Hard Truths Public Board 29th September, 2016 Presented for: Presented by: Author Previous Committees Governance Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive Heather McClelland - Head of Nursing & Midwifery - Workforce and Education 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. Presentation of June & July 2016 Hard Truths and Care Hours Per Patient Day submission Information 2. Overview of nursing workforce progress against investment Information 3. Progress against Agency Rules 2015/16-2016/17 Information 1
1.0 Summary This paper provides an overview of the Nursing and Midwifery workforce data for June and July 2016. LTHT has completed a review of its data collection for submission of Hard Truths (including care hours per patient day) to NHSI, as previously submitted data did not accurately reflect ward staffing. Acuity and dependency data collected in July shows minimal variation on previous data. The Trust currently has 392 Band 5 staff in the recruitment pipeline. There is a clear recruitment plan across the nursing workforce for 2016/17, taking into account Leeds-wide partner organisations. Challenges remain in some of the CSUs where multiple issues have created a significant gap in staff availability. These are being monitored and supported closely to ensure provision of safe care. LTHT is mostly compliant with the agency price caps and will continue to work closely with operational teams and partners to reduce the impact of agency payment caps. 2.0 Background This paper reports nurse staffing in response to national drives to improve quality of care, transparency and efficiency, including - National Quality Board How to Ensure the Right People with the Right Skills are in the Right Place at the Right Time (2013) - Lord Carter s Operational productivity and Performance in English NHS Acute Hospitals (2016) Data, from a number of sources, have been used to triangulate workforce information for June and July 2016. 3.0 Hard Truths - Nursing & Midwifery Staffing The Trust has a requirement to submit workforce data to NHSI on a monthly basis. Until May this consisted of - Planned vs Actual Registered and Unregistered Nurse Staffing levels - known as Hard Truths - Weekly submission on agency rate breaches (section 5.0 below). In May, a single measure, known as Care Hours per Patient Day (CHPPD), has been generated and submitted as part of the Unify submission to NHSI - please see Appendix 1 3.1 Hard Truths Submission - Nursing The Board is familiar with the national requirement to report the percentage of care hours planned versus the actual care hours delivered by both registered and unregistered staff, with 80% being the threshold set. Table 1 (Appendix 2) presents the data over the last year. The percentage of wards reporting actual staffing to be less than 80% of planned for June and July is 17% and 9% respectively. This shows sustained improvement since the introduction of 2
monthly validation in March, 2016. A review of these processes has now been completed and a paper is currently with operational teams for consultation. 3.2 Maternity Staffing The current midwife: birth ratio for LTHT is stable at 1:29 in both June and July (2016), rated as Green from guidance set out in Birthrate Plus (2013). With the tertiary level services and case complexity, LTHT is aiming for a rate of 1:27. The CSU consistently provides 1:1 care in labour 100% of the time and the caesarean section rate is currently at 20.2% (June) and 20.3% (July) which is well under the national rate of 26.5%. 4.0 Nursing & Midwifery Workforce The appendices attached provide detail on the specific areas of work in building and sustaining the nursing and midwifery workforce in the Trust. These are - CSUs with specific staffing challenges and use of temporary staffing to support - Appendix 3 - Recruitment and Retention - Appendix 4 - Acuity and Dependency - Appendix 5 5.0 Agency Rules - Temporary Workforce In the last year NHS Improvement has instigated controls on agency staffing to increase efficiency and to reduce costs - Appendix 6). Since the introduction of the caps the Trust has seen a reduction in spend on agency, which has now levelled out (Figure 2 - Appendix 6). However, agency still accounts for around half of all temporary workforce shifts filled. In October 2016, the Trust internal bank staff supplier will move to Reed, from NHS Professionals. This provides an opportunity to review agency rates, to increase the internal bank staff numbers and to drive down agency use. It is anticipated this will facilitate improvements in our temporary workforce availability and expenditure 6.0 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. 7.0 Summary In summary, progress has been made in improving the consistency of reporting on ward staffing. LTHT has completed a review of its data collection for submission of Hard Truths to NHSI, as previously submitted data did not accurately reflect ward staffing. Recently collected acuity and dependency data shows minimal variation on previous data. The Trust has a clear recruitment plan across the nursing workforce for 2016/17. Challenges remain in some of the CSUs where multiple issues have created a 3
significant gap in staff availability. These are being monitored and supported closely to ensure provision of safe care. LTHT is mostly compliant with the agency price caps, and will continue to work closely with operational teams and partners to reduce the impact of agency payment caps. 8.0 Publication under the Freedom of Information Act This paper has been made available under the Freedom of Information Act 2000 9.0 Recommendation The Board are asked to: Receive the report for information and note the work that is taking place to recruit staff and support individual CSU s who have significant staffing challenges. To note the changes to the Hard Truths data and introduction of CHPPD To note the on-going work to support the reduction in nursing agency expenditure and the potential implications for staffing in the Trust Author: Heather McClelland Head of Nursing & Midwifery - Workforce and Education 15th September, 2016 4
APPENDIX 1 - Care Hours Per Patient Day (CHPPD) CHPPD uses actual (rather than planned) staffing data (registered and unregistered) and activity (bed occupancy at night) to establish the number of hours of care available for patients. This is calculated across a month and is presented as the total Care Hours Per Patient Day (CHPPD) as well as separately for (Registered) Nursing Hours per Patient Day (NHPPD) and Unregistered Hours per Patient Day. National and international benchmarks exist for NHPPD but not currently for CHPPD. The CHPPD data calculation is automated as part of the monthly UNIFY return for Hard Truths. So far, the data shows significant variation across wards and departments. However, there are a number of factors to take into account - Acuity and Dependency - high dependency or intensive care units show high CHPPD as would be expected for these areas - Calculations are based on actual staffing data as per Hard Truths. As above this is still being validated manually until a standardised solution is implemented. - Enhanced supervision is not captured on the planned staffing templates so some wards and departments have higher than expected data for unregistered CHPPD. - Activity data is based on information from PAS which is not consistently captured. - No current benchmark data is available so comparison is limited, other than across the Trust or within CSUs. CHPPD will be one of the metrics presented in the new Nursing & Midwifery sections of the Model Hospital Dashboard (Figure 1 below). It is hoped the creation of a national standard dashboard will enhance transparency and comparability within and across organisations. The dashboard is still undergoing development but will be launched with a limited set of data in September 2016. 5
Figure 1: Model Hospital Dashboard Preview Source: Department of Health - Productivity and Efficiency 6
APPENDIX 2 - Hard Truths - Nurse Staffing Report Table 1 identifies the number of wards where actual staff numbers on duty fell below 80% of those planned. The right-hand column displays this as a percentage for the Trust. Those highlighted in blue present data since the last report. Data is collected from e-roster and NHSP, via Workforce Intelligence and reported monthly to NHSI. Day Registered Day Care staff Night Registered Night Care staff Total wards % of wards reported on Jun-15 14 16 12 4 32 37% Jul-15 17 16 12 8 39 46% Aug-15 28 28 28 22 61 72% Sep-15 30 32 24 23 57 67% Oct-15 18 19 17 12 39 46% Nov-15 15 22 11 14 38 44% Dec-15 17 22 12 15 40 46% Jan-16 10 22 8 13 37 43% Feb-16 16 21 7 15 37 43% Mar-16 5 5 1 4 12 14% Apr-16 6 12 3 9 22 25% May-16 4 5 2 6 11 13% Jun-16 2 8 3 6 15 17% July-16 5 4 1 4 8 9% Aug-16 2 4 1 8 12 14% Table 1 - Wards declaring <80% planned staffing (e-roster) Prior to March 2016, the Trust position exceeded 40%, which prompted a review to correlate technical and ward level data. This highlighted issues with both data collection processes and how the staffing resource is used across the organisation. Ward staff, educators, corporate teams regularly support clinical areas at short-term notice, but some of this is not captured on the roster and roster templates are sometimes out-of-date. These are all issues identified in Carter s productivity work and seen across other organisations. It is recognised that any inaccuracy in the staffing data will affect the Trusts ability to calculate and submit accurate CHPPD. Since April 2016, the CSU Heads of Nursing and Matrons review their data each month to validate the staffing return. This has provided sustained improvement in the quality of the data submitted but is a manual process. The CSUs have been fully engaged with the changes required to validate their information. 7
APPENDIX 3 - CSU with Specific Staffing Needs Some CSU s are continuing to experience significant challenges with staffing, in particular: Acute Medicine Cardiorespiratory Trauma Related Services Neurosciences Critical Care, with some emerging issues for Paediatric and Neonatal Intensive Care Theatres and Anaesthetics Factors that affect the ability to meet staffing requirements include difficulty in recruiting to posts, high turnover (leavers within the financial year) and high levels of sickness or other leave. This leads to reliance on temporary staff or constant movement of substantive staff from other clinical areas. The pressure on the substantive workforce can subsequently lead to further turnover. The Operational and Nursing Workforce and Education teams are working closely on a range of options to maintain patient safety and to recruit and retain nursing staff. These include - Activation of non-ward based nursing staff to support challenged wards on a short-term basis - Three times weekly formal review of staffing issues within the Operational Meeting, alongside routine identification of risk daily. - Review acuity and dependency data to ensure establishments are appropriate to patient needs - Review of educational opportunities for staff and students, including preceptorship. - Specialist and cohort recruitment campaigns - Review of skill mix across registered and unregistered roles - Use of temporary staff both bank and agency and including incentives to increase shift fill (see below) A significant proportion of our new starters are student nurses, midwives and ODPs who are qualifying in August, so will start during September and October. Table 2 (Appendix 4) shows the current recruitment numbers for each CSU (Band 5 s only). Temporary Staffing Incentives To improve the uptake of temporary staffing shifts in areas where staffing is at risk, a number of initiatives have been implemented. These include payments at top of band and bonus payments for completing a specific number of shifts through the bank service. Incentives will be reviewed as the Trust implements the new bank system (Reed - Leeds Teaching Hospitals Staff Bank) to encourage LTHT staff to work for the internal bank and to reduce the reliance on external agencies. 8
APPENDIX 4 - Recruitment & Retention Since the start of June 2016, 98 Band 5 nurses, midwives and theatre practitioners have started at LTHT with another 392 in the recruitment pipeline - 355 of which are recruits external to the Trust (Source - Cohort Recruitment). Most of these have completed student programmes in the last month so will join the workforce in September & October, including 12 students from the University of West of Scotland recruited in a new collaboration between lecturers at the university and the Nursing Workforce and Education Team at the Trust. The university have already expressed enthusiasm for the Trust s team to meet with and attend recruitment events for the final year students in 2016/17. Specialist recruitment events have been held for Acute Medicine and Neurosciences CSUs providing opportunities for prospective staff to meet the team, visit our clinical areas and discuss their options. The Respiratory clinical teams have worked with Nursing Workforce and Education to create a national advertisement for their specialist areas. There is now an established programme for recruitment of registered staff across the year and opportunities are explored continually. Dates have now been planned for university recruitment drives for the next academic year including local, regional and national universities. As part of the Workforce Transformation workstream within the STP, the Trust is working closely with partner organisations across the city to share recruitment opportunities. Our vision is that all recruitment will be done in collaboration, sharing resources and opportunities across the Leeds health economy. The Trust has been approached to undertake a specific piece of work around retention with NHS Employers and Health Education England, which will start in October 2016. 9
APPENDIX 5 - Acuity & Dependency/Care Contact Time Measurement of the staffing required to deliver care at individual ward, department and patient level is complex. LTHT uses evidence-based tools to measure and report acuity and dependency as recommended in the National Quality Board report (2013). Acuity and Dependency and Care Contact Time are now measured twice yearly to inform the calculation of ward establishments. The data from July 2016 has been collected and is currently being validated by the Nursing Workforce and Education team before sharing with CSU Heads of Nursing. Initial review suggests minimal changes to acuity and dependency from January 2016 and July 2015. 10
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Agenda Item 12.6 APPENDIX 6 - Agency Rules and Temporary Workforce Since October 2015, NHS Improvement has introduced a number of rules around agency use and expenditure in order to improve efficiency and transparency. The controls for nursing include 1. Agency frameworks, introduced Oct. 2015 - only those agencies on the recognised procurement framework may be used - LTHT is fully compliant 2. Rate caps - a stepped approach (23rd November, 1st February, 1st April) to reduction the agency pay rates has been implemented The rate cap currently sits at AfC + 55% 3. Caps on total agency spend - LTHT was capped at 6% of total Registered Nurse staffing spend, reducing annually by 1%. 4. Wage Rate Caps - from 1st July wage rates as well as pay rates (the Trust is charged) were capped, to increase the transparency of the rate paid to agency workers. 5. Expenditure ceiling - LTHT has been given an overall agency expenditure budget for 2016/17 of just over 26m with a pro-rata reduction in nursing expenditure of approximately 2m. Until the introduction of the April 2016 rate caps, the Trust had no breaches of the new agency cap rules and there was a relative reduction in agency spend (overall in nursing) despite consistent demand (Figure 2). 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 Agency Expenditure - Nursing ('000s) Agency Spend Figure 2: Agency Expenditure - Nursing Since the introduction of the April cap, the Trust has seen a reduction in the availability of agency staff within the capped rate (mainly affecting critical care), as agency workers move to work with other providers on higher (breach) rates. This has resulted in a gap in staffing with the potential risk to patient safety and service delivery. A decision has been made to breach the April caps for some areas. Operational activity linked to patient need and increased vacancy gap during June- July has increased the demand for temporary workers and subsequently agency staff. All decisions to breach caps are taken at Executive level, are monitored by the Nursing Workforce and Education team and reported weekly to NHS Improvement. 11