Giving Time Back To Care
A Case Study by 2gether NHS Foundation Trust
2gether NHS Foundation Trust provides specialist mental health and learning disability services to the people of Gloucestershire and Herefordshire. Our priority is to deliver quality services and exceptional customer experience. Our purpose is to make life better, both for the people we care for, and for the carers who support them.
We serve a combined population of 798,480 people who live within 1,900 square miles of rural and urban landscape. Ninety-six percent of our services are provided within the community and as close to an individual's family and friends as possible - this is an essential factor in helping to improve a person's recovery. At any one time, we deliver services to around 18,500 individuals while offering education and support to their carers and family. Last year, our 2,300 dedicated permanent and bank staff made more than 280,000 telephone and face-to-face contacts. We cared for nearly 1,300 people in our four hospital sites: Wotton Lawn, Charlton Lane, Greyfriars and Stonebow.
The aim of our project was to increase direct patient contact time for clinicians and improve continuity of care through a wholescale review of our workforce profile and training delivery. The background to this review was:
- Staff and managers reporting increasing patient contacts and acuity, placing greater demands on static numbers of clinical staff. This also requires greater planning for continuity of care, which was difficult with increasing numbers of part-time staff.
- Managers and staff found it difficult to achieve 100% compliance with statutory and mandatory training (which ensures the delivery of safe services, by trained staff, while maintaining their health and safety). For in-patient staff, training in year one of employment was 10 full days and required backfill to maintain safe staffing levels on the wards.
- Managers often found it difficult to recruit to contracts which were less than half-time and, therefore, vacancies were sometimes not filled, adding to pressures on teams. However, it was also acknowledged that part-time staff with carer responsibilities valued flexible working.
All new staff receive compulsory statutory and mandatory training, commencing on their first day of employment. During the first year of employment we achieve 99.9% compliance but this reduces thereafter. For in-patient staff, with 10 full training days in year one, plus backfill to maintain safe staffing levels, this added to trust staffing costs and reduced continuity of care as bank or agency staff are often used.
Our Training Department calculated the number of hours required for statutory and mandatory training in the first year of employment, and subsequent years, by each staff group, given that our training is tailored to specific roles and therefore varies by staff group. For clinical staff it can vary between 65 hours and 100 hours per annum.
We added annual leave entitlement based on length of service, which showed that staff working two days or fewer per week, in their first year of employment, would spend between 29% and 39% of paid time training or on annual leave (i.e., not in clinical contact), and between 22% and 29% in subsequent years. If staff worked 30 hours per week, time not spent in clinical contact was nearer to 20% per annum.
We used the data in ESR to provide us with a detailed workforce profile, looking at roles, length of service and contract hours over a two-year period. In March 2013, the percentage of part-time to full-time staff was 38% to 62%. Of this number, 5% of the total workforce, or 11% of part-timers, only worked one or two days per week. By March 2014, part-time staff had increased to 41%, of whom 12% worked one or two days per week. We believed these patterns to be inefficient use of skilled practitioners, and unsustainable in the medium to long-term.
However, we also knew from our Staff Attitude Survey that part-time and full-time staff had comparable levels of staff engagement. Our aim was, therefore, to continue to engage with and value all staff, while balancing employee need with service delivery, and setting minimum contract hours to maximise patient contact time. We knew we also had to remain an ‘employer of choice’ in a challenging recruitment environment with an ageing workforce.
Managers said that providing statutory and mandatory training for newly appointed in-patient staff in a block of time was easier from a shift cover and rota planning perspective rather than having temporary staff covering shifts on an ad-hoc basis. However, if we could condense training for in-patient staff from 10 days to 9 days and not compromise on the quality of the training, this would both benefit new starters and all in-patient staff year-on-year. We estimated we would return some 200 days to patient contact time for in-patient staff and also increase patient contact time for other clinical staff, albeit a smaller proportion. We would also improve continuity of patient care and, finally, there would be a financial saving to the Trust of circa £65,000 per annum, based on reduced backfill. The Project Management Office oversaw the project, which was signed off by the Trust’s Transformation Board in June 2014. The Director of Organisational Development was the project sponsor.
We adopted the following approach:
a) Undertake a detailed workforce analysis by service, staff group, length of service, statutory and mandatory training requirements, numbers / percentage of part-time staff; contract hours;
b) Scope the qualitative aspects of employing part-time staff;
c) Engage with managers, Staff Side representatives, Heads of Profession, trainers, subject experts, and wider staff (part-time and full-time);
d) Establish a working group to develop recommendations during 2014 seeking ‘sign off’ by:
i. the Trust’s Executive Committee gaining top down buy-in;
ii. our Joint Negotiation and Consultation Committee gaining cross-union buy-in; and
iii. our Workforce and Organisational Development Committee whose committee members represent staff at all levels, most staff groups and services and offer a bottom up view of initiatives.
We would evaluate the effectiveness of the project using the following criteria:
a) Staff engagement for part-timers reported via the Staff Survey staying the same or increasing year-on-year;
b) Decreased numbers of part-time staff working below an agreed threshold;
c) Increase in statutory and mandatory training compliance);
d) Maintaining quality of training content.
The project was led by Ruth Thomas & Sue Heafield, pictured above
The Trust agreed a minimum threshold for new contracts (applying to new employees and existing staff changing roles voluntarily) of 22.5 hours to be worked over a minimum of 3 days per week. Criteria were agreed (where it was appropriate) to vary this for operational, commissioning or funding reasons.
We reviewed training content with trainers and Trust ‘subject matter experts’, introduced more e-learning and revised our local programmes. Overall we achieved a reduction in statutory and mandatory training for newly appointed in-patient staff from 10 to 9 days, and a pro-rata reduction for other staff.
The implementation of a minimum threshold for new part-time contracts does not appear to have had a detrimental impact on the percentage level of engagement for part-time staff and engagement rates have improved – see the table below:
Staff Survey – Staff Engagement Results
Full time staff
National average results
In January 2016, part-time staff numbers had returned to 2013 levels (38% part-time and 62% full-time). Staff working 2 days or less was 3.7% of total staffing or 10% of part-time staff. These figures will be monitored, with a view to achieving all staff working more than 2 days per week, unless in ‘exempted posts’
|Statutory / Mandatory Training Compliance|
The biggest increase in compliance rates occurred by the end of 2014. However, it was important to ensure stabilisation of rates for evaluation purposes.
The Project Team confirmed initial estimates that the decrease in time spent on statutory and mandatory training for in-patient staff alone would return some 220 days of patient contact time. While this may seem a small figure, it equates to 1 whole-time equivalent clinician (5 days per week x 52 less annual leave and bank holidays).
The expected financial savings of £65,000 per annum have not yet been realised as our agency usage has increased in in-patient services for a range of unrelated reasons and agency use will continue to be subject to a separate review during 2016/17.
The quality of training content has not been challenged, although the Trust is looking at training to understand where e-learning:
a) can be used instead of face-to-face training; and
b) quality of learning can be improved.
Carol Sparks, Director of Organisational Development, said: “This project has allowed us to really see how our ESR data brings value to, and can underpin key decisions that we can make for the benefit of our staff and service delivery.
Staff told us that they would like to see shorter and more service-focused statutory and mandatory training, enabling them to spend more time on delivering care. They also recognised the difficulty in providing continuity of care where staff worked 2 days per week or less, whilst appreciating the opportunities for flexible working.
We therefore reviewed our staff profile in detail, reviewed how we delivered our statutory and mandatory training, and by combining all our ESR data were able to reduce training time, reduce the numbers of staff on very part-time contracts and respond to staff concerns and service need.
We have achieved this fine balance and increased staff engagement results, which now see us performing better than the national average.
Using ESR in this way has enabled us to make sure that our staff have the opportunity to do what matters most to them – having contact with our service users. This can only improve the overall service we deliver. We will continue to use ESR to inform future service developments in 2016/17.”
Having a detailed understanding of the workforce profile with an accurate analysis is essential as there can be hidden or unforeseen consequences of a particular set of demographics.
A project of this nature which impacts on staff both at work and at home required clear evidence of benefiting both patients and staff needed the right language to engage all staff and needed to be aligned to our Trust values.
Where a project impacts on a large number of staff, they need to be engaged at all levels to maintain motivation and this is best done by team managers who understand their team members.
We have used the data analysis exercise as a catalyst to now look at:
- other initiatives that support both work-life balance and service delivery;
- identifying gaps in our workforce data;
- improving recruitment processes; and
- targeted responses to workforce shortages.
A range of separate projects will commence during 2016/17.
We have not fully rolled out Manager Self-Service but this is currently being explored as the next stage of our development activity.
We are keen to share our knowledge and support other organisations who want to know how ESR can help increase the time to care. We can contacted via the details below:
Sue Heafield, Assistant HR Director - Workforce (firstname.lastname@example.org / 01452 894671)
Ruth Thomas, Head of Training (Ruth.Thomas11@nhs.net / 01452 894115 / 07814 144494)