STAFF AND STAFFING ISSUES
From the earliest days of the opening of NHS 24's first contact centre in Aberdeen there have been difficulties in both recruiting and retaining nurses - and that despite the fact that Aberdeen had emerged from extensive consideration of the most suitable area of Scotland for the first NHS 24 site. Over the 3½ years since then little has changed. Time and time again the Board has received Executive reports of yet another "robust" recruitment and retention campaign but the twin problems remain to this day. Of course nurse recruitment continues; the nub of the problem remains the difficulty in getting people to cover the rather unsociable shifts - particularly at weekends or public holidays - that often coincide with heavy call volumes.
With hindsight it now appears to us that that somewhat blinkered determination to succeed, some time, in resolving these 2 issues restricted more lateral thinking about the underlying problem - of continuing a good quality service without the specific resources that were considered necessary to do the job. If a process is designed very specifically to require resources that are simply not to be found in sufficient numbers to match the process, then the only thing to do (other than admit defeat) is to re-design the process.
We have, over the last 6 months, formed a very high regard for the work that Nurse Advisers do, often in stressful circumstances (not least when call-back demands are both high and prolonged) and we certainly believe that those highly qualified nurses will continue to play a very important role in the delivery of a consistently good service. We think they are well capable of playing an even more important role in future, exploiting the huge pool of talent and experience that they share as a team. We are pleased to see that NHS 24 is beginning to tackle some of that necessary radical thinking.
Nurse Advisers use algorithms - a succession of questions progressively set in order to reach a conclusion on the most appropriate response to the apparent needs of the caller. There are more than 200 such algorithms and there is a view that these highly qualified and very experienced senior nurses are unnecessarily tied to them. Instead of the algorithms being the useful tool at hand, particularly for the more complex and less common cases, they seem to have become the compulsory, uneditable and lengthy script for the entire telephone consultation. That can mean that these same very senior nurses find themselves restricted to getting through no more than 4 or 5 such calls in an hour - even when those particular cases call for a response that is almost immediately obvious to the nurse. Discretion, related to qualification and clinical experience, needs to be allowed.
We have heard comments from NHS 24 staff that they get little or no feedback from the various clinicians to whom cases might be referred. We have heard comments from clinicians that when they send feedback about cases referred, etc, they know that it is examined by NHS 24 management - but the clinicians never get any feedback! A very important linkage and learning opportunity is being missed here, for whatever reason, and it should be picked up. The main beneficiaries are likely to be NHS 24 nurse advisers - and subsequently the callers who seek their advice.We think consideration should also be given to allowing some limited discretion to trained and experienced call-handlers. That happens in the Scottish Ambulance Service and although circumstances are different the principle is very similar.
Many nurses working in NHS 24 have reported to the team how much they enjoy the work and how it offers them the opportunity to develop their knowledge, skills and careers. However, some nurses report that the combination of working unsociable hours and losing face-to-face contact with patients for long periods in their careers are key reasons for the high attrition rate the service continues to experience. The team suggests that NHS 24 and local Boards consider how they can address these issues. One solution put forward, and that the team would encourage to be developed further, is for NHS 24 and Boards to explore the development of unscheduled care by designing services where nurses rotate between telephone triage and face-to-face care both in and out-of-hours.
The high attrition rate has produced a large number of nurses, trained by, and with experience in, NHS 24 who are no longer working within the service. NHS 24 should be also be considering with Boards how these nurses may be encouraged to return to the service while continuing to work with their new employers.
In essence, the team feel that Boards, as well as NHS 24, could mutually benefit if they support nurses to contribute to unscheduled care services in primary and secondary care, by incorporating both telephone and direct clinical care into their contracts, whether by the mechanism of joint appointments or others. By increasing the number of nurses who have the ability to contribute to telephone and face-to-face services the overall pool will be expanded thereby offering more flexibility within the workforce, an essential requirement to address the pressures created at times of high call volume. For the nurses, this could produce more attractive rosters, and enhance career opportunities by offering developments, not only within management, but also clinical practice and research.