Pack 2009 Healthcare Commission (2005) Ward staffing, June Acute Hospital portfolio review. London; Healthcare Commission. RCN (2006) Setting Appropriate ward Staffing Levels in NHS Acute Trusts Royal College of Nursing, London September 2006 CD Page 7 of 8 V8

8 Appendix 1 Ward Establishment Agenda Item 6 (iv) (c) N.B. The Beds numbers appropriately reflect the position following the re-provision of additional beds in the main hospital and the closure of Kenwater (presently anticipated to be the position at June 2010) Present Establishment Increases in WTE required Wards Beds per Ward * Total Trained WTE Total Untrained WTE Total WTE Extra WTE to achieve delivery of 1.2 Ratio Extra WTE to provide delivery of 24% Time Out Allowance Total Proposed Increase in WTE New Establishment proposed ** Frome Lugg Arrow Leadon Dore (5.83) 1.08 (4.75) Monnow (2.72) 1.30 (1.42) Wye Teme WH TOTAL Admissions* * Admissions requiring 1.5 nurses to 1 bed Totals ** HDU beds excluded (see separate investment appraisal) CD Page 8 of 8 V8