Report to: Board of Directors

Date of meeting: 29th October 2012

Title of paper: EMERGENCY DEPARTMENT WORKFORCE STRATEGY

Time required onagenda:

15 minutes

Executive Summary:

This paper sets out a revision to the strategy for reforming the Emergency Department (ED) workforcemodel. This strategy works in conjunction with the originally agreed business case and aims to continuethe improvements and efficiencies already shown within the ED.

This paper proposes:

To allow the service director independent control of staffing and recruitment within ED, tooreduce reliance on agency nursing and locum medical staff.

To utilise the current variable pay budget and authorised overspend to establish funded nursepractitioner posts, thus reducing overall expenditure and improving quality and efficiency throughimproved continuity of staff.

To release senior clinician time to ensure the delivery of patient safety, quality and training.

This proposal represents cost avoidance of approximately £300k and the delivery of CQUIN 11 (theoperationalization of a Clinical Decisions Unit (CDU)) income of £600k.

The Drivers are as follows:

Patient volume – patient numbers have increased from 77,000 (2010) to a forecast of 93,000 forthis year at KMH.

Patient acuity –a shift from 27.5% major/resus patients to 35% this equates to an averageincrease of 30 major/resus patients daily.

The Risks identified and addressed within with this workforce strategy review are:

Clinical

Evidence of 3 significant missed fractures within a 2-3 week timeframe all involving locumdoctors

Evidence of near miss incidents involving the unavailability of senior clinical review Increase in complaints within paediatrics all involving locum doctors and nurses Lack of compliance with infection control policies involving agency nursing staff Increased time to be seen by a clinician correlating with times that locum doctors are on rota Sustainability of single point of access compromised due to lack of senior clinician to review on

discharge The successful operationalization of CDU relies totally on senior ED clinical decision making to

identify patients suitable for the pathways,

Workforce

Recruitment and retention of consultant posts at risk due to internal pressures e.g. loss of 2consultants within a 6 month period, increased workload and external competition,

Internal Deanery report highlighted stressful working conditions within the ED,

Junior medical workforce not receiving appropriate level of support during placement, Increased levels of sickness and absence directly cited as work related stress, National and regional shortage of ED doctors

Performance

4-hour target Time to see clinician Operationalisation of the CDU Financial Compliance against CQC standards

The evidence shows that the increased dependence on locum medical staff and agency nursing iscreating risks to clinical safety, the quality of care and the performance against the urgent carestandards.The purpose of this business case is to ensure that each patient is seen by the most appropriatelyskilled clinician, in the most cost effective way. This in turn will release senior medical staff to optimisetheir skills within the majors and resus setting and the support of supervision of doctors in training. Thesustainability of this model is created by the employment of Advance Nurse Practitioners to support themajors workstream and Emergency Nurse Practitioners to focus on all minor injuries, including children.This ensures delivery of a high quality, clinically safe service whilst addressing the current overspend.

This paper has previously been considered on two occasions by the executive management committeeand has been agreed for submission to the Board of Directors.

The Board of Directors is requested to:Approve investment of £348k to Ed nursing establishment

Next Steps/Action:Recruitment and mobilisation.

Person presenting paper(name / title):

Dr Ben Owens, Service Director for Acute and Emergency Medicine;Julie Dixon, Head of Nursing for Emergency Care

Originator of paper (name /title):

Dr Ben Owens, Service Director for Acute and Emergency Medicine;Julie Dixon, HoN, Emergency Care; Pam Duro, Service ImprovementSupport Officer.

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DIVISION OF EMERGENCY CARE AND MEDICINE

REVISED EMERGENCY CARE CENTRE WORKFORCE STRATEGY - PILOTSeptember 2012

1. INTRODUCTION

This paper sets out a pilot revision to the strategy for reforming the Emergency Care Centre (ECC)workforce model. This strategy works in conjunction with the originally agreed business case andaims to continue the improvements and efficiencies` already shown within the ECC.

The strategy focuses on the development of an emergency care pathway for the non-elective patientsattending Kings Mill Hospital, including:

Addressing the on-going difficulties with the recruitment of senior medical staff within theEmergency Department (ED); and advocating the use of agency locum medical staff financialresource, to appoint Advanced Nurse Practioners (ANP’s) and Emergency NursePractitioners (ENP’s) therefore avoiding cost pressures.

The operationalisation of a Clinical Decisions Unit (CDU) model within the EmergencyAssessment unit (EAU) facility.

The timely recruitment to the nursing establishment within the ED.

Drivers for Change

The fundamental driver for this case is the need to improve the quality of care provided for all patientsadmitted on the non-elective pathway, taking into account the following:

1. Demand for emergency services: the growth observed since January 2010 is illustrated in Figure1.

Figure 1

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This is accentuated by evidence showing an increase in the acuity of those patients attending, thetable below represents the shift in acuity of patients i.e. the increase percentage of major patients.These patients require increased input and time from both medical and nursing staff. The criteria forallocating patients into the major category has not changed.

Figure 1:2: KMH ED acuity change1. Figure 1:1: KMH ED attendances

Within the emergency department there have been an increase of 10.3% in the number ofattendances compared to 2010/11, year to date there has been an additional increase of 8%. Therehas also been a shift in case mix presentation, with major presentations having increased by 17.7%from 2010/11 which has been sustained through the current year, as demonstrated in Figures 2, 2:1.

Patientcategory May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12% Major+ Resus 27.50% 27.82% 27.83% 28.57% 27.53% 29.34% 34.27% 36.58% 36.01% 35.67% 33.39% 35.72% 34.93% 35.09%

% Minor 58.34% 58.17% 58.77% 58.22% 56.81% 54.74% 49.53% 47.43% 45.77% 46.34% 47.67% 47.49% 45.93% 47.54%

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2. Recruitment process within the ED

3.1 Extended gaps in rotas; which is exacerbated by the recruitment process.

All of these points results in high usage of agency staff, at over double the cost of substantive posts.Overall this again represents an inefficient use of Trust resource and poor quality service provision.

3.2 Proposal to allow Service Director autonomy of management with service budget.Once the overall budget has been set and recruited to autonomy be granted to the service director tomanage staff changes within the approved budget as he sees fit to manage the safe running of thedepartment. This includes authority to move spend within the budget without recourse to othermanagers assuming the budget is managed within agreed expenditure limits and appropriate HR dueprocess for recruitment is followed.

3. The workforce model will facilitate the operationalisation of CDU

The model will improve the overall quality and efficiency of the ECC by ensuring timely assessmentand treatment, avoidance of unnecessary admissions and identification of an appropriate stream ofpatients for the CDU. This in turn will result in a reduction in admissions to in patient wards, thedelivery of CQUIN 11 and an increased income via the ambulatory tariff. The value of this CQUIN is£600k.

The recommendations included in this document describe how the Emergency Department medicalstaffing model can be best designed to respond to these multiple pressures.

Whilst investment is required in this proposal, it is offset by reduction in the use of locum medical andnurse agency and the delivery of a consistent, high quality service.

2. CURRENT SERVICE AND PROPOSED DELIVERY OF SERVICE

Within the Emergency Department, the April and May 2012 cost for additional medical agency tosupport the increased capacity was £75k therefore this extrapolated is £453k See Appendix 6 . Thisresource has been essential to the delivery of the 4-hour target since December 2011, on theoccasions that the resource has been withdrawn the department has failed to achieve 95% patientsprincipally breaching waiting to be seen by a clinician Figure 3. Following an in depth, 6 monthanalysis of the breaches of the 4 hour target, time waiting to see a clinician consistently appears asthe highest ranking reason, with 25% off breaches occurring as patients wait to see a clinician,predominantly these breaches occur late evening and early morning (i.e. pre and post midnight).

Figure 3: Additional medical resource and breach correlation through June 2012.

Breaches due to Trustcapacity

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An analysis of minor and paediatric attendances to the Emergency Department during April 2012,highlighted that 58% of patients currently being seen by a doctor could have been seen by analternative practitioner i.e. an ENP (appendix 7). These patients will have been seen by either locumdoctors, middle grades or consultants, which is often to the detriment of the majors workstream. Thismodel seeks to sustain the “Right Person, Right Place” philosophy and will facilitate the single pointof access model (SPoA) and the facilitation of a clinical decisions unit (CDU).An essential aspect of the service model is that senior clinicians are able to review majorpresentations to ensure appropriate and timely decision making and outcomes.

The increase in the number of majors presentations, has placed additional pressure on the medicalworkforce to see patients in a timely manner. As part of the previous workforce strategy 3.0 WTEadvanced nurse practitioners (ANPs) were employed. This proposal aims to increase the number ofANPs, thus creating a consistent and reliable workforce. The ANPs will also be an integral part of thedevelopment of the operational element of the CDU, as these are the target group of patients for thisworkforce.

It is now well recognised both regionally and nationally that there is a shortage of emergencydepartment middle grade and junior medical doctors; this has recently been reiterated at theDeanery. This can be seen in the recent SHA cluster report dated 18.05.12, detailing medical staffingshortages in the East Midlands. This has resulted in a reliance on locum staff. There is inconsistencyin clinical competence, efficiency and reliability resulting in a requirement for increased supervision toensure that quality and safety standards are maintained. It is also nationally recognised that trainingdoctors are currently citing stress to the Deanery as a result of the increased demand for emergencyservices. There is also evidence that junior doctors feel more supported by substantive emergencydepartment staff. This has been confirmed by feedback from our own junior doctors. This model aimsto also support the junior medical doctors and nurse practitioners, thereby creating a sustainablefuture workforce model.

This alternative model is sought to ensure the delivery of a stable and consistent service whichfocuses on clinical quality and the delivery of the urgent care standards. By following the RightPerson, Right Place philosophy, the model should ensure timely assessment and treatment of allpatient groups and release senior clinicians to focus on appropriate decision making including thefacilitation of the CDU model.

Section 3 of the original workforce strategy references the increased value for money deliveredthrough this model. See enhanced excerpt below.

Staff Group Productivity

Middle Grade locum Minors £57.50 (cost per patientper hour)

Majors £92.00 (cost per patientper hour)

ANP Minors N/A Majors £36.95 (cost per patientper hour)

ENP Minors £21.63 (cost per patientper hour)

Majors N/A

Band 5 RGN (Trust) (No Enhancements) £15.00 (Enhanced) £17.50

Band 5 RGN (Agency - NP) (No Enhancements) £39.00 (Enhanced) £48.00 (BH)£57.00

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3. RECOMMENDATIONS

The Division of Emergency Care and Medicine seek support from the Executive to implement thefollowing recommendations:

i. Temporary Vacancy Cover and Timely Recruitment Backfilling maternity leave with fixed term contracts and secondments will help redress both

quality and cost concerns. Timely recruitment into vacant posts will ensure there are minimal rota gaps post resignation. Funding: the reduction in agency spend will support funding the policy of covering maternity

leave within the ED. It is recognised that once agreed and staff are fully recruited to costs will have to be managed

within agreed budgets by the service line.

ii. Additional ENP Appendix 7 evidences the demand for an additional 3 WTE ENPs. This is the most cost

effective and best value service for minor injury patients. ENPs are specialist serviceproviders for this group of patients.

iii. Additional ANP There is scope to improve the clinical quality and efficiency for patients within the majors

workstream by replacing locum medical staff with ANPs. Funding: as previously stated, the department is currently overspending on additional agency

locum staff to manage the increased capacity within the majors workstream. The ANPproposal would be offset by the current overspend on these additional posts.

Recruitment to these recommendations supports the “Right Patient, Right Place, Right Time”philosophy. It will ensure that senior medical staff are available to assess and manage the complexityof the patient who present through the major workstream. It will optimise the delivery of admissionavoidance at the front door and the development of a CDU/ambulatory care model. Essential todeliver the CQUIN 11 income of £600k.

The workforce model also supports the specialist pathways i.e. acute stroke and trauma. It alsosupports the education and training of both ANPs and junior doctors and addresses issues raisedthrough the Deanery. The improvement in the quality of care delivery will be evidenced through theconsistent achievement of the Urgent Care Standards.

In the current climate this is a suitable alternative model to the delivery of safe and effectivehealthcare at the front door. By investing in substantive posts in this area the creation of asustainable, efficient and effective workforce will ensure that future service provision is notcompromised.

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4. PROJECTED COST SAVINGS

Emergency Department ClinicalThe current additional resource (medical staffing) utilised to achieve the 4-hour target in two monthsalone is £75k (April/May2012). This additional resource has been in place since December 2011 andextrapolates to £453k per year. The department has stress tested this arrangement and where thepost has been withdrawn there is a direct correlation with a fall in performance.

Emergency Department NursingSix month agency expenditure within the ED has a cost implication of £300k, (£600k FYE) byallowing the department to recruit to vacancies as they occur, recruit to temporary leave e.g.maternity leave thereby being allowed to recruit to all established posts in a timely manner, the costof agency will be reduced by an expected 80%, a saving of £480k.

The additional resource requested in order to sustain this level of activity and income growth is offsetby the current overspend, thus creating a total cost avoidance of approximately £300k.

5. RISK AND BENEFIT ANALYSIS

Support of this pilot will mitigate the following risks:

1. Reduction in quality of care

2. Failure to achieve the 4-hour target

3. Failure to achieve CQUIN 11 (Cost implication of £600k)

4. Failure to sustain income growth

5. Overspend of operational budget

6. Reduction in training posts due to poor educational feedback to the Deanery

The main benefit from supporting the pilot will be a better quality of care for patients delivered bybetter quality people.

Other benefits:

1. Financial delivery of CQUIN and reduction in agency spend

2. More robust operating environment in which to deliver junior doctor training.

Implementation Risks

Risk Probability Mitigating ActionsInability to recruit Unlikely High demand for posts within ED and EAU from

high calibre staff. Timely recruitment process.Training posts for both ENPs and ANPs

ED activity levels may reduce Very unlikely ED presentations continue to rise despitecommunity initiatives to reduce the number ofpatients.

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6. KEY PERFORMANCE INDICATORS

Performance Indicator Measure of success Timeframe

Total time in A&E % within 4 hours Kings

Mill

95% of patient presentations to the

ED department are seen, admitted

and/or discharged within 4 hour

period. Excluding patients who

breach awaiting a bed.

Immediate

Median time to treatment from arrival to

treatment

Decrease time to treatment for all ED

patient groups

3 months from appointment of

staff

Increased number of paediatric/minor injury

patients being seen by ENP

More minor injury/paediatric

patients wil be seen by an ENP

3 months from appointment of

staff

Increased number of major category

patients seen by and/or reviewed by an ED

consultant

Senior clinical decision makers will

see more patients within majors

3 months from appointment of

staff

Increased number of minor injury/paediatric

patients "Seen and Treated"

Minor injury/paediatric patients who

are seen and treated by the same

clinician

3 months from appointment of

staff

Reduction in the number of agency nursing

and locum medical staff

Reduced costs of agency nursing and

medical staffing.

2 months from recruitment

into substantive posts

Risk to non-delivery of above targets: Delays in recruitment

Staff retention

Trust capacity and flow

Increased demand above current levels

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APPENDIX

1. ED TREND ANALYSIS – 6 monthly analysis

Metric Dec 10 to May 11 June 11 - Nov 11 Dec 11 - May 2012Attendances 42897 43699 45176Percentage increase on preceding 6months 1.87% 3.38%

2. CONTRACT MONITORINGThe following table sets out the income and activity trend for the previous 2 years as well this thisyear to date (mth 3) and includes King’s Mill ED and Newark Minor injuries unit.

3. MONITOR ACCESS TARGET PERFORMANCE

3.1 Performance against 60 minute standard, 22 June – 5th August 2012

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3.2 Performance against 15 minute clinical assessment standard, Feb 2011 - June 2012

0

10

20

30

40

50

60

70

Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12

Axi

sTi

tle

Time to initial assessment (95th percentile) for ambulance arrivalsto A&E to be seen within <=15 minutes

Target

Minutes

4. Case mix change in ED, April 2011 – June 2012

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5. Attendances

A&E YTD % ATTENDANCES FOR KINGS MILL AND NEWARK SPLIT 2012

APRIL MAY JUNE JULY TOTAL TOTAL %TOTAL

ATTENDANCES

KM < 4 HRS 7447 7630 7226 7907 30210 94.93% < 4 HRS 37927

KM > 4 HRS 296 288 636 395 1615 5.07% > 4 HRS 1659

TOTAL 7743 7918 7862 8302 31825 100.00% TOTAL 39586

NE < 4 HRS 1808 1954 1918 2037 7717 99.43% % < 4 HRS 95.81%

NE > 4 HRS 15 12 8 9 44 0.57% % > 4 HRS 4.19%

TOTAL 1823 1966 1926 2046 7761 100.00% TOTAL % 100.00%

LESS THAN 4 HRS FOR KINGS MILL = 94.93%

LESS THAN 4 HRS FOR NEWARK=

99.43%

LESS THAN 4 HRS FOR SFH = 95.81%

6. Financial Summary

EMERGENCY CARE & MEDICINE DIVISION

EMERGENCY DEPT. WORKFORCE MODEL

NURSE FUNDING REQUIREMENT

E.D. Nursing £000

2012/13 Expenditure Forecast 3,351

2012/13 Annual Budget 2,829

Cost Avoidance 522

Investment Required 348

Net Benefit 174

Investment Required WTE £000

ANP 3.00 174

ENP 3.00 174

6.00 348

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7. Audit of Possible ENP Patients - April 2012

Patient Group Total %

Minors 3050 79.78%

Paeds 773 20.22%

Grand Total 3823

Seen by

Minors Paeds Grand TotalTotalAtts %

TotalAtts %

TotalAtts %

ENP 1005 32.95% 218 28.20% 1223 31.99%Doctor 1714 56.20% 523 67.66% 2237 58.51%Not Specified 271 8.89% 14 1.81% 285 7.45%Other 57 1.87% 18 2.33% 75 1.96%Not Seen by EDDr 3 0.10% 0 0.00% 3 0.08%Grand Total 3050 773 3823

31.99%

58.51%

7.45%

1.96% 0.08% Grand Total

ENP

Doctor

Not Specif ied

Other

Not Seen byED Dr

32.95%

56.20%

8.89%1.87% 0.10% Minors

ENP

Doctor

NotSpecified

Other

Not Seenby ED Dr

28.20%

67.66%

1.81% 2.33% 0.00%Paeds

ENP

Doctor

NotSpecified

Other

Not Seenby ED Dr

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8. Workforce Efficiency Comparison

Nursing Establishment Efficiency Comparison. Comparison WTE and WTE: Per patient ratio

Band7

Band6

Band5

Band3

Band 2(Inc

clinicaladminroles)

TotalRGN

TotalUnregistered

Pt PerYear

Pts peryear: WTERegistered

Nurse

Pts per year:WTE

unregistered

KMH 9.6 11.55 27 8.8 14.22 48.15 23.02 95000 1973 4127

QMC 22.73 18.54 114.53 21 52 155.8 73 180000 1155 2466

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Medical Establishment. Comparison WTE and WTE: Per patient ratio

Consultant(WTE)

Consultant(Hrs/Day)

MG(WTE)

MD(Hrs/Day)

JnrDr/ANP(WTE)

JnrDr/ANP

(Hrs/Day) ENP (WTE)ENP

(Hrs/Day)

Total Hrsper day -

cover Daily Pts

Pts perclinicancover

per day Pts : YearPts:WTEClinican

KMH 5.5 18 6 54 12 61 6 30 163 260 1.60 95000 3220

QMC 18 11 34 16 493 180000 2278

DRI 40 60 92 34 226 340 1.50 124000

CRH 16 40 56 20 132 175 1.33 64000