“Planning ward nursing - legacy or design?”
Item 4 is a briefing from the Auditor General on his latest report, which is entitled "Planning ward nursing – legacy or design?" The report is a baseline report, which looks at the cost and utilisation of nurses on hospital wards. I invite the Auditor General to brief the committee on the report.
Mr Robert Black (Auditor General for Scotland):
The report is the first piece of work to take a comprehensive look at nurse deployment costs and quality in the national health service in Scotland. Each year, more than £1 billion is spent on nursing in Scotland. More than 50,000 nurses are employed by Scottish NHS trusts. As nurses make up almost half of the staff complement, nursing expenditure is one of the biggest areas of expenditure in the NHS in Scotland.
The report attempts to highlight the need for better planning of the nursing work force and the need for that to be supported by much better information. As part of that improvement to the information base, the report suggests that the Executive might like to look more closely at measures of the quality of patient care. We need to have that information before we can ensure that we are getting value for money out of the £1 billion that is spent on the 50,000 nurses.
Some of the key issues that are identified in the report recognise the complexity and challenge that are involved in planning the nursing work force in Scotland. To plan the nursing resource well, managers need high-quality timely information on staffing and the quality of patient care. Such information is needed not only at board and hospital level but right down to ward level in individual hospitals. The report highlights a significant variation in the availability of planning information in the NHS. We believe that that information is required before the cost effectiveness of nursing staff levels can be determined.
One interesting and, I think, significant finding is that comparatively few staff are dedicated to the vital task of ensuring that the right number of nurses are in the right place at the right time. Clearly, there is always a concern to minimise the administrative overheads of the NHS, but the staff who are involved in planning the nursing work force at hospital and ward level are few in number. Indeed, in some parts of the NHS, they are almost absent.
The report highlights the wide and largely unexplained variation in the number and type of nurses who care for patients in comparable wards across Scotland. The variation may be due to the absence of adequate forward planning of establishment levels. We also highlight the trend of increased expenditure on bank and agency nurses. There are a number of reasons for that trend, but we suggest that improved work force planning is one of the key ways in which high-cost bank and agency nurse expenditure could be contained.
As in almost all the work that we undertake in Scotland these days, the report represents a moving picture. In August, the Scottish Executive published its "Workforce Development Action Plan", which provides an opportunity to improve the management of nurse staffing levels throughout Scotland.
In summary, the first of the main recommendations that come out of the report for action by trusts, boards and the department is that the health boards, under the new unified structure, should consider taking on all the monitoring of the way in which the constituent trusts carry out work force planning. Secondly, the health boards should work closely with trusts to improve the management information that is available. Thirdly, the NHS in Scotland as a whole needs to develop and agree quality-of-care measures to enable the outcome of nursing care to be monitored. Through the boards working with trusts to improve the management information and through action to improve the quality-of-care measures, we will be able collectively to establish the extent to which we are getting value for money from this extremely important resource.
The study is a baseline study; it is a snapshot of what the audit found at one point in time in the Scottish NHS in relation to nurse expenditure. We are considering how to follow the issues up. Our latest thinking is that we might review early next year how the health department and the boards are monitoring the success of the work force action plan and the extent to which they have been able to take on the report's recommendations. We also intend to undertake a further limited review of bank and agency nursing later next year. We have examined the subject in the past and it is a significant area of NHS expenditure.
Barbara Hurst, who directed the study, is sitting on my right, next to Arwel Roberts, and she is happy to assist me in answering questions.
Thank you. The issues that you covered are at the heart of any successful national health service and Audit Scotland is to be congratulated on its report, which highlights major areas of required action. Much of what Audit Scotland does always strikes me as common sense. On page 3 of the report we are told:
"Little is known nationally however about how trusts plan their nursing workforce or set staffing levels at ward level."
On page 55, Audit Scotland recommends improved management information. It seems incredible to me that even fundamental information is not available to plan what is a major, core and essential NHS resource. Why has that situation arisen?
That question should be addressed to the Executive, rather than to Audit Scotland, but I am sure that Barbara Hurst can give you some insight.
Okay.
Barbara Hurst (Audit Scotland):
We certainly do not wish to imply that health trusts are not using any information, because that is patently not true. We have managed to collect a lot of information, so it is available and many trusts are using it. Through the report we were trying to pull together the information so that trusts could use comparative information. There is not a lot of sharing of practice between trusts. That would be a way forward and it would mean that there was more consistency. We do not want to leave the committee with the wrong impression that there is no information available, because there is.
So it is about communication and the sharing of information.
I think so. It is also about making better use of what is available.
I find the report very useful. A few headline points stood out, one of which was the extent to which wards throughout Scotland are under their establishment and do not have the number of staff that they expected to have. The report revealed a huge variation in how trusts address that issue. It seems fundamental, because it leads to trusts having to bring staff in at short notice. Certain trusts are not budgeting for maternity leave.
There are basic issues that are bound to put pressure on staff and to exacerbate the problem of the retention of nurses and the big challenge of attracting people to nursing in the first place. Many practical issues need to be addressed and the statistic in the report that struck me was that only two fifths of hospitals are staffed in line with the establishment that the trust set up for the wards. That is an incredibly low level. There is an awful lot of work to be done to ensure that we tie that in with the comments that Mr Black made about the quality of staffing output. Huge pressure will be built into the system if it is consistently understaffed and if trusts are not reviewing what the appropriate establishment is.
I sense that it is early days in terms of being able to measure the quality of patient care. I agree that that aspect needs to be worked on and expanded—compared with the number crunching, that is difficult to do. Has that work been done in England and Wales? How far advanced is that body of research?
The fair answer is that the research is not very advanced. The Audit Commission, our sister organisation in England and Wales, tried to do something similar and came up with similar findings.
We tried to use proxy indicators, which are okay as far as they go, but the problem is that they measure quality in terms of what does not happen to patients—for example whether a patient does not get a pressure sore—rather than a more positive aspect of quality. In some ways, we are handing the matter back to the nurses. This is a matter on which they need to get some agreed measures. It is not our place to do that.
It might be a question not of the number of nurses but of the quality of care, the qualifications and experience of staff and such matters that are harder to quantify.
That is exactly what we, I suppose in our naivety, thought that we could try to get some fix on.
You are right that we need more sophisticated information to make those correlations. We could not find any. We are not saying that that is because they are not there; it is because we do not have the right measures.
The Auditor General undertook an investigation into hospital-acquired infections. It would be interesting to see whether there is a correlation between the poor performance of some trusts in the number of staff who are on wards and instances of hospital-acquired infections. There might not be a correlation, but I ask Audit Scotland to examine that point and come back to me on it.
The main area that I have concerns about is the way in which nursing work force planning is currently undertaken. It appears to be somewhat disjointed in that each trust does its own thing. The missing cog is further education and higher education. Colleges and universities seem to determine in isolation how many people they are going to allow to start the degree course, or the pre-degree course in further education. There does not seem to be an in-built mechanism to take into account dropout rates in first and second year. I notice that the Auditor General's report does not make too much play of that aspect. It is part and parcel of the joined-up aspect of the service, which does not seem to be there and working. It is all right for the health service to consider its work force planning, but it cannot do that in isolation.
It is nearly four years since I was involved in the health service. An awful lot of changes appear to have taken effect in that period. We seem to have lost our way in respect of the grade of staff who are used within the wards. I notice that the Auditor General's report makes no reference back to the national grading structure. It appears that most trusts have now binned that and have created their own structures, for all sorts of reasons.
I do not know whether you have evidence of it, but the report comments that
"less trained nurses may carry out duties above their level of training".
If that is the case, I would certainly expect that someone would have brought it to the attention of the accountable nurse. If it continues, the Nursing and Midwifery Council might want to investigate the matter because the individual nurse would be operating without the necessary qualification and if anything were to happen the nurse could be struck off rather than the superior who has instructed the action.
Those are some of my comments on the report, which made very good reading over the break.
I detect that we are sailing towards very deep but important waters.
I will respond to a couple of those points because they are all very valid.
We tried to collect some information about hospital-acquired infections through the figures for the incidence of clinical risk. At the time, several trusts were putting those systems in place so we could not get comprehensive information. We could certainly revisit that issue.
The education of nurses coming into the work force was outside the scope of the report. If we return to consider how the action plan is implemented, we could pick up on some of the issues raised. Education would be a very valid issue for us to pursue.
I echo the Auditor General's concern about bank and agency nurses. As page 41 of the report indicates, it is difficult to measure the quality of care. However, it is difficult to maintain quality of care if an increasing number of bank and agency nurses are being used and patients are seeing different nurses all the time.
My recent experience was not in Scotland so I cannot blame Scotland. Nurses were coming in all the time and asking patients what was wrong with them. Patients were seeing different faces all the time. I might be able to cope with that, but older people and people in psychiatric care might find that very disturbing.
My second point is about clinical nurse specialists. You made the point that there is a huge variation in acute trusts. I realise that the report shows a snapshot of a particular point in time and we are embarking on a process of having more nurse specialists. I notice that you refer to nurse specialists directly involved in in-patient care. Are you considering looking at nurse specialists working in primary care and in out-patient care. For example, Forth Valley NHS Board has appointed two specialist diabetic nurses, which has led to a huge reduction in admissions to hospital of diabetic patients. Those nurses can see and monitor patients at home and the patients do not have to be brought into the hospital. That also has an impact on costs.
The number of specialist nurses in an area such as diabetes—and there are numerous other medical areas one could think of—can have a significant impact on hospital admissions, particularly short-term admissions.
A significant amount of money—£33 million—is spent on bank and agency nurses, but that is relatively small in terms of the £1 billion that is spent in total. Nevertheless, we felt that the way in which we collected the information did not allow us to start unpicking how trusts were still using bank and agency nurses. As the Auditor General said, we would like to revisit that issue in its own right and consider what is going on in more detail.
We did not do very much on nurse specialists in the acute sector for this report. I am interested in Keith Raffan's point about how they could be used in the primary care sector and we will take that point on board because we are considering out-patient care.
I take your point about agency staff forming a small proportion of the whole, but I am concerned about the rate of increase.
Yes. I am not belittling your point.
I thank Audit Scotland for the report and for its trailer for forthcoming attractions. Members should note the report and also note the fact that Audit Scotland will revisit the issues raised and report against progress. That follow-up work will be progressed in about two years. Does the committee agree to note the report?
Members indicated agreement.
Meeting continued in private until 15:31.