Safe Staffing in Community Services Dr Louise Thomson Laura Dunk Laurie Hare Duke Report presented to Lincolnshire Partnership NHS Foundation Trust October 2014
1. Introduction This report describes a review of staffing capacity and capability in community teams within Lincolnshire Partnership NHS Foundation Trust (LPFT). As there is no standard calculation available to determine community staff numbers and skill mix, the Institute of Mental Health s (IMH) Research Support and Evaluation team were asked to carry out and independent review of community staffing in integrated teams, older adult services and specialist community teams. The project aims to assess the capacity and capability of staff in community services within LPFT. Specific objectives are to: Review staffing levels in community teams Conduct a diary exercise to collect data on staff activity and caseloads Analyse staff caseload and activity data These objectives are reported for Integrated Teams, Older Adult Services and Specialist Community Teams. 2. Methodology 2.1 Data on Workforce Initial benchmarking of staffing levels within the different teams in Community Services was completed using available workforce data from LPFT. This data was descriptively analysed to determine the numbers of clinical and non-clinical staff, their full-time equivalent and their grade level per team. 2.2 Activity and Caseload Review Data on activities and caseloads of Community Service teams were collected using the tools specified designed by LPFT (see Appendix 1 and 2). These tools were administered to staff by LPFT during an agreed time period and sent to the IMH team for manual data entry into an SPSS spreadsheet. 2.3 Analysis of Activity and Caseload Data Analysis was conducted separately for each of the three groups: integrated care teams, older adult services and specialist teams. Initial data analysis focused on descriptive analysis of the composition, activities and caseloads for each team as follows: Numbers of staff, hours worked per week, grades Average number of clients seen per week (% new, %repeat) Average % working time per week on different activities (clinical care face-to-face, clinical care telephone, caseload management, clinical travel, etc) Where possible, comparisons have been made with available data from Trust s existing workforce data. 2 The Institute of Mental Health
3. Findings 3.1. Workforce Profile Workforce data was obtained from LPFT to match the three team groupings of Community Service teams. Data from was collated into the three team groupings: integrated care teams (comprising 10 teams), older adult services (6 team) and specialist teams (22 teams). The data was analysed to determine the average numbers of clinical and non-clinical staff (see Table 1), their full-time equivalent (see Table 2) and their grade level per category of Community Service (See Figures 1-3). The DART teams (Central, Lincoln, Grantham, Social Care and Prescribing) were collated into a single team within the Specialist Services category for appropriate comparison with the self-reported activity and caseload data. It should be noted that combining the DART teams did not strongly influence the central tendency of the Specialist category: measured separately this category has a mean of 8 compared to 10 when DART teams are combined. TABLE 1. Staffing levels by team groupings Team All staff Average Mean Standard deviation Range number of clinical staff a Average number of Non-clinical staff Clinical: Nonclinical staff ratio Integrated 18 7.6 1-29 15 3 5:1 Care Older Adults 10 3.8 5-15 8 2 4:1 Specialist Services b 10 13.7 1-62 8 1 8:1 All figures have been rounded. a Including social workers. b Data was not available for the Dynamic Psychotherapy or Forensic CAMHS teams. This data suggests that the Integrated Care teams have on average a notably larger staff, both clinical and in total, than both the Older Adult and Specialist Services, which were roughly equal. However, there was a large variation in staffing levels within these categories. Within the Specialist Services, for example, there was a range from a single staff member (Community Personality Disorder Psychology) to a team of 62 (combined DART teams). Thus, although there appears to be a difference between the Community Services, with Integrated Care teams showing the largest staffing levels, the differences within these categories was more significant. All teams had significantly higher numbers of clinical to non-clinical staff. The Specialist teams showed the largest average ratio at 8:1 compared to 4:1 and 5:1 within Older Adults and Integrated Care respectively. The breakdown of hours worked (Table 2) revealed a similar picture between teams, with full-time equivalents averaging between.84 and.90. Although Specialist Services have a much higher percentage of staff working full-time (73%) compared to Older Adults teams (54%), this is set against a greater number of staff within the former working part-time (particularly fte.60). 3 The Institute of Mental Health
TABLE 2. Hours worked by team groupings Team Average full-time equivalent Staff working fulltime (%) Integrated Care.84 65 Older Adults.90 54 Specialist Services a.90 73 All figures have been rounded. a Data was not available for the Dynamic Psychotherapy or Forensic CAMHS teams. When compared by grade bandings, there were some similarities and some differences between the Community Services. All teams had the majority (>50%) of their staff between bands 4 and 6, with band 6 being the single highest frequency across teams. Only the Specialist teams had a significant number of staff on bands 7 or 8 (15%), whilst the Older Adults teams had none higher than 6. FIG 1. Grade bands within Integrated Services teams (LPFT data) 4 The Institute of Mental Health
FIG 2. Grade bands within Older Adults teams (LPFT data) FIG 3. Grade bands within Specialist Services teams (LPFT data) 5 The Institute of Mental Health
3.2 Staff profile from Self-Reported Data The sample data retrieved from the self-report activity review and caseload questionnaires was analysed to determine team compositions across each of the different Community Services (see Table 3) and the Grade bandings for each team grouping (see Figures 4-6). Information from Crisis teams was included for comparison purposes (Figure 7). TABLE 3. Numbers of clinical staff and weekly hours worked per team Team Mean number of clinical staff (LPFT records) a Mean number of sample responses per team Integrated Care 15 13 29 Older Adults 8 8 31 Specialist Services 8 8 28 Crisis Teams Not available 18 23 All figures have been rounded. a Clinical staff only; excludes administrative and clerical staff groups. Number of reported hours worked per week To get an approximation of the level of response to the survey, the mean number of completed questionnaires were compared to the mean number of (clinical) staff members in each team category from workforce data. The results in Table 3 suggest that a majority of members from each team successfully responded to the survey. We can therefore take the sample to be broadly representative of these teams. Of note, the study sample did not include data from every service within each team category. For example, no data was received for the Lincoln or Gainsborough Older Adult teams. However, as the results reported here consist of mean averages across team categories, it is not expected that such omissions would have a significant impact. The reported number of working hours was similar between the teams, ranging from 28 to 31 hours per week. This corroborates the workforce data discussed above which found little differences in full-time equivalent contract hours. 6 The Institute of Mental Health
FIG 4. Grade Bands within Integrated Services teams (questionnaire data) FIG 5. Grade Bands within Older Adult teams (questionnaire data) 7 The Institute of Mental Health
FIG 6. Grade bands within Specialist Services teams (questionnaire data) The grade banding composition was similar to that found in the workforce data, with most staff holding grades 4-6. Specialist teams again demonstrated the highest number of staff above grade 7 (22%). Whilst the Specialist and Integrated teams showed some spread across the entire range of bands, the Older Adult teams were most concentrated with staff limited to bands 4-7. The Crisis teams were most similar to the Older Adult teams in this respect, reporting only 4 bands (3 and 5-7) with similar frequencies. FIG 7. Grade Bands within Crisis Teams (questionnaire data) 8 The Institute of Mental Health
3.3 Caseload From the questionnaire data, the total weekly caseload was calculated for each team along with the breakdown of new and existing clients. For comparison, the clinical caseload figures for the month of July were analysed based on LPFT data. Those clients not assigned a care pathway designation were excluded on the grounds that it is impossible to know whether they have been seen or are awaiting assessment. Some cases from the sample data also had to be excluded where self-reports revealed discrepancies between the total, new and existing clients seen. TABLE 4. Numbers of clients seen per week Team Total caseload (July records) a Total caseload (self-report) New clients (%) Existing clients (%) Integrated Care 11 10 12 88 Older Adults 12 10 26 74 Specialist Services 7 7 24 76 Crisis Teams Not available 9 35 65 All teams 10 9 22 78 All figures have been rounded. a Clinical staff only; excludes administrative and clerical staff groups. The total weekly caseloads were broadly similar across each team (see Table 4), with the Integrated and Older Adult teams reporting a slightly higher average than the Specialist teams (10 and 7 respectively). The Crisis team caseloads (mean=9) were also similar. Interestingly, the reported weekly caseload was only slightly less than the clinical records for the entire month of July. One possible reason for this unexpected result could be the fact that some clients may be seen more than once a month. The July caseload figures were also slightly lowered from the exclusion of patients not classified on a care pathway. The Specialist and Older Adult teams reported similar levels of new clients seen each week (24% and 26% respectively), whilst the Integrated Services saw predominantly existing clients (only 12% were new). Crisis teams saw the largest proportion of new clients (35%). 3.4 Activities From the questionnaire data, the percentage of time staff spent on each recorded activity across the two week period was calculated for the entire sample and for each team category (See Table 5). The breakdown of time spent on different work activities was very similar across Community Services (and Crisis Teams). Most time was spent on face-to-face clinical care and caseload management, with staff devoting between a quarter and a third of their time for each of these tasks. Little time was spent on telephone clinical care (<5%), with Crisis teams giving twice as much of their time on this activity. Significant amounts of time were also spent on clinical travel (10% overall), staff management and admin (8%) and learning/studying (8%). 9 The Institute of Mental Health
TABLE 5. Percentage of time spent per activity Activity Integrated Care Older Adults Specialist Crisis Teams All teams Services Face-to-face 32 29 25 28 28 clinical care Telephone 5 4 5 10 5 clinical care Caseload 27 27 29 25 27 management Clinical travel 12 10 7 12 10 Non-clinical 2 2 2 1 2 travel Staff 6 7 9 10 8 management and admin Teaching 2 2 4 1 2 Learning 7 12 9 5 8 Consultation 3 3 4 4 3 work Other 4 4 6 4 5 4. Conclusions This report provides an analysis of LPFT Community Service teams workforce data and self-reported questionnaire data on team profile, caseload and activity. A comparison between the workforce data and questionnaire data shows that the majority of members from each team successfully responded to the questionnaire. This indicates that the sample data should provide an accurate representation of these teams. Some of the key findings from this report: Integrated Care teams had significantly higher levels of staff than other Community Services. Staff from across teams worked roughly equivalent numbers of hours and spent their time doing broadly similar work activities, largely face-to-face clinical care and caseload management Specialist teams had the largest proportion of clinical staff (to non-clinical) and also the most significant numbers of staff above band 6 Older Adult teams showed the narrowest range of bands, with 98% of staff on grades 4-6. 10 The Institute of Mental Health
Appendix 1 Community Team Activity Review Introduction The Trust is undertaking an exercise to look at the needs of service users across the Trust and in individual teams, and the resources available to meet those needs. As part of this, staff are being asked to complete a two week diary exercise. The aim of this exercise is to find out how much time staff spend on different types of activity. Instructions for completing the diary sheet: Please complete the diary sheet for each day (or night) that you work (or should work) between Monday and Sunday. It will take only a couple of minutes each day. At the end of your working day please fill in the appropriate column showing approximately how much time you spent on each of the activities listed. Definitions of these activities are provided. For example, if you spent 68 minutes travelling to see a client then you would record 1 hour 10 minutes against the row labelled Clinical Travel. On any days in the diary week when you did not work please specify, the reason for your absence using the following letters: Non working day annual leave, sick leave Other e.g. carers leave, jury duty, bereavement. Return your completed diary sheets to your admin support lead Catherine Cheyne Catherine.cheyne@nottshc.nhs.uk by 30th th November who will submit the results to the Audit Commission. Definition of activities 1. Clinical Care delivery: Face to Face: Contact with a client or their relative/carer (covering assessment and ongoing direct clinical care) 2. Clinical Care Delivery: Telephone Contact: Contact with a client or their relative/carer (covering assessment and ongoing direct clinical care) 3. Caseload management: administrative work related to a specific client(s); (covering completion of assessment documentation and care plans, case conference(s); caseload management/review; multidisciplinary meetings, liaising with social services or other health professionals e.g. GP) 4. Clinical Travel: travelling between clients homes and other venues 5. Other Staff Management & Administration: Staff and staffing issues; (covering staff appraisal, performance reviews, preparing rotas, stock ordering, team and trust or locality meetings (not about individual clients). Teaching and Learning (Delivered): teaching and supervising other staff (e.g. clinical supervision) Teaching and Learning (Received): teaching and supervision received (e.g. receiving training/education; study days) Non clinical Travel: travel in working time that is not clinical travel 11 The Institute of Mental Health
Other (Not specified above): other non-patient related activity not covered by the above Background information: We need to collect information on the composition of the team in order to help with the interpretation of the diary data. All information will be treated in confidence. No individual will be identified. Please answer the following questions about yourself. Please tick which team you work in and tell us how many hours you are contracted to work each week? Please tick Team name Integrated team (name/location) Integrated team (name/location) Integrated team (name/location) Integrated team (name/location) Integrated team (name/location) Integrated team (name/location) Integrated team (name/location) Integrated team (name/location) Hours Worked Job Title Grade Thank you for your assistance. 12 The Institute of Mental Health
Week One - Monday XXX to Sunday XXX Activity Monday Tuesday Wednesday Thursday Friday Saturday Sunday Did you work? (please circle) Y/N Y/N Y/N Y/N Y/N Y/N Y/N Reason for not working (please circle) ( Non working day, annual leave, sick leave, Other e.g. carers leave, jury duty, bereavement ) For any clients that you saw, please tell us about the following: the number of clients you saw? the number of clients who were new? the number of clients who were repeats? Please record your time spent in hours and minutes on the following activities for each day worked Clinical Care Delivery - Face to Face Clinical Care Delivery - Telephone contact Caseload Management Clinical Travel Other Staff Management & Admin Teaching and Learning (Giving) Teaching and Learning (Receiving) Non Clinical Travel Advice giving or consultation with other agencies Activity not specified above Please detail activity not specified above (see page 5 if extra space is needed)
Week Two Monday XXX to Sunday XXX Activity Monday Tuesday Wednesday Thursday Friday Saturday Sunday Did you work? (please circle) Y/N Y/N Y/N Y/N Y/N Y/N Y/N Reason for not working (please circle) ( Non working day, annual leave, sick leave, Other e.g. carers leave, jury duty, bereavement ) For any clients that you saw, please tell us about the following: the number of clients you saw? the number of clients who were new? the number of clients who were repeats? Please record your time spent in hours and minutes on the following activities for each day worked Clinical Care Delivery - Face to Face Clinical Care Delivery - Telephone contact Caseload Management Clinical Travel Other Staff Management & Admin Teaching and Learning (Giving) Teaching and Learning (Receiving) 14 The Institute of Mental Health
Non Clinical Travel Advice giving or consultation with other agencies Activity not specified above Please detail activity not specified above (see page 5 if extra space is needed) Additional space for relevant activity not specified in diary exercise. Please be as concise as possible. Week One (XXX to XXX) Week Two (XXX - XXX) Monday Tuesday Wednesday Thursday Friday Saturday Sunday 15 The Institute of Mental Health
Appendix 2 Case Load Review 1. Team profile to be completed by team leader Please enter profiles for each team: If your team covers a defined locality rather than the whole trust, please supply the name of this locality Team Member Name Grade Hours worked Job Role 2. Caseload completed on one day (snapshot) by each staff member Type of Service This will be autogenerated from team profile data Client No: Sex Age (in years) Category (Use codes T1 T7) Frequency of contact (Use codes A - H) Reason for care (Use codes C1 C6) Date admitted to caseload (dd/mm/yy) CPA (yes/no) Risk 16 The Institute of Mental Health
1. Codes Codes Category This is a broad indication of need based on their diagnosis using one of the codes shown below. (a formal clinical diagnosis by a consultant is not necessary - please pick the code that most closely matches your understanding of the client). This is based on PBR clusters. Code Definition Cluster number and definitions Frequency of contact: Code A B C D E Definition Daily More than once a week Weekly Fortnightly Monthly 17 The Institute of Mental Health
F G H One - three monthly Three - six monthly Six monthly - once a year Primary reason for care Your clients maybe receiving care that fits more than one of the descriptions below, but for this exercise please just pick one which most closely describes the main care that is provided now. Code C1 C2 C3 C4 C5 C6 Definition Assessment Therapeutic interventions and/or physical treatments Monitoring and maintenance Review and or care co-ordination Urgent crisis management and/or intervention in order to prevent a hospital admission Support and advice, (e.g. providing information and advice on education, housing, social skills). Risk: Use one of these descriptions High and imminent High apparent Medium Low Very Low High and imminent apparent risk and presently a danger to self/others/from others High apparent but with no immediate risk to self/others/from others Medium or significant risk which is currently manageable Low apparent risk which is manageable Very low risk with no special precautions required 18 The Institute of Mental Health
Appendix 3 Community Service teams responding to the survey Integrated Care Older Adults Specialist Services Crisis Teams Adult Psychology Boston Older Adults Anorexia Nervosa Service CRHT Boston Boston ICT CMHT CAMHS Boston and Skegness CRHT Grantham Grantham and Sleaford Grantham and Sleaford CRHT Lincoln CMHT OA CMHT CAMHS Learning Disability CRHT Louth Lincoln North CMHT Louth OA CMHT Team Lincoln South CMHT Skegness OA CMHT CAMHS North Team Louth Integrated CMHT Spalding OA CMHT CAMHS PMHT SARC Stamford OA CMHT CAST Skegness CMHT Community Forensic Team Stamford Integrated CMHT Community Personality Disorder Team DART Dementia and Specialist OA Psychology Dynamic Psychotherapy Forensic CAMHS Harmful Behaviours Service LAC CAMHS NEL CAMHS ADHD Service NEL CAMHS Core team 19 The Institute of Mental Health
NEL CAMHS LD Team NEL CAMHS T3 Plus Neuropsychology Paediatric Psychology Service for Diabetes Physical Health Psychology Witham Court Specialist 20 The Institute of Mental Health