Safer Staffing in the Community

For Mental Health Services

Workshop Sept 11th 2014

Introduction

Safer staffing is currently a focal point for health services, in the light of various reports, Mid-Staffordshire enquiry, Keogh and, Berwick. Initially the focus is on inpatient areas and nursing numbers however the intention is stated to look wider at other areas within the health service.

Considering this, members of the Mental Health Forum responded with an interest to look at what may constitute safer staffing in Community Mental Health Teams. A workshop was arranged and members of the forum invited to attend to look at this matter and the complexities around this particular area.

For the workshop 25 Trusts were represented within the 39 attendees for the day.

The following document collates the views from the four workshops that ran, these being;

  1. What is being used now to determine staffing numbers in the community?
  2. Triggers for Escalation
  3. Key Challenges in Staffing
  4. The Challenges of Skill Mix and Maintenance of Safe Staffing

We have also at the end set out the actions we agreed on the day which centred around how this work will progress and feed into a more national picture and guidance.

We would like to thank everyone who attended for their participation in the day.

What is being used now to determine staffing numbers in the community?

  • Pulling data from clinical and staff information systems. It was acknowledged that this is not a scientific approach but none the less it is often the best we can do. We should not forget that Mental Health and Learning Disability services have implemented electronic care records far more comprehensively that our acute colleagues.
  • Counting the Numbers – Making comparisons between staff caseloads and between teams was still an important way to determine staffing requirements.
  • Supervision – when done well, supervision is the main way that caseload numbers are challenged and there is some approach to ensuring there is consistency. This will remain extremely important but it was acknowledged that supervision was often not done well.
  • Clusters and Payment by Results (PBR) – the work that all trusts have been doing to cluster their care in preparation for PBR has made it easier to properly define what we do and what individual staff should be focused on.
  • Demand Profiles – some Trusts have worked closely with Public Health to properly understand their population and health needs. Areas of high deprivation would of course need to be reflected in different staffing ratios.
  • Caseload management tools – a number of trusts had something in place to help them but there was very little collaboration across Trusts. Although the tools were not that sophisticated they did offer a reasonable approach locally.
  • Job Plans - there was a lot of support for staff having better defined job plans along the lines of Doctors. This properly accounted for the time needed for administration, training, meetings and gave real sessions available for clinical care. Job plans would form part of a JD.
  • Service Line Reporting (SLR) – many Trusts have moved to SLR and this had helped to define workloads and priorities.
  • Contract drives resources – the contract with commissioners was often the driver for how much needed to do. However, there was great variation in contracts from old blocks or care to specific numbers of care packages.
  • Zoning and RAG rating – Many trusts were using a form of zoning to look at caseloads and the RAG rating was helpful to make sure there was even distribution of responsibility. Acknowledged that the RAG ratings can vary but nonetheless this has helped people a lot.
  • Outcome Measures and Health Equalities Framework (LD) – Outcome measurements were more common than ever before although things like HONOS were a little blunt to decide on caseloads. The Health Equalities Framework (HEF) in LD was developed by the LD Nurse Consultants and was a much more sophisticated model.
  • “5 a day” approach – a crude model but none the less helpful when looking at what people are doing – are they doing enough or too much.
  • Name and Shame boards – the use of white boards to show caseloads and RAG ratings were still a very visual way to address workloads and workforce needs.
  • Caseload reviews by team – some examples of Trusts doing cross team reviews to challenge workloads.
  • Unmet Need reporting – a plea that if tears were records and reporting all their unmet need this would be invaluable to make the case for more resources and to acknowledge that many teams are turning work away back to primary care.
  • Cross Trust collaboration and benchmarking – In the North east the trusts (through the Nurse Directors) had come together to benchmark caseload management and staffing. All acknowledged there needed to be much more sharing.

Triggers for Escalation

Discussion took place around how we escalate staffing in the Community and the following bullet points were discussed.

  • Where do escalation sit in major disaster plans
  • Contingency plan – problem is long term
  • Short term = fire fighting
  • Culture - Community teams to back-up wards – no other way round
  • Give the same benefit to community teams as we do for the wards
  • Culture – “leave it with us and we will sort it out”
  • Day-to-day response – how do we measure risk
  • Do we need a red flag system such as waiting lists and 4-hourly response
  • Tolerance – do we have negative space
  • We need to look at the risk ratings of community teams
  • Getting pathways right (PBR Clusters)
  • What interventions would be missed
  • Knowing demands
  • Availability of crisis response
  • Fact module – step up, step down
  • Recruitment difficulties
  • Is staffing shortage being seen as an incident
  • Escalation should be as a inpatients
  • How many visits required – what are risks of supporting the wards and having short of staff in community teams
  • Backfill - not always people there
  • Look at budget setting and the complexity of community teams
  • Invite people into clinics rather than always going out to them
  • Teams to Manage holidays better
  • Zoning in the community - look at number of caseloads and if they are over 30
  • Review appointments if cancelled
  • Service Line reporting i.e. direct reporting or expectations something will change
  • Risk register
  • Long hours – e-rostering, dashboard triggers, using intelligent monitoring
  • Agree what the next steps are – what do we do
  • Not daily but may be weekly exception reporting
  • Use of triggers then weekly triggers could be staffing levels, sickness, disciplinary, delivery response times, increasing complaints and SI – this would be if 20% of the workforce was off over 5-days.

The Challenges of Skill Mix and Maintenance of Safe Staffing

Does genericism assist in maintaining safe levels?

Main points from the Workshops were:

  • Defining the generic worker
  • Defining safe levels
  • Better understanding of caseload management
  • Considering the terms therapeutic and effective staff numbers rather than safe staff numbers.
  • Defining and clarifying what is safe and the dangers of generic workers do work that is more aligned to professionally highly skilled trained staff.
  • Understanding and giving examples of quality of interventions
  • Considering the role of the developing Assistant Practitioner at Band 4 and how this potential role can contribute to the multi-disciplinary team skill mix.

Overall points from the Workshop:

  • There is a need to move away from the generic roles and focus on specific roles
  • Caseload waiting tools could be used as a means of defining caseload management and caseload sizes. This should be an indicator to safe staff levels
  • Redefine and focus on the immediate issues to ensure safety in particular
  • Supervision
  • Competencies and Capabilities
  • Training
  • Creating the role of the generic worker to fit the pathway
  • Consider the role of the Advance Practitioner
  • Consider the local needs of a demographic population group
  • Agree a leadership programme that focuses specifically on the areas we are talking about and agree this leadership programme to be the acceptable one to maintain safety and effectiveness.
  • All professional leads within the multi-disciplinary teams for Community Mental Health Teams should have a role a responsibility in defining and monitoring safe, effective staff levels.
  • Job plans whilst useful should not be too rigid. They should have flexibility to meet changing needs.
  • There is also a need to relook at commissioning numbers as no review of staffing levels in Community Mental Health Teams has been undertaken.
  • A rolling recruitment training programme needs to be established which considers all areas of the team not just the nurses.

Key Challenges in Staffing

A number of issues were raised in terms of current but also future challenges;

  • Recruitment and Retention, this related to current challenges due to geography, aging workforce, skill deficit and skill mix.
  • The impact of Social Care through the Care Bill and need for savings. Increase in numbers of people with increased social care issues.
  • Increase in particular diagnostic areas, e.g. personality disorders.
  • Integration of services.
  • The ‘make up’ of MH Community Services may impact on skills and development for professions.
  • Do and should services fit in line with PbR and clustering? Silo’s service users, is there an investment need in Mental Health in relation to PbR?
  • Caseloads reported between 15-50. Impacting on burnout/stress and influence of targets.
  • Services not in a position to say no, impacting on volume of referrals. Need the ability to say no.
  • Recruiting to role rather than profession/skill required.
  • Is CPA currently working, have we got it right?
  • Challenge of filling short terms vacancies through agency etc.
  • Difficulty of response times defined externally.
  • Are individuals being seen by the right person the first time? Looking at quality of staff who do first interview. Have we got right processes in place around succession planning to inform training institutions?
  • Looking to pre employment what is happening in training and profile of those coming in. Preceptorship could be better?

Solutions?

  • Adequate funding.
  • Developing a skilled workforce, deciding first what this means for desired competencies, getting the basic right, being value based and supervision.
  • Learn from history, lets not forget where we have come from and what has worked in the past.
  • Better demonstration of our value.
  • Proper professional identity (mainly discussed around nursing but flavours of this around other professions as well due to generic roles).

Actions going forward:

The following actions were agreed at the end of the day.

  1. Contact NHS England on how we best may take this work forward with a view to how we feed in some of this work, to inform our group further on what we need to do.Action owner; Peter
  1. To review further dates and pieces of work informed by feedback from NHS England on way forward. Action owner; Richard, Peter, Donna