Planning ward nursing –
legacy or design?
A follow-up report

Key messages/Prepared for the Auditor General for Scotland
January 2007

Auditor General for Scotland
The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and
value for money in the spending of public funds.

He is responsible for investigating whether public spending bodies achieve the best
possible value for money and adhere to the highest standards of financial management.

He is independent and not subject to the control of any member of the Scottish Executive or
the Parliament.

The Auditor General is responsible for securing the audit of the Scottish Executive and most
other public sector bodies except local authorities and fire and police boards.

The following bodies fall within the remit of the Auditor General:

•	departments of the Scottish Executive eg, the Health Department
•	executive agencies eg, the Prison Service, Historic Scotland
•	NHS boards
•	further education colleges
•	Scottish Water
•	NDPBs and others eg, Scottish Enterprise.

Background

Nurses have a crucial role to play in the delivery of high-quality, efficient healthcare, and effective workforce planning is critical to the success of the health service in Scotland. Nurses and midwives make up the largest staff group in the health service. There were 55,469 whole time equivalent (WTE) nurses and midwives at September 2005, representing 43 per cent of the workforce.1 Eighty-four per cent were employed in the hospital sector, costing £1.34 billion in 2005/06.2
  
In 2002, we published a baseline report that examined how ward nursing was planned in the NHS in Scotland.3 The report made a number of recommendations about:

•	workload and workforce planning, including the methods used to calculate ward nurse staffing requirements  
•	recruitment and retention
•	the use of bank and agency nursing
•	the information available to assess the quality of nursing care
•	the information required to inform workforce planning and management of nursing resources at ward level.
This report analyses progress against those recommendations. Since the baseline report, the context in which NHS boards plan the hospital nursing workforce has changed considerably; for example, nursing roles are developing to support changes in the way healthcare is delivered, and new contracts have been introduced for nursing and other staff groups. We have taken account of these changes in assessing progress.

Main findings

NHS boards and the Scottish Executive Health Department (SEHD) have made progress in addressing the recommendations made in Audit Scotland’s baseline report. This has laid the foundations for better ward nursing workload and workforce planning in the future.

The SEHD has implemented a range of initiatives to develop workforce planning in the NHS in Scotland. The National Workforce Planning Framework, published in 2005, provides a template and timetable for developing workforce plans at board, regional and national levels, supported by guidance on how to develop workforce plans.4 5 Boards and regions have now published their workforce plans. These address the key themes in the guidance, but they do not include all the information specified in the guidance and there is limited detail on the methods used to calculate workforce projections. 

In 2004, the SEHD published the Nursing & Midwifery Workload and Workforce Planning Project (NMWWPP) report, which included 20 action points addressing the recommendations made in our baseline report. The action points are now being taken forward by boards and progress is being monitored by the Project Steering Group.

Work is underway to improve the information available on the nursing workforce, nursing workload and the quality of nursing care. Further work is required before this information can become a routine part of  workforce planning.

The NHS in Scotland is currently developing its national workforce information gathering and reporting systems, primarily through the Scottish Workforce Information Standard System (SWISS). At a local level, boards use a variety of systems to collect information for operational purposes on most, or all, of the nursing workforce information identified in our baseline report. But there is still no national system for gathering nursing workforce information at ward level and this has limited the scope for comparisons of the nursing workforce among boards.

Four working groups have been established to develop nationally agreed tools for workload measurement and planning in adult acute care, paediatrics and neonatal nursing, primary care, and mental health and learning disabilities.6 Implementing the tools will begin in early 2007. Boards will need to carefully plan and manage the potential staffing and financial implications of using the tools. 

There has been limited progress since the baseline report in developing indicators of nursing quality. An NHS Quality Improvement Scotland (QIS) pilot project highlighted a number of difficulties, such as the complexity of establishing the relationships between nursing care inputs and quality of care and the resources required to develop indicators and gather good quality data. Work is now being progressed by SEHD in collaboration with Information Services Division (ISD), NHS QIS and the NHS in Scotland to develop a national set of clinical quality indicators and an agreed method of data collection. This work has been integrated into a national review of the role of the senior charge nurse. 

Most boards have not met national recommendations on building additional time into nurse staffing requirements to cover annual leave, sickness absence, study leave, maternity leave and protected time for senior nursing staff with team leadership responsibilities.

Nurse staffing establishments should contain sufficient staff to allow for predictable absences such as periods of annual leave, sickness absence, study leave and maternity leave. These are called predictable absence allowances (PAAs). Establishments that include insufficient PAAs put pressure on existing staff; put pressure on budgets if overtime or temporary staffing needs to be arranged; and can affect the quality
of care.

The NMWWPP recommended a minimum PAA of 21 per cent. Only four of the fifteen NHS boards and special health boards that we reviewed currently achieve the recommended levels of PAA.7 8 However, 21 per cent may not be high enough – current sickness absence levels are higher than those built into recommended PAAs.9 Boards also need to include additional PAAs to cover the increased annual leave that nurses are now entitled to under Agenda for Change.10 The SEHD has estimated that the effect of these measures is equivalent to a 1.2 per cent reduction in nursing workforce capacity but the effect will vary by board according to the age and experience of the local nursing force.

The NMWWPP also recommended that all nursing staff with team leadership responsibilities be given 7.5 hours protected time for those responsibilities. Only two NHS boards demonstrated that they had fully implemented this.11 Sufficient protected time is important to enable team leaders to develop leadership, managerial, educational and quality-related aspects of their role, including ward nurse planning.

The SEHD, NHS boards and NHS Education for Scotland (NES) have implemented a wide range of recruitment and retention programmes, including work to enhance the roles and skills of existing nursing staff. Vacancy rates changed little across Scotland as a whole between March 2002 and March 2006 and long-term vacancy rates remained low. Vacancy rates vary among specialties and NHS board areas.

The SEHD, NHS boards and NES have implemented a wide range of programmes to recruit, retain and develop the skills of nursing staff. These include schemes offering routes into employment such as the Return to Practice scheme for nurses not currently in employment, and schemes to develop the skills and experience of qualified nurses such as the Flying Start programme for newly qualified nurses and the Clinical Leadership Programme.

Short-term vacancies of less than three months changed little between 2002 and 2006. Longer-term vacancy rates, defined here as posts vacant for three months or more, were relatively low (0.7 per cent in 2005/06) across Scotland as a whole. They rose between 2002 and 2005 but then fell in 2006.

There are variations in vacancy rates among boards and specialties. In addition, there are particular pressures in some sub-specialties such as intensive therapy and theatres. Measures to reduce vacancies need to be targeted in particular specialties and boards.
 
Between 2001/02 and 2005/06, the use of agency nurses fell by 17 per cent, although expenditure changed little. The use of bank nursing increased by 73 per cent and expenditure increased by 121 per cent over the same period. This is partly due to measures taken to promote nurse banks by improving the management and terms and conditions of bank nurses. NHS boards need to keep the growth of bank nursing under review.

Bank nurses are NHS employees contracted to work when required, often at short notice, to cover planned and unplanned shortfalls. They are paid at NHS rates. Agency nurses are employed by commercial nursing agencies; the NHS pays the agency a fee which covers the nurse’s pay at levels set by the agency and a commission to the agency.

Spending on agency nursing represented less than two per cent of total nursing spend in 2005/06. Combined spending on bank and agency nursing represented approximately 5.5 per cent of total nursing spend.

Our baseline report recommended that NHS boards reduce their use of agency nursing staff. Bank nurses are less costly than agency nurses. They provide a flexible way of meeting temporary needs for nursing staff and they can offer flexible routes into employment for nursing staff. The SEHD has produced recommendations to help boards reduce agency use by consolidating nurse bank arrangements and improving the management of nurse banks.13 The SEHD has also developed an audit tool, in collaboration with NHS boards, to be used annually to monitor progress in meeting these recommendations. The tool was used for the first time in October 2006 and the results were not yet available when this report was prepared.

To help reduce the cost of agency nursing, national contracts for the supply of agency nurses have been established through the Strategic Sourcing workstream of the National Services Scotland (NSS) National Procurement programme.

These measures are beginning to have an impact. Between 2002 and 2006 the use of agency nurses, measured in WTEs, fell by 17 per cent across Scotland. Reductions were not seen in all boards, and there was a slight increase in the use and cost of agency nursing in 2005/06, due in part to continued use of higher cost, non-contracted nursing agencies. In response, the SEHD has instructed boards to end the use of non-contracted suppliers of agency nursing staff.14

In contrast, the use of nurse banks grew considerably, in terms of both spend and WTEs. The size of this increase means that the use of bank and agency nurses combined, measured in WTEs, has increased by 43 per cent. This trend should be regularly reviewed to ensure that bank nurses are not used as a substitute for effective workforce planning and to ensure that the quality of nursing care provided by bank staff is maintained.

Our study

In carrying out our study we:

•	analysed workforce statistics published by ISD
•	interviewed directors of nursing in the 14 area NHS boards and the Golden Jubilee National Hospital, regional nursing workload advisers, regional workforce development directors and the SEHD officials with responsibility for nurse workforce planning and quality indicators
•	reviewed Scottish Executive, NHS and other relevant documents.
Key recommendations

•	Following the recommendations of the working groups on workload measurement, boards should assess and plan for the implications of using workload measurement tools. 
•	The SEHD needs to ensure that a high priority is attached to developing nursing quality indicators in the future and
put in place strategies to monitor progress.
•	The SEHD and the NHS in Scotland should review their strategies for reducing vacancies in certain specialties with persistently high vacancy rates. 
•	The SEHD should keep the recommendations on protected time and predictable absence allowances under review to ensure they are appropriate in light of the results of the senior charge nurse review, trends in predictable absence and the impact of Agenda for Change.
•	Boards should keep the growth of bank nursing under review to ensure the quality of care is maintained and to ensure an appropriate balance between the use of bank nursing and substantive posts.
•	Boards should assess the factors increasing the combined use of bank and agency nursing and develop strategies for managing any underlying demand and supply pressures that remain unresolved.
•	Boards’ strategies for managing the growth in demand for nursing staff to cover temporary staffing needs should be integrated with recruitment and retention strategies and establishment setting, including the development of PAAs and protected time for senior nurse managers.
1	Information Services Division (ISD) Workforce Statistics.
2	Scottish Health Service Costs 2005/06, ISD, 2006.
3	Planning ward nursing – legacy or design?, Audit Scotland, 2002. 
4	National Workforce Planning Framework, Scottish Executive, 2005.
5	National Workforce Planning Framework 2005 – Guidance, NHS HDL(2005)52, SEHD, November 2005.
6	A fifth group is looking at Telford-based tools. Telford-based tools for workforce planning are a way of formalising professional judgements on appropriate staffing levels into formulae for calculating nursing establishments. 
7	We reviewed the 14 area NHS boards and the Golden Jubilee National Hospital.
8	Dumfries and Galloway, Golden Jubilee National Hospital, Orkney and Shetland.
9	Nursing and midwifery sickness absence, April 2005 – March 2006, ISD Workforce Statistics.
10	Agenda for Change is a new pay system for nursing and other non-medical staff that has changed nursing pay, terms and conditions and professional development processes. New pay scales and most terms and conditions were effective from 1 October 2004.
11	Dumfries and Galloway, Golden Jubilee National Hospital. 
13	Nationally Coordinated Nurse Bank Arrangements: Report and Action Plan, Scottish Executive, 2005.
14	National Procurement: Use of National Contracts for Agency Labour Purchase; and Review of Procurement in Scotland, HDL (2006) 39, SEHD, July 2006.

If you require this publication in an alternative format and/or language, please contact us to
discuss your needs. It is also available on our website: www.audit-scotland.gov.uk

Audit Scotland 
110 George Street 
Edinburgh EH2 4LH 

Telephone 
0845 146 1010
Fax 
0845 146 1009
 
www.audit-scotland.gov.uk 

ISBN 978 1 905634 47 7 

AGS/2007/1