Scottish Government

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Foreword by Jacqui Lunday, AHPO

A key priority for the NHS in Scotland is to deliver quality health care services that will improve the health and well being of the people of Scotland and staff are essential to achieving these aims. We need to make ensure that we value those dedicated staff we already have and those we may wish to employ in the future.

Health services need to respond to and reflect the health needs of the population by preparing for future health needs and particular challenges we face in Scotland in the 21st century.

Current activities such as service redesign, pay modernisation and role development all contribute to achieving a modern service, responsive to patient need. Developing the workforce and valuing staff are key factors that need to be underpinned by modern employment practices in relation to how people are managed and supported in the work place.

The changing NHS needs the skills and expertise of the allied health professions more than ever before to deliver services to patients. Modernised services may mean that AHPs need to work at different times and in different places to meet patient need but this can also suit their own life circumstances. We need to be creative in our approaches towards staff in supporting them in their need to balance work, home and other commitments while retaining their skills within NHSScotland. This will be essential in remote and rural areas, as well as areas of increasing demand, in order to secure sustainable services for the future.

Flexibility in employment and flexible working schemes provide some of the ways in which to do this. These approaches can also support the implementation of the Staff Governance Standard. Utilising tools such as Supporting the Work Life Balance policy and practice, developed by the the Partnership Information Network, will support employers as they introduce modern employment practices needed to support the development of a modern service.

Jacqui Lunday
Allied Health Professions Officer

1. Introduction

The vision for health care in Scotland outlined in the Kerr Report, Building a Health Service Fit for the Future, highlights the vital contribution allied health professionals ( AHPs) make to the NHS workforce. This is particularly strong in relation to the report's emphasis on primary care focused services and the management of people living with long-term conditions.

The AHP workforce has grown by 28% since 1997, which reflects the high value patients and services place on AHP skills and the growing need for the expertise they deliver.

Supply is being supported by initiatives to retain existing experienced staff, including:

• the development of a 'return to practice' scheme
• provision of development opportunities for support staff, junior and experienced practitioners
• the development of advanced practice and consultant roles.

But central to attempts to increase and develop the AHP workforce is the concept of balanced working lives for practitioners and support staff across NHSScotland and the linked notion of flexible working.

NHS organisations recognise that staff are their most valuable asset. There is now a legislative requirement placed on NHS Boards by Scottish Ministers ( NHS Reform (Scotland) Act 2004) to ensure the fair and effective management of staff. The Staff Governance Standard sets the policy context for supporting the implementation of this piece of legislation.

Supporting the Work Life Balance Partnership Information Network ( PIN) is part of the NHSScotland employment framework that offers staff a range of options that makes it easier to strike an appropriate balance between work and the rest of their lives.

Flexible working

The Kerr Report sets out the demographic situation in Scotland over the next 25 years or so.

Over that timespan, we are likely to see the proportion of older people in Scotland rise to 1 in 4, with 1 in 12 being over 80. These people are more likely to be living with long-term conditions, need hospitalisation for multiple episodes of care, and have longer stays when in hospital. In addition, a falling birthrate and declining population will have serious implications for the available 'pool' of people from whom the health and social care professionals of the future will emerge.

The picture is therefore one of an increasingly dependent population requiring sophisticated healthcare interventions, but a diminishing pool from which to recruit healthcare workers. These statistics emphasise the importance of planning now to safeguard the healthcare workforce of the future.

In addition, several important modernisation initiatives that impact on the workforce have been launched in recent years. Modernising Medical Careers, Modernising Clinical Careers, working time regulations and pay modernisation all have implications not just for staff pay and conditions of service, but also for the way staff work, the responsibilities they assume, and the development opportunities open to them. The implementation of pay modernisation and the Agenda for Change must support the delivery of key NHS priorities, including staff governance. Role changes and the development of new roles, in particular, commonly call for flexible approaches to working to meet patient needs.

Much positive activity has taken place at Scotland and UK level to try to offset the impact of these demographic changes and modernisation initiatives to ensure health services remain fit for purpose. In Scotland, the Centre for Change and Innovation ( CCI) has developed the Balanced Working Lives ( BWL) Programme which forms part of the wider implementation of the national Partnership in Practice policy and aims to:

• increase flexible work patterns and options
• speed up the implementation of policy
• encourage the involvement of clinical leaders
• share best practice.

The main lessons learned from CCI's BWL Programme are that:

• flexible working requires a balance to be reached between the needs of the individual, the team and the service
• there are many different paths to flexibility - one size does not fit all
• changing patterns of work requires planning, consultation and an open-minded approach
• increasing staff involvement in the process increases chances of success
• there are many good examples of flexible working from which we can learn.

Different clinical services and departments have different needs but creativity in approaches to service provision is possible and flexible working can be implemented and supported by the tools now available to achieve a better work/life balance for staff.

2. What is flexible working?

Flexible working is based on the recognition that throughout people's working lives, they will experience changes in circumstances that might lead them to want to change their work and life balance. They might, for instance:

• need to accommodate childcare responsibilities
• have to alter their work patterns to look after a sick relative
• wish to spend more time pursuing other interests like world travel or personal study and development
• need to change they way they work because of injury or illness
• want to amend the amount of hours they work as they approach retirement.

Flexible working options

There is a range of options available that individuals can choose to meet their, the team's and the service's needs best.

Job sharing

Job sharing schemes are based on one or more individuals sharing responsibility for a single post, with pay and benefits apportioned on a pro-rata basis. A variety of options exist, such as co-workers sharing a post on a daily, weekly, monthly or even annual basis.

There is a number of benefits with job sharing schemes, including:

• widening of skills and experience available to the service
• incentives for staff not available for full-time working
• development of a collegiate relationship between the job sharers, leading to improved performance.

Job sharing can be applied to any post, regardless of how junior or senior. It is important, however, to establish clarity about roles and responsibilities and clear lines of communication to avoid duplication of effort. It can also be challenging to fill a vacant shared post if one partner leaves the service.

Part-time working

This is a popular option particularly suited to, for instance, women returning from maternity leave, experienced staff returning to the service after a break, staff who have childcare responsibilities and those studying for further qualifications.

Part-time working requires careful planning. Overall staff numbers may increase, with implications for statutory and mandatory training, ongoing CPD and fixed overhead costs. Staff meetings and training sessions can be more complex to organise to coincide with rostered working hours.

Flexible hours

'Flexitime' schemes allow staff to choose their hours of work around set core times. Staff work the core hours but can be flexible about other times they make up their contracted hours.

Flexitime has several benefits, including:

• staff have greater freedom to fit work round other commitments
• service hours can be extended
• staff travel problems can be eased by, for instance, missing 'rush hour' jams
• working times can be negotiated to meet peaks and troughs in demand.

Flexitime requires, above all, good organisation and ongoing management to ensure that the service does not suffer any staffing gaps at key times. While it can be offered to full and part-time staff in a wide range of posts at several levels, it may not be suitable for all roles.

Team-based flexible rostering

Under this scheme, staff plan their working times and patterns to match predicted staffing needs over a set period of time. It offers increased flexibility to meet workload peaks and troughs, and has been shown to increase staff motivation and reduce sickness absence. Staff can 'bank' any hours earned or owed to them.

Like flexitime, good organisation and management is required. The scheme relies on voluntary co-operation of staff and should have a system of central administration.

Shift swapping

Shift swapping can be used in situations where flexitime is perhaps not suitable. It gives staff freedom to re-arrange shifts to meet their needs in agreement with colleagues. This eases out-of-work pressures for staff, which can have beneficial effects on sickness and absentee rates. The system requires central administration.

Voluntary reduced hours

This is a particularly useful option for staff who are facing a difficult personal or domestic situation that is likely to be time-limited. Under the scheme, they can negotiate to barter reduced pay for reduced hours for an agreed length of time, commonly up to a year. The reduced hours can be spread evenly over the period or taken as a block of time off. Staff benefits are maintained, but some may be pro-rated. At the end of the agreed period, staff have the right to return to full-time terms and conditions.

Annualised hours

Rather than agreeing hours of work on a weekly or monthly basis, they are agreed over the whole year. This means that staff will agree a schedule of basic rostered hours, with some hours kept in reserve to be negotiated for use during times of workload pressure. An interesting feature of the scheme is that salaries are usually paid in regular weekly or monthly instalments regardless of the number of hours worked during the period.

An annualised hours system calls for careful planning, consultation and organisation and can be complex to administer. However, it offers increased flexibility to cope with seasonal fluctuations in demand and can reduce overtime requirements.

Reduced working year

An option particularly geared to the needs of parents of school-aged children, although not exclusively, term-time working offers staff the opportunity to take time off during school holidays. The normal pattern is for staff to work all or most of their contracted hours during school term times, and then to take unpaid leave or reduce their hours during school breaks. Salaries are usually paid consistently throughout the year.

It offers a highly acceptable option to many parents, but there may be pressures if the service wishes staff to deliver on 'reserved' hours at inconvenient times for staff.

Bank hours

Some individuals may not wish to work a regular pattern of hours but prefer the increased flexibility of having their names held on a register or 'bank'. Many AHP departments respond to this by offering zero-hour contracts. These flexible staff members are inducted within the parent organisation and are available to cover periods of planned and unplanned absence as well as periods of increased work activity. Other approaches include using the nurse bank to recruit support staff who have undergone appropriate training and development to assist AHPs, when there are planned and unplanned shortfalls in staffing.

More detailed information on flexible working and explanations of the various working options can be found in Supporting the Work Life Balance, the Partnership Information Network ( PIN) policy document that is to be implemented in the NHS in Scotland.

Managing diversity within staff groups and teams can be challenging, but it is important to manage the expectations and the needs of all staff members in a transparent and open way. Managing diversity means considering the differing needs of all those affected and this might mean having different arrangements for different groups albeit all are considered equally. Decisions on flexible working need to be evidence based and objective and be responsive to and balance patient, staff and service need.

3. Why opt for flexible working?

Flexible working is about using people's time more creatively to deliver benefits for the individual, the team and the service. Put simply, delivering on flexible working is delivering on good Human Resources policy and practice as well as implementing the Staff Governance Standard.

Benefits of flexible working

Who benefits from flexible working?

First and foremost, patients benefit. There is evidence to suggest that retaining staff and strengthening their motivation translates into improvements in care, and flexible working has been shown to bolster staff retention and increase motivation.

Services also benefit. Providing flexible working options means that an organisation or service can:

• maximise the available workforce and increase staff hours
• increase staff loyalty and motivation
• reduce staff sickness and absenteeism
• increase productivity
• promote the service or organisation as a good employer to potential recruits
• retain valued employees.

And individual members of staff also benefit. They can show:

• greater responsibility in their roles
• greater commitment and loyalty to the service
• better relations with managers and colleagues
• higher self-esteem and confidence
• better health and concentration
• less inclination to bring domestic problems to work
• greater ability to control their working lives.

4. How can flexible working be introduced?

Changing the way staff work requires the contribution and consent of several groups of key players. They include:

• patients and service users
• the employer
• individual members of staff and the teams in which they work.

For flexible working schemes to work, each of these groups has to accept that they have particular rights and responsibilities, as shown in Table 1.

Table 1. Rights and responsibilities in flexible working

When introducing a scheme of flexible working, it is important to consider at the outset, what the goals are, how they will be achieved and how they will be monitored and evaluated.

Going about it the right way…

There is evidence to suggest that best results in recruitment and retention are achieved when several systems and practices coincide and are in place (Buchan J, 2002). A sense of autonomy and responsibility among staff linked to supportive and participatory management approaches lead to improved job satisfaction. In addition, flexible working schedules, continuing education and management development as well as career opportunities, also have a positive impact on the recruitment and retention of staff.

AHP departments already support a wide range of part-time working options. There is a need to build on this experience and consider new and more creative options in order to sustain services now and in the future.

When considering flexible working, employers must carefully consider a range of issues and ask themselves a number of questions. They need to ask:

• What will be the effect of the change on patient care?
• What will the effect be on staff levels and recruitment and retention?
• Is there a clear demand for the change?
• How can I involve the team in discussions?
• How good is the information I have currently about working patterns, workload peaks and troughs, and current roles and responsibilities?
• What contractual issues are at play, and to whom should I turn for contractual advice?
• Are there other areas of the service that have introduced a similar change, and how has it worked out?
• Should we consider piloting the change before making a final decision?

Above all else, the key is to keep an open mind. There will be challenges in introducing any change to working practices, but employers should try to see through to the end of the process and the likely benefits they will find there.

In implementing flexible working employers also need to:

• be clear that agreed changes in working pattern will deliver benefits to patients and staff
• ensure the change articulates with wider service and pay modernisation agendas
• review working patterns regularly to make sure they remain fit for purpose
• continue to involve people in the changes to ensure shared responsibility for making them work
• keep the wider team members fully informed of potential and agreed changes to working patterns
• develop systems of information to support planning and demand management
• share ideas with colleagues in Human Resources and throughout the organisation/service
• accept that while flexible working options can help solve a number of problems, they won't be the right answer to every workforce challenge
• take advantage of education and training opportunities and the wide range of information sources available to inform working pattern development initiatives.

These approaches will ensure best practice in relation to flexible working is introduced and implemented using the Supporting the Work Life Balance ( PIN).

5. Evaluation and further review

When introducing a flexible working scheme, evaluation needs to be considered at the outset. There are several ways in which this can be done that are consistent with measures of productivity and performance and some examples are given below.

An effective measure for short term monitoring and evaluation is the sickness absence rate.

This is an activity that is currently undertaken as good management practice and can be used as a measure within new initiatives. It provides an accessible and meaningful way to monitor the effect on staff and service and does not entail additional work.

For a longer term measure, staff turnover rates can provide an indication of improvement in staff recruitment and retention, again information that is routinely collected within the NHS in Scotland,

Impact on and benefits to patients can be measured using patient productivity measures. These include measures such as:

• number of patient attendances
• additional clinics during non-core hours
• range of treatments offered

Whatever evaluation tool or range of tools is adopted, the audit of flexible working practices needs to link with productivity and provide the data that will demonstrate impact on patients, services and staff. A cycle of review and evaluation of the implementation of change will be needed in order that working arrangements remain fresh and relevant.

Useful References

'Balanced Working Lives; a 'Can Do' Approach to Employing Nurses and Midwives'SEHD 2004

Buchan J 'The Greying of the UK Nursing Workforce: Implications for Policy and Practice' Journal of Advanced Nursing 1999; 30 (4)

Buchan J 'Attraction of Opposites' Health Service Journal vol 1 12 4/7/2002

Delivering the Benefits of Pay Modernisation in NHSScotland ( NHSHDL (2005) 28.

NHS Reform (Scotland) Act 2004

Partnership Information Network 'Managing the Work Life Balance; Policy and Practice' SEHD 2005

Staff Governance Standard - Second Edition August 2004