Use staff wisely to save NHS money
The NHS could save up to £2 billion a year by improving workflow and containing workforce costs, according to Labour peer Lord Carter’s review of NHS efficiency. Changes in areas such as rostering and management of annual leave must avoid increasing the pressure on staff.
The report, published in June, covers controversial ‘safe ranges’ for staff numbers and recommendations for shift lengths. However, some patient safety bodies are concerned Lord Carter may recommend widespread adoption of 12-hour shifts, despite evidence they place nurses at risk of burnout.
Safe Staffing Alliance chair Susan Osborne says: ‘There are nurses who like 12-hour shifts, but for a number it is affecting their home lives.’
She points to recent research led by nursing workforce expert Jane Ball, principal research fellow at the University of Southampton.It shows long shifts are associated with nurses reporting lower quality care, more missed care and higher levels of burnout.
Longer shifts are often favoured by trusts as they are slightly cheaper because overlap and handover only takes place twice a day.
In an interview earlier this year, Lord Carter said he wanted ‘clearer guidance’ on safe staffing levels, working with the Care Quality Commission, Monitor and the NHS Trust Development Authority to establish a safe range ‘so if you took a particular ward you would know you should be producing this many hours of care a day’.
But how Lord Carter’s recommendations on this issue will sit alongside the work on safe staffing that is being led by the chief nursing officer is far from clear.
RCN head of policy and international affairs Howard Catton suggests the Carter review has ‘moved into the driving seat’.
He points out that the concept of a safe range for nursing levels, referenced in Lord Carter’s comments, is one the RCN has promoted.
A range allows for local circumstances and clinical judgement to be reflected in actual numbers.
‘We will be cautious if what is being proposed on staffing is just a way to save costs, but then has a detrimental effect on patient safety or heaps pressure on a stretched workforce,’ he says.
The review flags opportunities for firmer control of arrangements around non-productive time for nurses, including annual and sickness leave and training, which varies between trusts, as well as for reducing delays in filling vacancies.
Addressing these two areas would save trusts money by lessening the need for agency staff.
Monitor nurse director Ruth May says making savings on staff time is ‘the most important contribution nursing can play’ in cutting an organisation’s costs.
‘By reducing the wage bill and optimising elements of staffing allocation you can produce significant benefits, some of which can be direct cost savings or used to support better care initiatives. Furthermore, rota optimisation of annual leave and unused rota hours can also be beneficial,’ she says.
‘Better use of staff is possible and can significantly improve care quality and the bottom line.’
Other areas of the report may be more controversial, such as different approaches to ‘specialling’ patients – the term for providing one-to-one care for patients with intense needs. These include dementia patients, mental health patients, and those who are acutely physically unwell.
Ms May points to University Hospitals Coventry and Warwickshire Trust, which created an enhanced team of 34 whole time equivalent healthcare assistants for its complex care patients.
Imperial College Healthcare NHS Trust in London has been working with Lord Carter’s review team on its staffing and spending, particularly looking at their approaches to ‘specialling’.
As a result, it is recruiting specialist support workers, establishing pools of nurses with mental health and dementia experience, and looking at clustering patients with dementia in one area to be cared for appropriately.
Imperial’s director of nursing Janice Sigsworth says this has enabled the trust to reduce staff numbers for specialling. ‘It has given us a much bigger focus on where we have high-cost staff. We are trying to drive down costs but keep the quality.’
Imperial is also working on electronic rostering and auto rostering, addressing under and overpayments, school holiday cover and the reliance on agency staff.
Ms Sigsworth says: ‘If we get all our housekeeping sorted out, then we can keep the nurses we need.’
She adds that controlling overall staff costs could avoid other measures such as skill mix reviews and downbanding, but is adamant all her wards will have safe staffing numbers.
The savings are an estimated £1 million this year and £2 million next year, partly due to reduced reliance on agency staff.
A suggestion that sickness and annual leave are being misused might surprise many staff, but the report highlights one trust that had annual leave overpayments of £10,500 in one month.
It states leave is ‘the largest part of non-productive time which is not systematically managed’ and suggests flexible working arrangements need regular review.
This worries Mr Catton, who feels some nurses working flexibly may be put off if they are expected to return to ‘normal’ working.
‘If the staff member does not have that flexibility, they might just walk,’ he says. ‘It’s a real risk if we get that balance wrong.’
Making better use of the staff they already have may help trusts make savings – especially on agency costs – or potentially manage with fewer staff. But it is an area fraught with the risk of unintended consequences – including driving people away from the profession.
Ms Osborne suggests the main issue is still being ignored. ‘We have a severe shortage of nurses and midwives,’ she says. ‘There is an urgent need to commission more training places’.