Final 25th March 2011
Summary of Main Workforce Issues Facing NHS Boards 2011/12
Information on significant changes in skill mix and the plans to take this forward
NHS Grampian has a strategic plan for the implementation of lean through our Continuous Service Improvement (CSI) projects. Coupled with the Safe Affordable Workforce (SAW) process there is much activity around service redesign, which will have a significant impact on skill mix.
Over the next 3 -5 years NHS Grampian will continue to manage the overall workforce and ensure efficiency of this limited resource. The organisation will see many changes in this time including the opening of the new Emergency Care Centre, the development of the HealthVillage, and the continuing shift in the balance of care. The organisation has also initiated the development of a Health and Care Framework (HCF), which will support prioritisation and decision making. This Framework is being developed with the organisation’s partners and will provide an Action Plan be agreed at the end of 2011. It will identify the impact of and on the future workforce of implementing the HCF Action Plan.
In order to ensure the robustness of the NHS Grampian Workforce Plans a process of “bottom up” workforce planning has been introduced. The methodology employed is that of the 6 Steps to Integrated Workforce Planning creating consistency and employing a number of tools to provide the key pieces of information. It will require all services to develop a Workforce Plan at a local level, which will be aggregated through sectors, and CHPs into the overall NHS Grampian Workforce Plan. This work is being based on services and not professions and looks at the overall teams and their interdependent services. The process has given services the opportunity to use an integrated approach to workforce planning aligning service and financial planning. From this process a number of themes have begun to emerge which will give a useful picture of the future NHS Grampian workforce. These Plans will provide details of the future workforce for NHS Grampian over the next 3-5 years.
One theme, which is repeated across many services, both clinical and non-clinical, is the need for a more flexible workforce. Flexibility for the workforce refers to roles, skills, and locations with a focus on maximising efficiency and the utilisation and deployment of the workforce. For example in Support Services there is a will to develop more generic workers who can be deployed to ensure best use of the workforce resource. The Directorate is considering introducing a new role – Facilities Assistant that would work in more than one area of Facilities, ease pressures on the system and use a broader range of skills. Within clinical services new roles are being identified which will be introduced across more than one profession or specialty or even across the public sector. This does not detract, however from the need to continue to employ individuals with specialist skills and knowledge. NHS Grampian will review what proportion of staff will be needed who are considered to be specialist and those who will play a more flexible role. An example of where this may occur would be with Advanced Practitioners both in Nursing and Allied Health Professions. The review process has begun with specialist / practitioner roles for nursing in Acute to ensure that the roles meet patient and service need utilising the Advance Nursing Practice Service Needs Analysis tool, Guidance for Advanced Nursing Practice and Job Planning. NHS Grampian is also developing a structure and process for the employment of Nurse Practitioners / Advance Nurse Practitioners in the first instance (principles of which will be widened to other staff groups) and will be in line with local workforce plans and national recommendations on Advanced Practice.
There is also an expectation that there will be a greater number of Health Care Support Workers (HCSW) within the organisation and work has already commenced on the development and introduction of these roles. Work to date has focused on introducing a clear framework for managers which highlights the roles, the skills, level of education/development and level of supervision required. Several clinical areas are piloting tailored approaches to HCSW development e.g. in Theatres. Work is ongoing to develop policy guidance in relation to delegation and information for managers. This will enable them to more effectively guide and support HCSW in their development to meet the needs of the service and the individual. Other policy documents are being developed to support HCSW involvement in medicine administration.
Another theme which is emerging is that of the utilisation of the workforce and how this can be made more efficient. Clearly by understanding team roles and developing new roles, services are identifying where there are opportunities to utilise the full capacity and expertise of the multidisciplinary team.
Existing and planned new service areas with particular workforce pressures and possible solutions;
CSI has focused throughout 2010/11 on six major areas of the service, namely:
- Length of Stay
- Community Transformation
- Theatres
- Maternity Services review
- Procurement Best Value (including Pharmacy services)
- Unscheduled Care Transformation
Each of these pieces of work have an underpinning theme of achieving financial balance whilst focusing on shifting the balance of care and all have significant impact on numbers and types of roles for the future.
Productive Community Services/Releasing Time to Careis working to identify the predictive demand for community services, releasing nursing time to invest in quality care. This has created more time with patients and less time in other non value adding tasks. Using data contributions to establish the current state of play in the teams has allowed planning and implementation of change in a systematic way, enabling robust measurement. The key outcomes for the programme are:
- Increased patient facing time
- Improvement in quality and safety
- Decreases in inefficient practices
- A revitalised workforce at the forefront of change and modernisation
- Releasing unutilised resource within the community
- Support for the Shifting the balance of Care agenda
CSI and Maternity teams are looking at the overall future of maternity services through a culmination of long-term strategy, service configuration and continuous service improvement processes. These have already identified some workforce issues including for example the utilisation of the workforce within the service as a result of the release of bed days from the wards. The combination of these efforts is likely to have a positive impact on the number of normal births and other key service improvement indicators.
Other major areas of redesign are being undertaken within the Aberdeen City CHP redesign of the delivery of GP services and the building of a new Emergency Care Centre in Aberdeen. Work to identify the required workforce has commenced in advance of the opening of the Emergency Care Centre in Grampian. A Medical HDU service is being piloted and is looking at new roles in light of the current skill set and identifying future requirements in advance of services opening. Work has been completed on skills and competencies required and these are used to develop individuals who will form the nursing workforce.
As part of the shared services agenda NHS Grampian will work with its local authority and voluntary sector partners to support shifting the balance of care for the elderly population. The organisation is currently developing Change Plans with these partners to ensure that out of hospital services are fully joined up. These Plans will be prepared and agreed by the NHS Board, the Local Authorities, third Sector and Independent Sector partners and submitted to the Scottish Government by 28 February 2011. This initiative is an excellent opportunity to collectively take forward and progress the ambitions to optimise independence and well being for older people at home and ensure that we have an appropriately aligned workforce.
NHS Grampian continues to work collaboratively with the North of Scotland Boards and NES in terms of workforce planning and development. A Workplan has been scoped and agreed which reflects the key projects and programmes and their requirement for workforce input. Areas which are included in this Workplan include Cancer Services, Cardiac service and Rohallion (Medium Secure Unit). Another area, which is being discussed, is that of the role of Practitioners/Physicians Assistants and the implications for remote and rural services and the changing medical workforce.
Other significant workforce issues that the Scottish Government should be aware of that may require a national focus;
From a medical workforce perspective there are a number of issues which are being addressed within NHS Grampian, including how the organisation can reshape the medical workforce when there is no obvious trained doctor solution to replace especially 24/7 services. For some acute specialties there will be difficulties potentially with regards to medicalstaffing i.e. lack of availability of solutions for medical vacancies. There are also a number of recruitment pressures due to no current vacancies within the system e.g. Scottish physicist trainee scheme.
A series of workshops is being delivered to Senior Charge Nurses (SCN) to further support the SCNs in “Managing the Practice Setting”. The main focus is on good rostering practice along with workforce planning, workload management, use of SSTS, Business Objects and national workforce tools.
The Safe Affordable Nursing Establishment programme in NHS Grampian has been implementing a peer review methodology to ensure a consistent and robust approach to workforce planning and management. The Nursing Midwifery Workload and Workforce Planning Programme (NMWWPP) national workforce planning tools are recognised as providing information for to this triangulated approach and work continues to ensure that the infrastructure to enable access is in place.
NHS Grampian is actively engaged and committed to the development of further NMWWPP national planning tools through various Short Life Working groups. However, at times this can present intense resource challenges given current staffing levels and service demands.
The organisation has been working hard to embed the Knowledge and Skills Framework and the benefits it brings to both staff and managers. As at the end of January 2011 the NHS Grampian has 74% of staff have completed Personal Development Review (PDR) recorded on e-KSF; which is clearly above trajectory to achieve 80% by the end of March 2011.
Key to sustainability is ensuring that the workforce has the capacity and capability to meet future service demands. This issue is reinforced by the need for a more flexible workforce with skills to work across the organisation. NHS Grampian will need to develop the workforce and ensure that there are suitable learning opportunities that can be accessed. These may not be the traditional learning opportunities of courses and development sessions and the utilisation of alternative methods of delivery and assessment of competence will need to be introduced.
As part of an organisational wide initiative, the workforce team have engaged service managers across NHS Grampian to cleanse the workforce data held in SWISS. The aim of this work is to improve accuracy of the data and consequently reporting to services and ISD. There will also be a knock on effect of improved information on eKSF which will support managers to use the tool more effectively. Through the development of a Workforce Information Dashboard, services will be able to access information which can be used alongside other relevant information e.g. financial, safety and quality.
How the workforce is contributing to efficiency savings
The Safe Affordable Workforce (SAW) initiative is an organisation-wide review of staff numbers, grades and skills. It is so called because patient safety and clinical care remain a top priority. It will deliver a safe, affordable and sustainable workforce at the same time as achieving cost reductions in each Sector and Directorate and is one of the ways we are seeking to achieve financial balance.
The SAW initiative is specifically to reduce our recurring workforce cost commitments wherever possible and as soon as possible without compromising staff and patient safety. A pilot process was taken forward to review senior management and executive structures with a view to streamlining activity and eliminating duplication. This has now been rolled out across every part of NHS Grampian
In total, services have identified a significant number of posts which would be affected, mainly through reduced hours or reduced bands although there are a number which would be removed from the system. Given the long service and stability of the overall NHS Grampian workforce another cost pressure expected is that of incremental drift as the current workforce is retained.
In order to support financial balance NHS Grampian will develop new ways of working some of which will rely on new skills to ensure that the organisation has a safe and sustainable workforce. The Vacancy Management Process will continue to be used to manage the future workforce. It has been used as a management tool to ensure that all vacancies are considered as part of the service workforce plan; it requires managers to review all vacancies in terms of their future Workforce needs. A further policy, which is supporting the vacancy management process, is that of the Redeployment Policy which has been updated and is being managed more rigorously by managers. However with this stringency and the implementation of the Safe and Affordable Workforce programme it will be more challenging to release staff for development activity and NHS Grampian will need to identify opportunities which ensure the workforce are competent. Ongoing changes to skill mix, along with reduced numbers of staff mean that the NHS Grampian workforce needs to be more flexible, possess a wider range of skills as well as developing new skills.
In January 2011 a voluntary severance scheme, supported and agreed in partnership, was offered to employees of NHS Grampian. The scheme which has limited funding available until the end of March 2011 has identified some non-recurring funding and will target certain workforce groups. It remains unlikely that frontline clinical staff will be prioritised for voluntary severance. For those who apply for Voluntary Severance, their managers will be asked whether they can support the application. This process will include identifying whether it is possible to redesign the function or area of work and remove the post from the structure, in line with the agreed Safe Affordable Workforce principles. In order to support staff a programme is being developed in partnership withSGHD and Right Management to equip staff with the skills needed to take advantage of new career opportunities available to them both within andoutwithNHS Grampian.
Further efficiencies have been achieved through the positive approach to attendance management adopted by NHS Grampian. This has meant an absence rate as low a 4.1% so far this year. This has been realised through supporting to staff in the workplace and proactive management of absence by managers Occupational Health Services and Human Resources.
The quarter 3 returns to the Scottish Government for NHS Grampian highlighted that there had been an overall reduction in workforce numbers of 387 wte. For the Managerial workforce this reduction is around 19% from baseline (September 2009) and supports the requirement to reduce managerial posts by 25%. The overall reductions are due to the redesign of services, careful management of vacancies, natural turnover e.g. due to retirement and the hard work of managers and their teams to ensure that there is efficient use of the workforce. As at December 2010, the estimated savings from the vacancy management programme has saved the organisation £3.33 million. The organisation is currently working on efficiencies to be achieved by reducing bank usage and external agency medical locum spend and is currently exploring the opportunities a national medical locum bank could offer. There are however risks in the continuing requirement to make ongoing efficiency savings and the challenge of maintaining patient safety. This is particularly relevant to the nursing workforce where NHS Grampian is already operating from a low baseline compared to the rest of Scotland.
NHS Grampian is also implementing longer shifts for the nursing workforce, although this is not applicable for all services there are advantages in this way of working for around 50% of wards. It is estimated that there will be great opportunity for efficiency and reduction in overtime and bank usage, especially if this is coupled with good rostering practice. Other benefits of this initiative include improved continuity of care and reduction in administration and paperwork.
As in previous years NHS Grampian is continuing to join up workforce, service and financial planning. Building on what has been achieved workforce planning is aligned and adopts the criteria of affordable, adaptable and available. Key for all managers is to balance the service demands that for most areas are increasing, with the workforce capacity and capability which will continue to need developed, with safety, quality and affordability. This is challenging, however, the production of local Workforce Plans utilising the 6 Steps Methodology, with consideration of a triangulated approach has helped services identify how they can keep their “triangles” in balance.