Medical Workforce Performance & Modernisation Report

Transcription

1 Aneurin Bevan Health Board th Wednesday 27 July 2011 Agenda Item: 6.1 Medical Workforce Performance & Modernisation Report 1. INTRODUCTION This report summarises activity and progress relating to the medical workforce agenda during 2010/11, and sets out the priority work plan for the next year to support the development of an efficient, effective and sustainable medical workforce to meet the objectives set out in the Annual Plan, 5 year framework, AQF and Clinical Futures. Key areas of focus for the Board to consider are: Medical Workforce Establishment Variable pay reduction Job Planning Clinical Leadership NCN and GPs Revalidation An overview of the key priorities within the 2011/12 work plan is provided in Appendix 1 (there are additional operational areas not shown). Where possible the report provides a level of benchmarking to compare Aneurin Bevan Health Board with NHS Wales. The Board is asked to consider and note the contents of this report. Financial Assessment and link to Financial Recovery Plan Risk Assessment Annual Quality Framework This paper details a range of work streams to further improve medical workforce management, enhance productivity and efficiency and assist in the achievement of the Health Board s financial plans. Risks associated with challenges: Projected deficit in available `doctors in training Capacity to deliver service reconfiguration Workforce Workforce redesign, including productivity and efficiency Investment in staff 1

2 Engagement of the workforce, clinical leadership and empowerment of frontline staff Focus on the development of intelligence and information related to the workforce to support more effective deployment of staff Standards for Health Services Wales Equality Impact Assessment Standard 7 Safe and Clinically Effective Care Standard 24 Workforce Planning Standard 25 - Workforce Recruitment and Employment Practices Standard 26 Workforce Training and OD The review and modernisation of the employment policy framework applicable to medical staff will be equality impact assessed. 2. CORE WORKFORCE The Health Board s medical workforce accounts for 10% of the overall workforce (heads), medical staff costs amounting to c 95m (22% of overall costs). The medical workforce within the HB has grown over the past ten years, in line with the rest of NHS Wales. The number of hospital medical & dental staff employed by Aneurin Bevan increased by 24% between , while the amount of money spent on this workforce increased by 78% during the same period. This compares to all-wales staffing growth of 27% and spending growth of 69%. (sourced NLIAH Workforce Planning Data 10/2010). Despite this, the most recent data published by NLIAH/WG (Sept 10), indicates that the HB still has a low ratio of medical consultants to its population when compared to other Health Boards (Table 1). Since 19 th April 2010, the Health Board has recruited 53 consultants of which 23 were new posts, the remainder to replace existing post holders with a review of job plans to ensure optimal alignment to service need. The Health Board currently has 8 consultant posts in the pre-recruitment stages, two of which are replacements. All vacancies are scrutinised against core demand and capacity planning, the medical establishment also needing to support the introduction of extended working days for consultant level staff and a the shift from consultant-led to consultant-delivered services. 2

3 Table 1 Senior Medical & Dental Staff Welsh comparison Health Board Population k Associate per 1000 Specialist popn Consultant per 1000 popn Junior Doctor per 1000 popn Specialty Doctor per 1000 popn Staff per 1000 Grade popn SAS total per 1000 popn Doctors total per 1000 popn Consultant :SAS ratio Abertawe Bro Morgannwg University LHB Aneurin Bevan LHB Betsi Cadwaladr University LHB Cardiff & Vale University LHB Cwm Taf LHB Hywel Dda LHB NHS Wales Previous investment within workforce and capital across England in response to the orthopaedic and A&E performance targets resulted in a consultant expansion programme which, in some areas of the service, has impacted on the ability of NHS Wales to recruit to medical posts. Despite this the Health Board has a good record within Wales of attracting applicants for both substantive and training posts. Table 1 details how the medical workforce in Aneurin Bevan benchmarks with the rest of Wales and indicates some potential to expand the Staff Grade and Associate Specialist (SAS) workforce. 3. VARIABLE PAY As part of Divisional and HB wide service reviews, core staffing levels are being reviewed in relation to existing and planned activity and demand. Core staffing levels need to ensure sufficient flexibility to deal with normal fluctuations in demand as well as annual leave, study & professional leave and maternity leave. Clarity of core establishment will then provide a clear focus on areas of variable pay which need to be addressed. The `High Value Opportunities Financial Implementation Programme 2011/12 has established the Workforce Management Enabling Programme which will support and drive the delivery of workforce efficiencies and effectiveness in two key focussed areas, one of which is to achieve a reduction in variable pay and delivery of intelligent workforce targets where appropriate. Variable pay for medical staff consists of the following elements:- Locum & Agency Additional hours/sessions Waiting List Initiative payments On-call payments and intensity supplements Junior Doctors Banding supplements 3

4 Locum/Agency During 2010/11, a 2m savings target was established against a reduction in overall spend on temporary medical staff. The project approach was based on 4 main areas: Controls Assurance Cost Containment Cost Reduction Improved Rota Management and alternative ways of working The introduction of and compliance with the renewed process and procedures for the approval of agency staff ensured a significant reduction in agency usage and associated spend. Weekly monitoring is undertaken by the Medical Workforce Modernisation Team in close liaison with Directorates/specialties to understand and further target opportunities for less spend. Medical Agency expenditure In 2009/ m In 2010/ m In year Reduction 1.88m The Health Board s ability to maintain service delivery across its two major hospitals requires adequate levels of medical staff to operate its 56 rosters. For certain specialties, the shortage of doctors in training during 2010/11 (recruited and allocated to the Health Board via the Deanery), coupled with the restrictive hours to ensure EWTD compliance, has seen the need to recruit temporary locum and agency medical staff in order to maintain safe staffing levels and minimise disruption to the service. Whilst increased controls and scrutiny during 2010/11 had reduced expenditure within this area of variable pay, the challenge to maintain the existing number of specialty rotas will continue to grow. Service reconfiguration and consideration of single site provision for key specialties, plans currently being developed via the Clinical Futures Programme Board, will aim to reduce the number of medical rotas required and support a more sustainable staffing model. In the interim, it is imperative that the Health Board continually reviews its rota management, roster effectiveness and seeks to further embed Night multi-professional team working (please refer to Section 5). To optimise the deployment of the medical workforce, resource plans have been developed to roll out and realise the benefits of the recently procured e-workforce Management/Rostering system across the HB 4

5 over the next two years. It is worth noting that ABHB is the only Health Board in Wales to include doctors as part of a Health Board wide rostering system. To maintain the appropriate levels of permanent staff it is clearly important to maintain the HB position as an employer of choice (see Section 6 Recruitment and Retention ). Additional Hours/Sessions The Consultant Contract assumes a core whole time contract of 10 sessions. Sessions over and above this constitute `additional capacity. While a reduction to 10 session working has been used in some areas (for instance, paediatrics) to support expansion in consultant numbers, it may not make economic sense to reduce consultants to a 10 session job plan where this would require additional consultants to be appointed with on-costs, notably sessions of supporting professional activity (SPA). The normal basis on which additional sessions are offered is plain time rates. Planned additional sessions over and above 10 are the preferred means of increasing capacity on a regular basis, rather than ad hoc temporary arrangements. A consultant may choose to accept such an offer. Where it is determined that a different rate is necessary to be offered for unplanned additional sessions (and this will only be considered for additional Direct Clinical Care activities and when undertaken in otherwise uncontracted time), then such sessions will be paid at no more than the waiting list initiative (WLI) rate. Waiting List Initiative payments As described above, Waiting List Initiative (WLI) payments are an accepted means for the Health Board to flex capacity to meet surges in demand and additional activity. Provision is made for such payments within the Consultant Contract. Use of this type of payment must be set against a backdrop of robust capacity planning and maximising the existing benefits of the Consultant Contract, in particular improving existing levels of productivity and efficiency through the job planning review process. 4. JOB PLANNING Overview Effective job planning is a key mechanism to support delivery of the HB s objectives. Although effective job planning can deliver some cost savings, the main benefits to the organisation of effective job planning are in optimising the contribution of the consultant workforce to key deliverables such as A&E patient-transit times, length of stay/flow, Referral to Treatment/access, etc, with a minimisation of the need for 5

6 extra capacity through variable pay. It is therefore imperative that the discussions are driven through the Divisional clinical structures. The Health Board, during Autumn 2010, identified the need to review the job planning performance framework as a key workstream within the wider targeted Medical Workforce & OD programme of work. A number of objectives were agreed between the Medical Director and Director of Workforce & OD and the Health Board s internal review was assisted by the Wales Audit Office audit on the benefits realisation of the contract. The audit had a particular (but not exclusive) focus on the extent to which job planning was embedded in the Health Board as an annual process and how effective it was in facilitating service improvement. It found that:- with the exception of a few specialties, the Health Board is not using job planning as an effective tool to support service planning and modernisation; As a result of the Health Board and WAO reviews, and following a period of consultation, the Health Board launched its revised Consultant Job Planning Protocol & Guidance in March 11. The protocol and guidance are attached to this report. In respect of job plans in excess of 10 sessions, the points made at para 3.2 apply, although the Health Board is mindful of the Welsh Government expectations around the contract. In particular WG have recently reinforced the typical 7 DCC (Direct Clinical Care) / 3 SPA (Supporting Professional Activity) split within the overall job plan. Table 2 - Health Board average sessions Health Board/Trust DCC SPA Other Management Total ABM Cardiff & Vale Cwm Taf Aneurin Bevan Hywel Dda BCU Central & East BCU West PHW Powys Velindre Wales Average

7 Since the audit was undertaken, completion of the 2010/11 job plan reviews undertaken across the Health Board reveals a further reduction in the average total consultant sessions, included within this is evidence of the Health Board s commitment to reducing job plans previously exhibiting a higher than average number of Supporting Professional Activity (SPA) sessions. (see Table 3 below) Monitoring of SPA activities is a priority for the next round of job planning, with the revised guidance and process providing a template for structuring SPAs to ensure clear objectives, outcome measures and that timescales are agreed to deliver service improvement and development. TABLE 3 - Change in average sessions 2007/08 to 2009/10 to 2010/11 for Aneurin Bevan Health Board DCC SPA Other Management Total 2007/08 Gwent Healthcare /09 Gwent Healthcare /10 Aneurin Bevan / Aneurin Bevan Source ABHB and Assembly Government Awareness Training The Welsh Audit office acknowledged that turning this guidance into practice is the real challenge facing the Health Board. In response, the Head of Workforce Development together with the Assistant Medical Director, have developed a programme of training currently being rolled out to Divisional Management Teams. It is accepted that divisions need to acquire an increased understanding of the purpose and key components of effective job planning in order to maximise the benefits, whilst performance managing agreed objectives and activity linked to measurable outcomes. This first stage of training will conclude on 2 nd September, followed by a series of multi-site seminars with key speakers from within the HB, the BMA and Welsh Government. 7

8 Consultant Contract Database A consultant contract database has been established to monitor and track job plan reviews and outcomes, currently being further developed to include appraisals and personal development plan (PDP) information to support GMC revalidation, this work to be concluded by 31 st August 11. The Roster System will also enable medical workforce information to be used more intelligently to help the Health Board better understand how the medical workforce is utilised, and whether it is delivering value for money, rollout to commence in the Family Services Division during Quarter /12. This database will be further updated as 2011/12 job planning is rolled out across the Health Board. Targeted activity has been agreed and whilst all Divisions have either commenced or in a preparatory stage, the following timetable has been agreed to achieve conclusion:- Family & Therapy Services 30 th June 11 Mental Health & LD Services 30 th September 11 Scheduled Care Services 30 th November 11 Unscheduled Care Services 30 th November 11 Verification & Payroll Reconciliation The Workforce and OD Division will provide summary reports within three weeks of each Division concluding the job plan reviews, the reports presented to each Divisional Director and General Manager to ensure regular scrutiny of job planning outcomes and harmony with the payroll. This reconciliation exercise will provide a further step to ensure that the necessary HR/Payroll administration has been undertaken to eliminate under/overpayments. 5. NIGHT (H@N) H@N is a change programme that uses a multi-professional approach to delivering care. The model proposes that the way to achieve effective clinical care is to have one or more multi-professional teams, who between then have the full range of skills and competencies to meet the immediate needs of the patients. It typically involves changing the staff mix at night by developing a team, usually of highly skilled advanced nurse practitioners, and reducing the reliance on doctors in training. Additionally, there is a requirement to review traditional rotas and consider opportunities for shift systems with cross cover of appropriate specialties. 8

9 The Project Board has established multi-professional, multidisciplinary Task & Finish Groups to develop and further embed integrated working arrangements at the Royal Gwent and Nevill Hall Hospitals. The work commissioned by the Project Board is reviewing and developing the key elements underpinning the model, namely:- Clinical Leadership Handover & communication Infrastructure Clinical Risk & Governance Training & Education Clinical Audit Whole Systems Working The development of fuller staffing arrangements is a vital component of the Health Board s overarching workforce development programme, fundamental to the delivery of Clinical Futures and sustainable staffing arrangements and operation within the enhanced local general hospitals, with remote in-reach support and expert advice available from the Specialist Critical Care Centre. Furthermore, it is a major element of the Health Board s continued work to sustain EWTD compliance for junior doctors. The H@N Project Board reports to the Clinical Futures Programme Board and will be publishing the H@N project plan by 31 st July RECRUITMENT & RETENTION All Wales recruitment statistics show that ABHB remains an `employer of choice. This is also demonstrated by the below average vacancy factor which has not risen above 5.5% and at its lowest, has achieved less than 3%. Workforce & OD continues to work closely with the service to maximise the opportunities available via the International Fellowship Scheme (MTI) to secure experienced medical staff from reputable non-eu teaching hospitals, already seeing the appointments of three such deanery sponsored appointments within Obstetrics & Gynaecology and Neonatology. Similar initiatives are being progressed with Accident & Emergency, Anaesthetics and General Surgery. This year and the next 3 4 years present significant challenges with a projected decrease in training posts and available junior doctors. Key specialties experiencing recruitment difficulties including Core Surgical 9

10 (*) and Medical Training, Paediatrics, Core Medical Training, Core Psychiatry Training, Anaesthetics and GP Registrar trainees (**). (*) The Deanery plans to reduce the number of Core Surgical posts in Wales (from 157 to 90)and increasing F2 posts as part of efforts to address these recruitment shortages by offering better progression (**) Deanery report (March 10) outlining an annual shortfall of circa 36 GP Vocational Trainees in Wales until at least 2012, and within 3 years of the report date that the likely shortfall estimated to be circa 100 (of the usual 408) GP specialty registrars employed in Welsh hospitals and General Practices in Wales. As acknowledged by the Welsh Audit Office, in general, consultant recruitment and retention at Aneurin Bevan is seen as positive. Despite having two very busy hospitals, the Health Board continues to be seen to be offering a positive working environment. A`New Consultant Induction Programme is planned for September 11, the event linked to a Continuing Professional Development syllabus provided by the Health Board throughout the year. 7. ENGAGEMENT OF PRIMARY CARE The recent appointment of the NCN GP Leads represents a major opportunity for the Health Board to engage both GPs and their patients in a proactive and positive relationship. It is vital that the newly established NCN leads are supported by a programme of OD to develop their local Network Communities as well as the wider NCN community. This programme of work will need to be mirrored within the Health Board to ensure and open, equal and balanced relationship between all parties. As a first step NLIAH have been asked how they might help the HB to develop such a programme. In addition the HB will be seeking to establish links with a range of GP surgeries to discuss and develop actions to address the issues raised in the recent GP 1000 Lives Culture survey relating to relationships with the HB. 8. CLINICAL LEADERSHIP The Health Board Annual Plan 2011/12 and the Organisational Development (OD) Strategy stress that effective clinical leadership at all levels and sectors of the organisation is vital to the delivery of safe and effective health services. This is reflected in the current 10

11 organisational structure and will be further strengthened through the establishment of Neighbourhood Care Networks. The Health Board s clinical leadership model is seen as an important stepping stone in improving clinical engagement in service modernisation. Whist a range of Leadership & Management Development programmes have been available to support clinical leadership, it has been recognised that an intervention tailored specifically to the needs of medical colleagues is required. In response to this a four-day bespoke clinical leadership programme aimed initially at Clinical Directors has been developed and will commence in September This reflects the requirements outlined in the Medical Leadership Competencies Framework (MLCF NHS Institute for Innovation & Improvement (July 2010) The Health Board is establishing a Clinical Forum, comprising the Locality Clinical Directors and Neighbourhood Network Clinical Leads, together with the secondary care Clinical and Divisional Directors. This will meet quarterly from Autumn 2011 to develop an integrated approach to healthcare planning and delivery. 9. GMC REVALIDATION Revalidation is the process by which licensed doctors will, in future, regularly demonstrate to the GMC that they are up to date and fit to practise. In doing so it aims to deliver further assurance to patients about the doctors who treat them. Revalidation is expected to begin in late The Welsh Government has tasked each Health Board with a completion of an electronic `self assessment tool to be submitted by 31 st August 2011, designed to assess the readiness for revalidation of Designated Bodies in Wales. Revalidation is reliant on the outputs from a number of local processes including medical appraisal. Outside of process, the Health Board has trained in excess of 50 consultants as accredited appraisers. 11

12 10. RECOMMENDATIONS The Board is asked to note the contents of this report. Sponsored by: Prepared by: Anne Phillimore, Director of Workforce & OD Grant Robinson, Medical Director Andy Jones, Head of Workforce Development (Medical) 13 th July

13 ANEURIN BEVAN HEALTH BOARD TARGETED MEDICAL WORKFORCE & OD PROGRAMME Appendix 1 OBJECTIVES ACTION REQUIRED BY RESPONSIBILITY STATUS 1. REVIEW OF JOB PLANNING, PRODUCTIVITY & VARIANCE Develop & publish revised job planning guidance & process to support effective job planning GR/AP Delivered Develop and rollout awareness training to divisional clinicians and managers responsible for effective job planning GR/AP In delivery Examination and review of SPA sessions linked to the consultant appraisal to ensure output driven activity linked to CPD, clinical effectiveness, quality, service improvement/development, education and management time, aligned to the requirements of the Annual Plan, 5-Year framework & AQF Divisional Directors Schedule of Job Plan Reviews commenced, activity being monitored centrally To undertake a review of consultant job plans exceeding 12 sessions and work collaboratively with the Divisional Directors and Clinical Directors to develop a plan to reduce these sessional commitments. o Monitoring activity and quality of job plan reviews undertaken across the Divisions, scheduled activity and completions dates agreed:- - Family & Therapy Services - Mental Health & LD Services - Scheduled Care Services - Unscheduled Care Services GP/AP/Divisional Directors AP Divisional commitment via the job plan reviews currently being performed 2010/11 job planning reviews across all Divisions commenced during first quarter. ANJ/AP/GRt Programme 2011/12 April 11 13

14 ANEURIN BEVAN HEALTH BOARD TARGETED MEDICAL WORKFORCE & OD PROGRAMME OBJECTIVES ACTION REQUIRED BY RESPONSIBILITY STATUS REVIEW OF JOB PLANNING CONT D Consultant Contract Database updated to include appraisal activity AP Near completion 2. LEAD EMPLOYER ALL WALES GPVTS Scope and lead the development of an Outline Business Case (OBC) for ABHB which clearly defines a model of delivery and resource plan to enable the Health Board to act as the `LEAD employer for all GP Vocational Trainee Registrars across NHS Wales, providing a recruitment, payroll and medical HR advisory service via a shared service model. o Initial Action plan identifying resources, indicative costs & stakeholder engagement (inc. harmonisation of policies and workforce governance risks) o Completion of feasibility study (Noted that comparable models operating across English regions driven and funded by the respective Deaneries; resource implications to establish Lead Employer arrangements and robust SLAs to govern risk and ensure Health Boards & GP Training Practices are compliant with Standard Operating Procedures/ adherence to robust employment policies; options presented including each Health Board operating integrated Lead Employer arrangements on a local level to ensure GP Trainees receive high standards of employment practice coupled with structured education & professional development AP AP Options for delivery presented to Workforce & OD Director for NHS Wales; Advised to present findings of the feasibility study to all-wales Workforce & OD Directors (July) to ensure wider engagement with Health Boards, prior to discussions with Deanery ANJ/AP/GRt Programme 2011/12 April 11 14

15 OBJECTIVES ACTION REQUIRED BY RESPONSIBILITY STATUS 3. NIGHT Establish a H@N Project Board to govern and provide support to the development of fuller site-based H@N multiprofessional team working GR Established Establish `Task & Finish Group meetings at RGH & NHH, commissioned by the Project Board to review and develop the key elements underpinning the H@N model: GR General Managers / Divisional Directors Commenced o o o o o o o Clinical leadership Handover & Communication Infrastructure Clinical Risk & Governance Training & Education Clinical Audit Whole Systems Working Meetings held monthly Produce a project plan and risk register to oversee the work programme, key actions and milestones GR/AP On target for delivery ANJ/AP/GRt Programme 2011/12 April 11 15

16 ANEURIN BEVAN HEALTH BOARD TARGETED MEDICAL WORKFORCE & OD PROGRAMME OBJECTIVES ACTION REQUIRED BY RESPONSIBILITY STATUS 4. REVIEW AND ENSURE PERFORMANCE MANAGEMENT SYSTEMS ARE ESTABLISHED TO REVIEW LOCUM/AGENCY USAGE & EXPENDITURE ACROSS ALL GRADES OF MEDICAL STAFF Weekly process of monitoring and tracking of locum & agency usage/expenditure established by the Workforce & OD Division; highlight reports provided to the Formal Executive Team; Already established AP Workforce Performance data currently being further developed to support divisional performance management Continued liaison with directorates/specialties, to understand and further target opportunities for less spend. Continuation GR/AP Undertake audit of locum & agency approvals and compliance with the `escalation & authorisation process AP//GR/Audit TBA Review employment policies to strengthen medical workforce management in relation to management of planned absence, sickness absence management AP Delivery Undertake a review of existing medical establishments and rota management across Acute Medicine AP/Divisional Directors Initial Review undertaken with SpR in Medicine ANJ/AP/GRt Programme 2011/12 April 11 16

17 ANEURIN BEVAN HEALTH BOARD TARGETED MEDICAL WORKFORCE & OD PROGRAMME OBJECTIVES ACTION REQUIRED BY RESPONSIBILITY STATUS 5. ESTABLISH A CLINICAL FORUM Establish a Clinical Forum comprising the Locality Clinical Directors, Neighbourhood Care Network GP Leads together with secondary care Clinician & Divisional Directors (Planning & Development of forum) GR/AP 30 th Sept GMC REVALIDATION On-going The Health Board is required to demonstrate to the Welsh Government (Health) its organisational readiness to deliver timely and quality consultant appraisals for Revalidation. Complete the "Organisational Readiness & Self Assessment" tool and within this undertake a baseline assessment of appraisal activity across the organisation for submission to Welsh Government Develop policy framework on consultant appraisal GR/AP GR/AP Assessment underway and action plan being developed. Clear indication of an all- Wales approach regards policy framework and IT infrastructure ANJ/AP/GRt Programme 2011/12 April 11 17

18 ANEURIN BEVAN HEALTH BOARD TARGETED MEDICAL WORKFORCE & OD PROGRAMME OBJECTIVES ACTION REQUIRED BY RESPONSIBILITY STATUS 7. CLINICAL LEADERSHIP Deliver 4-day `bespoke clinical leadership programme aimed initially at Clinical Directors within secondary care and Localities. Commencement Sept 11 AP/GR Completion of programme for all Clinical Leaders by INDUCTION PROGRAMME NEW CONSULTANTS Deliver a 1-day event to introduce newly appointed consultants and GP Leads to the HB. This event intended to run twice yearly and will link with the overall CPD programme which runs through the year. Sept 11 (Exact date TBC) GR/AP Induction content & agenda agreed. ANJ/AP/GRt Programme 2011/12 April 11 18

19 Appendix 2 19