With the pressure on to meet minimum levels of staffing, how can managers guarantee that their many temporary workers are trained and safe, asks Daloni Carlisle
The Francis Inquiry rightly highlighted the danger of low staffing levels, particularly of doctors and nurses, and called for minimum staffing levels to ensure patient safety.
The government has resisted calls for national mandatory levels, saying they risk driving standards down to the lowest common denominator, and would rather see trusts refine existing tools for local use.
What is now becoming apparent as trusts look into minimum staffing levels is that achieving them will sometimes mean using temporary workers. The question then is this: how can nursing managers be sure of the safety of these temporary workers?
‘The worker could get back into the system and no-one is any the wiser. Agencies have a very big part to play here’
For Jackie Knowles, head of clinical governance and compliance at HCL PLC, which supplies over 2,000 staff a week to clients that NHS trusts, this comes down to compliance.
“Compliant agency supply is integral to trusts wanting to meet a set minimum staffing level as agency supply can fill gaps for short term staffing fluctuations due to absence, leave cover or increases in patient acuity,” she says. “Compliant, competent, well vetted agency workers can fill this staffing need without compromising patient safety.”
The RCN is in principle against casualising the workforce, although policy director Howard Catton does recognise that temporary workers have a role to play in achieving minimum staffing levels - and that this must be done with safety in mind.
“It is absolutely essential that trusts are sure people are who they say they are,” he says. “You have to be sure that nurses have the skills, background and experience that the agency claims for them.”
At its most basic, says Ms Knowles, compliance is all about initial recruitment and ongoing checks that employment agencies must carry out on healthcare professionals, set out in the NHS Employers Standards and good industry practice.
“The Care Quality Commission inspects the NHS against these safe recruitment standards and therefore it is imperative that agencies supplying the NHS get their vetting and selection process right for patient safety,” she says.
The NHS Employers Standards apply to all staff, not just agency workers and are currently under revision to ensure these meet service needs and continue to be fit for purpose in the new NHS. NHS Employers expects to launch new standards early this summer. Their use is policed through procurement frameworks and individual trusts’ quality assurance teams.
Held to account
Nyla Cooper, programme lead on safe employment at NHS Employers, explains: “NHS trusts are strongly recommended to use agencies that have a framework agreement, such as with the Government Procurement Services (GPS), due to regulatory processes being in place to monitor their recruitment practices and compliance of the code of practice for international recruitment of healthcare professionals.”
So on one level, NHS trusts that use employment agencies that are approved under the various procurement frameworks that operate throughout the NHS ought to be assured they are getting compliant healthcare professionals. HCL is on all the major frameworks.
But Ms Knowles says: “If NHS hospitals are relying on agencies to be doing that compliance work for them, they need to be confident that the agencies are doing what is asked of them. The agency and trust must work in partnership to ensure the appropriate compliance levels are upheld.”
She would, for example, consider it good practice for trusts to request an agency placement checklist - a one-page summary about an individual’s compliance checks.
“Some of the trusts we work with are routinely requesting these checklists but some are not,” she says. “I think it should be mandatory. NHS trusts need to hold agencies to account.”
NHS Employers agrees, saying employers have a duty to seek written assurances that checks have been done. “Any additional checks applied by the employing organisation must be proportionate to risk and form part of their contractual agreements with that agency and as part of any scheduled auditing and monitoring processes carried out by the trust,” says Ms Cooper.
Mr Catton adds: “It is important that trusts are clear with agencies about the skills and experience they need and it is equally important they work closely with agencies and build relationships to ensure the people they want are the people who are delivered.”
The risks of not having the structures to hold agencies to account can be high, adds Ms Knowles. For a start, trusts sometimes find they have to go “off framework” when they need specialist staff at short notice - a situation that can often be avoided by using software that gives transparency around the workforce.
Trusts that do not have the right structures and agreements in place when working with off-framework agencies may face even greater risks, suggests Ms Knowles.
In January, NHS Employers and the Independent Healthcare Advisory Service published joint guidance on information sharing on healthcare workers. It was prompted by concerns that practitioners whose fitness to practice had been called into question in one workplace could go on to work elsewhere without their track record following them.
While this guidance was written to ensure information sharing about healthcare workers between the NHS and the independent sector, Ms Knowles believes it has important implications for agencies, too.
“A worker whose fitness to practice is under question may register with an agency,” she says. “If a rigorous vetting and selection process is not followed, there is a risk that this information never reaches the trust. The worker could get put back into the system and no-one is any the wiser; patient safety may be put at risk. Agencies have a very big part to play here.”
NHS Employers acknowledges this is a tricky issue. “There is a fine line between duties to share information about healthcare workers with the aim of protecting patients and the legalities which surround patient confidentiality, and individuals’ rights under the European Convention on Human Rights and the Equalities Act,” says Ms Cooper.
Everyone needs to understand their respective role here and NHS Employers is currently developing good practice guidelines with health unions that it expects to publish this month.
When all is said and done, though, Ms Knowles argues that temporary workers can contribute to maintaining patient safety - but only if trusts and their partner agencies are proactive in ensuring the right people get to the right place at the right time.
Stephen Burke on common compliance
As the single largest public health system in the world, employing 1.3 million people, of whom almost half are clinically qualified, the NHS’s workforce accounts for the largest proportion of the healthcare budget and is under continual scrutiny.
This workforce is also extremely mobile, moving in, around and out of the NHS infrastructure during what is usually a very long contract term. The Francis Inquiry has brought the spotlight yet again on to the workforce, focusing on excellence in recruitment, training and competency of staff.
Looking to the future, the ability to mobilise healthcare professionals is going to be critical. Ensuring these workers are compliant, and therefore of minimal risk to the service, is a time consuming and expensive process. Staffing agencies have a key role in supporting the NHS in this.
We believe that three key factors can underpin patient safety through workforce compliance: adherence to framework agreements, use of technology and nationwide adoption of the NHS Skills Passport.
Drastically cutting costs
Those frameworks designed for the provision of temporary staffing should be promoted across the primary care landscape by NHS England and the CCGs.
By way of illustration it was estimated that in 2010 approximately £360m was spent on temporary staffing in the primary care sector, with very little of this coming through framework agreements, opening the system to risk through variations in compliance and wild fluctuations in cost.
By using technology, and a model similar to the electronic patient record, a common compliance platform could be established. It would reduce duplication of effort, drive standards and support mobilisation of the workforce.
By centralising this essential recruitment requirement, costs could be drastically reduced while speed of response and supply would be greatly enhanced. HCL has invested in its own such technology platform, HCL Clarity, based upon workforce transparency and real-time management information, features often not readily available at trusts.
The Skills Passport for health and social care professionals has been piloted and has been nationally adopted in Scotland. Its roll-out across England would reduce the millions of essential but duplicated compliance procedures an individual is subjected to.
It also empowers healthcare professionals to take ownership of their own compliance, which can only drive standards - and patient safety - up.
Stephen Burke is CEO of HCL Workforce Solutions.
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