Meeting Date 25 May 2016 Agenda No 12 Report Title Draft Workforce Development Plan. Danny Hariram, Director or Workforce and OD

Transcription

1 Meeting Title Board Meeting Date 25 May 2016 Agenda No 12 Report Title Draft Workforce Development Plan Lead Executive Director Danny Hariram, Director or Workforce and OD Report Author Action Required Decision Discussion Monitoring (please tick) Strategic Objective(s) Executive Summary Objectives 2 and 5 This report provides detail on the Trust Workforce plan for Background / Context The Workforce Plan has been produced in response to the need to forward plan our workforce in the light of the Trust s challenges in a continuously changing environment. Key Issue 1 (replace with a brief summary of the issue) Key Issue 2 (insert more lines if required) Timescale for Benefits to be Realised Summarise the key aspects of the paper/proposal that the Board/Committee should consider

2 Assessment of Implications Financial Does this proposal have revenue (recurrent or non-recurrent) implications for the Trust? Yes / No Does this proposal have capital (recurrent or non-recurrent) implications for the Trust? Yes / No If yes, can these implications be fully covered by existing budgets? Yes/No If there are capital implications, the proposal was approved by the Capital Investment Group on The above financial assessment has been approved by the Director of Finance / Deputy Director of Finance (delete as appropriate) on Risk Equality and Diversity Failure to adequately plan our workforce and address our challenges will leave the Trust exposed in relation to staff availability and continuing over reliance on expensive temporary workforce along with turnover and retention concerns. This plan has been subject to an equality analysis and there are no implications for groups with protected characteristics OR Freedom of No exemptions apply Information Other Could include Monitor/CQC compliance, infection prevention and Implications control, NHS Constitution, recruitment and retention Identified (including patient safety and quality, legal and regulatory compliance) Recommendation The Board / Committee is asked to note the Workforce Plan Appendices N/A 2

3 WORKFORCE DEVELOPMENT PLAN

4 Contents 1. Executive Summary 5 2. Introduction 7 3. Strategic Context and Methodology 7 4. Trust Overview and Local Population Profile 8 Trust Overview Health Profile of the local Population 5. BTUH Workforce Profile 10 Baseline Demographic Profile 6. Workforce Challenges and Planning considerations 13 Workforce Challenges Other Forward Planning Considerations o Demand and Capacity o HEE Plan o Cost Improvement Plans and Efficiencies o Other factors affecting the future pay bill 7. Workforce Interventions aimed at Efficiency Savings 17 Recruitment Initiatives Role redesign and new ways of working Reducing Temporary Staffing Spend Apprenticeships and grow your own Reducing Sickness Absence Turnover and Retention Demography 8. Forward Establishment Plan ( ) 26 Governing Principles Trust View Summary 9. Conclusion Monitoring and Review References Appendix 30 Action Plan 4

5 Executive Summary The vision for Basildon and Thurrock University Hospitals NHS Foundation Trust is to be an excellent hospital providing high quality, safe care for our community. With the increased need for efficiency across the NHS and the Trust s current financial position, the Trust s strategic plan aims at reducing our underlying deficit while delivering a sustainable high quality of care to meet an increasing demand from our commissioners. This Workforce Development Plan sets out our approach as to how we will model our workforce to support our financial objectives. It describes our trust profile, identifies the current challenges and how these gaps can be filled to strengthen our productivity and improve efficiencies. It further describes our future staffing model and our planned workforce interventions to deliver the efficiency savings required in our financial plans. Our workforce priorities for are to: Intelligently plan the workforce and understand future workforce supply by working collaboratively with Health Education England (HEE). Continually review our budgets, vacancies and staffing levels in line with service demands. Maximise opportunities to utilise the workforce more flexibly and to obtain efficiency gains through service transformation & improvements Develop an affordable, sustainable and highly skilled workforce. Strengthen our workforce productivity and have an excellent reputation as an employer of choice within Essex and beyond. Improve experience, engagement and leadership of staff in order to enable them to deliver to their full potential. This plan recognises that these priorities are aspirational for the 3 year period of and that there are various uncertainties and emerging opportunities ahead. In 2015, Essex was named as one of three areas in the NHS in most need of transformation to health and care services. To address this, the Essex Success Regime will identify areas of joint working within south and mid-essex across the three main hospitals (BTUH, Mid Essex Hospital and Southend Hospital), CCGs, local authorities and other health care providers with the view to maintain a high quality of care against a backdrop of increasing demand and increasing financial pressures. In particular, ways of reducing duplication and saving resources within clinical and non-clinical functions will be identified and implemented. The implications of staffing configurations associated with this programme are still at the early stages of planning. Actual impacts on workforce numbers and configuration is unclear at this point for forward planning purposes. At BTUH our approach is therefore to strengthen our positon in year one (2016/17) and for now, maintain stable numbers in forward planning our staffing establishment model for Year 2 and 3 until there is more clarity on the future. Lord Carter s Review of operational productivity in NHS providers also directly affects BTUH. Opportunities for savings across the NHS have been identified through improving workflow and containing workforce costs. This would include, from a workforce point of view, a stronger hold on the management of sickness absence, better management of rotas and the reduction in temporary staffing 5

6 costs. Detailed operational reviews for the Trust are yet to be received and implemented, but will be aimed at reflecting good clinical practice which could also have a direct impact on workforce alignment and management. For these reasons, this plan is focussed on longer term staffing interventions that we can immediately work on to strengthen our current position and work towards meeting our aspirations by bridging the gap from where we are now to where we want to be. We have put together various interventions such as; better recruitment plans to fill our vacancies, reducing our reliance on temporary staffing, retaining our staff to reduce our turnover; managing our sickness absence and, also continually looking at various role redesign opportunities and changes in working practice as we wait to consider and apply the implications of the Essex Success Regime and Carter review on our workforce configuration. In summary, We are launching a drive on overseas recruitment for nurses that will be embedded into our business as usual processes in response to our constant need for these staffing groups. We will take stringent measures to reduce our temporary staffing costs with a 2m target for 2016/17. This also includes reducing and eliminating the need for contractors where possible and the implementation of agency price cap rules from NHS Improvement. We will manage sickness absence more closely with the aim of reducing our sickness absence cost in line with the Lord Carter Review. We expect that proposed changes coming out as a result of the implementation of the Essex Success Regime in particular will be clearer within the year. This workforce development plan should therefore be viewed as work in progress as it will be influenced by future changes to our workforce configuration and initiatives. This plan will be reviewed mid-year and annually, to reflect changes and new information in light of the changing landscape at which point we will pick up emerging priorities to shape our workforce and establishment model. 6

7 1.0 INTRODUCTION 1.1 BTUH is currently operating with a deficit and faced with the need to make 4% CIP savings from 2016/17 while delivering a high quality of clinical services that are cost efficient to the tax payer. 1.2 Our Workforce Development Plan for 2016 to 2019 is an enabling medium term plan designed to ensure that the Trust not only has staff in the right numbers with the skills and behaviours required, but that are staffing priorities are aligned to deliver the Trust s objectives within the current financial climate. 1.3 The plan elaborates on the current status of the workforce and our key challenges and our mitigating actions. It factors in the impacts of national policy, provides detail around our workforce supply and lastly, how we intend to achieve and maintain required staffing levels to meet our corporate goals. 2.0 STRATEGIC CONTEXT AND METHODOLOGY 2.1 Strategic Context With over 1.3 million staff performing over 300 different types of roles across more than a 1000 different employers, effective workforce planning will ensure that we have a workforce of the right size with the right skills and diversity organised in the right way, delivering the services needed to provide the best patient care Strategic workforce planning is now a higher priority on the NHS agenda than before as a result of the changing landscape in government policy, the financial state of the NHS and the effects of the implementation of the government White Paper Equity and Excellence, Liberating the NHS. In the recent 5 years, government policy has never been stronger on the need to deliver quality health care services at an affordable cost that sufficiently justifies the use of taxpayers money The BTUH Workforce Plan therefore takes into account NHS national policy that is currently shaping the future of NHS services. These include: The government s response to the inquiry into events at Mid-Staffordshire Hospital led by Robert Francis Hard Truths: the journey to putting patients first The NHS Patients Safety Review published by Don Berwick Sir Bruce Keogh s report NHS Services, Seven Days a Week NHS 5 Year Forward View, NHS England Locally, it also takes into account: Internal service reviews Divisional Workforce Plans Business Planning for 2016/17 Local business and operational strategies 1 Skills for Health

8 1. Baseline Data from ESR 2. Demand and Capacity Analysis 3. Divisional Plans Demand Forecast Supply 2.2 Methodology and Approach Our workforce planning approach follows an integrated model as recommended in the Monitor Strategic Workforce Planning Tool. To develop this plan, we have used our current workforce data pulled from our Electronic Staff Records system (ESR), Finance budget data, local population and demographic data and our divisional strategies and plans. It also factors in national and local policy and its implications for our workforce Our integrated approach is summed up below: BTUH Workforce Plan National and Local Policy Drivers Action Plan 3.0 TRUST OVERVIEW AND LOCAL POPULATION PROFILE 3.1 Trust Overview 3.1. Basildon and Thurrock University Hospitals NHS Trust provides health care services to a population area of about 450,000 over Basildon and Thurrock local authorities and some parts of Brentwood and Castle Point over 3 sites (Basildon University Hospital, Orsett Hospital, and the Billericay St Andrews Centre) The Trust is commissioned to provide an extensive range of acute healthcare services at Basildon and Orsett hospitals, plus x-ray and blood testing facilities at the St Andrew s Centre in Billericay. We also provide dermatology services across the South Essex area from seven sites. The Essex Cardiothoracic Centre (CTC) provides a full range of specialist cardiothoracic services for the whole county and further afield. In addition, we provide wider services to meet the needs of the local population such as audiology, cancer services, cardiovascular, general surgery, respiratory medicine, therapy services pain management diabetes and endocrinology to name a few. 8

9 3.1.3 In 2014/15, with a budget of about 294million, the Trust treated 77,500 inpatients and day patients, provided nearly 300,000 outpatient appointments and attended to 103,000 patients in accident and emergency. Ultimately, our priority is to develop high quality safe urgent care services 24 hours a day, 7 days a week while ensuring the best possible outcomes While the Care Quality Commission (CQC) awarded the Trust a Good rating in August 2015, we aim for excellence and continue to strive for innovation and improvement to deliver an excellent quality of service in the current financial landscape in the wider NHS The latest Office of National Statistics (ONS) population projections based on 2012 estimates show that the Trust s catchment population is expected to grow slightly faster than the national projection. This is reflected across almost all age bands. We are also aware of two potentially significant housing developments, which could lead to a greater population increase than projected by ONS analysis; around 40,000 homes at Purfleet while 20,000 homes are planned to the east of Basildon. Commissioner growth assumptions have therefore been pegged between 1-1.5% per annum due to demographic changes and 1.5-2% per annum increases due to non-demographic factors The demand for our healthcare services is therefore likely to expand faster than the financial resources available to provide it and therefore impacts on our model of service delivery. Consequently we continually need to configure our workforce to meet the demands of our populace. 3.2 Health Profile of the Local Population According to Public Health England (June 2015), the health profiles of Basildon and Thurrock indicate that: Deprivation is higher than the England average (20.65% vs. 20.4%) in Basildon and lower in Thurrock (13.4% vs. 20.4%). There are more children living in poverty in both Basildon and Thurrock compared to the national average (Basildon: 22.4 vs. 19.2%, Thurrock; 20.8Vrs 19.2%). Life expectancy is 8.8 years lower for men and 8.5 years lower for women in the most deprived areas of Basildon while Thurrock is 9.7 years lower for men and 7.1 years lower for women in the most deprived areas. Obesity in Children at year 6 and under 18 conceptions are higher than the England average in Thurrock (22. 1vrs 19.1, 31.1vrs 24.3) while in Basildon, obesity is lower at 17.9vrs 19.1 but higher in under 18 conceptions at 32.9 and Alcohol specific hospital stays are lower than average for both Basildon and Thurrock (Basildon: 12.4vrs 40.1, Thurrock 13.7 vs. 40.1) Adult obesity is high compared to the national average (Basildon 30.2 vs. 23; Thurrock 31.4 vs. 23). Alcohol and self-related harm stays are under the England average. Smoking related deaths are worse than the England average (Basildon vs Thurrock 322 vs ) The rate of sexually transmitted diseases, drug misuse, malignant melanoma and TB are better than average for both areas Consequently, the current local health priorities in Basildon and Thurrock are to reduce the prevalence of smoking, the prevalence of adult and child obesity, reduce health inequalities by tackling poverty and reducing smoking and obesity rates. 9

10 3.2.3 We therefore need to have a workforce that is responsive, flexible and agile to the changing environment. We need to understand workforce challenges on a larger scale, working as part of the wider health and social care economy on system wide solutions to deliver care for our local and the wider population. Having a flexible and adaptable workforce will be integral to the delivery of these care plans. Ultimately, we want our staff to be confident and be empowered to be creative, innovative and explore opportunities for improvement. We recognise that there are a number of external factors and challenges that we must also respond to in order to ensure that our priorities are sufficiently met. 4.0 BTUH WORKFORCE PROFILE 4.1 Baseline Data At year end 2015/16 BTUH employs approximately 4554 ( WTE) 2 staff substantively over 3 sites comprising a broad range of skilled staff and professional groups, working in clinical and non-clinical settings and unified by their commitment to patient, service user and carer experience. There is also an additional temporary staffing resource engaged via bank and agency that provides essential services and fill in staffing gaps as required. In March 2016 this was approximately 580WTE The Trust is structured into divisional areas according to the services we provide. Table 1 shows a breakdown of staff by divisional area. This indicates that direct clinical services constitute 85% of the workforce while corporate support services constitute 15%. Table 1 Trust Baseline Substantive Budget Substantive Temp Area Division Headcount WTE WTE WTE 3 Clinical Services 3,886 3, , Acute Medicine Division Clinical Support Services Division Cardiothoracic Centre Division Women and Children Division Surgical Services Division Medicine Division , Corporate Services Board Division Capital Projects Division Chief Operating Officer Division Environment and Infrastructure Division Finance Division HR & Occ Health Division Improvement and Performance Division Nursing Division Training & Education Division Total , , ESR data at 31 March Average temporary staffing usage in March

11 4.1.3 At the end of March 2016 the Trust was running at a vacancy level (substantive) of WTE vacancies. Registered nursing was running at a vacancy level of 13.4%. Turnover across the Trust was 15%. Sickness absence was at 4.1% and average temporary staffing usage per month (over a rolling 12 month period) was approximately 2.5M. Table 2 BTUH Workforce Indicators Staff Group Vacant WTE Vacancy Rate % of (Target 6%) Turnover Rate % (Target 10%) Sickness Absence Rate % (Target 3.5%) Average Temp Staff Usage per month Add Prof Scientific and Technical % 17.7% 4.7% 230K Additional Clinical Services % 18.9% 3.1% - Unregistered Nursing % 11.6% 7.0% 238K Administrative and Clerical % 15.3% 3.5% 234K Allied Health Professionals % 23.2% 3.1% - Estates and Ancillary % 13.1% 3.6% 42K Healthcare Scientists % 18.8% 1.5% - Medical and Dental % 10.4% 1.0% 825K Registered Nursing and Midwifery % 11.6% 4.5% 835K Grand Total % 15% 4.1% 2.5m Majority of our staff are nurses (including newly registered nurses) at 32.92%. Additional Clinical staff make up 22.05%, Administrative and clerical 19.74%, Medical and dental 13.62%, Estates 5.31%, AHPS 4.23%, Professional and Tech 2.9% and Health Care Scientists at 1.23%. The Trust employs majority of its staff in Band 2 (HCAS and administrative staff) and Bands 5 and 6 (registered Nursing and Midwifery staff). Fig A below shows the workforce profile by band and staff group Fig A) Workforce Profile by Pay Band and Staff Group Add Prof Scientific and Technic Additional Clinical Services Administrative and Clerical Allied Health Professionals Estates and Ancillary Healthcare Scientists Medical and Dental Nursing and Midwifery Registered The workforce issues relating to these statistics will be further addressed in section 5 with interventions detailed in section 6. 11

12 4. 2 Demographic Profile The female to male staff ratio is 75% to 25% which is comparable with national NHS staffing figures. This follows through at staff group level except within Estates and Medical staff groups where the male population is higher (62% vs. 66% respectively). When compared to the local population we have more female staff (75%vrs 51.20%) and less male staff 25% vs. 48.8%. Figs B and C below provide a snapshot of our gender and age profile. 80% Fig B) Gender Profile 25% Fig C) Age Profile 70% 20% 60% 50% 15% 40% 30% 10% 20% 5% 10% 0% Female Male 0% BTUH Local Population BTUH Local Population The age profile shows that 26% of our staff is over the age of 50 with 14.4% over 56 and/or approaching retirement age. The local population has a similar high percentage of people over 50 (33.5%) with only 33% between the working ages of 20 and 50 thereby having an adverse effect on our local employment pool Our staff population is predominantly white (66.83%) with a black and ethnic minority (BME) population of 26.45% (6.71% % unstated). When compared with the local population, majority are still white but in higher proportions (91.38% vs. 8.62). Fig D provides a snapshot of our ethnicity profile. Fig D) Ethnicity Profile 100% 80% 60% BTUH 40% 20% 0% White Mixed Asian Black Chinese or Other Not stated Total BME Local Poplulation 4 Comparisons made to the local population of Basildon, Thurrock, Brentwood and Castle point 12

13 Our ethnicity profile shows that the Trust is over represented on BME staff, however, the larger sections of the BME population are made up of Asian and Black ethnic groups who are mostly doctors and registered Nurses delivering key professional skills needed for the efficient running of services we provide The demographic profile of the Trust does not show an immediate concern for positive action with regards to majority of indicators in the Equality and Diversity Standard. However the Equality and Diversity Steering Group will develop and co-ordinate work around improving the experience of patients and staff by promoting equality and diversity. 5.0 WORKFORCE CHALLENGES AND PLANNING CONSIDERATIONS 5.1 Workforce Challenges If BTUH aims to be a model employer then we need to address our current workforce issues. Table 2 in section shows that the Trust is running below target in our major staffing indicators. These indicators reflect our workforce challenges which are recruitment, high attrition rates, an ageing workforce, high absence rates and high temporary usage which in turn have a direct impact on our pay costs. This section looks at these issues in more detail Our Recruitment Challenges BTUH faces recruitment challenges especially around the recruitment of band 5 and 6 nurses (as is the case nationally) to meet required safe staffing levels. Other hard to recruit areas include audiology, histopathology, ITU, Operating Department Practitioners and Paediatrics, Cardiac Physiology and Cardiac Perfusion (a national occupation shortage), Occupational therapists and Physiotherapists. We also encounter difficulties to recruit to the medical workforce in areas such as Paediatrics and A&E High vacancy rates within our hard to recruit areas increase our operating costs as services resort to expensive temporary staffing to cover shifts with bank/agency/locum costs running at an average of 2.5m per month In addition, attracting skilled candidates in general in a catchment area with close proximity to London Trusts is a challenge as these Trusts offer more attractive area allowances Our High Attrition Rates Trust turnover is currently at 15% with natural attrition (voluntary resignation) at 13%. At staff group level, turnover rates for AHPs, Health Care Scientists and Registered Nurses are among the highest at 23%, 18.9% and 15.8% respectively (with Band 5 nurses at 19%). This again highlights the recruitment challenges in 5.1.1; our staff leave faster than they can be replaced therefore increasing our pay costs through the reliance on temporary staff Reducing turnover to our target of 10% and below will not only reduce cost but also improve morale and strengthen our staffing baseline evidenced by improved staff survey results and increased productivity. 5 Average over 12 month period 13

14 5.1.3 Our High Use of Temporary and Agency Staff While it serves business purposes to have an element of flexibility in the workforce, the cost of agency and locum spend especially is high on the NHS agenda. The introducing of price caps is aimed at reducing agency spend across NHS Trusts. At BTUH, our target in 2016/17 is to make a savings of temporary staffing spend of 2 million. This will be progressed at divisional and corporate level Temporary staffing expenditure (bank, agency and locum) is approximately 14% of the pay costs at an average of 2.5m. The highest spend is within locum and registered nursing. (Table 2, section 4.1.3) Figures E and F below show that vacancies and sickness absence account for about 66% of booking reasons for bank and agency usage. Therefore we aim to reduce bank and agency spend over the next 3 years by recruiting into permanent posts and reducing sickness absence especially within registered and unregistered nursing where we have the highest usage of temporary staff. Fig E) Bank and Agency Booking Reasons Workload Increased Unplanned Leave Supernumary Sickness Planned Leave Paternity Maternity Fall Sitter 7 day working 0% 10% 20% 30% 40% 50% 60% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Admin & Clerical Fig F) Bank and Agency Usage by Staff Group Allied Health Prof Health Nursing & Care Midwifery Scientists Support Our High Sickness Absence Rates At 4%, the absence rate for the Trust is currently above the target rate of 3.5%. The cost of sickness absence over the last 12 month calendar period is estimated to be 4.3M, at an average of 360k a month (including pay and on costs) The highest occurrences of absence are among HCAs and Registered Nursing (7% and 4.5% respectively) while the highest reasons for sickness among these groups are anxiety/stress and musculoskeletal problems (30% of absence reasons) Potential savings from a reduction in sickness absence are identified in section Our Age Profile Currently 39% of our staff is above 45 years compared to 41% in the local population. However only 33 % of the local population is within the younger employable labour market within the 14

15 ages of for which there is a high competition for skilled staff from local and nearby hospitals and community services such as Broomfield Hospital, Southend and Queens Hospital We also have a high proportion of our workforce leaving employment due to retirements at 7% (of the 66% of known leaving reasons). Additionally 9% of our staff is within the near retirement bracket with a further 5.4% over the age of 60 meaning that we need to encourage younger staff into our workforce and improve our succession planning and knowledge transfer. 5.2 Other Forward Planning Considerations Demand and capacity analyses, our education commissioning plan, and cost improvement plans, when considered together with the workforce challenges highlighted in section 5.1 will be key in formulating the forward workforce plans for BTUH Demand and Capacity Analysis The 2015 Demand and Capacity analysis of clinical services using the IST Flow Model 6 and 2 Week Waiting Model looked at clinical activity levels over a 12 month period and evaluates the demand and activity levels against the required model factoring in a 1.2% growth for 2016/ Results indicate that while there are indeed areas of over capacity, increased demand could be absorbed within current resource levels in majority of areas. It indicates that outside of completely new service development, the Trust can support a 1.2% growth in demand through: Changing working practices so that there is efficient utilisation of resources and constant adjustment of over and under capacity activity between new appointments, follow ups and in patient activity. Reviewing pathways to determine how much unused capacity can be converted and deployed where needed. Reviewing clinic DNA and utilisation to determine scope for increased capacity within current job plans and activity levels. Reviewing theatre utilisation to absorb increased capacity. Where excess activity clearly cannot be absorbed through any of the above, this will be looked at on a case by case basis subject to executive approval As a result, the direct staffing implications in 2016/17 and beyond will be: Modest establishment growth where specifically required through demand and capacity outcomes. Constant review of staffing supply along clinic pathways to explore better use of staff to maximise efficiency; A review of consultant job plans in specific areas to absorb increased activity where required; Improve the flexibility of our non-specialised workforce that can be deployed to meet fluctuations in activity across teams/clinics (e.g. HCAs and Admin staff); Review roles and increased emphasis on role redesign. 6 NHS Interim Management and Support website 15

16 5.2.2 BTUH HEE Education Commissioning Plan ( ) The Trust s 5 year training commissioning intentions submitted to HEE in June 2015 predicted a modest 3% growth from 2015 till 2020 with a 1.2% growth forecast between 2016 and 2019 which is the planning period for this plan The forecast figures in Table 3 were produced in the light of identified business needs within the context of known financial pressures both nationally and within the Trust. The wider NHS landscape has not differed since then. Rather, there is a stronger emphasis on cost reduction and value for money If education commissioning growth was predicted at 1.2% from 2016 to 2019 then it follows that our 1.2% forecast growth applied to our demand and capacity analysis of our clinical services is aligned to our education commissioning needs It also follows that outcomes from demand and capacity analysis, once aligned to business needs in line with the wider financial strategy are not expected to affect our education commissioning plans at this stage. Table 3 HEE Commisioning Plan Forecast Demand % Change 2015 to to to to to to 20 Total Staff 1.5% 0.9% 0.2% 0.2% 0.2% 3.0% Total Medical and Dental Staff 5.1% 0.9% 0.0% 0.0% 0.0% 6.1% Consultants (including Directors of Public Health) 7.3% 0.9% 0.0% 0.0% 0.0% 8.3% Trainee Grades -6.0% 2.0% 0.0% 0.0% 0.0% -4.1% Career/ Staff Grades 18.0% 0.0% 0.0% 0.0% 0.0% 18.0% Other Medical & Dental (balancing figure) 6.5% 0.0% 0.0% 0.0% 0.0% 6.5% Total Non-Medical Staff 1.0% 0.9% 0.2% 0.2% 0.2% 2.5% Registered Nursing, Midwifery and Health Visiting staff -0.1% 0.5% 0.5% 0.5% 0.5% 2.1% Qualified Scientific, Therapeutic and Technical Staff 2.9% 5.9% 0.0% 0.0% 0.0% 9.0% Allied Health Professionals 5.5% 10.7% 0.0% 0.0% 0.0% 16.7% Healthcare Scientists 1.6% 3.1% 0.0% 0.0% 0.0% 4.7% Other Scientific, Therapeutic and Technical Staff 0.7% 1.3% 0.0% 0.0% 0.0% 2.0% Qualified Ambulance Service Staff Support to Clinical staff 2.4% 0.2% 0.0% 0.0% 0.0% 2.6% NHS Infrastructure Support -0.5% 0.0% 0.0% 0.0% 0.0% -0.5% General Payments 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Cost Improvement Plans and Carter Efficiency Savings The Trust s financial position indicates that savings need to be made in our planning period commencing from 2016/17. The Trust Financial strategy indicates a 4% saving required across pay and non - pay budgets in 2016/17 with possible further savings required in 2017/18 and 20118/ In addition, the NHS Five Year Forward View published by NHS England in 2014 highlighted the financial challenges faced by the wider NHS. The NHS is thus faced with the challenge to do more for less. This will in turn affect income and funding from our commissioners, but with the expectation that a high quality of service will continue to be provided. 16

17 Even further, the Lord Carter Productivity and Efficiency Review (of 32 Trusts including BTUH) commissioned by the Department of Health identified saving opportunities to be implemented by the NHS by 2020/21. While this is still at the initial stages of consideration, the 2 key workforce messages for BTUH is that we need to operate more efficiently and eliminate wastage by reducing our temporary staffing spend and sickness absence costs Ultimately, BTUH workforce models and strategies should seek to enable our financial plans, and improve efficiencies with cost reduction being at the forefront Other Factors affecting our future Pay Bill Our future workforce needs aimed at efficiencies and cost reduction also needs to consider the impact of other factors that directly affect our pay bill The NHS pay review body has negotiated a 1% pay rise across pay bands for 2016/17. This means, for example, that if the average substantive pay cost for a month is 14m (based on average for the 3 months to March 2016), an additional 140K per month would be required from April Further increases could be implemented in 2018 and 2019 based on negotiations and these would also affect future costs Public sector employer pension contributions are also set to increase from 2019, adding more to employer costs. Though outside of scope of this planning period, this is worth noting for future planning purposes The above considerations mean that pay costs will only continue to increase and therefore we need to maintain a strong focus on continually delivering efficiencies within our workforce WORKFORCE INTERVENTIONS AIMED AT EFFICIENCY SAVINGS As previously set out our forward workforce plan will need to support the Trust s strategic and financial objectives by making efficiency savings on its workforce. The detail below describes how we will address our workforce challenges to support the financial plan and looks not only at how savings could potentially be made but also how the currently employed workforce could be strengthened against the challenges described in section 4. Majority of these actions are expected to run through till 2018/19, however where savings have been costed this has been specifically around 2016/17 financial year. Detailed plans have been formulated to tackle recruitment issues to include: Targeted recruitment plans have commenced aimed at overall long term efficiency savings. These are being formulated at divisional level to incorporate the Trust level approach being developed. Using role redesign to fill gaps for hard to recruit (for example Junior Clinical Fellow - FY3). Reducing risks of inability to attract suitable candidates by growing our own. Though these actions will carry through to 2018/19 the immediate emphasis is on 2017/18 and the efficiencies expected have been costed in relation to this financial year as a starting point. Specific actions by staff group are detailed below and summarised in the HR action plan (Appendix 1) which highlights key actions and milestones around our recruitment and retention drives. 17

18 6.1 Recruitment Interventions Our Registered and Unregistered Nursing Workforce The significant supply shortage of Nurses across the UK is expected to carry into the next few years. Consequently, we have a high temporary staffing spend on registered nursing. It is therefore cost effective to look at various ways of meeting nursing demand outside of the UK employment pool In 2016/17 the Trust will seek to recruit 80 Nurses form overseas (40 general nurses from Europe and a further 40 general nurses from the Philippines) to reduce our nurse staffing shortfall. While it is accepted that EU nurses will have a higher turnover rate they are quicker to recruit and will fill immediate gaps while the outside EU recruitment will bring in a longer term cost benefit The first cohort of European Nurses is expected to be in post in April/May 2016, the second cohort by June 2016, and the Philippine nurses around October The estimated savings is 1m by mid (There is investment required of about 500K in agency and accommodation costs and about 300K in double running costs of bank/agency cover while the new recruits are waiting for their PINs) Overseas recruitment will progress beyond 2016/17 into 2017/18 and 2018/19 based on learning points from the 2016/17 campaign and in response to nursing turnover Medical and Dental workforce Specific recruitment plans for medical posts have been formulated through joint working between HR colleagues and the Divisions to map actions required to fill vacant posts and also move locums into substantive roles There is ongoing work around role development to make posts more attractive and easier to recruit (for example staff Band nurse 5.5 roles) We are also looking into offering developmental roles for overseas doctors through the Medical Trainee initiative which allows overseas doctors to take up to 2 years for life and career changing experience in the UK We have made overseas recruitment an integral part of recruitment initiatives for medical posts and continually scope new ways to deliver savings on locum spend. 18

19 6.2 Role redesign and new ways of working Nursing - Skill Mix Review A Nursing Establishment and Skill Mix Review 7 for all adult in-patient wards was conducted in the autumn of 2015 to review compliance with guidance and recommendations from government, Chief Nursing Officer for England and the region, NICE, CQC and NMC with benchmarking carried across Southend and Papworth Hospitals. It also explored ways to meet compliance requirements within budget while also taking into account recruitment challenges of registered nurses The results summarised in table 4 below indicate that across 24 wards WTE HCAs would be deployed in place of 8.16WTE registered nurses with a view to address the current issues around attracting registered nurses at the right level. Increases where needed in particular wards will be offset with decreases in other wards within divisions (for example Surgery and CTC review resulted in a WTE reduction while the highest increase is WTE HCAS was across Medicine). Table 4 Draft Nursing Skill Mix Review Division Staff Group Pay Band Current model Future Model WTE Change Registered Nursing and Midwifery Medicine Band Surgery CTC Band 5/ Additional Clinical Services(HCAS) Band 2/ Registered Nursing and Midwifery Band Band 5/ Additional Clinical Services(HCAS) Band 2/ Registered Nursing and Midwifery Band Band 5/ Additional Clinical Services(HCAS) Band 2/ Total These changes will provide direct savings through a reduction on bank and agency spend on hard to fill Band 5/6 and 7 nursing roles. The WTE changes have been factored into the establishment model in (section 7.2.3). 7 The full report which includes a detailed breakdown of establishment changes at ward level is available in the full Nursing Skill Mix Review Paper (November 2015). 8 Medicine: E.Cavell, F.Nightingale, ARCU, M. Warren, Pasteur, HASU, Lister, Kingswood, Osler, L.Cosins, W.Harvey, BCH and Frailty Wards Surgery: Bulphan, Linford, Burstead, Horndon, Elsdon, SRU Wards CTC : James Mackensie, Chelmer, Roding, AMU East, AMU west Wards 19

20 6.2.2 Nursing - Improving Retention by Development and Training of HCAS and Nurses We are developing Surgical Nurse Practitioner roles for nurses in line with business cases, in specialties such as Surgery and CTC. Training for these roles is available locally at ARU and is for two academic years. This will be an ongoing approach and will reduce pressure on the medical workforce A clear career framework is under development for the nursing workforce, following the skill mix review, to attract new staff and retain those in post. This is expected to be rolled out in summer The Trust has committed to supporting a consistent access across all divisions to Practice Education Facilitators to support nursing staff in practice. This will include those on the preceptorship programme, return to practice, and those working towards the Care Certificate A review of a Senior Staff Nurse position (Mid way Band 5 (5.5)) has been explored to identify if this will retain and encourage experienced staff to stay with the trust. This being trialled in Medicine and Acute and will be rolled out by September Advanced nurse practitioners will also be introduced with a view to increase efficiencies. Band 6 Sisters/Charge nurses will undergo development programmes to provide skills to deputise for senior sisters and to aid in succession planning A framework for clinical supervision has been designed in line with revalidation plans over the next 3 years (minimum of 3 occasions planned per year to meet with designated supervisors to reflect on professional and clinical issues and to provide support) Some specific career development plans for nurses have started in divisions and are to be progressed further in 2016/17. For example, in the Emergency Care department (ED) a rotation between ED & Acute Medicine has already been introduced. These posts will allow newly registered nurses who may not have had enough experience to start working in ED to spend six months initially in Acute Medicine whilst they decide what they want to specialise in. Further such changes will be explored across the entire nursing workforce in 2016 to improve skill mix and help retain staff Staff rotations within our clinical services and other external rotations between Trusts in our geographical patch are currently in development to upskill our nursing workforce and exposes them to a broad range of disciplines that will improve their careers Medical Role re-design There is a proposed piece of work (following the Derby model) around the middle grade doctor role. The Derby model makes the posts attractive for substantive recruitment by offering a local training programme towards consultant grades. Scoping is at an early stage with discussions with the Royal Derby Hospital to understand their model and pick learning points that can be introduced at BTUH in the autumn of There are additional plans around the introduction of a new medical post above FY2 level to be called Junior Clinical Fellow (FY3) by the autumn of This will encourage more doctors into these roles on a substantive basis instead of relying on middle grade doctors which are hard to recruit E-job planning was introduced in 2015 to increase transparency and monitoring of job plans and to improve the quality of data captured around activity. Further reviews around consultant job 20

21 plans will be undertaken in line with recommendations from the demand and capacity analysis to accommodate increased demand and activity across clinics. This is expected to provide savings by eliminating the need to increase establishment in certain service areas where growth is expected Workflow Coordinators will be introduced in difficult to recruit areas in A&E in 2016 where it is estimated that 60% of junior doctors work is carried out by less expensive clerical staff. This is estimated to make about 50% savings on locum costs for these posts. Assistant Practitioner posts will also be introduced in surgical services to support the planned reduction in junior doctors over the next 3 years The nursing directorate is planning towards the introduction of nurse practitioner roles in areas where there is shortage of specialty doctors in 2016/17. This will reduce the need for middle grade posts in those areas, reduce vacancy issues and ultimately reduce high locum costs Scientific, Therapeutic and Technical Staff We will aim to use more support staff within all professional groups as a resort to reducing reliance on professional staff who are harder to recruit and expensive to engage on bank/agency. For example, in Surgical Services, the use of Anaesthetic Care practitioners is to be explored in place of Anaesthetic fellows as they are easier to recruit and less expensive. In CTC Associate Practitioner posts are being deployed at band 4 level to support the hard to recruit band 6 Cardiac Physiology posts For hard to recruit scientific, therapeutic and technical professions we will be offering pre registration placements with the aim of recruiting them as newly qualified staff in future and deploy means to train our own staff and use a range of recruitment and retention initiatives to progressively reduce the levels of vacancies and deliver a sustainable service Administrative and Clerical and other support staff The use of digital dictation has been scoped and implemented in some areas. While this has not been as successful as planned it is currently in use for all radiology reporting. It is expected that the implementation of digital dictation will be revamped over the next 3 years with the aim of making some savings in the administrative workforce in areas such as clinical haematology. 6.3 Reducing Temporary Staffing Spend The target for temporary staffing spend reduction in 2016/17 is 2million. Corporate initiatives to retain staff will support the reduction in temporary staffing spend however specific initiatives are required for different staff groups in addition to increasing recruitment and in some cases restricting the use of temporary staffing to cover annual leave and sickness absence. The national lack of particular specialty doctors and other health care professionals may require overseas recruitment in these areas. 9 AHPs, Professional and Technical Staff, Health Care Scientists 21

22 6.3.1 Nursing Workforce The temporary staffing spend reduction from the nursing workforce will be achieved through various separate initiatives One work stream will look at improving business as usual recruitment under the Bohmer Project to reduce time to hire from vacancy approval to employment checks completed on successful applicants from 120 to 85 days. Shortening the time it takes to hire a permanent employee will reduce the length of time an agency person will be required to cover a vacancy and therefore reduce the temporary staffing spend The second work stream will focus on overseas recruitment of nurses into substantive posts therefore reducing the use of temporary staff, particularly agency staff and the associated costs Due to the high vacancy levels within the qualified nursing staff group, a project has been scoped specifically targeting the Band 5 nursing workforce to achieve a reduction in the general ward base agency spend. This forms a third work stream and requires a diagnostic to be run on the two highest temporary staffing spending wards (Edith Cavell and Linford Wards) to drill down, assess and identify a targeted approach to reduce temporary staffing spend in these wards. Actions identified could include better rostering options, vacancy filling, ward manager/matron role redesign or combinations of these as appropriate. While this diagnostic is expected to be completed by the beginning of April 2016, any interventions will take up to six months to realise benefits. This will be part of a rolling programme of diagnostic assessment and planned interventions for all of the general ward areas to meet the target reduction in spend We will also increase our use of HCAs to support ward areas using band 5 vacancies in order to reduce our use and costs of agency nurses. This will be done on a case by case basis to ensure that the quality care is not compromised by a change in skill mix Doctor s vacancy reduction leading to reduction in locum spend The Medical and Dental Workforce currently has a vacancy rate of 8.9% with locum spend at an average of 400K a month. Overseas recruitment (from Dubai) was commenced in 2015 to recruit 12 new non-consultant grade posts. Though start dates have now shifted to the spring and summer of 2016 due to difficulties of doctors passing the new IELTS test, this is estimated to provide savings by reducing locum spend by 1.5M a year. However there is anticipated risk that these doctors will not join the Trust The difficulties experienced with the Dubai recruitment drive and delayed start dates indicate that alternative recruitment methods are needed to reduce reliance on locum staff. New considerations are being made around an in-house approach to recruitment from EU countries. This will save on 3 rd party agency recruitment fees of 8000 plus VAT per placement, however should this be unsuccessful, the Trust may need to seek support from permanent recruitment agencies to fill these posts. 22

23 6.3.3 Contractors and Agency Staff The organisation currently has a number of contractors filling vacant posts with some undertaking specific time restricted projects. Contractors tend to be an expensive alternative to permanent recruitment. Replacing contractors with permanent employees will reduce the temporary staffing spend and contribute to our 2m target. The executive team robustly monitors all contractor spend on a monthly basis, both below and above price caps. The relevant managers are required to explore alternative options and exit strategies including permanent recruitment and skill mix considerations. For hard to fill posts new approaches may be required instead of standard recruitment, including the support of permanent recruitment agencies In addition, the Trust has documented and robust procedures in place for the booking of all agency staff. Any agency staff request for more than two weeks needs to go through an Executive vacancy control panel and for ad-hoc bookings this requires Executive sign-off. 6.4 Apprenticeship programmes and growing our own The government s apprenticeship levy seeks, from 2017, to raise 3bn a year to fund apprenticeships across the UK. The levy will come into effect in April 2017, and will be payable by employers at 0.5 per cent of their pay bill. All employers will receive an allowance of 15,000 to offset against the levy, which means the levy will only be payable on a pay bill in excess of 3 million per annum At BTUH, we are already using apprenticeship schemes to grow our own skill needs across the Trust and develop our staff while filling gaps within our workforce in a cost effective and affordable way. The Trust met its apprenticeship target of 70 for 2015/16 across various clinical work areas including HCAs and other corporate areas like telecommunications, business administration and HR. There are discussions to offer perioperative apprenticeships within some theatre/day units. More specifically the Nursing directorate is working towards the introduction of nurse associate roles at band 4 via the apprenticeship route in 2016/ It is expected that the HEE provision of 70 for 2015/16 will carry through into the next 3 years. Going forward into 2016 and beyond, apprenticeship and other development programs will be promoted across all work areas with numbers expected to be reach 70 year on year. 6.5 Reducing the cost of sickness absence Managing Absence Managing sickness absence more rigorously while increasing our occupational health and wellbeing support to staff is expected to reduce our sickness absence and proportionally reduce related costs. With an average cost of sickness over 12 months at 4.3m, it is expected that a reduction in absence rates should directly reduce the effect on the pay bill. Scenarios on possible savings that could be achieved based on targets of 3.5% to 3.8% (higher absence targets during the winter months) are depicted in table 5. 23