Feature / Making the system sweat

One of the concrete early signals from the Carter review of efficiency was that the NHS in England would be expected to adopt electronic rostering to allocate staff shifts. It would improve efficiency and productivity by ensuring the right staff were in the right place at the right time to suit patient needs, But don’t most NHS trusts already have e-rosters? Yes, but, as Lord Carter explained to the HFMA annual conference in December, many do not use them well.

When the NHS first adopted e-rostering seven or eight years ago, there was much excitement. They would save ward managers from having to spend days poring over huge sheets of paper to create a roster. No longer would they eye each new Post-It note on their computer monitor with suspicion, hoping it was not another written request for days off or particular shifts. They would have more time to nurse and manage, as rosters would be produced at the touch of a button.

By linking with financial systems, payroll would be more accurate, while managers would be able to keep track of leave and ensure all contracted hours were worked. Sadly, this Shangri-La has not been reached in many trusts, with reports that paper rosters are still the norm, even among those with e-rostering systems.

Lord Carter aims to change this. Ahead of the publication of his final report, the Department of Health said all trusts will be required to adopt e-rostering and use them well to ensure they are getting maximum use of staff – their single biggest expense. In his interim report, Lord Carter said a 1% increase in workforce productivity could avoid costs of £400m.

But how can trusts make the most of e-rosters? Some trusts are going through the process of learning to make the most of their e-rostering software, years after it was installed. In many cases, this requires a system reboot.

Northern Lincolnshire and Goole NHS Foundation Trust has used an e-roster system for five years, but director of finance and business support Marcus Hassall believes it is only in the latter years that it has begun to harness the full power of e-rostering.

‘For the first three years, we didn’t get it properly embedded. It was an add-on to what roster creators were doing before, making up the rosters on paper. We didn’t have their understanding on e-rostering to deliver the maximum benefits for patients.’

Some roster managers were creating rosters on paper and then inputting the information into the software. This could take some staff up to three days. ‘It doesn’t generate the benefits you can get from e-rostering,’ he says.

Derek Conlon, e-rostering and central bank staff manager, adds: ‘In the past it was thought that e-rostering was more about finance than patient safety, but our key message was about linking it to better nursing and quality of care.’

An e-rostering system – Smart’s Rosterpro – has been installed at the Royal Devon and Exeter NHS Foundation Trust for a number of years, covering the working hours of nurses and associated healthcare staff, such as healthcare assistants. But deputy chief nurse Tracey Reeves acknowledges it has not always been operated successfully.

‘When it was brought in, it was not done terribly systematically – in a way that would maximise the benefits and staff buy-in,’ she says. ‘We weren’t using all the functionality.’

As in other trusts, staff continued to work out rosters on paper before inputting the information into the e-rostering software.

System reboot

Both trusts are now turning the situation around. To reboot its e-rostering system, the Northern Lincolnshire trust called in its rostering software provider, Allocate, to examine how its use of the Healthroster system could be improved. This led to the trust looking at several areas.

Helen Clark, matron and the clinical lead for e-rostering, says she worked on getting staff to ‘own’ their working hours. One of the incentives used to get staff to use the system was moving the booking of requests, such as annual or study leave, onto the system. In turn, this helped the trust to influence when staff could take leave. For example, it could ensure every shift had an experienced, substantive staff member who was able to take charge.

Roster managers were urged to use the auto-roster option in the software. Mrs Clark says the release of version 10 of the Allocate software has encouraged this – it is now web-based, greatly speeding up the process, she says. ‘On average we have gone from 8% auto rostering to more than 40%. That’s still not huge, and not where we want it to be, but it is being facilitated by the speed of processing now.’

The time taken to create a roster – which used to take three days – is now down to five hours in some wards.

The position at the Royal Devon and Exeter has changed markedly. About five years ago, Ms Reeves led work that aimed to standardise shift times. Though it was not linked directly to the trust’s e-roster, the project had a significant impact on getting the most out of the system.

‘This allowed us to begin to build the foundation for better rostering. We redesigned all the shifts so we had the same starting and finishing times trust-wide. These are predominantly long days, which will not suit everywhere, but it’s what our staff told us they wanted.’

Initially, they set a target of having 60% of staff working these long, 12-hour shifts, particularly in inpatient areas. Currently, about 80% are working these shifts across most wards, making auto-rostering more straightforward.

Before it refocused efforts on its e-roster, the system allowed many individual requests for flexible working. But it is difficult to accommodate large numbers of requests in a standardised system.

‘We are a classic example of a trust that thought [e-rostering] would be the solution, but staff didn’t particularly like it,’ says Ms Reeves.

‘But when we started thinking about using the auto-roster element of the software, we couldn’t get it to work – there were too many requests. We had to go back to basics.’

The e-rostering system now allows flexible working, where necessary, but without compromising the balance of skills and numbers required. ‘If too many people on one ward are making requests, then we may think of moving one to another ward,’ Ms Reeves says.

With increases in its nursing establishment the trust decided to rebuild its rosters from the bottom up – deciding what skill mix and numbers were needed for each shift. This allowed the trust to set rules for each shift in the e-roster programme.

Ms Reeves adds: ‘We had to manage annual leave, so we introduced rules in the e-roster on the maximum levels of people on leave at any one time. At the same time, we made sure staff understood we needed to have some people on leave to eliminate peaks and troughs.’

Further steps were taken to entrench e-rostering. ‘An internal audit suggested rostering was not as well managed as it should be,’ she says. ‘It was possible that there were some overpayments to staff and there was a lack of tracking of hours. At that point, two years ago, we brought in a project manager to get on top of e-rostering and to make sure we are using the system properly. We then started to eliminate the risk of over- or underpayment.’

The onus is on the matrons who create the trust’s rosters to fill them six weeks in advance (the trust has 90% compliance currently). This means at peak holiday times, such as Christmas, senior managers and matrons can be assured they have the correct skill mix and numbers of staff for each shift. ‘The system links to our internal bank, so those people know work is potentially available,’ says Ms Reeves. ‘Our fill rate from our internal bank has improved.’

While he would not claim the Northern Lincolnshire trust is seeing the full benefits, Mr Hassall believes it is ‘getting there’. He says: ‘The difference we have made in the last two years is that we have tried to be more explicit about the rules in the system. This gives you the ability to drive efficiency in terms of the use of the roster.’

Rules now state the skill mix for a particular shift, as well as numbers of staff required.

Mr Hassall believes the financial benefits are significant, but they are not limited to finance. ‘We tested the impact over a year across 10 of our wards, and could evidence savings averaging £60,000 per ward. But we have also improved patient care by using our restricted resources better and getting more from it. We are reducing agency spend and increasing quality as agency staff often do not have the skills or local knowledge to work as effectively as substantive staff.’

The bulk of the saving is made up of ensuring all contracted hours are worked and avoiding paying for additional hours through overtime or additional staff, with a smaller amount from avoiding agency spending.

The Northern Lincolnshire trust has increased its nursing establishment, but just over a year ago it went through a period where nursing vacancies rose from 7% to 12%. At any other time it might have faced a huge increase in nursing agency spend, but it was able to minimise the impact of the vacancies using e-rostering.

Mrs Clark said at one point the trust had lost 40 whole-time equivalents, but managed to maintain fill rates for shifts without markedly increasing the amount of agency staff. The increased visibility in the e-rostering system allowed it to optimise the use of substantive staff – getting them into the right shifts.

‘With the rostering system in place we were able to monitor our spending and do a good job in filling the gap by using the system to deliver improved rosters,’ Mr Hassall says. ‘It was a great success in terms of cost avoidance.’

Mr Conlon adds that transparency of information has been a boon for staff. ‘Managers get reports on who works the most weekends or bank holidays or who has the most requests granted. The visibility and availability of the information for staff is very democratising for them.’

Allocate’s Healthroster solution is used by more than 60% of NHS trusts. Simon Courage, the firm’s director of product development, says e-rostering is needed to solve the complex equation of staffing an NHS organisation.

‘If a manager is creating rosters on a piece of paper, there is no visibility to the organisation; there is no overview,’ he says. ‘But Carter says there needs to be an overview so you know where the pinch points are. You cannot know where staffing might be problematic without an electronic source of all that information.’

Mr Courage says the software providers can help trusts maximise the benefits of their e-roster by keeping in touch after they make their sale. Allocate has a user group that meets annually, as well as regional groups and an online forum. It also has Allocate Insight, a range of services that assess a trust’s performance on the use of rosters, benchmarked against its customer base.

Everyday life

The e-roster has become central to everyday life at the Royal Devon and Exeter, Ms Reeves says. It is making the trust more efficient, particularly by avoiding costs – from reducing the use of agency staff to improving recruitment and retention.

Ms Reeves admits the trust was fortunate to have carried out actions that proved the building blocks for better e-rostering – the standardisation of shift starting times and rebuilding its shift numbers and skill mix from scratch. But she adds that ensuring the system continues to provide all its benefits is largely about good housekeeping.

The clear information about each shift delivered by the e-roster helps matrons keep on top of staffing needs. Senior nursing staff meet each week to ensure upcoming rosters are robust. If a gap is identified, they will use their experience to judge whether it needs to be filled to maintain patient safety. Or, in the case of a specialist post, such as in theatres, they may judge an agency worker is needed. But by booking an agency nurse in advance, they are more likely to be hired on a framework and at a better rate.

This process is repeated daily, to account for short-term absences, such as for sickness. This is helping control the trust’s use of agency staff, as often nurses can be reassigned from other parts of the trust.

E-rostering software can bring a range of benefits, including greater efficiency, but it is not a silver bullet on its own. The information base – staff numbers, skill mix required – must be accurate and staff must want to use it. Regular monitoring is essential to ensure, for example, that substantive and bank staff are used before agency workers and the numbers of staff on leave is balanced to eradicate peaks and troughs. Only then can e-rostering support an increase in workforce productivity.