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Nationally Co-ordinated Nurse Bank Arrangements
Report and Action Plan

Foreword

I welcome this report on complementary staffing at a time when the NHS is undergoing enormous change as it modernises services, improves the patient experience by streamlining services, and provides care in new and different ways. This brings with it considerable pressure with increasing demands in the working environment and changing patterns of service delivery emerging. There are a number of forces creating additional challenges for the workforce, meaning that there is a need to maximise NHS workforce capacity to ensure that clinical services can be delivered in the best possible way to ensure quality of patient care. Whilst the majority of nurses and midwives will hold substantive contracts, there will always be a need for complementary staffing to cover short-term absences that occur through annual leave, sickness and other instances. Healthcare is a 24-hour, seven-days-a-week service that has patient care at its heart. It cannot operate efficiently or effectively without complementary staffing arrangements and it should not make any apology for doing so.

That is why I am pleased that this project has looked in some detail at analysing the current pattern and usage of nurses and midwives working in banks in NHSScotland. The project has been met with great enthusiasm by those working on such banks and they have been very instrumental in providing good ideas and solutions for improving the way that the banks work. I would like to record my thanks to them for their input and to others who have worked hard to look at how nurse banks can work more efficiently and effectively to provide the best possible service. Also to Fiona Ireland, Project Manager, for her unstinting and zealous approach to this work, persuading others to participate and work together to share knowledge, experience and possible ways forward.

The services that the NHS provides are based on good teamwork and nurse banks form part of those teams. Nurse bank staff are NHS staff and as such should be treated with respect and fairness by their employer and fellow employees. The project recommendations take account of this along with other ways of streamlining the operational nature of nurse banks whilst retaining the good practice that currently exists. The solutions are therefore ones that can both be activated reasonably quickly and others that will take employers some time and effort to put in place. However they will be part of wider changes in the modernisation of NHSScotland including making more use of information technology to make healthcare more accessible and responsive.

I look forward to the benefits of the recommendations being realised and the improvements to patients and staff that will follow.

Andy Kerr, Minister for Health and Community Care

1. Background and Context

The function of NHSScotland is to provide high-quality, timely care from the right staff, in the right place, at the right time (SEHD 2002). This requires the supply of nurse staffing to match the demands of the service. It is recognised that the increasing use of complementary nurse staffing across Scotland is one option for maintaining the necessary supply.

Ensuring that the required numbers of nursing staff are maintained in spite of staff leave or increased activity is a part of daily life for operational managers and nurse leaders around the country. Support can be secured by other means, such as redeploying staff from another area to cover on a short-term basis, employing existing part-time staff for extra hours, or arranging overtime from full-time substantive staff, all of which are used to a greater or lesser extent across NHSScotland. When sources of staffing outwith the substantive workforce are required, however, there are two main sources _ nurse banks and nursing agencies. These two terms are defined below (throughout this report, 'complementary staffing' is the collective term used for staffing from nurse banks and nursing agencies).

Nurse bank
A nurse bank is a group of flexible employees, contracted to work on an as-and-when-required basis, often at short notice, to cover for planned and unplanned shortfalls in staffing. The employees are referred to as 'bank nurses' and are NHS employees, recruited and trained within the parent NHS organisation. Bank nurses may work within a variety of clinical areas, depending on their relevant skill set and are paid at NHS rates through NHS payroll systems. Almost every area of NHSScotland has access to a nurse bank, although organisation of the bank varies widely.

Agency
Agency nurses are flexible employees employed via a third party, a commercially driven and profit-making organisation which the NHS engages to supply staff on an ad hoc basis. The NHS pays the agency a fee that includes an element of commission and the remuneration that will subsequently be paid to the agency nurse, according to the agency's pay structure. The staff supplied are referred to as 'agency nurses'.

NHSScotland recognises the value of its workforce, the largest component of which is nursing staff, and it should be noted in the context of this report that there is an increasing drive to enable nurses and other healthcare staff to work flexibly. The Centre for Change and Innovation (CCI), in partnership with the NHS, has supported the initiative to balance working life with other commitments. One option is working as part of a bank.

The Facing the Future group has overseen initiatives aimed at increasing the number of nursing staff employed within NHSScotland. Facing the Future convened a Steering Group under the chairmanship of the Chief Nursing Officer to take forward a commitment in the Partnership Agreement (Scottish Executive 2003) _ the Partnership Agreement sets out the Scottish Executive's plans for improvements in public services _ to implement nationally co-ordinated nurse bank arrangements, to assist in nurse placement across Scotland, to improve patient services and to cut the cost of agency nursing.

This report and action plan are based on findings from that project in relation to the current organisation and management of nurse banks across Scotland.

2. Policy Drivers

The work described here was undertaken within the context of various policy initiatives.

The principle underpinning the Nursing and Midwifery Workload and Workforce Planning Project (SEHD 2004) is consistency in nursing and midwifery workload and workforce planning across Scotland. It recommends that the use of complementary staffing, defined above, must be balanced with the permanent nursing establishment.

Balanced Working Lives: sharing the picture (CCI 2004) suggests that there needs to be a shift towards flexibility within the core nurse-staffing establishment. It challenges the current arrangement of 'permanent full-time stable' and 'transient part-time unstable' staff.

The Scottish Health Workforce Plan 2004 Baseline (NWU 2004) provides a comprehensive account of the NHS workforce from a national perspective and promotes structures and processes that will ensure the workforce of the future is more closely aligned with the demands being made of it. There is evidence in the plan of increasing use of complementary nurse staffing.

Implementation of the key principles contained within the Scottish Health Workforce Plan 2004 Baseline and the recommendations of the Nursing and Midwifery Workload and Workforce Planning Project would go some way to providing an understanding of the factors influencing demand and reducing the supply of nurse staffing from complementary sources.

Temporary Measures (Accounts Commission for Scotland 2000), published in February 2000, made extensive recommendations to the then-NHS Trusts and NHS Boards on the use and management of complementary nurse staffing.

Audit Scotland has also referred to the use of bank and agency nurse staffing, recommending in their 2002 report, Planning Ward Nursing _ Legacy or Design? (Audit Scotland 2002), that NHS Boards review the use of bank and agency staff and investigate reasons for increased usage.

3. The Project: Aims, Methods and Process

Aims

The aims of the project on which this report is based were to:

• conduct a mapping exercise of management arrangements for existing nurse banks across Scotland;

• establish why nurses join nurse banks and gain an understanding of the characteristics, motivation and experiences of this staff group as part of the workforce;

• research flexible employment options utilised outwith NHSScotland that may offer alternative models for consideration; and

• explore options to meet the Partnership Agreement commitment.

The project Steering Group considered the various options and developed a series of recommendations for implementation across NHSScotland.

Methods

The breadth of information to be collected required input from a variety of sources within and outwith NHSScotland, using a variety of methods.

Information and Statistics Division, Scottish Executive Data (ISD)

A wealth of data was provided either directly or by the then-NHS Trusts and NHS Boards ¹ or extrapolated from central sources, such as payroll.

Focus groups

Five focus groups were held in January and February 2004, aimed at staff with responsibility for organising local nurse bank services and stakeholders with an interest in shaping nurse bank arrangements for the future. Eighty-five staff from a range of clinical and support roles took part. Videoconferencing sessions were offered to NHS Board areas unable to participate in focus groups.

Data collection

There are a number of models for nurse bank provision across Scotland. The breadth and depth of data to be collected was therefore considerable, including extensive interrogation of operational/management processes, contractual arrangements with bank nurses and resources employed in providing nurse bank services. Data were collected either by telephone or via an electronic questionnaire. Eighty-eight nurse banks responded to the data collection tool.

Questionnaires

A web-based questionnaire was devised for completion by charge nurses and team leaders with responsibility for arranging complementary staffing for their areas. Topics covered included advantages, disadvantages and satisfaction levels with existing arrangements, and continuity of care achieved using complementary staffing. One hundred and twenty-two responses were received.

A sample of bank nurses was sent a postal questionnaire to determine their views on and experiences of bank nursing. Over 1000 responses were received.

A short questionnaire was also devised to capture a baseline picture of bank nurse arrangements for practice nurses. From a sample of 100 practitioners who were emailed an explanatory letter and electronic questionnaire, 41 questionnaires were returned.

Review of other organisations

Organisations including the police service, airline industry, retail and hotel sectors, and call centres were approached, either directly or via literature searches, to gain an awareness of other temporary employment options within health and other organisations.

Process

There has been partnership involvement within the project Steering Group, with representation from UNISON, the Royal College of Nursing, the Royal College of Midwives, the HR Forum and the Scottish Partnership Forum. Key stakeholders from the service have played a major part in informing the work of this project.

4. Recommendations and Action

A number of key issues arose from the findings of the project and recommendations were generated which seek to assist NHS Boards in employing best practice while harnessing the management of complementary staffing.

This action plan, based on those recommendations, is essential to begin the rationalisation of the provision of complementary staffing and to ensure implementation of best practice in relation to complementary staffing across NHSScotland.

The action plan will have an impact reasonably quickly, although it is recognised that implementation will, in some areas, be more challenging than in others.

The action plan outlined on the following pages seeks to build on arrangements within NHS Boards to deliver opportunities for joined-up working that maximise effectiveness and efficiencies within the service.

NHS Boards will already be taking forward recommendations to review nurse establishments identified in the Nursing and Midwifery Workload and Workforce Planning Project, and implementing the Best Procurement Initiative (BPI) project's agency contracts will assist in reducing the reliance on and cost of complementary staffing.

Action Plan

Each of the 18 points below is followed by notes about taking the action forward and, where relevant, is supported by evidence from the project's findings.

General

1 NHS Boards will develop action plans based on this report by the end of June 2005.

NHS Boards to action.

2 Action plans will be implemented by the end of September 2005.

NHS Board Nurse Directors will take responsibility for ensuring implementation of the recommendations.

3 A framework for good practice and associated audit tool will be developed by June 2006 for use within NHS Board areas on an annual basis.

The Scottish Executive Health Department (SEHD) will commission work to be undertaken during 2005/06. This work will involve NHS Board nurse bank managers from around Scotland and links will be made with the SWISS (Scottish Workforce Information Systems Strategy) project.

Trends in Supply and Cost

4 NHS Boards will set targets on an annual basis to reduce the proportion of complementary staff utilised from agency as a percentage of the total nurse staff deployment.

Work within the SEHD will ensure links with the staff governance agenda. The staff governance working party will review the current mandatory statistical information to ensure this information is captured via the Performance Assessment Framework.

• The average cost of supply from bank nursing sources is almost half that of agency nursing.

• Nationally, bank nursing accounts for 3.4 per cent and agency nursing 1.3 per cent of the total nursing resource (ISD data 2002/03).

• The supply of complementary staffing from the nurse bank source has increased from 65 per cent to 75.5 per cent over the last four years.

Models

5 The organisation of nurse banks will be consolidated to NHS Board level.

NHS Boards to action: £500,000 transitional three-year funding will be made available across NHS Boards to support this consolidation. This funding will be ring-fenced for use to support nurse bank developments. Where centralised nurse banks already exist, the funding must be used to enhance current arrangements. At the end of the transitional funding period, savings will be identified and fed into clinical practice.

• Sixteen per cent of all nurse banks operate at NHS Board or Operating Division (former Trust) level.

• Retaining the local/personal perspective was one of the most important features identified in focus groups, and the user and bank nurse surveys.

Management and Operational Issues

6 The majority of administration duties within NHS Board nurse banks will be performed by clerical staff.

NHS Boards to action. The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Management and operational procedures will be included in the nationally agreed audit tool.

• The inappropriate use of highly skilled clinical staff in organising bank nurse bookings is more likely to occur where the nurse bank is locally organised.

• Over 70 per cent of the charge nurses/team leaders responding to the survey indicated some level of agreement that centralisation of the nurse bank function reduces the amount of clinical time lost to arranging staffing cover.

7 NHS Boards will ensure that appropriate senior nurse support is deployed within the nurse bank management structure to provide line management, ongoing professional advice and support to nurse bank staff.

NHS Boards to action. The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Management and operational procedures will be included in the nationally agreed audit tool.

• Less than half the nurse banks offer performance appraisal to bank staff.

• Lack of appropriate personnel is an obstacle to the provision of mentoring, personal development planning and clinical supervision for bank nurses.

8 Processing applications for nurse bank positions will be given the same priority and follow the same protocol as substantive posts.

NHS Boards to action. The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Management and operational procedures will be included in the nationally agreed audit tool.

• The nurse bank should be considered as an employment gateway to the organisation.

• The longest average time recorded by a nurse bank for the recruitment process was five months.

• Almost half of all nurse banks report that the recruitment process is hindered by Disclosure Scotland.

• A fifth of nurse banks are restricted in recruitment by the number of induction spaces made available to them.

• Generally, recruitment practices for nurse banks follow accepted good practice.

9 Terms and conditions agreed with individual nurse bank staff will reflect their competence and value to the organisation by acknowledging in their contracts incremental credit for prior experience.

NHS Boards to ensure harmonisation across their areas. Guidance on the implementation of Agenda for Change with respect to bank nurses will be provided by SPRIG (Scottish Pay Reference and Implementation Group). The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Management and operational procedures will be included in the nationally agreed audit tool.

• A small number of nurse banks do not recognise applicants' previous experience in their contracted grade and incremental point.

• Failure to recognise previous experience was a cause for dissatisfaction for many bank nurse respondents, particularly where internal candidates were treated differently.

• Equity of employment status/terms and conditions compared to those of substantive employees was an issue highlighted by the focus groups.

10 NHS Boards will have systems in place to ensure that bank nurse remuneration reflects the duties of the shift.

NHS Boards to action. The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Management and operational procedures will be included in the nationally agreed audit tool.

• Over half of nurse banks do not have the facility to pay bank nurses at different rates, unless they have a separate contract for each grade.

• Of those nurse banks where the facility to pay at different rates is available, most staff are paid the rate appropriate to the duties of the shift worked.

11 NHS Boards will ensure provision of appropriate induction programmes for nurse bank staff and should make funding available to award payment to bank staff for attendance.

NHS Boards to action. The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Management and operational procedures will be included in the nationally agreed audit tool. The PIN (Partnership Information Network) guideline on induction, currently under development, will apply equally to bank nurses.

• The content of induction programmes for bank staff varies widely across NHS Board areas. Of the bank nurse respondents who had attended induction, 30 per cent said it had been 'useless' or 'not very valuable' in preparing them to work.

• A small proportion of bank nurse respondents reported that they had not attended induction.

• Two nurse banks offer the induction programme outwith core office hours.

• All but one nurse bank pay new recruits to attend induction; criteria apply in some cases.

Continuing Professional Development

12 NHS Boards will ensure provision of appropriate mandatory training programmes and should make funding available to award payment to bank staff for attendance.

NHS Boards to action. The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Provision of mandatory training and continuing professional development (CPD) will be included in the nationally agreed audit tool.

• Forty-seven per cent of bank nurse respondents indicated satisfaction with existing arrangements for mandatory training provision.

• All nurse banks provide mandatory training to a greater or lesser extent.

• Not all nurse banks monitor attendance at mandatory training.

13 NHS Boards will ensure that nurse bank staff have access to CPD activity and should make funding available to award payment to bank staff for attendance at defined training sessions relevant to their working environment.

NHS Boards to action. The first annual self-audit (see 3) will be carried out by NHS Boards in July 2006. Provision of mandatory training and CPD will be included in the nationally agreed audit tool.

• Forty-one per cent of bank nurse respondents indicated dissatisfaction with the existing provision of access to ongoing training.

• Around 25 per cent of nurse banks do not pay bank nurses to attend professional training.

Information Technology

14 NHS Boards will continue to use existing nurse bank IT systems, consolidating their use across the Board area, subject to appropriate contractual arrangements.

Monitoring of IT capacity will be detailed on completion of further work to be undertaken nationally (see 15).

• Three commercially available software systems are being used by nurse banks within Scotland.

• Nurse banks using the commercial software rated the products highly.

15 Formal evaluation of the range of possible options to provide a nurse bank IT system from a national perspective will be initiated.

The Nationally Co-ordinated Nurse Bank Arrangements Steering Group has commissioned and will fund work to be taken forward by the SEHD IT Strategy Group to determine a final statement of requirements, option appraisal and recommendation for IT system(s) and technical governance arrangements in the form of an action plan. This work will be concluded by April 2005.

• Seventy-four per cent of the nurse banks operate without any IT support.

• Fifty per cent of the nurse banks operating across former Trust areas or NHS Board areas utilise two of the commercially available software systems.

• The functionality and interrelationships of the various data components in nurse bank systems are complex.

Use Of Agency Staff

16 Financial monitoring of agency spend at NHS Board level should discriminate between BPI contracted and non-contracted agency expenditure.

Local and national implementation. The self-audit and annual ISD returns will reflect this requirement from 2005.

• The BPI project, running concurrently, will ensure that all NHS Boards have access to agency nursing through nationally contracted agreements.

17 NHS Boards will ensure policies and procedures are in place to approve the use of non-contracted agency staff at senior level and ensure ongoing scrutiny is applied, to ensure value for money.

NHS Boards to action.

• Most NHS Boards have strategies in place to reduce reliance on agency as a source for complementary staffing.

Next Steps

18 NHS Boards will work together to demonstrate flexibility in deployment of bank nurse staffing across NHS Board boundaries.

Local and national implementation. The flexible deployment of staffing across NHS Board boundaries will be facilitated by Regional Workforce Groups.

• 1.3 per cent of bank nurses had multiple contracts across NHS Board areas during 2002/03 (ISD data).

• Monitoring of compliance with working time regulations is an area of concern, particularly across NHS Board boundaries.

5. Appendix 1

Steering Group membership

6. References

Accounts Commission for Scotland (2000) Temporary Measures Managing Bank and Agency Staff Edinburgh: Accounts Commission for Scotland

Audit Scotland (2002) Planning Ward Nursing _ Legacy or Design? Edinburgh: Audit Scotland

Centre for Change and Innovation (2004) Balanced Working Lives: sharing the picture Edinburgh: SEHD

National Workforce Unit (2004) Scottish Health Workforce Plan 2004 Baseline Edinburgh: SEHD

Scottish Executive (2003) A Partnership For A Better Scotland: partnership agreement Edinburgh: The Stationery Office

Scottish Executive Health Department (2002) Working for Health: the workforce development action plan for NHS Scotland Edinburgh: SEHD

Scottish Executive Health Department (2004) Nursing and Midwifery Workload & Workforce Planning Project Edinburgh: SEHD

Footnote

1 Most of the project data collection was carried out prior to the abolition of NHS Trusts in Scotland in April 2004.

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