Time to care: The UK cut
Securing a future for the hospital workforce
Workforce challenges facing hospitals have reached crisis level and as the UK prepares to leave the European Union the need for workforce transformation has become more critical than ever. With unprecedented levels of staff shortages and increasing evidence of staff burnout in UK hospitals, are current workforce models sustainable?
Our latest research provides an in-depth analysis of the challenges facing hospital workforces in the UK, and recommends good-practice examples for health care leaders to increase staff morale and wellbeing, recruit and retain top talent, and offer new models of care.
- a shortage of the skills required to respond effectively to increasing patient complexity
- a critical lack of time for hands-on care
- emerging evidence on safe staffing levels
- shortages of certain clinical specialties, for example in emergency departments
- a lack of access to, or gaps in, performance monitoring information and availability of real-time data
- rigid and lengthy training models that fail to equip the workforce with more flexible skills
- increasing pressure on the funding available for health care
- removing the silos between hospital and community care
- changing demographics of the nursing and medical talent pools
- increasingly competitive market for staff with required skills, such as digital literacy
- entry of millennials into the workforce, with specific expectations around work and careers
- increasing patient complexity and higher patient expectations of treatments available
- a need to re-design care pathways, ways of working, and hospitals to support wellbeing
- establishing a ’culture for digital transformation’ and optimising the use of technology
- impacts on the future of work due to emerging technologies e.g. artificial intelligence and robotics
Transforming the workforce success stories
Improving the health of the workforce with a ‘Workplace Wellness’ programme
Yorkshire and Humber Academic Health Science Network (YHAHSN) worked in partnership with Sheffield Hallam University and the National Centre for Sport and Exercise Medicine to roll out a ‘Workplace Wellness’ programme for the NHS, private sector health organisations and the wider public sector. The programme provides staff with health and wellbeing benefits, including health and wellness assessments, and motivation interviews on physical activity, nutrition and drinking habits. An evaluation of participants in the pilot programme at Sheffield Teaching Hospitals NHS Foundation Trust, Bradford Teaching Hospitals NHS Foundation Trust and Airedale NHS Foundation trust, undertaken by Sheffield Hallam University, found that:
- 97% rated their experience of the programme as excellent or very good
- 95% reported making changes to their health or lifestyle
- 45% were identified as having one or more risk factors for cardiovascular disease (CVD), of these 42.9% improved their health by reducing at least one risk factor within six months of starting the programme
- for every £1 spent on the programme, the NHS as an employer saved £3 in costs.
Seven NHS organisations are now delivering the programme through ‘train the practitioner’ methods. Three private sector organisations and two local authorities are also offering the programme to their workforce, with one local authority aiming to partner the delivery of the programme with police and fire services in the area.
Improving recruitment and retention with a new reward strategy
Sandwell and West Birmingham Hospitals NHS Trust (SWBH) employs around 7,500 staff. In order to improve recruitment and retention, the Trust created a reward brand, ‘SWBH Benefits’, accessible through a web portal and smartphone app. Launched in October 2016, this offers easy access to the Trust’s health and wellbeing offerings, salary sacrifice schemes linked to childcare, cycle to work and car lease, library services, as well as a range of national and local discounts available to staff. An in-house survey shows increased staff engagement, with 86% of staff feeling that the reward scheme is a positive improvement, contributing to a reduction in staff turnover from 12.8% to 11.3%, in sickness absence from 4.9% to 4.5%, and in the time taken to fill vacancies from 26 to 21 weeks.
At North Devon Healthcare NHS Trust (NDHCT), an improved reward strategy has helped to achieve improvements in recruiting and retaining staff across all professions. The strategy includes:
- a recommendation scheme introduced in January 2017: staff receive £1,000 per successful introduction
- relocation packages and on-site accommodation, including support for partners to find work through a local business network
- monthly staff awards: employees can nominate colleagues for outstanding contribution and teamwork
- comprehensive advertising of reward scheme and an A-Z directory of benefits whenever a vacancy is advertised.
Since 2016 the approach has contributed to a fall in nursing vacancies from 10% to 4%, a rise in the number of applications, and a reduction of 2% in staff turnover. NDHCT is continuing to review the selection of benefits that staff receive as part of its wellbeing strategy, with additional focus being placed on work-life balance and staff wellbeing.
Responding to the changing needs of medical trainees with a clinical fellowship programme
Struggling to fill junior doctor posts and relying heavily on locum doctors, the Royal Wolverhampton NHS Trust initiated an innovative clinical fellowship programme to attract UK and overseas trainees. The programme provides trainee medical staff flexibility by offering posts that are equivalent to but outside of core medical training and specialist registrar grades. The clinical fellows gain associate membership of the University of Wolverhampton Academic Institute of Medicine and have access to a fully-funded Masters qualification in General Medicine or other specialties.
The leadership at the Trust recognised that training should be tailored to the individual needs and expectations of doctors. Starting in 2016, it recruited 100 doctors, an increase from 60 in 2015, attracting applicants from the UK and overseas (mainly South Asia, Nigeria, Egypt and Europe). This helped to reduce significantly the rota gaps in a variety of specialties. The programme costs an additional £243,000 annually for training and administration, but following the introduction of the programme, cumulative spending on junior doctor locums was reduced by £1.3 million. The programme supports the principles of global learning and knowledge exchange, and aims to help staff apply the learning from their time in the UK when they return to their home countries.
Empowering staff to improve service delivery with a ‘5 Step’ Quality Improvement Model
To enable their staff to deliver safe, high-quality care, the Southern Health and Social Care Trust (Northern Ireland) has developed a range of accredited programmes, learning opportunities and tools for building quality improvement capacity and capability. The approach is built on a ‘5 Step’ Quality Improvement Model, integrating project management and improvement science to provide a simple guide on how to improve services. The model consists of e-learning modules, which are accessible to everyone. A Continuous Improvement Team supports participants in iterative learning as they carry out a structured quality improvement project.
In addition to e-learning the support includes practical workshops, one-to-one facilitation, peer support and complementary e-learning resources. Alternatively staff can choose to bring their improvement challenge or project to a Quality Improvement Clinic, be inspired by staff quality improvement ‘Vodcasts’ produced by employees, or join one of the Quality Improvement Network sessions. To date, over 915 (6.5% of total staff) staff have nominated themselves for the 45 minute ‘Introduction to Quality Improvement’ e-learning programme. Over 100 small step and team/service-based quality improvements have helped staff deliver safe, high quality health and social care.
Examples of quality improvement projects include optimising medical handover, thereby freeing up staff time and improving workflows in pathology, and allowing for more efficient deployment of staff and technology. The Trust’s results from its participation in the Northern Ireland wide HSC Staff Survey in 2016 found:
- 80% of staff feel satisfied with the quality of work and patient care that they are able to deliver (above the NHS national average of 76%)
- 67% of staff said they would recommend the Trust as a place to work (the NHS national average is 54%)
- 76% of staff said that care of patients is the organisation’s top priority, which is 15% more than in the previous survey in 2012.
Increasing flexibility of rostering and reducing rota gaps with an annualised rostering system
Brighton and Sussex University Hospitals NHS Trust struggled to attract junior doctors to work in its Emergency Department (ED) and was losing all grades of staff due to the pressure from unsustainable rotas, resulting in significant staffing gaps and high agency costs. The departmental clinicians worked with IT developers at HealthRota on a new annualised rostering system which provides safe staffing levels, meets the needs of individuals at different career levels and creates the flexibility to accommodate staff leave and project requirements. The systems ensure the ED has 24/7 consultant cover and is an attractive, albeit busy, place to work.
For junior doctors the system provides:
- a calculation of a set number of clinical shifts that have to be worked over the year.
- a system for training posts, for clinical work and non-clinical projects in education, leadership etc.
Middle and senior grades are supported by:
- an annualised rota, self-managed by emergency doctors within the department. Each shift is worth a set number of professional activities (PAs), and each member of staff is contracted to do a set number of PAs over a period of time. The shifts needing cover are decided according to patient need, optimising cover and making optimal use of staff clinical time, while also allowing individual flexibility.
Outcomes of these measures include:
- a full rota of junior doctors and trainee doctors attracted back from abroad
- no further need for junior doctor locums, resulting in saving of over £1 million in costs annually
- a good work-life balance; in an internal survey, 81% reported good work-life balance; 90% believed the job allowed them to participate in quality improvement and innovation projects they would otherwise not have time for; 100% said they would recommend the job to others.
The Trust now has more applicants for emergency medicine than posts available. The ED succeeded in increasing medical staff numbers by 21 clinical fellows and 9 registrars by filling unfilled posts and creating new posts. Self-rostering became a major factor in the retention and recruitment of senior clinicians, as it allows senior clinicians to combine work with family commitments or portfolio careers. This is particularly important for women, and in the last year the Trust appointed seven new full time equivalent (FTE) female consultants.
Improving patient safety with a safe-staffing mobile app
Research shows that ensuring the right staffing levels is not only crucial for patient safety, but also significantly impacts staff satisfaction and wellbeing. At Nottingham University Hospital, nurse leaders did not have accurate real-time information about staffing positions from ward to board. They relied on manual collation of nurse staffing levels at key times in the day. These data were unavailable to the whole Trust, and failed to indicate support available elsewhere within the organisation. In response to this problem, the hospital implemented an easy-to-use app for mobile devices, covering all wards. The app was co-developed by nursing and IT departments. Managers and staff can see an accurate staffing position in real time, from ward to board. The app is pre-programmed with details of planned staffing for each shift for every ward. At handover, the nurse in charge inputs actual staffing numbers and other relevant information. The app reports fill rate and skills mix, and immediately flags issues such as high numbers of bank or agency staff or inappropriate skills mix. The nurse in charge then uses professional judgement to assess whether the ward or department is safely staffed. Staffing changes during the shift are updated to maintain an accurate live position. The app generates a report that can be viewed at Trust, site, divisional, directorate and ward level, allowing rapid response to remedy problems. Outcomes include:
- internal staff deployment across different departments increased, resulting in less bank and agency staffing and cost reductions: for example the stroke directorate saved £60,000 over a three-month period
- staff felt empowered to coordinate staffing according to needs of specific departments and patient acuity
- patient safety increased: for example between August 2015 and September 2016 falls were reduced by 25 per cent and medication errors by 16 per cent. The reduction in harm (in particular falls) and cost are multi-factorial of which safe staffing plays a part. The app is currently being rolled out across all NUH wards.
About the research
In November 2017, the Deloitte Centre for Health Solutions published Time to care: Securing a future for the hospital workforce in Europe – a multi-country study comprising interviews from more than 50 senior stakeholders and a crowd-sourced survey of over 1,350 doctors and nurses across 11 European countries.
Time to care: Securing a future for the hospital workforce in the UK is the follow-up report. Its findings are based on the UK cut of survey data collected for the European study (115 UK doctors and 201 UK nurses), supplemented by interviews across UK hospitals, reviews of literature on workforce issues in the UK and analysis of additional UK datasets.