Mel was bringing a creative solution to a wicked problem.
Quality improvement is about giving the people closest to issues the time, permission, skills and resources they need to solve them. Through this quality improvement programme using North Bristol NHS Trust's (NBT) Patient First improvement methodology, Melanie Murrell (associate director of nursing workforce recovery) was able to come up with a creative solution to a challenging problem. This quality improvement project is aligned to NBT's sustainability priority in making the best use of their limited resources together with providing high quality care to their patients and people priority.
The trust implemented a bank 'break glass' rate which was higher than their usual bank rate and could compete with the OFA rate, which would help the trust achieve its aims of reducing the number of Off Framework Agency (OFA) nurses and replacing them with 'break glass' rate nurses. At the time they devised the rate, it was quite unprecedented, substantially higher than the 'Agenda for change' standard hourly rates. The intervention also needed to not be detrimental to their system partners who were also facing similar challenges.
The overall strategy involved a phased approach:
- First phase – Removing tier 4 OFA using the 'break glass rate'.
- Second phase – Focusing on reducing use of general agencies.
- Third phase – They are currently working on reducing specialist agencies.
- Fourth phase – Reducing bank fill due to bank staff being recruited into substantive posts.
This solution considered the different motivations for staff in choosing to do additional bank/agency shifts. The solution allowed staff with specialist skills to feel rewarded and valued for that experience.
As such, the trust developed a solution which met their improvement priorities, was attractive to staff, financially sustainable with the same robust level of control as OFA to maintain efficacy and could be adopted across system partners.
Engagement
A crucial element of this work was engagement with unions and staff affected, as well as close collaboration with colleagues in the trust's finance and HR departments. The nursing team was the driving force behind the intervention, with critical support from the finance team on data, and from the HR team particularly around the approach to bank staff. The time spent engaging with different stakeholders was well spent as it gave the team credibility and raised confidence in their ability to deliver.
Unions - The trust wanted to be clear that the intention was not to encourage staff to leave substantive posts and move to bank. The 'break glass' rate is an attractive rate, but it is used in a very controlled manner requiring senior leader sign off in the same way that OFA requires senior authorisation.
Staff – The trust has done a lot of work engaging with temporary workers. This has involved raising their profile, engagement in focus groups and the inclusion of bank workers in the annual NHS staff survey. Ultimately, the trust leadership wants to show it values bank workers and substantive staff as both groups deliver great services for patients.
Senior leaders – The majority of senior leaders were supportive of this project, particularly senior nursing leaders. They did have to persuade their finance director that this intervention was the right thing to do, as they were initially spending more money but in what they felt was the right way and keeping the money in the NHS. By profiling agency usage and modelling some scenarios, the team was able to convince others of the approach based on the case for improved quality of care and potential future savings.
Monitoring and evaluation
NBT acknowledge that there were risks with the designed intervention, however, these risks were carefully considered at the beginning and robust controls were implemented to mitigate them. Unions were concerned that it might lead to people leaving substantive posts to pick up 'break glass' rate shifts. However, the number of available shifts weren't predictable and weren't high in volume, so it didn't provide a suitable alternative for someone who consistently worked bank shifts. The team closely monitored the intervention post implementation at three and six months and found it didn't lead to people reducing their hours to pick up 'break glass shifts'. They also did a lot of work to gather feedback to help them understand who was picking up 'break glass' shifts and why. The intelligence that they gained helped to inform how to move forward as well as understanding 'how' it was working and if it was delivering what they needed.
Equity
A significant proportion of bank workers are from black and ethnic minority communities. As part of this intervention, they have been working through questions such as 'Why is this?', 'Are there sufficient opportunities for bank staff from all communities to move to substantive posts?' and 'How do we help bank staff to feel as if they belong?'. It has also informed their mindful thinking on how they make shifts available and the types of shifts they offer. Another area they have been exploring is career progression for longstanding bank staff members.