Audit Committee, 13 Feb 2007

Meeting date: Tuesday, February 13, 2007

Official Report 198KB pdf

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“Planning ward nursing”

Under item 2, we will consider "Planning ward nursing—legacy or design? a follow-up report". I invite Robert Black, the Auditor General for Scotland, to speak to us.

I will ask Barbara Hurst to introduce the report as she has been leading the team that undertook the study.

The report follows our previous report from 2002. Clearly, it deals with an important area—nurses are the biggest staff group in the health service and, in 2005-06, more than £1.3 billion was spent on hospital nurses and midwives.

In our previous report, we concluded that improvements were needed in four areas, which were nurse workforce planning, information for planning the workforce, recruitment and retention and the use of bank and agency nursing. We have considered all four of those areas in this follow-up report.

It is fair to say that a lot of progress has been made in most of those areas. For example, with regard to nurse workforce planning, we found that many of our previous recommendations have been picked up and are being worked on. In 2004, the Health Department published action points for boards to develop nurse workforce planning, which addressed many of the issues that we raised, and the department is now monitoring progress against those actions and has funded regional advisers to support the work. Workforce plans have also been developed on local, regional and national bases. Quite a bit of work is going on in that regard.

Similarly, in terms of the information to support nurse workforce planning and management, the health service national workforce information system should improve the quality and scope of the information that is available. The Health Department set up an expert advisory group that has recommended tools that measure nursing workload and that boards will be expected to implement this year. Furthermore, the Health Department, NHS Quality Improvement Scotland, the information services division and directors of nursing are actively working to examine nurse quality indicators. Those developments are all encouraging, although more work still needs to be done.

On allowances for staff absences, in our previous report, we encouraged boards to review the allowances that were built in to nursing establishments so that predictable periods of absence and managerial time for senior nurses could be built in. Clearly, this is an important area because insufficient allowances put pressure on existing staff and budgets. In 2004, the Health Department made recommendations about the levels that boards should achieve. We have found that boards are at different stages of implementing those recommendations and that not all boards have met them.

On recruitment and retention, the health service has implemented a number of programmes, including work to enhance the roles and skills of existing nursing staff. Exhibit 1 in the key messages document shows that, across Scotland, vacancy rates—including long-term vacancy rates—increased slightly between March 2002 and March 2005 but fell in 2005-06. Long-term vacancy rates remained relatively low overall. However, that slightly disguises the fact that vacancy rates are higher in some NHS board areas than they are in others, and in specialties such as theatre nursing, intensive care and care of the elderly.

The Audit Committee has discussed the use of bank and agency nurses on several occasions. The report examines the issue again. There will always be a need to use some temporary nursing staff to meet temporary needs. Some of the needs arise from one-off activities, such as specific waiting times initiatives, and others arise from the unpredicted absence of permanent staff. However, as we have highlighted in previous reports, their use must be well managed to reflect quality and cost considerations. Between 2001-02 and 2005-06, the use of agency nurses fell by 17 per cent. Expenditure changed little but fell as a proportion of total spending on nurses and midwives.

Nurse banks have several advantages over agency nursing. Over the past few years, the Health Department and boards have implemented a range of measures to promote the use of nurse banks, including improving the terms and conditions of bank nurses and merging nurse banks. However, over the past four years, there has been a 73 per cent increase in the use of bank nurses, and expenditure has increased by 121 per cent. That increase can be explained only partly by the substitution of bank nurses for agency nurses. It is essential that boards plan the use of bank nurses as part of their wider workforce planning and that they keep that growth of bank nursing under review. We understand that the Health Department is now monitoring the use of bank nurses and the arrangements that boards have put in place to merge and manage nurse banks.

I have given only a brief overview of the report, but we will be perfectly happy to answer any questions.

I welcome the report. Having read the initial study, I am aware of some of the issues surrounding ward nursing and am encouraged that so many of the initial report's recommendations have been implemented. However, will a timeframe be set for implementing the recommendations and measures that Audit Scotland has identified in the follow-up report? Sometimes, when issues are identified, the matter is then just left to health boards.

Secondly, in relation to the roles and skills of existing nursing staff, and in relation to whether that issue affects whether vacancies are short term or long term, was any work undertaken to look at the types of job that nurses are doing, the mix of patients that they look after and the dependency levels of those patients? Were changes in shift patterns, such as the move towards 12-hour shifts, taken into account? Did any particular problems come to light?

Thirdly, is Audit Scotland satisfied that health boards are complying with the working time directive by allowing people to work extra hours through nursing banks?

Working backwards through those questions, I will kick off by answering the final question. I will pass the more detailed questions to the team.

The fact that nurse banks are being merged in board areas will certainly help people to comply with the working time directive and to monitor that. However, I think that work remains to be done on cross-border working. The Health Department and health boards need to consider that.

I will pass over to the team the questions on implementation timeframes and on the skills mix of nursing staff.

On the skills mix of current nursing staff, was the question about what the department and the national health service in Scotland are doing or about the issues that we explored in our report?

My question was whether vacancies are greater in areas where the existing skills mix is poor and where the workload is complicated because of patient dependency levels.

We did not look in detail at vacancy rates for particular nursing groups with a specific skills mix. Rather, we examined the difference between vacancy rates for registered nurses and for non-registered nurses.

The Scottish Executive and the health boards are developing measures of dependency levels that will consider what staffing levels and skills mixes are appropriate in the light of issues that arise from the existing workload.

I do not think that we can answer the question directly today but we can say, first, that vacancies can be broken down into different broad categories and, secondly, that the Executive is working with health boards to get a better understanding of the mix of nursing staff that is required for the workload that is generated by different levels of dependency.

I am aware that there are persistently high vacancy rates for posts in intensive care, theatres and care of the elderly. Given that intensive care and theatre settings require highly skilled nurses, is there perhaps a lack of adequate training places for such roles? Also, care of the elderly now involves sustaining people in their own homes for much longer, so dependency levels will be much greater than was the case when the baseline study was carried out. Obviously, that will have an impact on the individuals who work in that environment as they might be more likely to sustain back injuries.

Our study was slightly constrained by a temporary lack of detail in the ISD Scotland data on vacancies as broken down by specialty and subspecialty. We could identify subspecialty breakdown of vacancy rates only up to, I think, 2003, so we used the interviews to try to confirm whether difficulties continued in those areas. We received verbal confirmation from the Executive and the health boards that that was the case, but we were not able to access detailed quantitative data from the ISD Scotland statistics because of a temporary hiatus in the time series for those data.

My genuine concern is that, because intensive care and theatre nursing require further qualifications, it is not easy to top up nursing levels for those areas by using the nurse bank. In saying that, I do not denigrate any of the work that takes place in care of the elderly—which requires a different type of individual—but I have a concern about how health boards can work with high levels of vacancies in those areas. There is nothing in the report that gives me comfort that the department is actively trying to manage that problem out.

Our report did not consider the consequences of having to manage that problem at board level. We list various schemes under which the Executive is trying to develop the roles of nursing staff, but we did not look specifically at whether those schemes are used in areas where vacancy rates have remained persistently high.

There is perhaps also an issue about the use of agency nurses in some very specialist areas, where no other option may be open because a vacancy needs to be covered. It can be more difficult to try to reduce or abolish the use of agency nurses in very specialist areas.

Margaret Jamieson asks a fair question. The reason why we highlight the fact that higher vacancy rates occur in different specialties is that boards need to think more carefully about training in those areas. In the case of care of the elderly—an issue that is close to my heart—there were more untrained staff in such wards when we carried out our baseline report, but Margaret Jamieson is right to point out that, because more people are maintained in the community, more trained staff will be required. Although we have not made specific recommendations on the subject, we expect the department to look quite closely at the training issues that arise in respect of particular specialties.

Has the change in shift patterns had any impact?

We are unable to comment on that.

So, the study did not take into account whether such changes had had an impact.

On the issue of the timeframe for implementing the report's recommendations, some of our recommendations relate to on-going work for which work streams are already in place, some of which have timescales. For example, the work on nursing quality indicators has been linked to the senior charge nurse review that is being led by the department and has an anticipated reporting time. Therefore, the department already has timescales against some of the recommendations. However, clearer timescales could be set for implementing some of our other recommendations. For example, on the recommendation that boards should meet their predictable absence allowances, the department has been quite clear about what it expects boards to do but we think that it could be clearer about when they are expected to do that.

We will await that with interest.

If I have picked up what the witnesses have said properly, there was a comment about difficulty in obtaining data. With so many managers in the NHS, why is it difficult to get data?

There are two issues that have led to the temporary hiatus that Neil Craig discussed. As well as the move of staff on to agenda for change, which has been a big change process, the new Scottish workforce information standard system has come in, which has meant more change. It has been during the bedding in of those two big pieces of work that there has been a temporary blip with information.

One of the motives underlying the creation of the SWISS database has been a desire to increase the standardisation and consistency of data across health boards to facilitate comparative analysis, as we have recommended in our report. Some of the shortcomings in the existing data are being picked up through the current developments in the data systems, including SWISS.

So standard models are emerging, which give a baseline.

Your report has certainly sparked off some important activity. I notice such findings as "Work is underway" and "Further work is required". What is happening now is clearly work in progress. To pick up on Margaret Jamieson's point, the real cause for concern is recruitment and retention in crucial clinical areas including intensive care, theatres and care for the elderly. At least you have identified the problems, so attention can be paid to them and action taken. Timescales have been mentioned. When can we expect to see some actual delivery in those areas?

The situation varies from area to area. For example, the quality indicators work is attached to the charge nurse review, which is being rolled out this year. The deadline for reporting back on that is later this year. Boards are expected to implement the recommendations that were made in December in respect of which developmental tools should be used for measuring nursing workload in different clinical areas. That needs to be picked up this year. Although that is, as you say, work in progress, some imminent deadlines apply to work in some key areas. It is not as if the commitment is entirely open ended, with no end in sight.

I have a few questions about the figures in exhibit 2 in the report, which is headed "Nursing and midwifery sickness absence by board". There is a huge difference between the best and worst performers in terms of sickness and absence rates. Do the boards accept that that is a critical indicator of how well their management is performing? It is generally accepted in many areas that low sickness and absence rates indicate good management, whereas high sickness and absence rates indicate rather less good management, such as in Argyll and Clyde, in Lanarkshire and at the Golden Jubilee national hospital. Orkney, on the other hand, is where everybody should aspire to be. Do we have up-to-date figures for general nursing absence and sickness rates?

When you say "general"—

Are the boards furnishing us with that information? The document just gives us sickness absence rates for nursing and midwifery. I am sorry—I had been looking at that chart as applying to midwifery only, but I now realise that it applies to nursing, and that the data for nursing and midwifery have been collated.

I return to my original question: do the boards accept that such figures are a measure of their management skills?

I point out that the figure of 4 per cent is one of the efficient government targets. I think the boards are taking that pretty seriously, although it is fair to say that 4 per cent is quite a challenging target for a nursing workforce, in which we might expect slightly higher levels of sickness compared to elsewhere. All the figures show us that. It is not that surprising that Argyll and Clyde NHS Board, which was going through a big period of change, showed a slightly higher than average rate of sickness absence. It is fair to say that the boards are taking the target seriously.

There are no further questions. We shall have the opportunity to discuss this subject in private later, when the committee can decide on its response. I thank Barbara Hurst and the team for answering the committee's questions.