Recruitment and retention of staff in the NHS is an increasingly pressing challenge, with around 100,000 advertised vacancies and an NHS-wide nursing vacancy rate of around 11%. With demand increasingly outstripping supply, NHS staff are working harder than ever. This has begun to take its toll, with NHS staff survey results reflecting the level of strain the workforce is under, and staff wellbeing and engagement declining – 57% of staff said they have gone to work despite feeling too unwell to perform their duties, and over two thirds feel there are not enough staff at their organisation for them to do their job properly.
The interim NHS people plan sets out a strategy to tackle these issues, from developing a 'new offer' for NHS staff, to bolstering continuing professional development (CPD) funding and increasing the supply of newly qualified staff through higher education and alternative training routes. The government announced in the recent spending round that nurses would receive £1000 each over the next three years for CPD. Additionally, local systems are beginning to collaborate on developing an offer for staff to encourage them to join and stay in the system – using system working as an opportunity to create a more varied offer for staff, as well as joining forces to attract people to the system.
Creating a system as a place to work
A traditional workforce model encourages staff to develop a sense of belonging to a single organisation. System working now asks staff to think in a different way. Given the behaviour and cultural change this demands, system leaders are working to ensure it is underpinned by a sense of security and support to build the skills and relationships needed to work in this way. To maintain morale and engagement, systems need to create an environment in which working for a system or place enables the same degree of engagement, satisfaction and feeling of belonging for the workforce that organisation-based working offers.
This includes fostering a culture in which system working is the norm and leading by example, with close collaboration among senior staff in the system. Some trusts are working with partners to align terms and conditions to reduce local competition and streamline recruitment processes to support future potential flexible working arrangements. Others are collaborating to develop an offer for staff which promotes their system as a good place to work, regardless of the organisation they are working within.
Organisations with severe workforce challenges may struggle to collaborate on recruitment when faced with an urgent need to address their own staff shortages. In an environment in which an overall shortage of staff leaves trusts competing for an insufficient number of people to fill a growing number of vacancies, trusts are increasingly seeking efficient ways to join resources, both to bolster the local campaign to bring people into the system, but also to underpin future flexibility in ways of working. It is also a conduit for organisations to build relationships around a shared aim to increase the size of the workforce.
In areas where shortages are concentrated – particularly rural areas – it isn’t enough to incentivise people to join a trust as an employee. Promoting the NHS as a good employer also needs to be underpinned by work to promote the local area as a good place to live. Initiatives to promote the system as a place to work can act as a draw to then recruit staff into trusts in the local area, supported by joining resources and local knowledge to promote the benefits of living in a local area – something a national or even regional campaign cannot reliably do for every part of the country without the intimate familiarity with places held by those working and living in them day-to-day.
Not only are trusts looking at ways of working within their STP or ICS to draw people into their patch, they are also increasingly looking to work alongside local education institutions including colleges and schools to promote local employment and contribute to increasing opportunities for young people in their local area, where there is demonstrable evidence that doing so improves retention.
Cambridgeshire and Peterborough STP
In the Cambridgeshire and Peterborough STP, the system partners work as a system delivery unit to support workforce related projects at a system level. The system developed a memorandum of understanding (MOU) to enable staff to work flexibly across the system. Members of staff are employed by their own trust, but the MOU enables mutual recognition of staff credentials and assurance of skill and competence, removing some of the barriers to sharing resource and staff passporting.
In support of a system-wide approach to recruitment and resource, the STP has developed a system-wide branding and attraction project across health and social care, to attract staff to work in the system and place, rather than simply one organisation. Borne out of recognition of the need to reduce competition between local employers and combine forces to attract people to the area, in a truly collaborative way, system partners developed a promotional film and microsite, illustrating the benefits of coming to work in Cambridgeshire and Peterborough in health and social care. This project was launched publicly in a shopping centre in Peterborough to raise awareness of the campaign.
The STP has also done extensive work around collaboration on apprenticeships. Currently reinvigorating the widening participation agenda, trusts in the region have agreed to implement an apprenticeship collaborative to maximise levy spend, including increasing access to levy funds by employers who don’t currently pay it. This has included jointly running recruitment events in the system, and linking up workforce planning colleagues to identify and address recruitment hotspots for specific roles, in particular radiographers. System partners recognise the value of the apprenticeship levy and apprenticeships themselves, and the initiative to work collaboratively across the system aims to maximise the opportunities while tackling some of the complexities of using the levy in full.
All system partners are engaged actively in plans to ensure a whole system recruitment week to coincide with national apprenticeship week in early 2020, offering a range of exciting events to schools, colleges and the wider public, to promote the region and diversity of careers on offer.
Greater Manchester Health and Social Care Partnership
The Greater Manchester Workforce Collaborative is developing an employment offer, promoting Greater Manchester as an attractive place to work to support recruitment and retention in the region.
More than 30 public sector employers across Greater Manchester signed up to a continuous service commitment where staff can keep their service related benefits such as annual leave entitlement sick pay and maternity schemes when they move between organisations which have adopted the commitment, to enable flexibility to move between organisations.
There have also been over 5,000 public sector apprenticeship starts since the introduction of the apprenticeship levy in 2017 and this is rising, with 20% more starts in 2018/19 compared with the previous year. Four local authorities and three trusts have met the 2.3% public sector apprenticeship target during this period.
The system has developed a more coordinated approach to apprenticeships, resulting in four times as many individuals undertaking apprenticeships in the year to March 2018. The work included a public sector network to share good practice and discuss opportunities for collaboration across the system, carrying out joint tendering across boundaries to improve negotiating apprenticeship training contracts and offer a more varied experience for learners, and an MOU to agree that Greater Manchester’s public sector organisations will pay the national living wage for all apprentices.
A Greater Manchester-wide career and jobs fair in April 2019 for general practice, pharmacy, dentistry and optometry engaged 300 members of the public and over 40 exhibitors from a wide range of sectors connected to primary care. A joint recruitment campaign across Greater Manchester in June 2018, Be a Greater Manchester nurse, brought together trusts, GP practices and the independent care sector to promote Greater Manchester as a place to study and work as a nurse. This formed part of the wider nurse incentives programme which was developed to reshape the support nurses receive in the area, including a guaranteed employment scheme for nurses who complete their studies in Greater Manchester. This programme is system led and by the Greater Manchester project management office (nursing, midwifery and allied health professionals) hosted at Manchester University NHS Foundation Trust.
Through the work of the Greater Manchester project management office (nursing, midwifery and allied health professionals), Greater Manchester saw a 3% increase in the number of pre-registration students starting nursing programmes in the academic year 2017/18 compared with 2016/17, in the context of a 6% fall in starters nationally.
Enabling staff to work across the system
In a climate of severe workforce pressures, and where there is an overall shortage in many professional groups, trusts can find themselves competing locally to recruit and retain staff. Incentives for staff to come and work in one trust may disadvantage another nearby. Trusts are cognisant of the local system dynamics of recruitment and retention that make filling workforce gaps a process of give and take between organisations competing for the same insufficient supply of staff.
While collaborating on recruitment and retention is one way to help trusts reduce unhelpful competition for staff, flexible working within systems through passporting arrangements, shared staff banks, or enabling staff to develop portfolio careers, are some of the ways trusts are working with their partners to take a system-wide view of what the workforce needs are and how they can be met with existing resources.
With increasing flexibility of roles, there is also an opportunity for staff to develop 'portfolio' careers, moving between roles and sectors where initiatives such as staff passporting arrangements allow staff to move from one organisation to another without changing employers. This enables staff to develop a wide range of skills and experiences, which benefits their experience of working in the NHS, but also enriches the skill mix of the workforce, and supports cross-sector relationships. There is potential for closer working to either help fill rota gaps or lessen their impact.
South London Mental Health and Community Partnership
South London Partnership’s (SLP) three trusts Oxleas NHS Foundation Trust, South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS trust, looked to improve career and development opportunities and working environments for clinical staff as part of its nursing development programme.
Staff moving to new permanent roles or secondments in different trusts faced a long wait and delayed start to their new role, and so were not motivated to stay within SLP trusts. The time taken to fill posts can affect care continuity and become costly with agency cover often required. The partnership aimed to offer staff flexibility to move easily, quickly and promote the trusts as attractive employers.
The partnership developed an 'employment passport', which allowed staff to move between trusts easily. Several processes were redesigned as part of the work, including:
- Pre-employment checks – confirmation that they have been completed by the original
employing trust, and are clear with the individual approved to work. Trusts retain their
own approaches to managing anomalies safely.
- Mandatory and statutory training – common areas do not need to be repeated providing
the training is current, regardless of variations in delivery, and additional courses are only
required where training is out of date or specific to the new employer.
- Appraisals and development records – individuals are invited to share records of their
performance appraisal and development review with their new employer to continue
their development path. The nursing development programme has introduced a shared
career ladder for band 2 to 6 nurses across the trusts.
Ensuring safety throughout the recruitment process was essential. Each trust remains responsible for providing a safe workplace and the passport does not override this. It provides an alternative streamlined process for most transfers between SLP trusts. Variation in mandatory and statutory training was a challenge, for example only one trust has a mandatory smoking cessation course. It was not manageable to harmonise each course and so a more pragmatic approach was taken which respects each trust’s individual position.
Staff can now move across trusts into new jobs or secondments up to 75% more quickly and initial evidence suggests it is effective for trusts to move quickly between trusts. While the passport was originally aimed at nurses, other clinical and non-clinical groups have benefited.
Learning points include the importance of senior management’s support, and a culture that is positive about change. Ongoing work helps ensure managers understand that the passport does not devalue previous checks, and SLP will continue to review the initiative.
West Yorkshire Association of Acute Trusts
West Yorkshire Association of Acute Trusts (WYAAT) is a collaboration of six acute trusts in the West Yorkshire and Harrogate ICS, Airedale NHS Foundation Trust, Bradford Teaching Hospitals NHS Foundation Trust, Calderdale and Huddersfield NHS Foundation Trust, Harrogate and District NHS Foundation Trust, Leeds Teaching Hospitals NHS Trust and Mid Yorkshire Hospitals NHS Trust, that are working together on behalf of patients to deliver the best possible experience and outcomes. Their philosophy is that WYAAT is the combination of the trusts not a separate organisation and have been working together to make decisions for the benefit of the system, and to remove barriers to flexibility for staff to move around the system. Work has included developing collaborative arrangements for staff passporting, standardised job descriptions and a shared medical staff bank.
The hospitals have developed a portability agreement, which will form part of the NHS Improvement staff portability toolkit. In particular, the trusts are currently looking to enable flexible working across pathology and vascular services, but all clinical services have embraced the agreement immediately improving patient care.
In support of this work, the trusts working across the ICS have also undertaken work to standardise job descriptions. After learning that there were 27 job descriptions available in the system for a single role, they carried out analysis of the similarities, differences and language across the descriptions, and created a standard description using the commonalities, adding an addendum of specialist duties as necessary. The system is now looking at how staff in existing roles can be moved over to the new job descriptions, supported by extensive conversations and moving slowly and testing as they go to enable staff to feel confident in the process.
While moving money around the system and sharing staff rosters was uncomplicated, there were challenges around liability to address. Staff remain employed with a host organisation and as part of a portability agreement there was a need for a degree of trust in other organisations’ hiring, disciplinary and performance management processes. This was achieved by a focus on normalising collaboration, and sharing and learning from one another in order to build relationships. Underpinning this is ground work to develop the culture and behaviours needed to help people understand the role they play in forming a system, so that they do not feel like change is being forced upon them, and they can feel empowered to be part of it.
The system is now on a good trajectory, with a culture in which organisations work on the principle that it is better to do something together once, rather than do it individually six times. While the environment of competition has meant that people working in the system have often felt isolated, enabling people to spend time with their peers gives them an opportunity to tackle challenges and leads to a sense of energy.
Working together to fill rota gaps
Trusts are increasingly seeking to collaborate on staff banks, both to reduce agency spending and to share resources. The vast majority of trusts use staff banks, and in some STPs and ICSs trusts are connecting their staff banks, giving staff more flexibility, making more effective use of workforce capacity across the system, and reducing agency spend across trusts by increasing the fill rate via bank.
Trusts using shared staff banks describe the benefits of developing a system-wide overview of rota gaps and bank staff availability. Models such as these can help reduce duplication of induction, employment checks and occupational health checks across trusts, and supply more robust information about the working patterns of staff who may otherwise be signed up to banks across multiple trusts as well as employed in a substantive post in one trust.
Rotherham NHS Foundation Trust
Within the South Yorkshire and Bassetlaw ICS (SYB ICS), trusts have come together to develop a shared nursing/non-medical staff bank as well as piloting of a medical collaborative bank. The six acute trusts in the ICS delivered a collaborative recruitment exercise for nursing/non-medical bank and agency cascade service in 2018. This led to NHS Professionals being appointed as strategic partner. Subsequently the trusts have also implemented collaborative bank model Bankshare, as well as supporting increased agency control and reducing unwarranted variation in processes.
The trusts have agreed not to employ staff members through an agency if they already hold a substantive post at one of the partner organisations, instead using only the collaborative staff bank. This will have the effect of enabling greater visibility of how many hours staff are working, and reducing both overall agency spend, and off-framework agency usage.
The medical bank pilot has been taken forward by four of the trusts in SYB ICS supported by a common master vendor agency, Holt Partners Ltd. This has been in place since May 2018 with an evaluation underway to inform ongoing participation and wider engagement across the system.
Challenges included the move from a competitive agenda to a more collaborative environment. Workforce is a key issue in terms of collaboration, due to the limited supply of staff in relation to the number of vacant posts. In a competitive environment, there are fewer incentives to take a system view of workforce supply, and trusts compete for staff. Building organisational readiness to collaborate is underpinned by effective system level governance, a focus on relationships and programme facilitation.
Collaborative banks depend on the alignment of systems and processes between the trusts involved. This includes skills and training requirements for staff across trusts, rates of pay, terms and conditions and role descriptions, and the larger the group of trusts using the shared bank, the more time it can take. Trusts implementing this model often describe working in phases, starting with a few neighbouring trusts before engaging more widely across a region with multiple sectors.
Royal Wolverhampton Trust
The Royal Wolverhampton NHS Trust, part of the Black Country and West Birmingham STP, has collaborated with trusts across the system on exploring options for a joint staff bank, which aims to enable staff to work more flexibly across the system.
They are looking to develop a collaborative nursing staff bank in three tiers, working locally with Walsall Healthcare NHS trust as the first tier, reaching out more widely to HR directors across the Black Country to develop a proposal for a system-wide bank. The trust is working across the West Midlands, as the third tier, to explore the potential of a medical staff bank. The local, system and regional approach has made varying levels of progress and the trust has found it easier to progress a smaller scale collaborative bank in the first instance than the medical staff bank across the region.
Building relationships and trust within the system has been a key enabler, as creating any form of joint staff bank requires trusts to be comfortable with letting staff go to other trusts in light of their own workforce pressures, as well as a need to trust the recruitment processes of other trusts and the qualifications of their staff. The work has progressed through slowly building relationships and developing people’s thinking and readiness, rather than making bold moves from the top down.
Some of the considerations include variation in the rates trusts pay for bank shifts, as well as the different systems for rostering the trusts are using, especially given the financial burden of purchasing a new system. Different models of care also add to the level of complexity of sharing staff between organisations. With different levels of vacancies and workforce pressures, the incentives to collaborate on workforce initiatives vary and garnering the political will to engage is more challenging.
Trust leaders feel that system-wide regulation may support the progress of system working. The trust has reduced its own turnover, but is conscious that this has potentially happened in part at the expense of other trusts whose staff have moved to the Royal Wolverhampton NHS Trust. Measuring trusts’ performance as part of the system was felt to be a potential incentive to progress system working and reduce the need for organisations to focus inwards.