Hard Truths Public Board 24th September 2015 Presented for: Presented by: Author Previous Committees Governance Professor Suzanne Hinchliffe CBE, Chief Nurse / Deputy Chief Executive Jill Asbury, Head of Nursing, Nursing and Midwifery Education & Workforce None Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points 1. To bring to the attention of the Board any nursing / midwifery workforce risks Information 2. Progress against the investment into nurse staffing 2015/16 Information 3. Feedback from key findings from the July 2015 Ward Workforce Health Check including Hard Truths, 2014 data. Information 4. The results of the Care Contact Time, 2014 self-assessment exercise. Information 1
1.0 Summary Agenda Item 11.5 The following paper brings together a range of measures that provide a strategic overview and focus on ward workforce measures for the month of July 2015. This information is triangulated with the Ward Healthcheck, whose RAG rating is based on a percentage compliance with 11 standards that are key to influencing patient outcomes and experience, (the Board receives the Ward Healthcheck paper describing the results at each meeting). Using this approach it can be seen that the impact of staffing is integral to the LTHT review of factors that affect the experience and outcomes of patients. The Ward Workforce Health Check (WWH) data has been used for July 2015 to inform this paper. The paper includes: areas where there are particular nursing workforce challenges / risks information on the reduction in registered nurse turnover trend data on nursing staff at bands 1-5 joining and leaving LTHT progress made towards 15/16 nurse recruitment information and results of the exercise undertaken to determine the care contact time that nursing staff spend with patients. information on midwifery staffing and maternity red flags, NICE (2015) for the Hard Truths (2014) data, a summary of the number of wards where the staff on duty are <80% of that planned. information on the LTHT participation in the Department of Health Procurement & Efficiency programme information and an initial risk assessment on the recently released TDA/Monitor Guidance on Nursing Agency Rules, September 2015. 2.0 Nursing Workforce : Challenges / Risks The challenges within the nursing workforce during the summer months have been particularly taxing over the last 3 years, as seen in appendix 1 the outflow of staff from the organisation over the months of May to August outstrips those joining by, at times, up to 25 on some months. This has not been as extreme this year but is still the trend. Traditionally, a reduction in both patient acuity and numbers made this manageable. However, as the well documented local and national picture describes, this is no longer the case with the result that the workforce challenges are exacerbated. Table 1 displays the Clinical Service Units that are facing particular workforce challenges and the use being made of temporary staff to bridge the current gap. For these CSU s they hold services where like services are held within DGH s, and the work in the smaller hospitals is often perceived as being less intense and hence they suffer from competition from local hospitals Appendix 2 describes the actions being taken to support both the CSU s and the wards within those CSU s where particular challenges exist. Identified in the table below are two wards with excess of sickness these are all in management processes and with 3 members of staff on phased return following long term sick, and 4 members of staff on long term sick with complex issues and no prospect of returning to work as yet. 2
Table 1: CSU s with Workforce Challenges CSU Band 5 Staffing Gap (wte) Temporary Staffing Use Agency (wte) (wte) Recruitment Pipeline (wte) Maternity Leave (in month average CSU %) Sick Leave (in month average CSU %) Datix Incentive In Place Cardio- Respiratory (8 wards) 23.24 19.1 14.9 Agency 16 4.8% (J10 : 15.6% L20 : 17.2%) 2.3% 12 (11 from J12) J10 & J12 (Registered Staff only) Abdominal Medicine and Surgery (13 wards) 64.21 37.0 23.4 Agency 34 2% 4.5% (J42 : 15.8% J83 : 13.2%) 3 (even spread) None Acute Medicine (14 wards) 66.11 26.9 51.0 Agency (of which 18.6 associated with the Supported Discharge Ward : J30) 22 4.2% (across 6 wards all over the 5% threshold) 3% 11 (6 from J08) J7, J8, J16, J21 & J26 (Registered Staff only) Trauma Related Services (8 wards) 20.26 22.6 26.8 Agency 16 3.9% (L39 : 16.9%) 2.1% 7 (from L22 & L34) None Neurosciences (6 wards) 34.67 36.0 11.9 Agency 8 1.6 5.2 4 None 3
3.0 Retention Appendix 3 displays the significant progress being made in improving nurse retention, particularly at band 5, with the first 6 months of this year showing a sustained range of 13.4-13.9%, down from a peak at this time last year of 16.1%. This is evident in the reduction in leavers seen across the summer months this year in comparison to previous years. It is hard to discern a single reason for this, but in discussions with nurses re-joining LTHT after a period away they describe a change in culture to one of positive support, one in which development and improvement for both services and individuals is encouraged and where they feel they would be listened to. 4.0 Staff Recruitment : Support to Hard to Recruit Areas The Board is aware of the partnership with on their EU Programme and the 24 Italian nurses who are currently working with LTHT. There is a further round of Italian recruitment planned for November 2015, this will continue to be targeted at those CSU s described in table 1. The Chief Nurse met with the first cohort to offer the opportunity of being recruited into substantive positions in LTHT. This will be progressed at the forthcoming Open Day. The RCN Recruitment Fairs are used to showcase those CSU s where recruitment is a greater challenge. There are 2 taking place over the next 3 months. Adverts targeted towards specific wards or specialities have been successful and those staff are currently in the recruitment pipeline, 4.1 Recruitment Pipeline The Trust has hosted 3 Open Day s and a university interview event in the February, March, May and July 2015, with a further Open Day planned for October. The results of which are in the table below. The detail of the allocation by CSU at band 2 and 5 is described in appendix 4 & 5. Table 2 Speciality Interviewed and Appointed since 28/2/15 (start dates likely to be September as majority newly qualified) Peri-Operative Practitioners 32 Children s 93 Adults 289 Midwives 44 4
Appendix 6 describes those who have started in the organisation on a week by week basis from the start of the financial year. Please note the total numbers above will differ from those on the forward plan; due to those who have started since 28/2/15 and those who have withdrawn their applications following appointment / offer acceptance. Band 3 Clinical Support Worker short term contracts are offered to all newly qualified nursing and midwifery staff whilst they await notification of their registration with the NMC. These posts are within the clinical area that they have secured a Band 5 post. 4.2 Return to Practice : Partnership with Bradford University The first group of 9 have completed their course and are awaiting their results. Of these, 8 have been recruited to substantive posts in LTHT, with 1 pursuing a career with Leeds Community Health. A small group of 3 began in June, and 1 is commencing in September. Despite our small numbers it is still an avenue we wish to pursue. There are opportunities to take a similar approach for Operating Department Practitioners wishing to return to a theatre career, these are being actively pursued. 5.0 Patient Acuity and Dependency Monitoring : 6 Monthly Staffing Review The 6 monthly patient acuity and dependency review was completed on 2 August, the results of which were recently received. The Operational Heads of Nursing and the Head of Nursing Education and Workforce will be reviewing this data alongside the ward establishments in early September. 5.1 Care Contact Time As part of the suite of measures to be included in this review is the care contact time. This approach recommended by NHS England measures how ward staff, both registered and un-registered spend their time. The aim being where the contact time is low, actions can be taken to increase this. The tool used was developed by Central Manchester University Hospitals, and is recommended by NHS England and used across the country. This is the first time LTHT have undertaken this exercise. All inpatient and assessment areas completed the collection which involved all registered and un-registered nursing staff self-reporting their primary activity every five minutes using a code which identified the activities as described below. 5
Table 3 Direct Care (Nursing) Meals Medications Patient Communication Nursing Procedures Patient Hygiene Patient Observations Other Off the ward with patient Direct Care (Process) Ward Round Admissions Discharges Other Indirect Care (Nursing) Shift Handover Nursing Documentation Professional Discussion (Face to Face) Professional Discussion (Telephone) Relative Communication Environment/Cleanliness Ordering Patient Tests Other Non-Patient Activities Student Support Break Ordering Stocks Search for items Staff training Off ward without patient Other The collection took place in August, between the beginning and end of the day shift and did not include staff on night shifts. The data was then entered by the ward into a data collection tool which then calculated the percentage of time taken for Direct Care (Nursing), Direct Care (Process), Indirect Care (Nursing) and Non Patient Activities. The results on a ward by ward basis are displayed in appendix 7, direct care and process are united in the graphs. 5.2 Analysis There is no evidence to suggest what the maximum or minimum direct care should be. The majority of peers (who have more experience of this tool) take 60% as the mid-point. The results for LTHT show a fairly consistent picture, with some variation, around the 60-65% range. The wards where the results show above 70% or below 50% will be re-surveyed using a reviewer external to the ward rather than self-assessment, as will wards where their results are outwith their peers. The trends that can be seen are; for day case areas where significant amounts of time are spent on indirect care compared to their 24hr counterparts. Paediatric wards are significantly different to their adult counterparts, in the amount of direct care reported by both staff groups, but the effect of parental involvement in care is not described in any of the work on care contact time. The results show variation between the Clinical Service Units, but within the CSU s are, (for the most part), remarkably consistent. As described above, the output will be reviewed with the Operational Heads of Nursing and actions to improve direct care contact with patients will be put in place. The collection of this information will be routinely collected every 6 months, with ad hoc collections where required by the service or for validation purposes. 6
6.0 Maternity Staffing Metrics Maternity staffing thresholds are reviewed in line with Birthrate Plus (2013). The revised metrics provide an overall staffing birth to midwife ratio and to the community midwifery caseloads. 6.1 Midwife to Birth Ratio s The thresholds described below have been concluded based on the Birthrate Plus (2013) high level analysis: Green = 27-29 Amber = 30-32 Red = above 32 In line with this, LTHT, with the tertiary level services and case complexity, should be aiming for 1:27 as an optimum. 6.2 Current Funded Staffing Position Table 4 Month No. of Deliveries Midwife : Births May 2015 857 1:29 July 2015 866 1:27 Maternity recruitment continues to be successful and as such the green range is expected to be maintained. The successful recruitment into the community teams has reduced these caseloads to 110 / midwife from 137 / midwife in July 2014 and the planned recruitment for 15/16 should reduce these further and bring them into line with the national recommendations of 90-96 / midwife (Birthrate Plus). The birth to midwife rate is a guide and there are operational escalation plans to ensure safe staffing levels at times of peak activity. 6.3 NICE Guidance & Red Flags NICE have recently released safe staffing guideline 4, which relates to Safe Midwifery Staffing for Maternity Settings. The reporting of red flags in this setting have been reviewed by the Regional Heads of Midwifery Forum to ensure a consistent approach. Those listed below have been agreed. The Maternity Service s Risk Management Policy will be amended to reflect these in their incident reporting trigger list, and will be reported and reviewed within the CSU governance structure and through to the Trust Risk and Safety Committee. a) Delay of 30 minutes or more between presentation and triage b) Any occasion when 1 midwife is not able to provide continuous one to one care and support to a woman during established labour. c) Delayed recognition of and action on vital signs. 7
7.0 Hard Truths, 2014 : Summary of number of wards triggering <80% since data collection commenced: trend and current position The Board is familiar with the national requirement to report, and have displayed on the NHS Choices website, the percentage of care hours planned versus the care hours delivered by both registered and un-registered staff. The Trust Development Authority (TDA) express concerns when 40% of the reported wards within an organisation have fill rates of less than 80% of the planned staffing. Within LTHT the percentage of wards showing fill rates of less than 80% has risen above this threshold for the first time in 5 months. The table 5 describes the total number of wards where actual numbers on duty fell below 80% of those planned to be there, with the final column displaying this as a percentage. Table 5 Summary of numbers of wards triggering <80% Cumulative data. Day Registered Day Care staff Night Registered Night Care staff Total wards % of wards reported on Jun-14 11 24 11 15 40 45% Jul-14 12 27 12 14 38 43% Aug-14 17 26 10 14 41 46% Sep-14 14 15 10 11 37 42% Oct-14 14 9 15 7 32 36% Nov-14 5 20 9 12 35 39% Dec-14 11 28 8 15 39 45% Jan-15 8 27 10 14 37 43% Feb-15 10 27 7 14 37 43% Mar-15 10 27 7 15 34 37% Apr-15 9 19 6 11 28 32% May-15 14 19 6 11 31 34% Jun-15 14 16 12 4 32 37% Jul-15 17 16 12 8 39 46% 7.1 Analysis This shows a deteriorating position and is very similar to July 2014, for all the reasons described in section 2. With the numbers in the recruitment pipeline this is anticipated as being a short term problem and the actions to mitigate and support wards, in the short term, form part of the escalation process for supporting staffing. In the medium to long term the recruitment pipeline and activities continue. 8.0 Department of Health Procurement & Efficiency Programme : Lord Carter The Board received information about the contribution LTHT is making to this work programme being led by Lord Carter. The Trust is actively involved in an 8 month DH Workforce Efficiency Collaborative; the aim of the LTHT project is to improve patient safety and the patients and their families experience through the effective and efficient provision of enhanced supervision ( specialling ) of those patients who are at risk of falls, causing intentional or un- intentional harm to themselves, other patients, visitors or staff members. 8
8.1 Progress Agenda Item 11.5 The tender process to support Enhanced Supervision, particularly for those patients causing intentional or un-intentional harm, has been awarded and plans for the move across to the successful company are being developed with Estates and Facilities, with the aim being a 1st October 2015 launch. Currently 3 CSU s, (Abdominal Surgery and Medicine, Acute Medicine Neurosciences), and 7 wards are involved in the LTHT Collaborative, with the potential of a fourth CSU (Urgent Care) joining. Data measures have been agreed. A census will take place, on the participating wards, in early September to gather data to understand the initial (and ongoing) assessments that determine: when enhanced supervision is required, how it is decided and what skill set is required to achieve this safely. This will assist in the development of an assessment / sign-posting tool for use by ward staff to ensure a consistent approach by all. Clinical Support Staff with mental health experience have been recruited to to support short term patient need. Recruitment of similarly skilled substantive staff is in train with 178 applied, 45 shortlisted and interview panels being established. The successful candidates are expected to be in post in November. A process for the allocation and deployment of these staff is being developed. 9.0 Nursing Agency Rules In September the Trust Development Authority in conjunction with Monitor launched their plan to support Trusts to reduce their nursing agency costs. Based on the 14/15 expenditure Trusts have been given a ceiling they are not expected to exceed for the remaining 6 months of the year. This is a month by month ceiling and not a year end figure. A trajectory showing a year on year reduction has also been given and these are described across 8 bands depending on the 14/15 baseline for each organisation. The trajectory for LTHT is in band E and is described below : 2014/15 Nursing Agency Spend rate Banding Q3 & Q4 2015/16 Ceiling 2016/17 Ceiling 2017/18 Ceiling 2018/19 Ceiling 6% to 8% E 6% 5% 4% 3% For LTHT the out sourced bank supplied by is not an agency and this has been recognised within the guidance. An initial high level exercise suggests that this is an achievable ceiling for LTHT and poses little risk to business, but a more detailed review is being completed to ensure this. The Board will receive updates in future papers of the actions being taken to ensure an appropriate reduction in cost without impacting on patient care. 10.0 Financial Implications and Risk Investment in nurse staffing has previously been agreed. Vacancies do present an ongoing risk to patient care but the staffing resource is managed on a daily basis by 9
10 Agenda Item 11.5 senior nurses to ensure safety, in accordance with the escalation procedure that is displayed on every ward. This has been logged on the Trust Risk Register. An update on the recruitment position and plans was given by the Chief Nurse to the Risk Management Committee. Rosters are planned 8 weeks in advance, therefore where a planned roster does not demonstrate safe and effective staffing, the CSU Head of Nursing, working in conjunction with their triumvirate teams have an opportunity to review and plan accordingly. 11.0 Equality Analysis All the equality monitoring associated with the recruiting process is not altered by the contents of this paper. Any adjustments that need to be made to accommodate the needs of those being recruited will continue in line with current LTHT policies. 12.0 Summary In summary, significant progress has been made in reducing the turnover and improving the retention of both registered nurses and band 5 nurses in particular. Aligned to this, the target of recruiting 450 registered staff by the financial year end remains on track. LTHT continues to have a number of challenges in recruiting staff to 5 Clinical Service Units, these are the focus for recruitment from the European Union in partnership with and are subject to specific recruitment campaigns with both a local and national focus. The newly gathered information on care contact hours will be used, where the opportunity exists to increase the time spent with patients by nursing staff. LTHT are employing a number of strategies to bridge the current staffing gap, whilst endeavouring not to increase the use of agency nurses; using incentives, the DH Workforce Efficiency Collaborative to improve how LTHT manage the requirements for enhanced patient supervision and the recruitment of substantive staff. A detailed assessment of the projected costs associated with nursing agency use in line with the recently released Nursing Agency Rules, (TDA/Monitor 2015) is underway. This is to ensure the expenditure sits within the given ceiling of 6%. The initial high level assessment suggests that this will not pose a risk to the safe and effective delivery of high quality care that LTHT currently provides to patients. Where wards are in need of support to deliver high quality care, this is provided by the Support Team from Corporate Nursing with oversight from the Executive Team through the Weekly Quality Meetings. The Board receives this information via the Ward Healthcheck paper. 13.0 Publication under the Freedom of Information Act This paper has been made available under the Freedom of Information Act 2000 14.0 Recommendation The Board are asked to:
Receive the report for information and note the work that is taking place to respond to the red areas at CSU level and at an organisational level to support and improve nurse staffing. To note the first attempt to capture an organisational understanding of the direct contact / process time staff deploy with patients and associated actions. To note the red flag reporting agreed for the maternity services. To note the contribution that LTHT is making towards the Department of Health Procurement & Efficiency Programme workforce stream. Jill Asbury Head of Nursing Education & Workforce 26th August 2015 Please note : Supporting information can be found in the appendices 11