Safe and Effective Staffing Levels for the Allied Health Professions: a practical guide
by Robert Jones and Fiona Jenkins
Foreword by: Phil Gray FCSP (Hon), MSc, BSc
Allied Health Professionals are key healthcare team members in providing safe, quality patient care and appropriate levels of staffing are fundamental to delivering such care. But calculating what are appropriate staffing levels can be extremely difficult. Where do you start? What factors do you take into account? How do you know that you’ve succeeded? This groundbreaking book provides the solution.
Written by two internationally respected and highly experienced AHPs, this book provides a clear and logical methodology for the calculation and determination of safe and effective staffing levels. The authors deliver their findings from extensive research into the existing knowledge base and what is happening worldwide and present the evidence base for their recommendations.
The methodology includes practical tools and techniques which make essential reading for everyone with responsibility for staffing in healthcare. Although written from an AHP perspective, this book is an invaluable resource for all disciplines providing healthcare.
ISBN 978 1 910303 00 9
Published July 2014
Price: paperback/ebook £19.99
Click here for more information
Phil Gray FCSP (Hon), MSc, BSc
I am delighted to welcome this very timely and significant book by Robert and Fiona – two nationally and internationally respected and highly experienced allied health professionals (AHPs) with great expertise – which will assist both United Kingdom (UK) and international AHP managers and leaders and others in one of the biggest health challenges of today … what are the safe and effective staffing levels which will ensure the provision of quality AHP services? And what are the credible methodologies for determining staffing levels given the huge variations that exist in different health settings and between different organisations?
I have been involved in the challenges of workforce planning and staffing levels for AHPs and nursing for over 35 years, most recently during more than 15 years as the former Chief Executive Officer of the UK’s Chartered Society of Physiotherapy, with its 52,000 members. Yet determining staffing levels is neither simple nor obvious, nor is there any standard, nationally or internationally agreed methodology in nursing, medicine or AHPs. If it was that simple, methods would have been agreed years ago. The reality is that the provision of health services differs significantly depending on the hospital or community setting; patient need and level of dependency; patient population, size and turnover; age profile; types of specialties; skill mix; and, crucially, the levels of healthcare funding available.
What makes the whole agenda – and therefore this book – so urgent for AHP managers and leaders in the UK is the recent health scandals centred around inadequate and unsafe nursing staff numbers for care of the rapidly growing numbers of frail older people needing care in hospitals. This has resulted in several hard hitting reports during 2013, including the major Francis Report, plus the Berwick, Cavendish and Keogh Reports. Similar pressures also exist internationally.
The result has been the search for possible statutory minimum staffing levels – which are unlikely to work – or the urgent commission of UK research to agree a new, credible and sophisticated nurse staffing methodology. This could take years to produce.
The other important context worldwide has been the rapid growth in the demand for health services from the population, including older people, during a period of deep economic recession where the UK and other governments are either cutting healthcare funding or, at best, keeping them static while demand escalates.
For the AHPs the challenge is twofold. Firstly, since the national spotlight is on safe and effective nursing numbers, AHP managers and leaders need to be able to challenge firmly any local attempts to improve nursing safety by reductions in AHP staff numbers, making these services unsafe and ineffective. Secondly, AHP managers and leaders need to be equipped with the practical processes and a credible methodology to determine the appropriate safe and effective staffing levels for providing a quality “service for patients locally with all its variations. AHP services have a major part to play in keeping people out of hospital, maintaining their independence or rehabilitating them after injury or illness.
Robert and Fiona’s book is a major step forward for the AHPs in dealing with the immediate challenges they face on staffing levels. It will equip managers and leaders of AHPs and other healthcare disciplines with the means to produce a well argued and credible set of proposals for senior healthcare management. Further national research over the next few years may possibly produce further methodologies, but today, this book is a very welcome and important addition to the literature which fills a gap for all AHP managers and leaders both nationally and internationally.
- List of Figures and Tables
- About the Authors
- Books in the Allied Health Professions Essential Guides Series by Robert Jones and Fiona
- About this book
- Origins of our approach
Key Investigations and Reports
- The Francis Report
- The Berwick Report
- The Keogh Report
- The Cavendish Review
- Wales, Scotland and Northern Ireland
- Other comment and conclusion
Media Focus and Reporting
Where do the Professions Stand? Statements, Publications and Recommendations
- Medical services
- Allied health professions
- An international perspective
Are there Staffing Level Methodologies for the AHPs?
- A case study
6 Methodology for Determining Safe and Effective Staffing Levels for the AHPs – The Jones/Jenkins Approach
- What it’s not
- What is our main aim?
- The four countries of the UK
- Basis of our methodology, the concept – what you do
- The steps for calculation
- The AHP working week in the UK
- Workload data examples
- Example 1 – A typical AHP
- Example 2 – A service department with 10 WTE
- Example 3 – A worked capacity example
- Example 4 – an example from NZ
- Example 5 – an NZ Service with 10 WTE
- Staff activity analysis
- Tips for implementation
- AHP services activity sample pro forma: briefing notes
- The Form Part 1 – General information
- The Form Part 2 – Patient-related activity
- The Form Part 3 – Non-patient-related activity
- The Form Part 4 – About your contracted hours and caseload
- Example of reports from activity sample data
- Data and information management
- Application of activity sampling in the context of staffing level determination
- Average levels of patient-related activity
- Benchmarking AHP services
- Introducing our Benchmarking Tool
- How to use the tool – briefing notes
- The 7-days-a-week question – what staffing level?
- Care pathways in the context of staffing level determination
- Business cases
- Appendix 1 HCPC professions
- Appendix 2 Principles for computerised information systems for AHP services
- Appendix 3 Key elements in a business case
- Elements in a business case – an example
- Appendix 4 Suggested data checklist for AHP managers and leaders
- Appendix 5 Numbers of Hospital Beds and Staff per 1000 population – examples of calculation
Following publication early in 2013 of the independent inquiry into serious failings in care provided by the United Kingdom’s Mid Staffordshire NHS Foundation Trust, the Francis Report,(1) there has been an increasing recognition that appropriate clinical staffing levels are needed to protect patient safety and provide effective, good quality, compassionate care, respecting patient dignity. For the allied health professions (AHPs) (see Appendix 1) this should relate to all areas of service: ward-based, out-patients, community, primary, secondary and tertiary, in all specialties and geographical areas to give assurance that staffing levels are both safe and effective.
Although the main focus on staffing levels nationally has been on nursing services, as a result of the many serious issues set out in the Francis Report,(1) it is clear that patient care requires multidisciplinary and interdisciplinary intervention. There is a risk that staffing numbers in professions such as the AHPs could be significantly reduced, for example, when budgets are under pressure, or during periods of maternity and annual leave, compromising the ability to provide effective treatment and safe care.
For many years it has been recognised within the AHPs that there is need for a robust evidence-based methodology with guidance for the determination of safe and effective staffing levels. In 1991, for example, one of the earliest pieces of work on staffing levels was written and published by the District Physiotherapy Manager for Doncaster Health Authority, Joyce Williams.(2) This booklet arose largely from a series of three workshops which took place in Doncaster in the early 1980s(3,4,5) and has been the basis of much work that has taken place ever since. However, there is no generally recognised and accepted evidence-based methodology in place for use today. Much staffing levels work throughout the National Health Service (NHS) appears to be based on historical perspectives about what went before, ‘rolling the staff establishment over’ each year, increasing or decreasing the number of whole time equivalent (WTE) staff by service redesign and innovation, altering staff establishments almost by estimation or a more or less ‘finger in the wind’ approach and savings requirements – cost improvement programmes (CIP) and cash releasing efficiency savings (CRES). CRES and CIP are often implemented on an organisation-wide basis where a single percentage resource reduction is required ‘across the board’ with seemingly little or no analysis of clinical priority and consequent outcomes. It is true that there is some AHP staffing level determination work taking place in a number of locations, but when viewed nationally, this is on a piecemeal basis, hence the need for an evidence-based methodology for determining safe, effective and appropriate staffing levels.
About this book
Important objectives of this book are to support AHP managers and leaders and all those in other disciplines (including service planners, commissioners and policy makers) working on determining staffing levels to facilitate provision of AHP input, to ensure safe care and effective quality outcomes for patients; to report on our review of work done on this issue to date; to give an overview of the national focus on staffing levels in healthcare and to share widely the methodology and supporting tools which we have developed and used.
Staffing level determination is a complex issue which has a crucial bearing on quality service provision. In this book we do not centre on the many elements which comprise quality patient care – this would be a book in itself. However, if our methodology is implemented the resulting staffing levels in different situations and circumstances will ensure that there is the necessary time to facilitate quality care and enable patients to achieve their goals, while providing treatment with compassion, effectiveness and efficiency and respecting dignity.
In Chapter 2 we summarise the impact of important investigations and reports in relation to NHS staffing levels and in Chapter 3 give a flavour of the widespread comment, argument and speculation on NHS staffing levels in the media, indicating the level of public interest. The focus of Chapter 4 is a review of statements, publications and recommendations about NHS staffing levels, providing an overview of any policies and procedures in place and giving a ‘feel’ for the position of professional bodies and trade unions in healthcare. There is more material available about nursing than any of the other professions, perhaps reflecting that nursing is the largest professional discipline. Medicine and the AHPs are reviewed but there are very few evidence-based policies and recommendations in these professions. International perspectives, particularly in relation to physiotherapy, are also considered in Chapter 4 in order to clarify what we can learn on this topic from other countries.
In Chapter 5 Are there Staffing Level Methodologies for the AHPs?, we report an overview of our scoping work undertaken to investigate whether there is a nationally accepted methodology for determining staffing levels in the NHS AHPs, and to consider various local initiatives and developments over recent decades. As physiotherapy is the largest AHP with a history of some work in this area and as we both have backgrounds in physiotherapy and have managed and led wider AHP services over many years, we used physiotherapy as the case study, but the lessons learned equally apply to the other AHPs.
We present our methodology for determining safe and effective staffing levels for the AHPs in Chapter 6. The processes underpinning our methodology are, firstly, a full assessment of the work which is required to provide a new service, service redesign or review of an existing service: the demand. It is essential that this demand assessment encompasses the many factors which contribute to service quality to ensure that there is enough time for individualised, compassionate care which enables patients to achieve their goals and best possible outcomes. Secondly, calculation and analysis of the ‘average’ annual activity which can be undertaken by an ‘average’ staff member (by grading/band and AHP group) and aggregating this figure by the number of staff required to match the demand: capacity. This indicates appropriate evidence-based staffing levels and also incorporates several factors, such as the amount of time available and use of time, throughputs, skill and grade mix, caseload volumes, dependency and costs.
Origins of our approach
Our staffing determination methodology tool has been developed over many years. It is informed by a range of factors and approaches including our experience in AHP management and leadership working nationally and internationally, our work with professional bodies and membership of various Department of Health (DH) and other working groups. The methodology also incorporates elements of methodologies such as that designed and promulgated by Williams,(2) updated for use in healthcare provision today, together with a series of tools and techniques which we have developed, tried and tested and used in our own management and leadership practice. We have conducted many AHP workshops and masterclasses nationally and internationally, and this has enabled us to learn from others and incorporate their ideas into our work. We have undertaken research, scoping and service reviews and have sought information from many sources in the UK and further afield. In order to gain as much information as possible on methods of determining staffing levels in AHP services, we have studied more than 200 publications, contacted at least 30 organisations in the UK and 25 internationally, as well as undertaking ‘online’ searches. We consider that our methodology is a logical, evidence-based and common sense approach designed to support managers, leaders and all those with responsibility and an interest and who are working in the area of AHP workforce and staffing.
Our methodology will support:
• Evidence-based determination of safe and appropriate staffing levels (workforce design).
• Patient safety.
• Quality service provision and implementation of standards.
• Day-to-day management and leadership and staff deployment.
• Skill mix, case mix work and service model developments.
• Service planning and commissioning.
• Justification of staffing levels.
• Service redesign and innovation.
• Activity analysis and reporting.
• Business cases and cases for change.
• Demand and capacity management.
• Seven day per week service planning.
• Service costing and pricing.
• Resource management.
• Implementation of good quality employment practices.
• Staff learning, development and research and development (R&D).
• Option appraisal.
At the time of publication of this book there is no nationally accepted methodology for undertaking staffing level determination work, nor any guidelines in general use across AHP services. There are no explicit policies or recommendations from professional bodies or Government, although work has taken place on a piecemeal basis for many years. This is a complex area and one that has been the subject of controversy, political ‘standpoints’ and wide-ranging interest from patients and their representative organisations, the media, the public, professional bodies, trade unions and others from both within and outside the NHS. When we were working on final drafts for this book, the parliamentary Health Select Committee published a third report, After Francis: Making a Difference,(6) Section 5 of which covers nursing and healthcare assistant staff in the NHS; clause 141 states:
“The standard procedures and practice (for setting fundamental standards) should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards as well as clinical staff.”
It is not specified which staff groups are included but the term ‘clinical staff’ generally refers to medical, AHP and other direct patient care staff groups. It continues:
“These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration for the benefits and value for money of possible staff to patient ratios.”
In this book we do not recommend national staffing norms, but rather a practical methodology based on sound calculations derived from the evidence from practice. As Robert Francis put it in his recommendations:
“To lay down in a regulation ‘thou shalt have N number of nurses per patient’ is not the answer. The answer is ‘how many staff do I need today in this ward to treat these patients?’ … What we need is evidence-based guidance.”1
Our methodology’‘fits’ with this approach and demonstrates how it can be done. The Government response indicates that they are not supportive of introducing minimum staffing numbers or ratios on the grounds that this would lead to a lack of flexibility in workforce planning. However, the Government endorses Robert Francis’ recommendation that evidence-based guidance should be issued to:
“inform local decisions on staffing levels, and proposes to work with NICE, CQC [Quality Care Commission] and NHS England to develop such guidance. In reference to “the new inspection regime, the CQC will have a remit to inspect staffing levels and to report if wards are inappropriately staffed, and is to require providers to use evidence-based tools to determine staffing numbers.”(1)
The full Government response to the Francis Report1 was published in November 2013.(7) The Government accepted (in full or part) 281 of the 290 recommendations in the report and have asked the National Institute for Health and Care Excellence:
“to carry out a comprehensive review of the evidence relating to staffing levels in the NHS and to evaluate available relevant data on nursing activities at ward level.”(8)
NICE will produce guidance on safe, efficient staffing levels initially focusing on adult wards in acute in-patient settings(8) and then move on to:
• Accident and emergency units.
• Maternity units.
• Acute in-patient paediatric and neonatal wards.
• Mental health in-patient settings.
• Learning disability in-patient units.
• Mental health community units.
• Learning disabilities in the community.
• Community nursing care teams.
Although NICE is only producing guidance about nursing staffing levels, clearly this a much wider NHS issue in the context of safe, effective, quality clinical service provision. The AHPs represent a very significant “level of activity providing many millions of patient interventions annually, which are essential to the provision of quality care. Therefore, we believe that now is the right time for work to be undertaken to provide guidance for these essential, wide-ranging and busy services, and this can be achieved through the adoption of a clear methodology; hence the publication of this book at this time.
1. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 1 January 2005–March 2009 Volume I. Chapter 23. London: Department of Health; 2013. www.midstaffsinquiry.com/assets/docs/Inquiry_Report-Vol1.pdf
2. Williams JI. Calculating Staffing Levels in Physiotherapy Services. Rotherham: PAMPAS Publishing; 1991.
3. Williams JI. No.1 Caseload, Casemix, Workload and Costing. Doncaster Health Authority Physiotherapy Service; 1985.
4. Williams JI. No.2 Monitoring Effectiveness in Physiotherapy Services. UK: Doncaster Health Authority Physiotherapy Service; 1986.
5. Williams JI. No.3 Measuring Efficiency in Physiotherapy Services. UK: Doncaster Health Authority Physiotherapy Service; 1986.
6. Parliamentary Health Select Committee. Third Report. After Francis: Making a Difference. London: UK Parliament; 2013.
7. Department of Health. Hard Truths; the Journey to Putting Patients First. The Government response to the mid Staffordshire NHS FT Public Inquiry. London: HMSO; 2013. www.gov.uk/government/organisations/department-of-health