Board Briefing Board Briefing of Nursing and Midwifery Staffing Levels Date of Briefing October 2018 (September 2018 data) This paper is for: Sponsor: Chief Nurse- Dame Eileen Sills (DBE) Decision Author: Workforce Team (Chief Nurse s Office) Discussion Reviewed by: Director of Nursing, Adult Services (Chief Nurse s Office) Noting CEO* Information ED* Board Committee* TME* Other* * Specify
1.0 Summary This briefing provides the Board with an overview of the Nursing and Midwifery workforce during the month of September 2018 and is set out in line with the National Quality Board (NQB) Standards and Expectations for Safe Staffing published in 2016. It provides assurance that arrangements are in place to safely staff our services with the right number of nurses & midwives with the right skills and at the right time. 2.0 Key highlights for September 2018 The vacancy rate has decreased from the previous month to 13.0% where the staff in post has increased proportionately more than the establishment. We have an additional 244 wte nursing and midwifery staff in post in September 2018 compared to Sept 2017. On 28 th September 2018 there were 485 external candidates in the Recruitment Pipeline who are expected to join the Trust over the next few months. The annual turnover in September is at its lowest level since June 2016 at 14.1%. Agency spend is up marginally, to 4%, in September, attributable to continued rise in demand for RMN support for patients with mental health needs and the need for flex beds to remain open due to increased patient and service demands. Sickness and Mandatory training rates have not changed significantly in month however, PDR rate has increased to almost 80% which is a 9.2% increase compared to September 2017. 3.0 EXPECTATION 1 RIGHT STAFF 3.1 Evidence Based Workforce Planning In order to ensure the safe and effective delivery of patient care it is essential that we have the right establishment of posts and the right staff in post. Table 1 sets out the current overall nursing and midwifery workforce metrics in comparison to September 2017. Staffing measures September 2017 September 2018 Change Nursing Establishment WTE 6123.92 6371.66 247.74 Nursing Staff in Post WTE 5301.49 5545.77 244.28 Vacancies WTE 822.43 825.89 3.46 Vacancy rate 13.4% 13.0% -0.5% Annual turnover 15.5% 14.1% -1.4% Red Flags raised 130 145 15 Agency % of Pay bill 6.7% 4.0% -2.7% Planned v Actual Hrs used 98.5% planned hours filled 99.7% planned hours filled 1.2% Table 1
6600 6400 6200 6000 5800 5600 5400 5200 5000 4800 Nursing and Midwifery Staff in post vs Establishment 5600 5550 5500 5450 5400 5350 5300 5250 5200 Nursing and Midwifery Staff in Post WTE staff in post establishment Table 2 Table 3
3.1.1 Mid-Year Establishment Reviews All Directorates were offered a mid-year establishment review in the summer and had the option to opt out if they had no requirement to alter their establishment and were not requiring any input outside of the annual review process. All areas were provided with data packs to enable them to review their data in a consistent manner. 8 directorates out of 17 attended a review through July and August and these are outlined below: Transplant, Renal and Urology Cardiovascular Evelina London Gastrointestinal Medicine and Surgery Surgery Commercial Theatres, Anaesthetics and Peri Operative Medical Specialties All directorates were provided data on their key workforce metrics, including their performance against roster KPIs and Safecare data where applicable. In the majority of Directorates there were no additional staffing requirements identified as part of the reviews. However, within the Cardiovascular Directorate, it was acknowledged that there had been a rise in acuity levels on Stephen Ward with a corresponding increased demand for nursing staff to ensure safe staffing. This is being mitigated by redeployment of staff from other areas or the use of temporary staff. The plan is to continue monitoring using SafeCare data, to maintain patient safety as required with additional staff and to review again as part of the annual establishment review and business planning cycle in November. If additional resource is required this will be included within the business planning cycle. The annual workforce reviews will take place throughout November and early December 2018 with the annual workforce board report being presented at the Trust Board in January. The report will encompass the requirements from the recent Workforce Safeguards document released by NHSI in October 2018 and provide assurance to the Board regarding safe nursing and midwifery staffing levels.
3.2 Recruitment and Retention Tables 4, 5 & 6 display the trends in three key nursing and midwifery workforce metrics, namely vacancy, turnover and sickness. These demonstrate fluctuations in the vacancy rate however, it has remained more stable over the past few months, despite changes in the establishment. The overall annual voluntary turnover remains fairly steady. Active recruitment strategies continue, however, retention of our staff remains a key focus with a number of activities being undertaken Trust wide. We have also recently signed up to the Retention Collaborative led by NHSi and this commences in November. The process for recruiting newly qualified nurses will change in 2019 with all host students being given a conditional offer of employment in December 2018. Open days, assessment centres and on boarding for host and non-host students will be commenced 6 months earlier than in previous years, in order to secure a higher proportion of host students into employment and attract non-host students to GSTT. Table 4 Table 5 Table 6 Table 6
3.3 Activity and Acuity The number of bed days in September 2018 stood at 46,264 (Table 7). This is 1,825 more than the previous month. However, this is an additional 9,385 bed days from the same period in 2017 which demonstrates a 25% rise in activity. From an acuity perspective, Level 1b (heavily dependent or acutely unwell) patients in non-critical care beds, continue to be the most predominant across the Trust which is consistent with the past few years. Count of bed days Proportion of bed days Level Month 0 Level 1a Level 1b Level 2 Level 3 Total level 0 Level 1a Level 1b Level 2 Level 3 September 2018 7,507 9,831 26,501 2,410 16 46,264 16.2% 21.2% 57.3% 5.2% 0.0% August 2018 6,883 9,032 26,192 2,312 22 44,439 15.5% 20.3% 58.9% 5.2% 0.0% Table 7 The fill rate for registered staff was 95.8% in comparison to an unregistered staff fill rate of 116.0%, with an overall fill rate of 99.7%. There are times when it is appropriate to utilise unregistered staff to support safe staffing in the absence of registered staff. Heads of Nursing, Matrons, Site Nurse Practitioners and Ward Leads make these operational patient safety decisions on a shift by shift basis to ensure all areas are safely staffed. There is representation from the Chief Nurses Workforce team at the daily sitrep to support all resources being effectively utilised across the Trust to ensure safe staffing and minimise any impact on activity, especially in areas where flex beds are unable to be closed. The Trust average Care Hours Per Patient Day (CHPPD) was 10.7 for the month of September, level with the previous month. The required CHPPD, on average was 8.3, however there was variation across different specialties as would be anticipated. 4.0 EXPECTATION 2 RIGHT SKILLS 4.1 Mandatory Training, Development and Education The current compliance with mandatory training across the nursing and midwifery workforce is 85.5%. This has deteriorated marginally from the previous month overall. Table 8 demonstrates the breakdown of compliance at Directorate level. All establishments have an
uplift built in to support staff with undertaking their mandatory training and development whilst maintaining safe levels of staffing. This will be reviewed at the annual establishment reviews due to take place in November and December. 100.0% Mandatory Training by Directorate September 2018 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% Table 8
The current PDR rate across the nursing and midwifery workforce is 79.7% which is an improvement on the previous month and also, as outlined in the headlines, is a 9.2% improvement on the corresponding period in 2017. Compliance with completion of PDRs at Directorate level is shown in Table 9. All areas are monitored on their PDR rates through the Directorate PRMs. 120.0% PDR Rates by Directorate September 2018 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Table 9
4.2 Working as a Multi-professional Team The organisation is committed to considering new roles and particularly looking at roles which cross traditional professional boundaries. The Trust, in collaboration with LSBU and Health Education England (HEE), have embarked on recruiting to the Nursing Associate role. The first cohort will be placed within the community setting with a plan to recruit 40 trainee Nursing Associates onto a programme in December 2018. Through business planning, the requirements for the Nursing Associate role across other Directorates will be scoped. This will help to determine numbers of future cohorts and financial modelling required. In addition, there are a number of staff members who are currently undertaking the Assistant Practitioner apprenticeship who are going to transition their learning to date onto the Nursing Associate programme. This route is a feasibility study to determine a proof of concept only, and GSTT, in collaboration with LSBU, have been given special permission from the NMC and HEE to pilot this programme. 5.0 EXPECTATION 3: RIGHT PLACE AND TIME 5.1 Efficient Deployment and Flexibility With the implementation of Safe Care across all adult inpatient areas in the Trust there is now visibility, in real time, throughout the organisation, of appropriate levels of staffing for our patients. The use of Safecare Live is now fully embedded in the daily Sitrep to assess the patient acuity and staffing, twice daily in all areas, at the beginning of the day and night shift. There are some areas who are collecting data 3 times daily due to known variation in activity throughout the day. The collection of the data highlights and supports decision making as to the deployment of temporary staff or the need to move staff to support patient needs in other areas. Maternity Services continue to use SafeCare for staff check-in and red flag functionality. In September 2018, 145 red flags were raised by staff highlighting concerns with staffing. Table 10 shows the distribution of red flags and the comparison to August 2018. Staff are encouraged to raise red flags where there may be concerns with safe staffing levels and this, in addition to the increased and ongoing high levels of activity, may have contributed to an increase in red flags compared to previous months. Evelina London have almost completed their initial implementation plan for the introduction of Safe Care into their areas. This is currently functioning alongside their existing system, PANDA, and uses the Shelford Children s Safer Nursing Care tool to assess acuity and dependency. Savannah Ward and Beach Wards have now successfully gone live. Mountain ward will follow at the end of October ensuring that all non-critical care ward areas will be live before December 2018. The critical care areas in the Evelina (PICU and NICU) and outpatient areas will follow thereafter.
100 90 80 70 60 50 40 30 20 10 0 Red Flags in August Red Flags September 2018 Red Flags in September Table 10 5.2 Efficient Employment, Minimising Agency Use From January 2018, all Directorates have engaged with roster challenge boards which are designed to improve rostering against agreed KPIs. These are being led by the Chief Nurse Workforce team to ensure that all areas are producing effective, fair, safe and efficient rosters. There has been a significant amount of work undertaken to add new areas onto Health Roster e.g. Dental Services, and to ensure rosters are properly allocated on Health Roster with recent changes in Directorate structures.
All nursing areas 1st Jan - 28th Jan 29th Jan - 25th Feb 26th Feb - 25th Mar 26th Mar - 22nd Apr 23rd Apr - 20th May 21st May - 17th Jun 18th Jun - 15th Jul 16th Jul - 12th Aug 13th Aug - 9th Sep Planned Hours 566,517 571,193 569,053 567,288 573,163 572,317 575,132 581,105 583,312 Actual Hours 514,127 516,410 516,655 505,775 526,567 525,061 528,982 526,385 519,971 Actual CHPPD 8.7 8.6 7.9 8.3 8.4 8.4 8.3 8.6 8.5 Required CHPPD 8.1 8.2 8.2 8.3 8.2 8.3 8.2 8.3 8.3 Shifts Without Charge Cover 490 474 402 518 319 327 495 351 324 Additional Duties (No of shifts over budget) 4,843 4,870 4,712 4,730 4,463 4,330 4,831 4,288 4,620 Overall Owed Hours (Net Hours) 173,053 140,632 134,682 142,480 118,881 129,691 144,170 131,664 132,081 Annual Leave % - Target 11-17% 12.4% 14.7% 16.7% 14.3% 9.8% 11.7% 11.9% 14.6% 16.1% Total Unavailability % - Headroom/uplift Allowance - Target 24% Roster Approval (Full) Lead Time Days - Target 42 days 26.7% 28.4% 29.0% 27.5% 22.2% 24.1% 24.8% 26.4% 28.7% 23 18 18 21 20 22 23 23 24 Table 11 Table 11 demonstrates the key KPIs and other key metrics relating to the efficient deployment of staff at Trust level for the roster period 13 th August 9 th September 2018. Significant work is ongoing to improve a number of these metrics with a key focus on improving the timing of roster publication, recording of in charge shifts and continued reduction in the number of hours owed whilst maintaining a close scrutiny on annual leave management. All of these are being addressed through the monthly challenge boards. A point of note is the required vs actual CHPPD, which demonstrates overall that current staffing levels in adult general wards matches the acuity of the patients.
Having efficient rosters will support the measures taken to reduce agency spend across rostered areas. The agency spend (which represents invoices paid in month) in September 2018 was 4.0% of the total nursing staff pay bill (Table 12), which represents a better position than the same month in the previous year and demonstrates the continued focus on temporary staffing spend despite the operational pressures in the Trust. The increase in spend in September 2018 was particularly notable in Acute Medicine where there was a significant rise in the number of RMNs and enhanced carers required to support vulnerable patients with complex mental health and physical needs. Work is underway to help address the provision of enhanced care across the Trust. This was in addition to the fact that most of the flex capacity was open throughout September due to ongoing operational pressures. Table 12 Table 13 highlights the actual usage of temporary staffing in September 2018 in comparison to each month in the preceding year. This is broken down into Bank and Agency WTE.
2,076.9 2,056.5 1,847.4 1,742.8 2,152.7 2,152.9 2,625.0 1,992.1 2,120.1 2,281.7 2,468.9 2,616.5 2,475.1 1137.6 1258.1 1035.7 933.3 1043.7 935.9 1005.4 808.4 835.1 806.4 848.1 871.4 1019.4 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Bank WTEs Agency WTEs Table 13 Table 14 outlines the total temporary staffing usage, including the reasons for usage. As noted above, there continues to be usage of temporary staff to support the enhanced care of patients, notably the use of RMNs.
Other Invoice - No Booking Special (non-rmn) 3214.5 3314.6 2883.1 2676.1 3196.4 3088.8 3630.3 2800.5 2955.2 3088.1 3317.0 3487.9 3494.4 RMN Other Leave Mat/Pat Leave Annual Leave Sickness Vacancy Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Table 14 6.0 Request to the Board of Directors The Board of Directors are asked to note the information contained in this briefing, the use of the red flag system to highlight concerns raised, the continued focus on recruitment and retention and the reporting of the roster KPIs.