Good practice in managing the use of temporary nursing staff

Transcription

1 Good practice i maagig the use of temporary ursig staff 12 July 2006

2 NHS Employers is part of the NHS Cofederatio ad has specific resposibility for represetig the views of NHS employers i Eglad o workforce matters. NHS Employers edorses this guide ad ecourages employers to lear from the messages withi it.

3 cotets Preface 4 Itroductio 5 Part 1 Moitorig ad plaig for the use 6 of temporary ursig staff Maagig the use of temporary ursig 6 staff strategically Settig ad moitorig temporary ursig budgets 7 Part 2 Cotrollig demad for temporary 9 ursig staff Uderstadig the reasos for bookig temporary 9 ursig staff Settig the right establishmet 9 Rosterig effectively 12 Creatig a flexible workforce 14 Cotrollig bookigs of temporary ursig staff 14 Maagig vacacies 17 Part 3 Appoitig suppliers of temporary 23 ursig staff Aalysig the costs of usig temporary 23 ursig staff Usig ursig baks ad NHS Professioals 24 Usig ursig agecies 26 Part 4 Usig temporary ursig staff 30 Recruitig temporary ursig staff 30 Traiig ad performace assessmet of 31 temporary ursig staff Iductig temporary ursig staff 32 Reducig the risk of fraud 32 Appedices 1 Actios for differet maagemet levels 33 2 Maagig attedace 38 ed otes 39 Maagig absece 18

4 preface 1 This good practice guide has bee prepared by the Natioal Audit Office i collaboratio with the Audit Commissio ad the Departmet of Health. It draws o the research carried out as part of the Natioal Audit Office s study o the use of temporary ursig staff i NHS acute ad foudatio trusts. It is iteded as a practical guide for trust boards ad maagers to help them to use temporary ursig staff effectively. 2 The guide comprises a arrative of the saliet poits i the use ad maagemet of temporary ursig staff ad icludes a umber of good practice checklists. The actios are addressed to trust boards (executive ad o executive directors); executive directors (for example, the chief urse, fiace director, huma resources director); middle maagers (for example divisioal maagers, cliical maagemet team heads, specialty maagers); ad ward maagers (for example moder matros ad ward sisters). Actios for each maagemet level are grouped together ad summarized at the ed of the guide (Appedix 1). 3 The guide also provides case studies draw from study visits ad the work of the Departmet of Health s Natioal Agecy Staffig Project. Further ad fuller examples of good practice are available o the project s website: Good practice i maagig the use of temporary ursig staff

5 Itroductio 1 The boards of NHS acute ad NHS foudatio trusts have a statutory duty to assure themselves of the quality of care they provide to patiets; a statutory duty to achieve fiacial balace ad a statutory duty of staff welfare. Poor maagemet of the use of temporary ursig staff could put all three duties at risk ad accordigly the subject should be give a high priority. 1 The structure of the good practice guide Part 1 Moitorig ad plaig for the use of temporary ursig staff 2 Temporary ursig staff ca mea staff supplied through ursig baks, ursig agecies or NHS Professioals. Good maagemet of the use of these staff ca help trusts to achieve reductios i cost ad improve the quality of care give to patiets. Trusts are oly to likely to succeed i improvig their maagemet of temporary ursig staff if they implemet a plaed, logical approach that gives as much cosideratio to the uderlyig reasos creatig demad for temporary ursig staff as it does to addressig the maagemet arragemets for their supply. Part 4 Usig temporary ursig staff Part 3 Part 2 Appoitig suppliers of temporary ursig staff Cotrollig demad for temporary ursig staff 3 This guide looks at the steps that trusts ca take to improve the maagemet of their use of temporary ursig staff. It is set out i four parts (Figure 1) ad icludes checklists to assess trusts performace ad case examples of actios take by idividual trusts to improve their maagemet of the use of temporary ursig staff. As you read through the guide you will eed to cosider how appropriate these practices are to your trust s idividual circumstaces. Good practice i maagig the use of temporary ursig staff

6 Part ONE Moitorig ad plaig for the use of temporary ursig staff 1.1 As more choice ad cotestability is itroduced ito healthcare it is likely that activity levels i idividual trusts will fluctuate more drastically ad become more upredictable tha at preset. As such workforce plaig will become more challegig but eve more importat if trusts are to be able to balace their budgets. Trusts eed to cosider to what extet it is desirable for them to use temporary ursig staff to help them accommodate variatio i activity levels i their plaig. 1.2 I lookig at this part of the guide ask yourself whether your trust: Has i place a clear workforce pla based o forecast levels of activity ad plaed service developmets. Plas strategically for the use of temporary ursig staff. Sets a budget for the use of temporary ursig staff ad moitors performace agaist it. Maitais a accurate ruig total of expediture o temporary staff ad ca idetify the supply source for each shift. Maagig the use of temporary ursig staff strategically 1.3 All foudatio trusts will have, ad all aspirat foudatio trusts will eed to have, a service developmet strategy from which will flow a clear workforce pla based o forecast levels of activity ad plaed service developmets. The pla should idetify the umbers of staff that will be required i the future ad iclude plas that address ay variace betwee umbers ad skills. This will help trusts to avoid a future situatio i which they are forced to rely o temporary ursig staff to make up for skill shortages withi their permaet staff. 1.4 Where trusts experiece sigificat variatio i activity level o a daily or seasoal basis they should cosider the best method of staffig up for these fluctuatios. They may cosider that the use of temporary ursig staff is the most effective method of accommodatig fluctuatio. However, they should also cosider other methods such as buildig more flexibility ito their permaet workforce. Where trusts do decide to use temporary ursig staff they should pla, budget for ad moitor their use of temporary ursig staff i order to esure that temporary ursig staff are used to good effect. 6 Good practice i maagig the use of temporary ursig staff

7 1.5 Where trusts decide that they eed to reduce their expediture o temporary ursig staff they should ot attempt to separate makig the best use of temporary ursig staff from makig the best use of permaet ursig staff. Trusts that have high use of temporary ursig staff eed to adopt a strategic approach to maagig expediture by first tacklig the issue from the demad side ad gettig the establishmet of permaet staff right before tryig to tackle supply side issues such as reviewig the performace of the ursig bak or ursig agecies (Case study 1 overleaf). 1.7 Materity leave accouts o average for 2.5 per cet of ursig costs but o idividual wards ca commoly reach levels of five to te percet. Such radom variatio ca reder ward ursig budgets uachievable. Some trusts use a cetral budget cotigecy to cover the cost of materity which ca smooth the impact of the costs of materity leave by spreadig the effect across the trust. Settig ad moitorig temporary ursig budgets 1.6 Ward budgets should be accurate ad owed at ward level by staff with a geuie commitmet to ad resposibility for improvig the quality of patiet care. Trusts should esure that ward maagers have iput ito the budget settig process ad that ward budgets iclude a elemet for the plaed use of temporary ursig staff if appropriate. Oce budgets have bee agreed the Director of Nursig should moitor both total ad temporary ursig expediture agaist budget ad ivestigate the reaso for ay sigificat variatio. Good practice i maagig the use of temporary ursig staff

8 Case study 1 A strategic approach to reducig reliace o temporary ursig staff Covetry ad Warwickshire Hospitals NHS Trust faced sigificat fiacial difficulties over several years with expediture o bak ad agecy urses cotributig to the problem. I order to address the problem, the Trust s ew Executive team itroduced a plaed, icremetal programme to set the trust s ursig establishmet at a fair level, ad the to tackle the uderlyig problems of urse turover ad high sickess before drivig dow o the high use of first agecy ad the bak staff. Over two years they succeeded i reducig their total expediture o temporary ursig staff by over 1 millio. Cotiuig cultural chage Address attedacce problems Set the right establishmet ad skill-mix Build flexibility ito permaet workforce Reduce use of agecy urses Reduce use of bak urses Address turover problems Improve fiacial iformatio, maagemet ad capacity Fiacial Year Expediture o bak Expediture o agecy Total expediture o ursig staff ursig staff temporary ursig staff ( millio) ( millio) ( millio) Good practice i maagig the use of temporary ursig staff

9 Part TWO Cotrollig demad for temporary ursig staff 2.1 Uderstadig ad cotrollig the demad for temporary ursig staff is as importat as maagig their supply. However, trusts ofte eglect to cocetrate attetio o their demad for temporary ursig staff makig it ulikely that they will achieve log term success i cotrollig their expediture i this area. 2.2 I lookig at this part of the guide, ask yourself whether your trust has: A clear uderstadig of the reasos why temporary ursig staff are beig booked. A review process i place to esure that ursig establishmet levels are appropriate to deal with fluctuatios i patiet volume ad acuity. A effective rosterig process which miimises the demad for temporary ursig staff. Has udertake steps to create a flexible permaet workforce. A documeted process i place to cotrol bookigs of temporary ursig staff. Procedures i place to cotrol vacacy levels. A writte policy i place for dealig with sickess absece. Udertake a aalysis of variatio i absece levels across the trust ad take actio to reduce uacceptable levels of absece. Uderstadig the reasos for bookig temporary ursig staff 2.3 I order to begi to cotrol the demad for temporary ursig staff it is importat for trusts to uderstad the reasos why they are booked. Trusts should have a system i place to record the reaso for all temporary staff bookigs ad should verify this iformatio agaist idepedetly collected iformatio for example o vacacies ad sickess absece. Settig the right establishmet 2.4 The use of temporary ursig staff is iextricably liked to the use of permaet ursig staff. Hece settig a appropriate ursig establishmet is essetial to the maagemet of temporary ursig staff. If ursig establishmets are reviewed too ifrequetly the they ca become the product of accretio offset by budget costraits rather tha a true reflectio of the umber ad skill-mix of urses that are eeded. Cosequetly ward maagers may feel that they eed to routiely brig i temporary ursig staff to operate their ward safely. Good practice i maagig the use of temporary ursig staff

10 2.5 Research has emphasized the importace of gettig the right umber ad skill-mix of urses to the quality of care delivered. The US Agecy for Healthcare Research ad Quality 1 cocluded that, i both hospital ad ursig home settigs, rates of complicatios ad adverse icidets are iversely related to staffig levels. Icreasig staffig levels led to lower rates of medicatio errors ad other adverse outcomes icludig peumoia, cardiac arrest ad uriary tract ifectios. There was also evidece that the richer the skill-mix of urses, the better the outcomes a fidig supported by two UK studies. 2, There are may differet methods of calculatig ursig establishmet levels ad this guide does ot recommed ay oe particular method. It does however highlight the importace of trusts havig processes i place to esure that ursig establishmet levels ca reflect chages i patiet volume ad depedecy. Trusts ca achieve this through periodic establishmet reviews; through bechmarkig staffig levels agaist other trust ad through IT based workforce maagemet systems (Case study 2). 2.7 Trusts ca bechmark their ward staffig levels i agaist comparator trusts usig the Healthcare Commissio s ward staffig tool 4 ad the Audit Commissio s aalysis of the Acute Hospital Portfolio (Figure 2). For more up to date bechmarkig iformatio trusts will eed to form bechmarkig groups ad share iformatio with comparable trusts. 2 There is sigificat variatio i establishmet per bed i some specialties The umber of whole time equivalet umber of ursig staff which trusts judged that they eeded to employ per bed i Specialty Lower Average Upper quartile quartile Coroary Care Uit Cardiology Ear, ose ad throat Care of older people Geeral medicie Geeral surgery Gyaecology High depedecy uit Itesive care uit Medical admissios uit Neurosurgery Ocology Paediatric medicie Rehabilitatio Stroke uit Surgical admissios uit Trauma Trauma ad orthopaedics Urology Source: Natioal Audit Office/Audit Commissio aalysis of Healthcare Commissio data collected from 4600 wards i 173 trusts 10 Good practice i maagig the use of temporary ursig staff

11 Case study 2 Use of iformatio techology to maage demad At the Pricess Margaret Hospital i Widsor, part of the BMI group, they have developed a sophisticated demad maagemet system which has helped reduce expediture o ursig staff whilst admissios cotiue to icrease. The system is used to eter patiets depedecy data, roster ursig staff o to wards ad geerate real time maagemet iformatio about workforce plaig ad the extet ad cost of the use of ursig staff. The hospital has coducted time series aalysis to determie the average amout of time ursig staff eed to sped with patiets before, durig ad after surgery for all commo operatios (for example hip replacemets) ad for medical patiets. This data has bee etered i to the system ad, together with iformatio about the umber of patiets booked ad the expected time of their scheduled operatios, allows ward maagers to predict the umber of urses they will eed o their ward throughout the day. Ward maagers prepare rosters for staff a moth i advace takig ito accout staff prefereces ad patiet requiremets. Each day the ward maager will go ito the system ad look at the curret patiets ad admissios for the followig day. The system will automatically calculate the umber of urses that should be workig throughout the day ad the ward maager ca evaluate this iformatio agaist the umber of urses that she has rostered o the ward. If ecessary the ward maager ca adjust staffig levels o her ward as follows: By askig staff to work a differet shift if more staff tha ecessary are rostered o the ward; By usig the system to look across the hospital to determie whether staff ca be borrowed from aother ward which has more urses tha required; By usig the system to work out how log it may be ecessary to brig a temporary urse e.g. for three hours rather tha a full shift. The Director of Nursig ca obtai real time maagemet iformatio from the system which allows her to moitor expediture o all ursig staff ad to detect ad deal with all staffig issues as they arise. Sice the system was implemeted, the paid hours per patiet day have decreased by 0.8 hours per patiet due to more efficiet rosterig. At a average cost of 15 per hour this results i a et savig of 210,000 sice the itroductio of the ew system i September Good practice i maagig the use of temporary ursig staff 11

12 2.8 May privately ru hospitals use IT based workforce maagemet systems to esure that day to day staffig levels reflect chages i patiet volumes ad depedecy. Some NHS acute trusts are pilotig the use of similar systems. Such systems ca help trusts save moey by ot rosterig staff uecessarily ad improve patiet safety by esurig that there are always sufficiet staff to cope with the volume ad depedecy of the patiets o the ward. Rosterig effectively 2.9 Oce a agreed ursig establishmet has bee determied, it becomes much easier to optimise the use of permaet ursig staff by effective operatioal maagemet. Trusts ca make the best use of their ow permaet staff ad maage their demad for temporary ursig staff by rosterig effectively. Some examples of effective rosterig iclude: The use of self-rosterig to allow staff to express their prefereces for shifts ad take owership of the roster. The itroductio of rules to esure a fair allocatio of shifts e.g. all ursig staff must work oe weeked per moth. Spreadig aual leave ad study leave evely throughout the year (Figure 3). Always rosterig permaet staff o to expesive shifts (weekeds ad ights) so that temporary ursig staff ca cover less costly shifts ad work uder supervisio Some trusts have itroduced the use of IT rosterig packages to help ward maagers prepare rosters (Case study 3). The packages ca determie miimum staffig levels ad grade mix required for each shift ad ca aalyse shift patters ad take accout of staff prefereces to help assig duties fairly. IT based rosterig systems ca also make it easy for staff to self-roster withi set parameters ad reduce admiistratio time for ward maagers. 3 Guy s ad St Thomas aual leave calculatio Ward A has 21 traied staff. Assumig each member of staff has 7 weeks leave each this meas there are 147 weeks of aual leave which eed to be take throughout the year. (21 x 7 = 147) Ward A should therefore aim to have three members of staff o a aual leave each week throughout the year to achieve a eve distributio of leave ad miimise the eed for temporary ursig staff. (147/52 = 2.8) If urses have differet amouts of aual leave the add up all weeks of aual leave due to traied staff ad divide by 52 to achieve the same result. 12 Good practice i maagig the use of temporary ursig staff

13 Case study 3 IT based rosterig Bedford Hospital NHS Trust has piloted electroic rosterig o four wards i a effort to improve the cost effective maagemet of its ursig ad midwifery staff. As a result of the pilot the trust has itroduced a ew electroic rosterig system which will be implemeted i a phased roll out that is expected to take approximately te moths. The trust aticipates that the combiatio of the electroic rosterig system, ad a ew rosterig policy which it itroduced simultaeously, will improve the utilisatio of existig staff ad reduce expediture o temporary ursig staff ad overtime. It should also esure that all departmets are staffed appropriately ad miimise cliical risk. The trust aticipates that the system will improve its ability to moitor sickess ad absece by geeratig comparisos ad idetifyig treds ad priorities for actio. Furthermore it will improve plaig of aual leave ad study days. The trust estimates that i total the project will result i et savigs of 250,000 i the first year risig to over 500,000 i subsequet years. The task of improvig patiet care whilst cotrollig cost led North Tees ad Hartlepool NHS Trust to trial the use of electroic rosterig. The trust believed that electroic rosterig could help them to: Reduce expediture o temporary ursig staff ad overtime. Use permaet staff more productively through cross ward staff movemet liked to depedecy based rosters. Remove the complexity of rosterig i light of workig restrictios, irregular shift patters ad the eed to achieve a balace betwee the eeds of staff ad the eeds of the wards. Reduce time spet o paper based rosterig. The trial was very successful ad resulted i a reductio i temporary ursig ad overtime expediture of 44 ad 40 per cet respectively whilst showig a icrease of 45 per cet i staff utilisatio. This is partly because seior urses were able to view resource availability ad utilisatio across wards ad redeploy staff as required. The trust is ow rollig the software out across all wards ad is cosiderig usig the system to maage the rosters of juior doctors ad allied health professioals. Good practice i maagig the use of temporary ursig staff 13

14 Creatig a flexible workforce 2.11 The Departmet of Health s, Improvig Workig Lives Stadard states that NHS employers should accept joit resposibility with staff for developig a rage of workig arragemets that balace the eeds of patiets ad services with the eeds of staff. 5 Trusts ca reduce their demad for temporary ursig staff ad improve recruitmet ad retetio i their permaet staff by allowig staff to work flexibly through iitiatives such as: Creatig a pool of permaet staff who ca be allocated across divisios or across the trust (Case study 4). Allowig staff to work o aualised hours cotracts which give the urse ad the trust some flexibility about whe hours are worked durig the year. Allowig staff with school aged childre to work o term time oly cotracts. Allowig staff to icrease or decrease their work commitmet by buyig or sellig aual leave from the trust However, uless use of flexible workig is well cotrolled it ca result i a icrease i the demad for temporary ursig staff. Trusts should balace the demads of their staff with the demads of ruig a 24 hour service. I order to do this they will eed to regularly review the situatios of those o flexible cotracts to determie whether they are still required ad attempt to balace the differet prefereces of their staff, for example by ecouragig staff without school aged childre to work more hours durig school holidays ad fewer durig term time. Cotrollig bookigs of temporary ursig staff 2.13 Some trusts have icreased their cotrol over bookigs of temporary ursig staff by itroducig trust wide bookig guidelies (Figure 4 overleaf) ad by icreasig the seiority of the member of staff who ca authorise temporary ursig bookigs. May ursig directors ad assistat ursig directors ow hold weekly meetigs with their ward maagers at which they assess levels of bookig ad discuss the reasos why temporary ursig staff were required. 14 Good practice i maagig the use of temporary ursig staff

15 Case study 4 Itroducig flexibility ito the permaet workforce Salford Royal NHS Trust sought to itroduce flexibility ito its permaet healthcare assistat workforce i order to reduce spedig o NHS Professioals ad agecy urses. The trust recruited a pool of thirty healthcare assistats ad i tadem implemeted a o agecy policy for healthcare assistat shifts. Staff i the pool are assiged to wards where there is high usage of healthcare assistats. The pool has ever reached its full establishmet as the ew recruits are ofte used to fill ward vacacies. As these vacacies have reduced the umber of requests to NHS Professioals has also falle. I additio, the trust: revisited its temporary ursig staff bookig policy ad required that all iteral sources of staff be explored ad exhausted before a request for a temporary urse is made; made ward maagers accoutable for the use of temporary staff icludig overseeig ward iductio of ew starters ad verifyig timesheets; ad reduced the umber of agecy suppliers from eight to four i order to built stroger relatioships with the agecies. This resulted i a improvemet i the percetage of shifts which the agecies have bee able to fill. NHS Professioals supported the trust with a extesive awareess ad recruitmet campaig by: cold-callig staff who have ot worked recetly to geerate availability; workig collaboratively with wards to target ad recruit agecy staff o shifts i the lead-up to the chages; providig maagemet iformatio to support the trust i idetifyig wards makig high usage of agecy urses; ad providig seior maagemet with iformatio o wards with high vacacy ad staff sickess levels. As a result of these steps, the trust reduced its use of agecy urses, geeratig savigs of 1.3 millio. Good practice i maagig the use of temporary ursig staff 15

16 4 A good practice decisio tree The decisio tree used by Guy s ad St Thomas NHS Foudatio Trust to determie whether to book temporary ursig staff. 1 Idetify staff shortage Staff shortage may be caused by: Materity leave Staff vacacy (loger tha a week) Sickess 2 Immediate cosideratios (how urget is the bookig?) Ca this shortage be accommodated withi existig resources ad skill mix? What is the aticipated workload for the period i questio? How will the shortfall affect patiet care / delivery? Ca less importat work be postpoed util more staff become available? 3 Explore all optios If it is cosidered vital that a additioal perso is eeded ca they be sourced from withi the orgaisatio? Have you cotacted all of your permaet staff to see if they ca fill the shortage? Have you cotacted your maager to iform them of your staff shortage allowig them to try ad source from elsewhere withi the Trust? 4 If additioal staff caot be foud through the above optios Proceed to request staff from the staff bak. The decisio to request staff must be validated by a secod perso. 5 Book temporary staff Complete bookig form icludig: Details of shift time ad date; Name of perso makig bookig ad perso validatig bookig; Locatio ad cotact umber of ward/area; Professioal/grade/experiece required; Reaso for bookig request; Positio maagemet umber. 16 Good practice i maagig the use of temporary ursig staff

17 Maagig vacacies 2.14 Vacacies are cited by trusts as the most commo reaso for bookig temporary ursig staff. 6 May trusts deliberately hold vacacies to create workforce flexibility through usig temporary ursig staff. It is therefore importat that trusts moitor the umber of vacacies that they are holdig to esure that levels remai acceptable. I order to reduce uecessary use of temporary staff caused by vacacies trusts should: Seek to reduce turover ad improve recruitmet ad retetio rates through the use of secodmets, rotatio, family-friedly policies, sabbaticals, improvig child care facilities ad providig traiig ad developmet opportuities (Case study 5). Allocate all establishmet posts, whether filled or ot, with a uique umber to facilitate a commo defiitio of the umber ad locatio of vacacies throughout the trust. The use of a uique referece umber is a excellet mechaism for icreasig cotrol over the whole process of usig temporary staff. It ca be used to cotrol demad, geerate iformatio o reasos for bookig ad track the temporary staff bookigs all the way through the system to paymet. Avoid the practice of freezig vacacies i times of fiacial pressure ad the fillig these posts with temporary staff. Avoid uecessary delays i the recruitmet of permaet staff by streamliig recruitmet procedures (Case study 6 overleaf). Case study 5 Improvig recruitmet ad retetio St. George s Healthcare NHS Trust reduced its expediture o temporary ursig staff from 14.6 millio to 11.6 millio over a year through a wide rage of measures icludig the itroductio of flexible workig policies ad career breaks to aid recruitmet ad retetio ad the itroductio of a childcare coordiator who offers a rage of facilities to support urses with childcare resposibilities. The trust also appoited two seior urses with resposibility for recruitmet ad retetio: oe for ursig posts ad aother for midwifery posts. These staff work closely with the local uiversities to coordiate cliical placemets ad to orgaise career evets for studet urses. They also moitor ad provide support to wards with particular recruitmet difficulties. I additio the trust reviewed the skill mix i all cliical areas as part of a five project Nursig Turaroud Programme. Good practice i maagig the use of temporary ursig staff 17

18 Case study 6 Streamliig recruitmet procedures At the Uiversity of Leicester Hospitals NHS Trust, there is a cetralized recruitmet process which orgaizes quarterly recruitmet days for healthcare assistats. Typically, about 100 prospective cadidates atted each evet ad a waitig list is kept of successful cadidates should a vacacy arise betwee ope days. This process saves moey o recruitmet ad meas that vacacies ca be filled quickly to reduce the use of temporary urses. Leicester s turover rates have also bee reduced by improvig local urse leadership ad through Improvig Workig Lives. The trust provides a job-shop for careers advice, provides high-quality appraisal to all urses ad offers educatio ad developmet. There are dedicated educatio leads i each cliical divisio as well as cliical support urses, whose role is to metor ewly qualified staff ad urses recruited from other coutries who are ew to the NHS. Maagig absece 2.15 The Healthcare Commissio foud that i the average rate of sickess absece for ursig staff is 7.5 per cet (16.8 days per year). However, our aalysis shows that there is wide variatio i the sickess absece levels betwee wards (Figure 5), specialties (Figure 6 overleaf) ad grades (Figure 7 o page 21). There is also sigificat variatio i the average rates of sickess absece betwee differet types of departmet or specialty. The greatest problems reside i services dealig for the most part with older patiets such as stroke uits, rehabilitatio, geriatrics ad geeral medicie. There is less sickess absece i departmets that provide specialist services, such as coroary care uits, cardiothoracic surgery, itesive therapy uits ad paediatrics although rates remai high. 18 Good practice i maagig the use of temporary ursig staff

19 5 There is sigificat variatio i sickess absece rates across wards The percetage of time lost to sickess absece i wards i acute trusts i Eglad durig oe moth i 2004 Percetage of time lost to sickess absece Wards i Eglad Source: Audit Commissio aalysis of data collected by the Healthcare Commissio. N = 4,600 wards i 173 trusts. Good practice i maagig the use of temporary ursig staff 19

20 6 There is more sickess absece i departmets which provide services for older people The percetage of time lost to sickess absece i acute trusts i Eglad by specialty durig oe moth i 2004 Coroary Care Uit Cardiothoracic surgery Itesive therapy uit Paediatric medicie Geeral surgery Surgical admissios uit Medical admissios uit Cardiology Gyaecology Geeral ad specialised surgery High depedecy uit Trauma ad orthopaedics Ear, ose ad throat Ocology Urology Truama Geeral medicie Neurosurgery Care of older people Rehabilitatio Stroke Uit Percetage of time lost to sickess absece Source: Audit Commissio aalysis of data collected by the Healthcare Commissio. N = 4,600 wards i 173 trusts. 20 Good practice i maagig the use of temporary ursig staff

21 7 Staff employed at lower grades have higher rates of sickess absece The percetage of time lost to sickess absece i acute trusts i Eglad by grade durig oe moth i Grade H Grade G Grade F Grade E Grade D Grade C Grade B Grade A Source: Audit Commissio aalysis of data collected by the Healthcare Commissio. N = 4,600 i 173 trusts. Good practice i maagig the use of temporary ursig staff 21

22 2.16 Variatio i sickess absece rates is ofte related to the effectiveess with which lie maagemet cotrol sickess absece. I order to improve the maagemet of sickess absece trusts should: Udertake a aalysis of sickess absece by ward, specialty, grade ad idividual (Case study 7). Ivestigate ad act o the reasos for above average sickess levels. Read the Health ad Safety Executive Guidace HSG 249 Maagig Sickess Absece ad Retur to Work which will help trusts put i place suitable arragemets. Regularly review all log term sickess cases to see if there is ay opportuity for staff to retur to work either i their previous job or i oe more suited to their ew circumstaces. Read the recommedatios i the Natioal Audit Office s good practice guide o maagig attedace 7 ad implemet as appropriate. Case study 7 Improvig the maagemet of sickess absece I Jue 2005 the Whittigto Hospital NHS Trust board decided to ru a specific project to address sickess absece levels i the trust, which had averaged six per cet i the precedig 15 moths. The aim of the project was to address the detrimetal cosequeces of employee absece i terms of quality of patiet care, staff morale ad cost implicatios. The target set by the board was to Demostrably reduce sickess absece withi the trust by a miimum of a oe per cet reductio over a six-moth period ad i stages workig iitially to a local target of four per cet ad thereafter to a target of 2.7 per cet. I order to achieve this target the trust udertook a umber of activities icludig: Adoptig the use of the Bradford Score Idex (see Appedix 2) ad targetig the top 50 abseces i the trust which cosisted of 15 log term sick cases ad 35 cases of idividuals who were frequetly abset for short periods. Streamliig the IT system to improve the capture of sickess absece data. Deliverig traiig across the trust to ehace maagers skills at effectively maagig sickess absece. Revisig ad implemetig chages i policy ad procedures e.g. updatig the sickess absece guidelies. Throughout the project the project team worked closely i partership with staff represetatives ad commuicated the goals ad results of the project to staff, for example through the staff magazie. They feel that this has bee key to the trust achievig a reductio i sickess absece rates of oe per cet across the trust from six to five per cet i 12 moths. They estimate that this has saved the trust approximately 700 workig days sice July This has bee calculated usig the umber of days that they would have expected idividuals i the top 50 to have take sick from July 2005 compared with the six moths prior to the project commecig. 22 Good practice i maagig the use of temporary ursig staff

23 Part THREE Appoitig suppliers of temporary ursig staff 3.1 All trusts eed to draw o temporary ursig staff to some extet. It is therefore importat that trusts ca demostrate that they are procurig temporary ursig staff through mechaisms that miimise the cost ad assure the quality of temporary staff. 3.2 I lookig at this part of the guide, ask yourself whether your trust: Uderstads the whole cost of usig temporary ursig staff. Has evaluated its iteral bak to cosider whether efficiecy savigs could be realised through better use of iformatio techology. Has udertake a evidece based assessmet of whether or ot to use NHS Professioals. Uses ursig staff oly from agecies o the NHS Purchasig ad Supply Agecy Framework Agreemets. Has arragemets i place to procure agecy ursig staff at best value. Has performace measures i place to assess all providers of temporary ursig staff to the trust. Aalysig the costs of usig temporary ursig staff 3.3 Whe comparig the relative costs of differet types of ursig staff, may trusts compare oly pay rates. Trusts should compare the detailed costs of the differet grades of ursig staff i which they use sigificat umbers of temporary ursig staff. This will allow them to make iformed decisios about staff allocatio. Figure 8 overleaf sets out a table that trusts ca use to compare the relative cost of permaet, bak/nhs Professioals ad agecy ursig staff withi their trust. Good practice i maagig the use of temporary ursig staff 23

24 Usig ursig baks ad NHS Professioals 3.4 Most trusts use either NHS Professioals or a ursig bak as their primary supplier of temporary ursig staff. Trusts should make a objective ad evidece based decisio o which to use takig ito accout both cost ad quality stadards. Trusts should bechmark their ursig bak(s) agaist the quality stadards operated by NHS Professioals. Where their quality stadards fall short of NHS Professioals they should udertake a detailed exercise to determie the cost of brigig them up to these stadards. Where these costs are higher tha those icurred by usig NHS Professioals, they should develop a busiess case which evaluates the costs ad beefits of egagig NHS Professioals to maage their temporary staffig service. I some cases, where trusts wish to ivest their maagemet capacity ad capability i other areas, outsourcig their temporary staffig service to NHS Professioals has proved effective (Case study 8). 8 Table for comparig the relative costs of staff Permaet Bak NHS Professioals Nursig agecy Basic pay per hour Pay per week based o 37.5 hour week Employer s Natioal Isurace Cotributios at 12.8 per cet o earigs betwee 91 ad 610 per week Employer s pesio cotributios at 14 per cet x pesio uptake (uptake of pesio to be calculated by trust) Agecy commissio rate /a /a /a NHS Professioals commissio rate /a /a /a Bak overheads /a /a /a Overhead costs to cover aual leave, sick leave /a /a /a ad study leave at 22 per cet Total 24 Good practice i maagig the use of temporary ursig staff

25 Case study 8 Usig NHS Professioals Ashford ad St Peter s NHS Trust has established a partership with NHS Professioals as part of a series of measures aimed at chagig workig practices i cojuctio with Improvig Workig Lives. As part of the project, the trust sought to reduce the use of agecy staff as patiets had greater cofidece i the trust s ow staff ad the icosistet quality ad high cost of agecy ursig staff was adversely affectig staff morale. Staff o the trust s bak were trasferred to NHS Professioals i December 2001 ad over the followig three years the trust s expediture o agecy ursig staff fell from 4.7 millio to 1.6 millio. By usig NHS Professioals the trust estimates that it has bee able to avoid costs of 3.1 millio sice It has also bee able to reduce the umber of requested shifts which remai ufilled from oe i five to oe i te. Year ( millio) ( millio) ( millio) ( millio) NHS Professioals Agecy Total The itroductio of NHS Professioals led to a umber of beefits: Staff at all levels were ivolved from the start of the project with a iitial period of cosultatio to explai the objectives ad reasoig behid it. I order to reduce agecy expediture ad attract staff, a icrease i bak pay-rates was required o a ivest-to-save basis. NHS Professioals improved commuicatio ad cotiuity betwee the trust s sites ad provide the trust with a cosistet stadard of temporary urses who have atteded madatory traiig ad completed a trust iductio course. This has had a positive effect o permaet urses who feel reassured about the quality of temporary urses. Traiig ad developmet has bee made more rigorous with a two-day iductio programme. Sice NHS Professioals bega operatig i the trust, over 120 substative appoitmets have bee made from their staff. NHS Professioals has also provided ew career opportuities for staff who wish to gai experiece i specialist areas. Moreover, the flexibility of the retur to practice part of the service has bee very successful for substative posts with the majority of applicats completig the ecessary courses ad takig up permaet positios i the trust. NOTE 1 Prior to establishig a partership with NHS Professioals. Good practice i maagig the use of temporary ursig staff 25

26 3.5 Where trusts do decide to ru their ow ursig bak they should esure that the bak provides value for moey by: Formig oe cetral bak which maages staffig requests across the whole trust (or trusts). Establishig agreed measures agaist which the performace of the bak ca be assessed. Ivestig i a urse bak maagemet system which is capable of beig itegrated with other systems withi the trust e.g. rosterig ad payroll systems thereby cuttig admiistratio costs. The system should be capable of producig reports o: Number of requests by ward. Percetage of requests filled by grade at log ad short otice (less tha 48 hours). Reaso for use by ward. Aalysis of seasoal variatios. Treds agaist target usage of temporary ursig staff. Usig ursig agecies 3.6 Most trusts rely o agecy ursig staff to some extet. Whilst agecy ursig staff have a importat role they are ormally more expesive tha the equivalet permaet, bak or NHS Professioals staff. Excessive reliace o agecy ursig staff is ofte cotributed to by poor maagemet cotrol. Trusts ca reduce their reliace o agecy ursig staff: Itroducig policies that do ot allow substative urses from the trust to work i its hospitals through a agecy. Ecouragig agecy ursig staff to joi the ursig bak or NHS Professioals i preferece to ursig agecies. Usig recruitmet ad retetio premia to ecourage hard to recruit staff to work i substative posts. Itroducig specialist rates for hard to recruit bak ursig staff. Traiig up staff i areas where there are atioal shortages (e.g. Operatig Departmet Practitioers) to avoid reliace o ursig agecies to fill posts. 26 Good practice i maagig the use of temporary ursig staff

27 Case study 9 Usig IT to support the ursig bak Blackpool Fylde ad Wyre Hospitals NHS Trust has 1,100 beds ad employs just over 2,000 urses ad midwives. The curret temporary staffig arragemets were set up i May 2003 ad this coicided with the implemetatio of a IT system desiged to moderize the way temporary staffig is maaged ad to provide the opportuity to reduce the use of agecy urses. The trust curretly has 1,100 bak staff of which 600 are bak oly staff; the remaiig staff also hold substative posts withi the trust. The challeges facig the Trust were: the eed to reduce expediture o agecy ursig staff which had rise to 1 millio a year i ; the eed to improve the educatio ad traiig of bak staff; ad the eed to improve maagemet arragemets to deliver a more effective ad efficiet temporary staffig service. The trust cosidered the possibility of usig NHS Professioals but decided to istead to ivest i a i house cetral ursig bak which would maage all bak ad agecy bookigs. A umber of iitiatives were implemeted to improve the service ad to match NHS Professioal s stadards. These iclude the implemetatio of web eablemet, which allows ward staff to book ad the visualise their bak bookigs via their ward PC. The system liks to the bak office so that bookigs ca be costatly updated. This reduces the amout of paper work that is geerated by requests for shifts ad allows bak urses to view the shifts they have booked. Ward maagers had to adjust to the fact that they had to drastically cut their use of agecy ursig staff ad use bak ursig staff istead. Support from executive directors, especially the director of ursig, was crucial at this stage. However, the strategy has bee very successful ad the trust has reduced its expediture o agecy ursig staff dramatically from 1 millio i to 34,000 i A overview of expediture over the last two years is give below Expediture o 3,245,370 3,080,311 bak staff Expediture o 33,904 0 agecy staff Total 3,279,274 3,080,311 Good practice i maagig the use of temporary ursig staff 27

28 3.7 Where trusts do use ursig agecies they should esure that they are gettig best value from the agecies i terms both of cost ad quality of ursig staff by: Oly usig ursig staff o NHS Purchasig ad Supply Agecy Framework Agreemets to the agreed terms ad coditios. Puttig i place a Service Level Agreemet with the ursig agecy. Cosolidatig the umber of agecies supplyig ursig staff to the trust. Adopt the use of the NHS Professioals cliical codig system so that all trusts have a commo approach to describig roles. Formig procuremet cosortia with other trusts to achieve bulk purchase discouts (Case Study 10). Have robust procedures i place to check trust records of rates charged ad hours worked agaist agecy ivoices (Case study 11). Maitaiig a effective iteral approval protocol for orderig from commercial agecies. Providig adequate otice of available shifts to improve fill rates at lower costs. Eforcig a clear policy that the trust will ot pay rates higher tha those o the agreed framework i order to obtai fill. Case study 10 Procurig through cosortia NHS trusts i Bristol, Bath ad Westo have worked together as a cosortium to egotiate local service agreemets for the supply of agecy urses uder the NHS Purchasig ad Supply Agecy s South West agecy framework agreemet. Part of this process ivolved udertakig local audits usig the Purchasig ad Supply Agecy audit tool prior to awardig the local service agreemets. I additio, low commissio rates were egotiated (ie per cet for preferred suppliers) with a limited umber of preferred agecies o a approved list based o cost, quality ad supply. Six mothly reviews are udertake of the performace of all agecies listed as approved to supply to the cosortium, ad agecies may be allocated preferred to secodary status depedig o recet performace. Measures of performace take ito accout cost, quality ad cotiued efforts of agecies to fill shifts. The NHS trusts i the cosortium have preseted a uited frot to agecies from the start of the local egotiatios ad have worked together to maage agecy use through robust operatioal policies ad sharig of maagemet strategies. A local cosortium of Aitree, Royal Liverpool ad Broadgree ad St Heles ad Kowsley NHS hospital trusts was established i The cosortium has 3,500 urses available o a bak ad allows placemets betwee trusts. The cosortium uses its purchasig power to secure best value for moey from local ursig agecies. Cotracts are based o NHS Purchasig ad Supply Agecy Framework Agreemets ad quality stadards ad systems match those available from NHS Professioals. The arragemet has elimiated the eed for agecy cover i two of the trusts ad reduced it to less tha 15 per cet of total expediture o temporary staffig i the third, from a overall figure of 53 per cet two years previously. A reductio i expediture o agecy urses from 7 millio i to 1.5 millio i has bee achieved. 28 Good practice i maagig the use of temporary ursig staff

29 Case study 11 Checkig agecy ivoices The Trust Stadig Fiacial Istructios at Cetral Machester ad Machester Childre s Uiversity Hospital NHS Trust stipulate that all charge rates ad uits of time detailed o ivoices must be checked for accuracy ad all ivoices must be arithmetically correct. However, the trust recogised that these checks ca be very complicated ad time cosumig i relatio to temporary staffig trasactios due to the volume of trasactios ad multiplicity of rates at which time ca be charged. I respose to this, a software tool was developed which ca idetify iaccurate ivoices ad substatially reduces the time that ward maagers eed to sped checkig the ivoice before they ca authorise paymet. Usig the software, 50,000 of urse agecy overcharge has bee detected ad recovered relatig to a 12 moth period. A further 30,000 has bee idetified relatig to a 23 week period (left udetected, the overcharge would have cost 68,000 per aum). The latest overcharges occurred eve though NHS Professioals were i place ad despite the audits coducted upo the agecies, demostratig the subtlety of the overcharges. The software has also bee applied to other disciplies ad agai substatial levels of overcharge have bee detected. Give their ature ad complexity, it is felt that these overcharges will be occurrig across the NHS as a whole. The Trust iteds to test earlier periods to recover all overcharges to date. The software also streamlies existig processes utilisig auto- ig facilities ad speeds up the ivoice certificatio process. The system also geerates useful maagemet iformatio reports such as: Icidece of duplicate shifts (curretly udetected by existig bak maagemet software). Usage of agecy ursig staff by shift type (e.g. ight shift, day shift, Suday shift etc.). The volume of shifts authorised, uauthorised ad i dispute. Whilst this aspect of the software has bee tested, use of the software has yet to be trialled ad rolled out across all areas/wards. Good practice i maagig the use of temporary ursig staff 29

30 Part four Usig temporary ursig staff 4.1 Good workig arragemets are eeded to maage the use of temporary ursig staff ad miimise risks to patiets. Research has foud that people are sigificatly more likely to make errors whe they have received iadequate traiig, whe they are workig i ufamiliar or pressurised eviromets or whe they are tired. These igrediets ca be typical of the circumstaces i which temporary ursig staff may fid themselves. Trusts eed to implemet proper iductio, traiig ad performace review procedures for temporary staff ad moitor compliace with the Europea Workig Time Directive i order to miimise risks to patiet care. 4.2 I lookig at this part, ask yourself whether your trust: Has processes i place to esure that all temporary ursig staff are subject to the same recruitmet, traiig ad performace assessmet procedures as permaet staff to esure that all staff are fit for purpose. Has processes i place to esure that all temporary ursig staff receive effective iductio to ufamiliar workig eviromets. Has processes i place to moitor the umber of hours beig worked by ursig staff. Has take actio to miimise the risk of fraud relatig to the paymet of temporary ursig staff. Recruitig temporary ursig staff 4.3 The Departmet of Health s, Code of practice for the supply of temporary ursig staff states that all temporary staff are subject to the same requiremets i respect of quality ad cliical goverace as permaet staff. It also sets out the recruitmet ad selectio criteria agaist which all staff workig i the NHS should be judged. Trusts should esure that the recruitmet ad selectio procedures used by all bodies which supply ursig staff to the trust, icludig NHS Professioals, iteral baks ad ursig agecies, comply with the stadards set out i the code of practice. 30 Good practice i maagig the use of temporary ursig staff

31 Traiig ad performace assessmet of temporary ursig staff 4.4 Temporary ursig staff should have access to the same traiig ad developmet opportuities as substative staff. Where trusts obtai their ursig staff from ursig NHS Professioals ad ursig agecies they should request iformatio o the traiig provided to ursig staff ad assure themselves this is sufficiet for the trust s requiremets. Where the trust rus its ow ursig bak the urse bak maager should be allocated resposibility for esurig that all bak staff receive their madatory traiig ad have a aual performace appraisal resultig i a persoal developmet pla (Case study 12). Some trusts have used specialist traiig of bak ursig staff to fill vacacies withi the trust ad reduce reliace o agecy ursig staff (Case study 13 overleaf). Case study 12 Traiig ad persoal developmet of bak ursig staff All bak ursig staff at the Uiversity Hospital of Birmigham NHS Foudatio Trust are give persoal reviews ad provided with support to eable them to develop their skills. The trust has two cliical educators who are dedicated to the developmet of bak urses ad a dedicated PA who esures all madatory traiig is atteded ad kept up-to-date. The operatioal maager of the bak ad the cliical educators also hold mothly ope surgeries which bak urses ca atted if they wish to discuss ay developmet or persoal issues. Couty Durham ad Darligto Acute Hospitals NHS Trust specifically recruits Healthcare Assistats to the urse bak i groups of 24 at least four times a year. Recruitmet ad iductio traiig is cotrolled cetrally ad i additio Healthcare Assistats also atted a series of skills workshops icludig: Basic Aatomy ad Physiology, Itroductio to Health ad Safety, Assistig Patiets to Mobilise, Pressure Area Care, Maual Hadlig, Diet ad Assistig Patiets to eat, Respiratory Coditios ad associated observatios, Diabetes, Itroductio to Record Keepig, Supervised Experiece o a Acute Ward. The classroom learig is reiforced o the ward by practical assessmets udertake by a registered urse. O completio of six moths experiece bak Healthcare Assistats who work for the Trust o a regular basis are ecouraged to udertake a NVQ3 i Health ad Social Care. Good practice i maagig the use of temporary ursig staff 31