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Nursing & Midwifery: Workload & Workforce: Planning Project

chapter 4. Results

In total, 102 completed questionnaires were returned - a response rate of 100% of valid questionnaires ( see footnote 9). Some of the original returns, however, were incomplete and revised questionnaires were subsequently resubmitted. In some cases, complete responses were not received for all questions, and this is reported in individual sections.

Results are discussed in relation to the areas for which questionnaires were developed:

• adult acute care (18 returned)

• paediatrics (17)

• maternity (19)

• psychiatry (17)

• primary care Part A - community hospitals and treatment centres (14)

• primary care Part B - community teams (17).

Large amounts of data were generated, and these appear in full in the enclosed CD-ROM. This section of the report concentrates on key topics which were consistent across all areas.

1. Adult acute care

Of the 18 questionnaires issued to acute Trusts/organisations, 18 were returned completed.

Nursing workload and workforce planning systems

Most familiar tools
'Based on Historical Budgets', 'Nurse per Occupied Bed', 'National Recommendations' and 'Telford or similar' were the tools with which respondents were most familiar.

Tools currently used
Within general medicine, general surgery, medicine of older people, accident and emergency and outpatients, the most-commonly reported nursing workforce planning system was 'Based on Historical Budgets'. This was followed by 'Telford' and 'Nurse per Occupied Bed' in in-patient areas. 'National Recommendations' were the most-commonly used systems for intensive care and high dependency units (ITU/HDU) and theatres/recovery units.

In relation to the numbers of tools used by Trusts/organisations per specialty, two reported no tools used across all specialties and the remainder 0-3 per specialty (these excluded 'Based on Historical Budgets').

First most-commonly used tools (excluding 'Based on Historical Budgets')
Respondents were asked to describe the first most-commonly used tool, but not to include 'Based on Historical Budgets'.

Thirteen respondents identified the first most-commonly used tool within their organisations (Table 4.1).

Table 4.1 Adult acute care: first most-commonly used tool

There was a wide range of frequency of use (see CD-ROM for full details). Eleven respondents were able to provide details of total nursing numbers, but only six were able to reveal numbers of staff by clinical grade, and only three of the 13 systems described took account of student nurses. The majority of the systems were formally recognised by the relevant organisations, but no organisation reported that the recommendations of the nursing workforce planning system had been fully implemented. Resource issues, financial constraints and 'recommendations in the process of being implemented' were examples of reasons given for non-implementation.

The first most-commonly used nursing workforce planning systems were well understood by senior managers, charge nurses and clinical staff. Nine of the 13 tools were reported to provide details of a nursing establishment that met the needs of the clinical area. There was a split view, however, on whether the systems were resource intensive and whether all the required information was readily available.

Only seven Trusts/organisations reported having dedicated resources allocated to nursing workforce planning, amounting to just over 6.35 WTE, the majority of whom were categorised as 'workforce planners'. Senior managers, Directors of Nursing, charge nurses and clinical staff tended to use nursing workforce planning systems, with human resources and workforce planning staff less frequent users. Most Trusts reported that the Director of Nursing had accountability for the system. Respondents reported that the systems were used mainly to check current nursing establishments, to estimate new nursing requirements, and to review nursing establishments in the light of changes within clinical areas. Location of use is shown in Table 4.2.

Table 4.2 Adult acute care: location of use

'Planning for a Clinical Change' and 'Professional Recommendation from within Organisation' were the two main reasons cited for opting to use the first most-commonly used system. Six used it to plan a service change, but there was little evidence of integration with workforce planning for other staff groups.

Second most-commonly used tools (excluding 'Based on Historical Budgets')
Respondents were also asked to list the second most-commonly used tool (Table 4.3). Further details can be found on the CD-ROM.

Table 4.3 Adult acute care: second most-commonly used tool

When last used
All 18 Trusts/organisations who completed the questionnaire were asked when a nursing workload and workforce planning system had last been used. Eleven of the 18 had used one within the past year, but four had last used one more than two years ago and two did not know when one had last been used. Eleven indicated that they were considering introducing a new system in the near future.

Specialty areas
In addition to those systems listed on the questionnaire, respondents were also able to identify tools they believed to be effective in particular specialties, such as the National Recommendations for ITU/HDU, 'Criteria for Care' for general medical, general surgical and related specialties, and National Association of Theatre Nurses (NATN) guidance on perioperative staffing.

Most interested in using
The tools they were most interested in using were: 'National Recommendations'; 'Acuity Quality Method'; 'Telford or similar'; and 'Nurse per Occupied Bed'. The majority (13) were not interested in using 'Based on Historical Budgets' (Figure 4.1).

Figure 4.1 Adult acute care: most interested in using

Resources (including budgets and establishments)

All 18 Trusts/organisations described the process of setting the nursing budget for 2003-2004, with eight using a roll-over budget from the previous year plus 'uplifts', and five basing it on historical budgets or establishments (taking into account other factors such as pay inflation and service pressures). Four used a workforce review and one used what they described as a 'zero-based submission'.

Establishments are shown in Appendix 6.

Patient care characteristics

Quality of care/dependency scoring systems
Thirteen reported using quality of care measures (some using more than one), ¹² including:

• audit, incident reporting, complaints, and national standards such as NHS QIS and CNORIS

• In-House Tools

• Quality Pointers

• NATN guidance

• Monitor.

Six used the data generated from the quality measure to inform nursing workforce planning, and five of these respondents reported that this had influenced nursing skill mix.

Patient dependency scoring systems were used by 15 Trusts/organisations, with 11 rating patients at least daily (and four twice daily). Seven used the ratings to inform nursing workforce planning, with five using them 'sometimes'. The others used them to provide information on, for example, length of stay and costs, staffing shortages, daily staffing requirements and workload within clinical teams, and surgical audit.

Level 1 patients
All 18 Trusts/organisations reported having Level 1 patients ( see earlier) on a routine basis. Level 1 patients were cared for in most specialty areas but were most commonly found in general surgical and general medical areas.

Staffing requirements for Level 1 patients were calculated by a number of methods, the most common of which was to use a nurse to patient ratio of 1:1 or 1:2. Thirteen respondents expressed uncertainty or dissatisfaction with the system currently used to calculate nurse staffing for these patients.

Outreach teams from ITU existed in four organisations, although others were considering introducing this service. Outreach teams, usually consisting of nurses (two also had anaesthetist support), covered daytime hours either five or seven days a week, but were dependent on adequate ITU staffing levels.

Nursing and midwifery workforce characteristics

Protected time
Respondents were asked if there was any 'protected time' allowance ( see earlier) for charge nurses to be released from clinical numbers. Only two Trusts/organisations confirmed an allowance, but a further seven answered 'sometimes'. Descriptive comments on the nature of the protected time ranged from 'one day a month', through 'varies depending on workload', to 'time allocated for meetings and appraisals'. A large majority (14) supported 'one day a week' as the optimum minimum protected time allowance for charge nurses, with one other respondent proposing that half of their time be considered outwith clinical numbers.

Predictable absence allowance
The current predictable absence allowance ranged from 0-21.5%, with one organisation reporting '0%' ¹³ in parts of the organisation, and one unable to quantify. ¹⁴ Of the 17 Trusts/organisations who provided details of an allowance, 13 reported that it was fully funded, three partially funded ('eroded over time, funded in some areas only'; '7 of 21% funded'; '17 of 20% with major review currently under way'), and one provided no details of funding ( see footnote 13). There was strong support (14 respondents) for a predictable absence allowance greater than 21%.

Flexible working (including bank and agency use)
A number of flexible working practices were reported as being in use in the majority of Trusts/organisations, including shift swapping, part-time working, time off in lieu, self-rostering, flexible shift patterns and use of the bank (the first three being used in all Trusts/organisations). Flexible working practices most-commonly used 'routinely' (every week) were 'change duty roster', 'bank' and 'on-call'. The practice most-commonly used 'frequently' (most weeks in at least some areas) was 'overtime', while that most-commonly used 'occasionally' (every few months) was 'cancel work (if possible)'. 'Staff pool' was the practice which scored most under the 'never used' category.

When asked to indicate the top four measures they would prefer to employ, the weighted options cited were:

• 'internal transfer of staff from other area of organisation'

• 'change duty roster'

• 'extra basic hours'

• 'bank'.

The majority of Trusts/organisations (15) had access to a Trust/NHS Board Area General Bank and eight had access to Trust/NHS Board Specialist Banks covering, for example, intensive therapy, accident and emergency and theatres (six had access to both). Nine reported using a 'preferred provider' for the supply of agency staff.

Respondents were able to list a number of methods of reducing bank and agency spend (see CD-ROM).

Workload pressures
Respondents were asked to identify additional factors that create workload pressures for nurses and midwives. A wide range of responses relating to administration, management, clinical and education issues was given, and these are reported more fully on the CD-ROM. Examples include the amount of work created by the implementation of good practice guidelines such as those produced by NHS QIS (through the previous organisations now combined in NHS QIS - see footnote 3, page 17) and additional clinical governance-related activities.

Role expansion/new roles
Details were provided of initiatives implemented in response to reduction in junior doctors' hours, pay modernisation or changing workforce programmes. Initiatives described are listed on the CD-ROM. Examples include: 'night nurse practitioners', 'acute medical receiving triage nurse' and 'observational study to review time spent on extended roles'.

2. Paediatrics

Eighteen questionnaires were originally issued, but one organisation advised that it was not relevant to them. The remaining 17 were completed and returned, giving a 100% response rate.

Nursing workload and workforce planning systems

Most familiar tools
The most familiar tools were 'Based on Historical Budgets', 'National Recommendations', 'Nurse per Occupied Bed' and 'Telford or similar'.

Tools currently used
Within general medicine, general surgery, community children's nursing and other specialty areas, the most-commonly used system was 'Based on Historical Budgets', followed by 'National Recommendations'. In theatres, 'National Recommendations' was the most-commonly used, followed by 'Based on Historical Budgets'.

In relation to numbers of tools used by Trusts/organisations per specialty, four reported no tools used across all specialties, and 13 reported 0-4 across some of the specialties (excluding 'Based on Historical Budgets').

First most-commonly used tools (excluding 'Based on Historical Budgets')
Seven reported the most-commonly used tool (Table 4.4).

Table 4.4 Paediatrics: first most-commonly used tool

There was a wide range of frequency of use (see CD-ROM). All seven of the systems detailed under the 'first most-commonly used' were able to provide details of total nursing numbers, but only three could do so by clinical grade. Two took account of student nurses. The majority of systems were formally recognised by the relevant organisation and four reported that recommendations of the system had been fully implemented. Two of the remaining three cited 'still under review' and 'financial constraints' as reasons for non-implementation.

The first most-commonly used systems were well understood by senior paediatric nurses, senior managers and charge nurses. Five were reported to provide details of a nursing establishment which met the needs of the clinical area.

Only one of the seven Trusts/organisations who supplied details of a first most-commonly used tool reported having part of a WTE post dedicated to nursing workforce planning. All reported that senior managers were accountable for the tools, in conjunction with charge nurses, senior paediatric nurses and Directors of Nursing. The systems were used mainly by charge nurses, senior managers and senior paediatric nurses, and less by human resources staff. Systems were used mainly to review establishments in light of changes within clinical areas, to check current nursing establishments, and to estimate required new nursing establishments. Location of use is shown in Table 4.5.

Table 4.5 Paediatrics: location of use

'Planning for a clinical change', 'priority area' and 'professional recommendation from within the Trust /organisation' were the three main reasons cited for opting to use the first most-commonly used system. Five respondents provided details on the extent to which the system was integrated into other service planning initiatives within the Trust/organisation. These included being integral to paediatric service re-design and ensuring effective use of the nursing resource and staffing levels.

Second most-commonly used tools (excluding 'Based on Historical Budgets')
Only two respondents described a second most-commonly used system in their organisation - Criteria for Care and NATN for Theatres. Both were used to check current nursing establishments, to estimate new nursing requirements and to review nursing establishments in light of changes in the clinical area.

When last used
All of the 17 Trusts/organisations were asked when they last used a nursing workload and workforce planning system. Six had used one in the past year, four last used one more than two years ago, and six did not know when one was last used. Ten claimed to be considering introducing a system in the near future.

Specialty areas
The systems known to be effective in a particular specialty were varied and included the NATN guidelines for theatre staffing and national guidelines for paediatric intensive care units and school nursing.

Most interested in using
The tools respondents were most interested in using were 'National Recommendations', 'Acuity Quality Method', 'Nurse per Occupied Bed' and 'Telford or similar'. There was not one particular nursing workload and workforce planning tool which the respondents were 'not interested' in using (Figure 4.2).

Figure 4.2 Paediatrics: most interested in using

Resources (including budgets and establishments)

The process for setting the nursing budget for 2003-2004 was described by 16 of the Trusts/organisations, with nine employing 'roll-over budget from previous year plus uplifts' and five 'based on historical budgets plus other factors'.

Establishments are shown in Appendix 6.

Patient care characteristics

Quality of care/dependency scoring systems
Seven Trusts/organisations reported using quality of care measures, but eight provided details on the types of quality of care measures used ( see footnote 12). These included audits, incident reporting, complaints, CNORIS, patient satisfaction, and in-house tool.

No Trust/organisation reported using any of the quality rating scales listed on the questionnaire, but 'others' reported to be used included 'PA audit (adapted for paediatric use)', 'in-house audit tool' and 'asthma audit'. Only one reported using the data generated from the quality measures to inform nursing workload and workforce planning and to influence skill mix.

Nine of the 17 Trusts/organisations reported using patient dependency scoring systems. Three used data from the scoring system to inform nursing workload and workforce planning, with one using them for this purpose 'sometimes'.

Children who require 1:1 or 1:2 nursing care ¹⁵
Thirteen reported routinely having children who required 1:1 care within paediatric settings, but it appears there is no standard term for children requiring 1:1 care. Six of the 13 Trusts/organisations used the term 'special care' or 'specialed'; other terms included 'constant care' and 'complex needs children'.

Five of the 13 used 'Telford' or 'Professional Judgement' to determine the nurse staffing required for these children, while the others used a variety of systems.

Seven reported being 'satisfied' or 'very satisfied' with the system, and four reported being 'dissatisfied' or 'very dissatisfied'.

Seven Trusts/organisations reported routinely having children who required 1:2 care, but again, no standard term was used. Descriptions such as 'high dependency' and 'acute care' were found. Two of the seven used 'Based on Clinical Need' to determine the nurse staffing required for these children, with others using a variety of methods including 'Professional Judgement' and 'Patient Dependency Assessment'. Only two reported being 'satisfied' with their system (none was 'very satisfied'), and four were either 'dissatisfied' or 'very dissatisfied'.

No Trust/organisation reported having an outreach team from a paediatric intensive care unit, although mention was made of outreach teams from the mainland and the National Paediatric Retrieval Service, who deal with the transfer of sick children.

Nursing and midwifery workforce characteristics

Protected time
Six Trusts/organisations confirmed there was an allowance for charge nurses to be released from clinical numbers, while one claimed this was available 'sometimes'. Descriptions of the allowances included 'Partial supernumerary (meetings, training development of staff/appraisal etc.)', '100% supernumerary', and 'one day per week for office day and one day per month for clinical governance'. Strong support was expressed for a protected time allowance of one day per week, with 12 of the 17 Trusts/organisations choosing this option; two proposed a greater proportion.

Predictable absence allowance
The current predictable absence allowance ranged from 0-20% (only one organisation reported '0%' - see footnote 13, page 27), with one Trust/organisation unable to quantify (see footnote 14, page 27). Of the 15 who provided details of an allowance, all of whom reported 20% predictable absence allowance, 12 reported that it was fully funded and three partially funded ('eroded due to changes in complexity'; '17 of 20% with major review under way'; 'variable funded allowance average 12%'). Fourteen out of 16 supported more than 21%.

Flexible working (including bank and agency use)
Three flexible working practices were used in all 17 Trusts/organisations - shift swapping, part-time working and time off in lieu. Flexible shift patterns and bank were also commonly used. The practices least used included annualised hours, staff pool and zero hours contracts.

The practices most-commonly used 'routinely' (every week) were 'change duty roster' and 'bank'. That most-commonly used 'frequently' (most weeks in at least some areas) was 'time off in lieu', and those most-commonly used 'occasionally' (every few months) were 'time off in lieu', 'overtime', 'agency' and 'cancel work (if possible)'. Staff pool was not used in 13 of the 17 organisations.

Respondents were asked to indicate the top four options they would prefer to employ in their Trust/organisation:

• 'change the duty roster'

• 'extra basic hours'

• 'bank'

• 'time off in lieu'. ¹⁶

Thirteen Trusts/organisations had access to a Trust/Board Area General Bank and 11 had access to Trust/Board Area Specialist Banks. Six of the specialty banks were paediatric banks. Eight had access to both a general and specialty bank. Additionally, nine reported using a 'preferred provider' for the supply of agency staff.

A number of measures were detailed by 11 of the 17 Trusts/organisations as methods of reducing bank and agency spend (see CD-ROM).

Workload pressures
Factors noted as creating extra workload pressures included 'patient and public expectations', 'provision of mentoring' and 'teaching of student nurses'.

Role expansion/new roles
Initiatives described are listed on the CD-ROM. Examples include: 'nurse-led removal of k-wires in an orthopaedic clinic', 'introduction of ambulatory care units', and 'ambulatory care practitioners in some areas'.

3. Maternity

Nineteen questionnaires were issued to Trusts/organisations, with a 100% response rate.

Midwifery workload and workforce planning systems

Most familiar tools
The tools respondents were most familiar with were 'Based on Historical Budgets' and 'Birthrate Plus'.

Tools currently used
Within early care, day care, ante-natal, post-natal, intrapartum care and community settings, 'Based on Historical Budgets' was the most-commonly used system. This was followed by 'Birthrate Plus' for early care, day care, ante-natal, post-natal and intrapartum care. Within neonatal ITU and special care baby units, 'National Recommendations' were used by 10 of 14 respondents.

In relation to numbers of tools used by Trusts/organisations per specialty, four reported no tools used across all specialties, and the remainder 0-3 per specialty (excluding 'Based on Historical Budgets').

First most-commonly used tools (excluding 'Based on Historical Budgets')
Eleven Trusts/organisations described a first most-commonly used midwifery workload and workforce planning system, and eight gave no response (Table 4.6).

Table 4.6 Maternity: first most-commonly used tool

There was a wide frequency of use (see CD-ROM). Seven respondents noted that the system provided total midwifery numbers, and five reported the system provided numbers of staff by relevant clinical grade. Only one respondent reported that the system took account of student midwives. Eight stated that the system was formally recognised by their organisation. The recommended staffing levels had been fully implemented in six Trusts/organisations, with three responding 'no' and a further two 'not known'. Two of the respondents reporting 'no' to full implementation provided explanations: 'resource implications and models of care', and 'outcomes formulate the manpower plan and its implementation taking advantage of vacancies and retirals'.

The systems were understood mostly by senior midwives and senior managers, but appeared to be understood less by midwives. Six respondents felt that the midwifery workforce planning system detailed an establishment which met the needs of the clinical area. Six also agreed that information required for the system was readily available within the organisation. It is difficult to draw clear conclusions in relation to the resource intensity of the midwifery workforce planning systems.

Only four of the 11 who described a first most-commonly used system reported having dedicated resources allocated to midwifery workload and workforce planning. One organisation reported having one WTE senior manager, two WTE workforce planners and finance support. Three reported the following:

• 'senior midwifery manager'

• 'Birthrate Plus is a funded one-off project and will involve one midwife per site for three months to gather data'

• 'project midwife (one WTE for one year)'.

Senior midwives and senior managers were the main users, with Directors of Nursing, human resource staff and workforce planners less frequent users. Senior managers and the Director of Nursing ranked joint highest in terms of being accountable for the midwifery workforce planning system.

Midwifery workload and workforce planning systems were used mainly to review establishments in the light of changes within clinical areas, but also to check current midwifery establishments and estimate new ones. Location of use is shown in Table 4.7.

Table 4.7 Maternity: location of use

'Planning for a clinical change' was the main reason detailed for opting to use the first most-commonly used system, but only up to six respondents reported any evidence of integrating workforce planning with other service planning initiatives within the Trust/organisation.

Second most-commonly used tools (excluding 'Based on Historical Budgets')
Six respondents offered a second most-commonly-used system (Table 4.8).

Table 4.8 Maternity: second most-commonly used tool

When last used
Seven Trusts/organisations last used a midwifery workload and workforce planning system within the past year, but a further six had last used one more than two years ago and four did not know when one had last been used. Thirteen Trusts/organisations indicated that they were considering introducing a new system in the near future, with 12 claiming they were considering, planning to use or re-run 'Birthrate Plus', one considering 'Birthrate Plus' or 'MatS', and one awaiting guidance from the Royal College of Midwives (RCM) on 'Birthrate Plus'. Another Trust/organisation reported, however, that it had used 'Birthrate Plus' and 'MatS' and had found them to be 'unreliable and labour intensive'.

Specialty areas
The tools known to be effective in specialty areas included 'Birthrate Plus' in all areas except neonatal (12 respondents), the BAPM system in neonatal units (three) and 'MatS' in maternity/consultant-led units (three).

Most interested in using
Respondents were most interested in using 'Birthrate Plus', followed by 'National Recommendations' (Figure 4.3).

Figure 4.3 Maternity: most interested in using

Resources (including budgets and establishments)

The process for setting the midwifery budget for 2003-2004 was described by all 19 Trusts/organisations, with the most common single response being 'roll-over budget from previous year plus uplifts' (five respondents), but variations on 'based on historical budgets/ establishments' having six responses.

Establishments are shown in Appendix 6.

Maternal and neonatal care characteristics

Home births
Respondents were asked to explain the contingency plans in place within the maternity service to deal with home births. Eighteen responses were provided, demonstrating a variety of arrangements ranging from 'fully available as a choice for all women', through 'all requests met where possible unless clinical indications or staffing issue which makes this unfeasible', to 'staffing cover dependent on geographical location'.

Thirteen Trusts/organisations provided details on how the maternity unit provided midwives for home births. Again, a variety of responses was recorded, including:

• 'part of work of integrated maternity service'

• 'community midwifery team operates out of hospital; in remoter areas this is provided by community midwives in LHCC localities but this is becoming unsustainable due to onerous on-call requirements'

• 'geographically linked teams provide on-call rota (1st and 2nd in call); cross-cover from other areas if several births due at once'

• 'one midwife from Midwifery Birthing Unit first response to home birth; second midwife goes out for support when requested'.

See CD-ROM for further examples.

Quality of care/dependency scoring systems
Eleven respondents reported using quality of care measures, with most employing clinical audit, clinical effectiveness, risk management, complaints, clinical governance, CNORIS, and incident reporting (see footnote 12, page 26).

Only two of the 19 Trusts/organisations reported recording maternal dependency information, and 13 reported recording neonatal dependency information. The methods of recording neonatal dependency included:

• 'categorised as NNITU/high dependency/transitional or special care'

• the BAPM Guidelines.

Nine of the 13 respondents recorded neonatal dependency information daily, with two recording it twice daily and a further two recording three times daily. Three reported that the data generated from the neonatal dependency scoring system were used to inform midwifery workload and workforce planning and a further five stated they used data to inform planning 'sometimes'.

Midwifery workforce characteristics

Protected time
Nine Trusts/organisations reported protected time for team leaders (a further three stated this was available 'sometimes'). Five had protected time for supervisors of midwives, and six for link supervisors.

The most favoured options on minimum protected time allowance from direct clinical care for each professional group were:

• one day per week for team leaders (8/17)

• one day per week for lead midwives (8/14)

• one day per fortnight for supervisors of midwives (7/19)

• one day per month for link supervisors (5/18).

Predictable absence allowance
The current predictable absence allowance reported ranged from 0-20% (only one reported '0%' - see footnote 13), with one organisation unable to quantify (see footnote 14, page 27) and one awaiting outcome of the Birthrate Plus exercise. Of the 16 Trusts/ organisations who provided details of an allowance, 13 reported that it was fully funded, one was funded in all areas with no allowance in community, and two were partially funded ('17 of 20% allowance' and '12-18 of 20% allowance - differs across sites').

There was strong support (14) for a predictable absence allowance greater than 21%.

Flexible working (including bank and agency use)
A number of flexible working practices were used in all of the 19 Trusts/organisations: shift swapping, part-time working, time off in lieu, and bank. These were closely followed by 'rescheduling of workload' and 'flexible shift patterns', which were used in 17 organisations. The flexible work practices used least commonly were 'staff pool', 'annualised hours' and 'term-time working'.

The flexible working practices most-commonly used 'routinely' (every week) were 'bank' and 'extra basic hours'. The practices most-commonly used 'frequently' (most weeks in at least some areas) were 'change duty roster' and 'time off in lieu'. The one most-commonly used 'occasionally' (every few months) was 'rescheduling of workload'. 'Staff pool' and 'agency' were reported by some respondents as never being used.

Respondents were asked to indicate the top four options they would prefer to employ in their Trust/organisation:

1. 'change duty roster'

2. 'extra basic hours'

3. 'bank'

4. 'internal transfer of staff from other area of the organisation'.

Eleven had access to a Trust/Board General Bank, and 17 to a Trust/Board Specialist Bank. Seven had access to both a general and specialist bank. Three Trusts/organisations reported using a 'preferred provider' for agency staff, but it should be noted that 14 of 17 reported never using agency (see above).

A number of measures were detailed by 16 Trusts/organisations as methods of reducing bank and agency spend (see enclosed CD-ROM).

Workload pressures
Additional factors creating workload pressures for midwives included increasing amounts of paperwork and computer data in-putting, accessing laboratory results and locating and retrieving case notes.

Role expansion/new roles
Initiatives described are listed on the CD-ROM. Examples include 'advanced neonatal practitioners' and 'midwife-only care/discharge in post-natal areas'.

4 Psychiatry

Seventeen questionnaires were issued to Trusts/organisations for psychiatry. The response rate was 100%.

Nursing workload and workforce planning systems

Most familiar tools
The tools respondents were most familiar with were 'Based on Historical Budgets' and 'Telford or similar'. Many respondents (15) had no awareness of 'Regression Based Systems'.

Tools currently used
Within all the clinical specialties listed and under the 'other' category, the most-commonly used system was 'Based on Historical Budgets', with 'Telford' the second ranking system in adult acute admissions, elderly acute admissions, adult continuing care, elderly continuing care, and intensive psychiatric care.

In relation to numbers of tools used by Trusts/organisations per specialty, five reported no tools used, and the remainder 0-3 per specialty (excluding 'Based on Historical Budgets').

First most-commonly used tools (excluding 'Based on Historical Budgets')
Twelve described a system in their organisation, and five gave no response (Table 4.9).

Table 4.9 Psychiatry: first most-commonly used tool

The majority of responses in relation to frequency of use of the system were in the 'random' or 'other' categories. These included 'at time of service review or development', 'one-off exercise', 'annually', 'every two years' and 'in response to increased workload' (see CD-ROM for more information).

All of the systems detailed under the first most-commonly used system were able to provide details of total nursing numbers; ten also reported that the system could detail numbers of qualified and unqualified staff, with six claiming it could provide details of staff by clinical grade. Eight of the systems were formally recognised by the relevant organisation and five reported that the recommendations had been fully implemented. The reasons reported by six respondents for non-implementation of the recommendations were diverse, and included 'exercise was snapshot and does not reflect peaks and troughs in service', and 'not fully implemented as many in-patient areas downsizing as part of modernisation process'.

Eleven respondents reported that the system was understood by senior managers and seven by charge nurses. There was less clarity on whether the system detailed an establishment which met the needs of the clinical area, with seven either reporting uncertainty or disagreement with this statement. Half of respondents agreed that the information required for the system was readily available within the organisation.

Four of 12 Trusts/organisations reported having dedicated resources allocated to the system. One had four WTE workforce planners, one had '0.8 WTE project facilitator for one year', one reported 'part of senior nurse role' and another indicated 'senior mangers' but provided no detail on WTE.

Senior managers, charge nurses and Directors of Nursing were the main users, with human resources staff and workforce planners less frequent. Nine respondents indicated the Director of Nursing was accountable for the system, and nine also indicated that senior managers were accountable.

Systems were used mainly to review nursing establishments in light of changes within the clinical area, to check current nursing establishments, and to estimate new nursing requirements. Location of use is shown in Table 4.10.

Table 4.10 Psychiatry: location of use

'Planning for a clinical change' and 'Professional Recommendation from within Trust/organisation' were the main reasons cited for opting to use any of the first most-commonly used nursing workload and workforce planning systems.

The extent to which the system was integrated into other service planning initiatives was explored, with four reporting no integration with other workforce planning and three stating it was used when 'planning service change or development'.

Second most-commonly used tools (excluding 'Based on Historical Budgets')
Only one Trust/organisation reported a second most-commonly used nursing workload and workforce planning system ('Nurse per Occupied Bed').

When last used
Eight out of 17 Trusts/organisations last used a system within the past year, but four last used one more than two years ago; a further four did not know when one had last been used.

Ten Trusts/organisations indicated they were considering introducing a new system in the near future, with five proposing to establish a workload and workforce planning system/strategy.

Specialty areas
While eight nursing workload and workforce planning tools were identified, there was no clearly identifiable system that was known to be effective in a particular specialty. Only 'Psychiatric Monitor', identified as being effective in mental health, acute psychiatry, continuing care and rehabilitation, gained two responses; all others, which included 'Telford' (acute psychiatry and continuing care), 'Acuity Quality' (high physical dependency areas) and the 'Birmingham System' (elderly care mental health), gained one each.

Most interested in using
Respondents were most interested in using 'National Recommendations' and 'Acuity Quality Method' (Figure 4.4).

Figure 4.4 Psychiatry: most interested in using

Resources (including budgets and establishments)

The process for setting the nursing budget for 2003-2004 was described by all 17 of the Trusts/organisations. The most common was 'based on historical budgets or establishments plus other factors/uplifts' (nine responses), followed by 'roll-over budget from previous year plus uplifts' (six).

Establishments are shown in Appendix 6.

Patient care characteristics

Quality of care/dependency scoring systems
Fourteen Trusts/organisations reported using quality of care measures (see footnote 12, page 26). A range of measures were reported, including:

• patient satisfaction audits and complaints

• referrer satisfaction

• clinical governance standards

• audit, including audit of national standards, guidelines and good practice statements

• local and national guidelines

• NHS QIS standards

• SHAS quality standards for learning disability.

Three respondents used the quality data to inform nursing workload and workforce planning, and one respondent reported that this had influenced skill mix through reprovisioning of psychiatric services and regular reviews by charge nurses and managers.

Ten Trusts/organisations reported using patient dependency scoring systems.

Six Trusts/organisations reported recording patient dependency information at least once per day. Only one stated that patient dependency information was used to inform nursing workload and workforce planning, with a further five claiming it was 'sometimes' used.

Patients requiring constant/special care
Fifteen Trusts/organisations reported having patients who required constant care in a number of specialty areas. Staffing requirements for constant care patients were calculated by a number of means. Six used a 'professional judgement approach', while other clinical areas appeared to have capacity within nursing establishments to care for 1-2 constant care patients without requiring additional resource. Six respondents reported being 'satisfied' or 'very satisfied' with the system used to determine staffing requirements for patients requiring constant care.

Fourteen Trusts/organisations had patients who required special care, again in a number of specialty areas. Five respondents calculated staffing requirements using a 'professional judgement approach', while others followed local organisational policies and national guidelines. Six were 'satisfied' or 'very satisfied' with the system used to determine staffing requirements for patients requiring special care.

Outreach teams from the intensive psychiatric care unit were available in three Trusts/ organisations, with nursing support provided for special and constant care patients by two; the other team prevented admissions to hospital rather than provided support to in-patients. One team was reported to cover up to 24% of patients requiring constant and special care, but no details were provided for the other. In terms of effectiveness, one Trust/organisation expressed 'uncertainty' about the support offered by the outreach team, while the other had confidence that it was effective for patients requiring constant care and special care.

Nursing workforce characteristics

Protected time
Six Trusts/organisations confirmed an allowance for charge nurses to be released from clinical numbers, with a further six answering 'sometimes'. Protected time was offered in a number of ways, with many depending on adequate staffing and resource and concurrent clinical activity.

There was strong support (11 of 17) for an allowance of one day per week as the minimum protected time required for charge nurses. Additionally, the four respondents who ticked 'other' all recommended a protected time allowance greater than one day per week, ranging from a minimum of two to five days per week.

Predictable absence allowance
The current predictable absence allowance ranged from 0-23% (only one reported '0%'), ¹⁷ with one Trusts/organisation unable to quantify (see footnote 14, page 27) and one able to provide data for learning disability service only ('20-23% funded'). Of the 14 Trusts/ organisations who provided details of an allowance, 10 reported this was fully funded, one said it was funded in all areas except for day hospital, community psychiatric nurses (CPNs) and learning disability community-based staff (for whom there was no allowance), and three reported partial funding ('17 of 20% allowance but with major review currently under way'; 'funded in some areas but not in others and currently being investigated'; 'variable 16-20 of 20% funded').

There was strong support (13 from 17) for a predictable absence allowance of greater than 21%.

Flexible working and bank and agency use
All 17 Trusts/organisations were using two flexible working practices: 'part-time working' and 'time off in lieu'. This was followed closely by 'shift swapping', 'bank' and 'flexible shift patterns'. 'Annualised hours' was not used in any of the organisations, and 'term-time working' was used in only one.

The practices most-commonly used 'routinely' (every week) were 'bank', 'change duty roster' and 'extra basic hours'. The practice most-commonly used 'frequently' (most weeks in at least some areas) was 'overtime'. That most-commonly used 'occasionally' (every few months) was 'cancel work (if possible)'. 'Staff pool' and 'agency' were most frequently reported as 'never used'.

The weighted choices for the top four measures they would prefer to employ (in order) were:

• 'change duty roster'

• 'internal transfer of staff from other area of organisation'

• 'extra basic hours'

• 'bank'.

Seven respondents reported having access to a Trust/Board Area General Bank and 10 respondents had access to a Trust/Board Area Specialist Bank providing mental health and learning disabilities nurses; three could access both general and specialist banks. Seven Trusts/organisations reported using a 'preferred provider' for agency staff.

A number of measures were detailed by 13 Trust/organisations as methods of reducing bank and agency spend (see CD-ROM for details).

Workload pressures
A wide range of responses relating to administration, management, clinical, education and rurality issues was given. Examples included:

• 'lack of clerical support/admin support'

• 'staff appraisal'

• 'long-distance escort of patients sectioned under the Mental Health Act'

• 'increased personal development/training issues thereby creating gaps in daily workforce'

• 'lack of service from other agencies such as social care results in additional workload'.

Further examples are given on the CD-ROM.

Role expansion/new roles
Initiatives described are listed on the CD-ROM. They include 'introduction of Cognitive Behaviour Therapist', 'nurse prescribing' and 'Patient Group Directions'.

5. Primary Care Part A¹⁸

There were originally 17 Primary Care Part A Questionnaires issued but three Trusts/ organisations advised that they were not relevant to their organisation. The remaining 14 questionnaires were completed and returned, which represented a 100% response.

Nursing and midwifery workload and workforce planning systems

Most familiar tools
The tools with which respondents were most familiar with were 'Based on Historical Budgets' and 'Telford or similar'.

Tools currently used
A wide range of specialty areas were described as being present within Trusts/organisations, with the most commonly listed system within all areas being 'Based on Historical Budgets'. No Trust/organisation reported using 'Acuity Quality Method' and 'Timed-Task/Activity Method'.

In relation to numbers of tools used by Trusts/organisations per specialty, four reported no tools used across all specialties and the remainder 0-2 per specialty (excluding 'based on historical budgets').

Most-commonly used tools (excluding 'Based on Historical Budgets')
Ten of 14 respondents described identified the most-common tool being used within their Trust/organisation (Table 4.11).

Table 4.11 Primary Care Part A: most-commonly used tool

There was a wide range of frequency of use (see CD-ROM). All 10 of the nursing workforce planning systems used were able to provide details of total nursing numbers, and nine were able to provide details of qualified and unqualified staff. Only five could provide numbers of staff by clinical grade, and one took account of student nurses. The majority of the systems (eight) were formally recognised by the relevant organisation, but only four organisations reported that the recommendations of the system had been fully implemented. The reasons reported by six organisations for non-implementation of the recommendations included 'resource issues', 'some vacant posts frozen due to financial recovery plan' and 'Trust model now outdated'.

The most-commonly used systems were understood best by senior managers. Five tools were reported to provide details of a nursing establishment which meets the needs of the clinical area. Six Trusts/organisations agreed that the information required for the nursing workforce planning system was readily available, but there was a spilt view on whether the systems were resource intensive.

Three Trusts/organisations reported having dedicated resources allocated to nursing and midwifery workload and workforce planning systems. One indicated that they were human resource staff, but provided no details of whole time equivalents. One set out that this was part of the responsibility of one WTE lead nurse, and the other detailed '0.8 WTE of a project facilitator for a year'.

Charge nurses, senior managers and Directors of Nursing were the main users, with less frequent use by workforce planners and human resources staff. Directors of Nursing and senior managers tended to be accountable for the systems, followed by charge nurses.

Systems were used mainly to review nursing establishments in the light of changes within the clinical area, to check current nursing establishments, and to estimate new nursing requirements. Location of use is shown in Table 4.12.

Table 4.12 Primary Care Part A: location of use

'Planning for a clinical change' and 'professional recommendation from within the Trust/organisation' were the two main reasons cited for opting to use the most-commonly used tools. Four out of nine respondents stated that the system operated as a 'stand-alone' system and was not integrated with workforce planning for other groups.

When last used
Seven of the Trusts/organisations last used a nursing and midwifery workload and workforce planning system in the past year, but three had last used one more than two years ago and a further three did not know when one had last been used.

Eight Trusts/organisations indicated they were considering introducing a new workforce planning system in the near future, and 10 provided comments on these proposals. Four advised that a workforce planning system or strategy was proposed, and two organisations reported plans to recruit workforce personnel to support this.

Specialty areas
Six nursing and midwifery workload and workforce planning systems known to be effective in a particular specialty were cited, each gaining one response. They included the RCN Assessment Tool (older people), the Keith Hurst Tool (in general, psychogeriatric and community hospital wards), and the Grampian Model (GP acute beds, continuing care and psychogeriatric).

Most interested in using
Respondents were most interested in using 'Acuity Quality' and 'National Recommendations' (Figure 4.5).

Figure 4.5 Primary Care Part A: most interested in using

Resources (including budgets and establishments)

The process for setting the nursing budget was described by all 14 Trusts/organisations, with 'roll-over budget from previous year plus uplifts' the most common (six responses), closely followed by 'based on historical budgets or establishments plus additional factors' (five).

Establishments are shown in Appendix 6.

Patient care characteristics

Quality of care/dependency scoring systems
Ten Trusts/organisations reported using quality of care measures (see footnote 12, page 26). Ten responded with further comments, one of which was to state 'the data [are] not linked to workforce planning', but no further details were provided. The remaining nine used a combination of measures including clinical audit, clinical governance, pressure sore incidence, complaints, critical incident reporting, SIGN guidelines, SHRUGs and NHS QIS. Two of the ten Trusts/organisations made mention of local standards, and one of these reported regular nursing audit.

One Trust/organisation reported using 'Monitor', while three used other measures - 'local quality indicators', 'Trust internal audits of quality of care', and 'local standards/SHRUGs/ Maxwell's Multidimensional Learning Tool and Quality Visits'. Additionally, the two who stated 'no' under 'others' also supplied details: 'SHAS/Caspe' and 'QIS/SIGN guidelines'.

Only one Trust/organisation reported that the data from the quality measure were used to inform workload and workforce planning - the one which reported use of 'Monitor'. Additional free text comments suggested this was supported by 'professional judgement' and 'clinical expertise'. This was not reported, however, to have influenced nursing skill mix.

Ten Trusts/organisations used patient dependency scoring systems, with 'SHRUGs' being the most common (seven respondents). Others included the 'Blackpool Dependency System', 'CAPE' and a local system.

Some reported using more than one patient dependency scoring system, or using the same system in different ways in different settings. Only five recorded the patient dependency information once per week or more. Three reported using the data generated from patient dependency scoring systems to inform workload and workforce planning and a further four used this 'sometimes'.

Neither of the Trusts/organisations who reported that patient dependency information was not linked to workload and workforce planning provided any details on how the information was used. Four Trusts/organisations did, however, respond (for details, see CD-ROM).

Nursing and midwifery workforce characteristics

Protected time
Four Trusts/organisations confirmed an allowance for charge nurses to be released from the clinical numbers and a further three answered 'sometimes'. Charge nurses were rostered as supernumerary, had dedicated 'management' time or were additional to numbers required on shifts, but in practice workload pressures were liable to impinge on protected time.

There was strong support (10 of 14) for one day per week as protected time, with one respondent proposing 50% and another that charge nurses should be 'supernumerary'.

Predictable absence allowance
The current predictable allowance ranged from 17-22%, with one organisation unable to quantify ( see footnote 14). Of the 13 Trusts/organisations who provided details of an allowance, 10 reported it as fully funded, one was not funded, ¹⁹ and two stated it was partially funded (responses included: '17 of 20% funded but with major review under way', and 'currently funded only in some areas but anticipated this will be resolved after activity mapping excercise is complete').

There was strong support (13 of 14) for a predictable absence allowance greater than 21%.

Flexible working and bank and agency use
Four flexible working practices were used in all Trusts/organisations: 'shift swapping', 'part-time working', 'time off in lieu' and 'bank'. These were followed closely by 'flexible shift patterns' and 'job sharing'. The flexible working practices used least included 'term-time working', 'on call' and 'flexi-time'.

The highest rated practice used 'routinely' (every week) during 'daytime hours' (Monday-Friday 8am-4pm) in nine Trusts/organisations was 'bank'. The practices used 'frequently' (most weeks in at least some areas) were 'change duty roster', 'time off in lieu' and 'extra basic hours'. The practice used most commonly 'occasionally' (every three months) was 'internal transfer of staff from another area of the organisation'. 'Staff pool' was never used in 10 organisations and 'on call' was never used in nine.

The highest rated practice used 'routinely' (every week) during 'out of hours' (Monday-Friday 4pm-8am and weekends) was 'bank'. Those most commonly reported 'frequently' (most weeks in at least some areas) were 'change duty roster' and 'extra basic hours', and those used 'occasionally' (every three months) were 'internal transfer of staff from another area of the organisation' and 'time off in lieu'. 'Staff pool' was never used in 11 and 'cancel work (if possible)' was never used in 10.

The weighted choices for the top four measures* they would prefer to employ (in order) were:

• 'change duty roster'

• 'extra basic hours'

• 'internal transfer of staff from other areas of organisation'

• 'bank'.

(* one organisation provided two second choices)

Eight respondents had access to a Trust/Board Area General Bank and three had access to a Trust/Board Area Specialist Bank. Additionally, eight Trusts/organisations reported using a 'preferred provider' for the supply of agency staff.

6. Primary Care Part B²⁰

Seventeen questionnaires were issued to Trusts/organisations for Primary Care Part B (community teams). The response rate was 100%.

Nursing workload and workforce planning systems

Most familiar tools
The tools with which respondents were most familiar were 'Based on Historical Budgets', 'Caseload Profiling Tools' and 'LHCC Needs Assessment'.

Tools currently used
For all professional groups listed, 'Based on Historical Budgets' was the most-commonly used system, followed by 'Caseload Profiling Tools' for District Nurses and Health Visitors and 'LHCC Needs Assessment' for Public Health Practitioners.

In relation to numbers of tools used by Trusts/organisations per professional group, five reported no tools used across all professional groups, and the remainder 0-5 per professional group (excluding 'Based on Historical Budgets').

Most-commonly used tools (excluding 'Based on Historical Budgets')
Twelve respondents identified the most-common tool being used within their Trust/ organisation (Table 4.13).

Table 4.13 Primary Care Part B: most-commonly used tool

There was a wide frequency of use (see CD-ROM). Eight of the most-commonly used systems were able to provide details of total nursing numbers in addition to qualified and unqualified nursing staff, although one system could only provide details of qualified nursing staff. Seven were reported to provide numbers of staff by relevant clinical grade. Only two took account of student nurses. Seven respondents reported that the system was formally recognised by their organisation, but only two stated that the recommended staffing levels had been fully implemented. The reasons reported by organisations for non implementation included 'caseload profiling alone does not provide evidence for General Manager to base staffing establishments and funding has not been available to do so', and 'supports longer-term management plan and changes implemented as opportunities arise'.

The most-commonly used systems were well understood by senior managers and team leaders, but less so by clinical staff. Only three respondents agreed that the system they were using detailed an establishment which met the needs of the local population. Nine Trusts/organisations reported that the system took account of group-based activities for health visitors and eight reported it took account of these for district nurses. Eight Trusts/ organisations stated that their most-commonly used system took account of visits which require more than one district nurse.

Three Trusts/organisations reported having dedicated resources allocated to the use of the systems. One detailed a senior nurse, one clerical staff IMT, and the other a 'project manager one WTE during project and an economist on an ad hoc basis both for the duration of the Arbuthnott Project'. The staff groups reported as being most involved in using the most-commonly used systems were clinical staff, senior managers and team leaders, followed by Directors of Nursing.

Clinical staff and team leaders were the staff groups reported most frequently as being accountable for the system, closely followed by senior managers. Systems were used mainly to estimate required new nursing establishments and to review establishments in light of changes within a catchment area. Location of use is shown in Table 4.14.

Table 4.14 Primary Care Part B: location of use

Respondents were asked if the workforce planning system was based on data which are by-products of patient records. Seven reported that this was the case. One of these stated that the data were held in paper format, and the other six reported both in paper and electronic formats.

'Planning for a clinical change', 'professional recommendation from within organisation' and 'priority area' were the three main reasons cited for opting to use a nursing workload and workforce planning system. Details on the extent to which the system was integrated into other workforce planning and service planning initiatives were provided by 10 respondents; three reported being stand-alone or not integrated in some way to systems for other staff groups.

When last used
Six of the 17 Trusts/organisations last used a nursing workload and workforce planning system in the past year, but one last used one more than two years ago and nine did not know when one was last used. Nine were considering a new system.

How workload is currently measured ²¹
All 17 Trusts/organisations responded, giving a wide variety of options. Three claimed to have no system or did not measure, while two opted for 'professional judgement'. The remaining twelve responses covered a range of systems, including various categories of 'Caseload Profiling', 'Caseload Numbers', the 'Community Nurse Data Collection System' and 'Audit'.

Professional groups
A variety of nursing workforce planning systems known to be effective in a particular professional group were cited, including the Arbuthnott Resource (for district nurses, health visitors and practice nurses), Octagon (district nurses and health visitors), Caseload Profiling (district nurses and health visitors) and a range of vulnerability tools (health visitors).

Most interested in using
Respondents were most interested in using 'Caseload Profiling Tools', 'National Recommendations' and 'LHCC Needs Assessment'. In the main, they were not interested in using 'Based on Historical Budgets' (Figure 4.6).

Figure 4.6 Primary Care Part B: most interested in using

Resources (including budgets and establishments)

The process of setting the nursing budget for 2003-2004 was described by all 17 Trusts/ organisations. Eight respondents reported using historical budgets, and five of these took account of other factors such as cost pressures. Seven based nursing budgets on allocations from the previous year, some of which also included uplifts.

Establishments are shown in Appendix 6.

Patient care characteristics

Quality of care
Ten Trusts/organisations reported using quality of care measures, the most common of which was a combination of 'audits/incident reporting/guidelines/standards/pressure sore incidence/ complaints and others'.

Only one Trust/organisation reported using any of the quality rating scales listed ('Monitor'). Two reported using data generated from quality measures to inform workload and workforce planning, and both also commented that this influenced skill mix. Two more were planning to use a new quality rating scale in the near future.

Measures of dependency on community nursing service
Eleven of the 17 Trusts/organisations reported recording information on measures of dependency on the community nursing service.

Information on dependency on community nursing teams was recorded in a variety of frequencies, ranging from 'daily', through 'annually', to 'dependent on need'. Three respondents used data on dependency on the community nursing team to inform nursing workload and workforce planning. Of the five Trusts/organisations who reported that these data were not used to inform planning, only two provided free text comment. One reported that data were 'not routinely collected', and the other referred to a pilot that is under way.

Nursing and midwifery workforce characteristics

Protected time
Respondents were asked if there was any allowance included for caseload management and planning for each professional group and only eight responded 'yes' to at least one option. For district nurses and health visitors, seven had allowances and nine had not. There were more Trusts/organisations who did not have allowances for practice nurses, treatment room nurses and school nurses than those who did, and nine did not have an allowance for public health practitioners, compared to three who did.

Details were sought of the allowance, and comments included: 'built into the establishment'; 'expectation that this will be done within normal working hours - time management key factor'; and 'one hour at beginning and end of day but can be lost if work pressures demand'.

There appeared to be a mixed view regarding whether there should be an allowance for caseload management and planning, or whether this should be integral to the role.

Respondents were asked to provide details of what they felt was the minimum allowance for caseload management and planning for each professional group listed. Thirteen supported half a day per week for district nurses and 12 supported this for health visitors; additionally, 11 supported half a day per week for school nurses. There was support in part for an allowance for each of the professional groups.

Predictable absence allowance
The current predictable absence allowance ranged from 0-21.5%, with one organisation stating '0%' (see footnote 17, page 46) and one unable to quantify (see footnote 14, page 27). Of the 15 Trusts/organisations who provided details of an allowance, 13 reported this was fully funded, one stated it was partially funded ('17 of 20% but with major review under way'), and one reported it was not funded.

Respondents were then asked to provide details of the optimal percentage for predictable absence allowance per professional group. Eight reported support for 21-25% allowance for district nurses, health visitors and public health practitioners. There was support in the main for a predictable absence allowance for all professional groups listed, with one organisation supporting a minimum allowance of 25% for all staff groups.

Flexible working and bank and agency use
There were two flexible working practices used in all 17 of the Trusts/organisations: 'part-time working', 'and 'job sharing'. These were closely followed by 'time off in lieu', 'bank', 'rescheduling of workload' and 'shift swapping'. The flexible working practices used least included 'zero hours contracts', 'staff pool', 'annualised hours' and 'compressed working hours'.

The flexible working practices most-commonly used for 'daytime hours' (Monday-Friday 8am-4pm) 'routinely' (every week) were 'bank' and 'on call'. The practices most-commonly used 'frequently' (most weeks in at least some areas) were 'change duty roster' and 'time off in lieu'. The practices most-commonly used 'occasionally' (every few months) were 'internal transfer of staff from other area of organisation' and 'cancel work (if possible)'. 'Staff pool' was not used in 11 of the 17 Trusts/organisations and 'agency' was not used in nine of the 17 during daytime hours.

The flexible working practice most-commonly used for 'out of hours' (Monday-Friday 4pm-8am and weekends) 'routinely' (every week) was 'on call'. The practices most-commonly used 'frequently' (most weeks in at least some areas) were 'change duty roster' and 'bank'. The practices most-commonly used 'occasionally' (every few months) were 'rescheduling of workload/visits', 'change duty roster' and 'cancel work (if possible)'. 'Staff pool' was not used in 12 Trusts/organisations and 'agency' was not used in nine of the 17 out of hours.

When asked to indicate the top four options they would prefer to employ, Trusts/ organisations reported (in order):

• 'change duty roster'

• 'extra basic hours'

• 'bank'

• 'internal transfer of staff from other area of organisation'.

Ten Trusts/organisations had access to a Trust/Board General Bank, six had access to Trust/Board Specialist Banks and three had access to both general and specialist banks. Additionally, six reported using a 'preferred provider' for the supply of agency staff.

A number of measures were detailed by 15 Trusts/organisations as methods of reducing bank and agency spend, including: 'recruitment of relief nurse teams', 'different ways of working - research based, best practice and service redesign', and 'district nursing "relief staff" used to cover planned absence'.

Respondents reported a variety of measures used to currently measure workload, including 'Professional Judgement', 'Caseload Profiling' and the 'Blackpool Dependency Tool'. Three Trusts/ organisations reported that they either had no system or did not currently measure workload.

Workload pressures
A wide range of responses relating to administration, management, clinical, education, rurality issues and the increased pressures caused by heightened patient expectations of services was given, including:

• 'lack of appropriate administrative support'

• 'securing protected time for clinical supervision, involvement of clinical practitioners on LHCC management groups/other committees during working day'

• 'reduced length of stay in hospital (two) and increased district nursing workload in relation to disease management which keeps patients out of hospital'

• 'training (mandatory and ad hoc), for example in single shared assessment'

• 'remote geography travel time'

• 'patient demands/expectations'.

Further examples are offered on the CD-ROM.

Role expansion/new roles
Initiatives described are listed on the CD-ROM. ²² Examples include: 'out of hours review', 'additional practice nurse posts in relation to chronic pain management', and 'introduction of nurse triage in primary care'.

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