Vacant possession

Published: 09/01/2003, Volume II3, No. 5837 Page 24 25

A review of the nursing workforce at a trust facing a large deficit reduced turnover, improved recruitment and cut reliance on agency staff. Susan Osborne reports

Two years ago, St Mary's Hospital, London, was moving rapidly towards a financial deficit of£5m in what seemed to be a regular trend. Over£12m alone was spent on temporary nursing and midwifery staff and the gross costs spent on that workforce were deemed to be higher than those of other trusts in London. Kensington & Chelsea and Westminster health authority took the view that the overspend was caused by poor management and considered that the nursing and midwifery workforce needed to be downsized.

The vacancy factor was 26 per cent, with a turnover of 34 per cent, which equated to about 300 whole-time equivalent registered nurse and midwife posts vacant. The Department of Health classified the trust as a 'tracker trust' and London regional office initiated monthly monitoring meetings. The trust was filling only 5060 per cent of its vacancies with temporary staff.

One in four posts were vacant. This was a desperate situation and at times the standard of care was sub-optimal. Little attention was paid to the calibre of recruits and often staff were promoted beyond their ability so there was a lack of good role models at senior level.

Today, the trust has a vacancy factor of 11.5 per cent - about 100 WTEs - a turnover rate of 20 per cent and a fill rate by NHS Professionals of 90-95 per cent. There are very few vacancies in accident and emergency, which for London is a great achievement, and there is a waiting list of nurses who wish to work on the paediatric intensive care unit.Morale and patient care have improved significantly. St Mary's Hospital moved from a onestar rating in 2001 to three stars in 2002.

In 2000, the director of nursing decided to undertake a review of the nursing and midwifery establishments.

One-to-one meetings were scheduled with each ward/department sister accompanied by their senior nurse - a total of 48 clinical areas. Each ward sister was asked to provide three months' off-duty rosters, details of staff sickness/absence and a view as to the safe levels of staff required to provide a service, along with any other issues they wished to raise.

The questions centred on the number and grade of staff needed on each shift to provide a minimal staffing level. The rosters were examined for the management of annual and study leave, performance management of staff in relation to sickness, and patterns of rostering.Other questions related to the management of the ward/department, standards of patient care and the amount of time spent undertaking non-nursing duties.

Interviews were also scheduled with each clinical nurse specialist or team to ascertain their contribution to the service.

The total number of hours used by all staff involved in this first phase of the review was 1,412.

The estimated cost of those hours spent by staff equates to about£34,000. The director of nursing considered the 170 hours she had used for this exercise was time well spent as it enabled her to gain an understanding of the issues senior nurses were facing daily.

The method used was very simple and relied on the professional judgment of the senior nurses involved and their 'gut' feelings of being expert practitioners with their own individual service provision.

1The director of nursing and deputy and associate nurses corroborated the evidence and visited clinical areas. The final analysis was discussed fully with the ward/department sister and their senior nurse, and agreement obtained for the final establishment that would provide a minimum but safe service to patients.

The findings showed that the overall establishment was at least 70 WTE registered nurses and midwives short of providing a minimal staffing level. An estimated£1.5m was required to adjust the establishment. The findings from the review formed part of the negotiations with the HA to enable the trust to break even.

The review also found that a different picture of the establishment was held by the human resources department, finance department and the clinical areas, which resulted in a discrepancy of 140 WTE posts overall. There was little information on temporary staff usage except as gross costs for the total hospital usage. Clinical nurse specialist posts had been included as part of the ward establishments which led to a distortion of ward costs. All posts had been funded at 0.96 WTE, which led to a shortfall at grassroots level or an overspend as sisters were unaware of how their establishments had been funded.

There had been no regular discussion with staff to agree budgets, and the last review had taken place in 1984. Budgets were also set at out-turn, which meant that if a ward had not filled all of its vacancies, either with substantive posts or temporary staff arrangements and showed an underspend, its budget would be set at the underspent amount for the next year. If, on the other hand, an overspend situation had arisen, that area would be funded to that full amount and would benefit.As there were not enough nurses and midwives available, there was a gradual erosion of the establishments over time, with an inevitable crisis.

A three-year business case was presented to the HA demonstrating the need to invest in the workforce to reduce vacancies by undertaking an international recruitment campaign, thereby making savings on agency commission rates and stabilising the workforce. The business case envisaged that over a three-year period, the workforce would be stabilised and savings of£1.3m would be made on employing agency nurses. The HA finally agreed to fund around half of the additional establishment requirements, which was£750,000 per year.

Work had already started on introducing a hospital staff bank. The staff bank later became one of the early implementer sites for NHS Professionals London. The strategy was to match the take-home pay rate for a bank member of staff to that of an agency member, and encourage agency staff to join the hospital bank. Gradually, embargos were introduced on the use of agency staff so ward/department staff would take the initiative and start to actively recruit their preferred agency staff to the hospital staff bank.

Staff became great ambassadors for encouraging colleagues to join the bank when they were made aware of the amount of money spent on commission rates to agencies, such as£96 for a 12-hour shift in the intensive therapy unit.

The review raised recommendations for action that have been implemented over the past two years. These include the establishment of a training programme on budgeting, an out-of-hours administrative service for clinical areas, budgets set on actual agreements, staff to be funded at actual WTEs, and annual reviews of nursing and midwifery establishments.

The trust board agreed to support fully the approach proposed to stabilise the nursing and midwifery workforce and it was ranked within the first three strategic priorities of the trust's business plan.

An international recruitment programme was initiated with recruitment from Italy, Spain, the Philippines, New Zealand and Australia.We have crecuited 35 nurses from Spain, nine from Italy and 160 from the Philippines.

The campaign to transfer agency staff to the hospital's staff bank gathered momentum and there is now a 60:40 bank: agency ratio, compared to a 15:85 ratio in 2000.

The rate of vacancies being filled has increased from 50-95 per cent due to the reduction of vacancies, and savings have been realised from a reduction in commission rates in the range of£500,000 per year.Two thirds of temporary staff are employed as NHS Professionals.

Performance indicators show the standard of patient care has improved significantly over the past two years.The prevalence of pressure-ulcer incidence in July 2001 was 8.33 per cent and in July 2002 it was 6 per cent. Formal complaints for the whole trust, in the region of 195 for 2000, have fallen by a third.

The vacancy rate is now 11.5 per cent, with a turnover of 20 per cent compared with 26 per cent vacancies in 2000 and a turnover of 34 per cent.

The number of 'on-spec' applications has increased as the reputation of the hospital has improved.We now receive about 15 a month.

A 12-hour administrative and clerical service is being planned to help all clinicians increase the amount of time they spend with patients.A housekeeper service is also being planned for 2003-04.

Clinical benchmarking is being rolled out trustwide.There is a pilot to reschedule the patient's day to provide more routine and structure to hospital care.This will enable nurses and midwives to focus more on the patient's experience so their needs can be met more effectively.

Key points

A review of nursing at an acute London trust with a deficit of£5m has halved the vacancy rate and saved£500,000 a year on agency staff.

The review took the director of nursing 170 hours.

It has cut nurse turnover by over one-third.

Once made aware of the costs of employing agency staff, nurses were encouraged to join the hospital bank.

The trust has moved from from a onestar rating to three stars.

REFERENCE

1Benner P. From Novice to Expert: excellence and power in clinical nursing practice.

Addison Wesley, 1984.

Susan Osborne is director of nursing, St Mary's Hospital trust, London.