The PCT was going through a period of change as 4 PCT’s were being combined into 1. The Provider Services performance was unknown as there were no information systems available to produce an accurate measurement of activity.
The reference costs were unlikely to be accurate as the District Nurse costs for the 4 small PCT varied from 12.48 to £34.77 / activity, and the Health Visitors from 16.89 to £33.77 / activity, when largely speaking they worked in similar ways. This lack of accurate operational information available to the Management Board meant they were unable to evaluate where and how improvements could be made to proactively improve the reference costs and utilisation.
Following a three week study, working with the local management team Meridian identified a number of areas which if addressed would substantially improve management information and the accuracy of reference costs.
Provider Services:
District Nurse Activity during the study (observations) averaged at 53.7B direct time spent with the patients, and over the year 2005/6 statistical analysis of District Nurses showed variations in face to face contact times between the different PCT’s of 32.8 minutes to 72.1 minutes. The Health Visiting Service observations averaged at 52.7B with the statistical analysis of face to face contact times showing a variation of 28.2 minutes to 53.3 minutes.
The breakdown of each services observed activities are listed below. The Evening and Night Service, Community Matrons, and Intermediate Care were all shared services between the 4 PCT’s and therefore no statistical comparisons are available.
Observed Activity
District Nurses: 38% Direct & 16% Travel
Evening & Night Service: 41% Direct & 28f% Travel
Health Visitors: 40% Direct & 12% Travel
Community Matrons: 37% Direct & 18% Travel
Intermediate Care:
Rapid Response: 36% Direct & 21% Travel
Ctr: 51% Direct & 19% Travel
Therapies: 28% Direct & 23% Travel
NOTE: Observed percentages are consistently higher than actual percentages over a long period for 2 reasons:
Individuals naturally make themselves busier doing what they think the observer would expect to see. The observers are always put with the individuals who are seeing patients and therefore do not observe a reflective amount of indirect activity.
The level of clinicians actually working at any time was low due to a high absence and holiday, which placed greater stresses on those working and promoted further absence. This also highlighted poor resource planning.
Provider Services
1. Develop and implement a suite of management tools (management system)
Improve the daily, weekly, monthly, quarterly and annual management of the business
2. Management training (behaviour change)
In the tools and techniques to enable staff to manage our resource effectively and equitably
Provider Services
In consultation with the Community Nurse Managers and Process Improvement Teams, the planned activity targets for the 2 largest services were agreed:
District Nurses:
75% Direct including Travel
Health Visitors:
65% Direct including Travel
The result was less people were required to complete the same amount of activity and produced a benefit of 75 WTE or E2,252,000 for District Nursing and 29.57 BE or 1,146,889 for Health Visiting giving a programme return on investment of 15:1. The surplus WTE could be used in other services where there was a requirement for more activity than the current WTE could deliver. This was achieved by designing a capacity planning tool which built up from individual to team to speciality. At each level the activity was agreed as achievable by the nurses/managers involved. management information system was also introduced which now provides accurate timely information on all operational indicators for the management team weekly meeting. Weekly activity has now increased to an annual potential of 140B of 2005-6 activity.
Evening & Nights District Nursing
The Evening and Nights Service was looking at strategic decisions on how to provide the service in a different way. The measured activity was 46ff of their time in patient contact, but it is recognised that if this service is provided it will always have a low activity percentage due to “Station Fill”.
Community Matrons
This service was still very new and a considerable amount of their time was being devoted to training individuals to become Community Matrons.
Their patient contact percentage was 41B which according to the management was within the expectations of the services current position. The management information systems were found to be very useful and would be used for performance management as the service matures.
Intermediate Care
The 3 sub-services were very different with the management information producing the results for patient contact percentage of:
Rapid Response
Actual 56%
Target 75%
CTR
Actual 40%
Target 65%
Therapies
Actual 49%
Target 65%
It can be seen the targets are considerably higher than measured but these services are seen to be capable of increasing activity rather than reducing resource, and strategies are being implemented to achieve this. The benefit produced would be in the region of E2 million 6 – 1004 / avoided admission.