King’s College Hospital NHS Foundation Trust Auditing

1. My choiceof organization is King’s College Hospital NHS Foundation Trust. King’s College Hospital (KCH) is located in Camberwell in London. It is one of London’s largest and busiest teaching hospitals, and has a strong profile of local services primarily serving the boroughs of Lambeth, Southwark, Lewisham and Bromley a population of 700,000 (KCH, NHS Foundation Trust, 2019). It also serves as a tertiary referral centre in certain specialties to millions of people in southern England. KCH moved from the NHS Trust to the NHS Foundation Trust in 2006 (KCH, NHS Foundation Trust, 2019). 

Being a foundation trust, KCH gets its bulk of money from HMRC/Parliament Taxation and National Insurance through Department of Health (DOH) via Barnett Formula (The King’s Fund, 2019). Boussie (2016) describes the Barnett formula as “a system of grants that dictates the level of public spending in Northern Ireland, Scotland and Wales”. DOH further divides its money into 3 areas: Commissioning, Monitoring and Training & Development.

Commissioning supplies money to NHS England and Public Health England. NHS England further supplies Clinical Commissioning Group (CCG) who commissions services to any healthcare organisations (secondary care, mental health, rehabilitation, etc). The CCG’s main job is buying goods and services and it implements this by Payment by Results which is a system that pays NHS healthcare providers a standard national price or tariff for each patient that is seen or treated. (NHS Digital, 2019)

Monitoring is responsible for authorising, monitoring and regulating NHS foundation trusts. Foundation Trusts, unlike NHS Trusts are solely in-charge of their money and can use it anyhow they like. They are allowed to retain financial surpluses and losses and borrow capital within limits to improve and develop services for the users. Monitoring also relies on CQC (Independent Regulator of all health and social care) for quality care and maintaining standards and on NICE for guidelines. Monitor is now merged with NHS Trust Development Authority to form NHS Improvement since April 2016.

Training and Development takes care of all trainings in the health sector (https://www.theguardian.com/society/datablog/2016/feb/10/how-does-money-flow-through-health-service-england-nhs).

Coding system is another way KCH gets its cash flow. This involves assigning a code to an illness or treatment for classification or identification which is then used for auditing and billing purposes. (KCH NHS Foundation Trust, 2018).

Finally, KCH has other sources of cash inflow which includes: Overseas commercial operations services with two outpatient and minor surgery Clinics open. One in Abu Dhabi and one in Dubai. A further Clinic in Dubai will open in September 2018 and a full scale inpatient hospital in January 2019, also in Dubai. KCH has a globally recognised Research site with a substantial growth in Research income. (KCH NHS Foundation Trust, 2018).

Other areas of cash inflow includes:  rental revenue from leasing of buildings, beds or equipment to other bodies or organisations, private patient services, road traffic accident patients, avoiding or reducing agency staff working, engaging patients in their own care (eg some patients on ongoing IV Infusions like Enzyme Replacement Therapies are trained to cannulate themselves at home and administer their infusions), prescription charges  as well as other non-NHS income (such as charitable bodies, cash donations, clinical excellence awards, car parking, staff nursery, etc). (KCH NHS Foundation Trust, 2018).

In conclusion, although financial pressure remains high on the Trust, a cost improvement programme and a 5-year financial recovery plan have been put in place to improve financial sustainability. (KCH NHS Foundation Trust, 2018).

2. My choice of clinical setting is the ward. Skill Mix refers to the skills and experience of staff, their continuing education and professional development, years of experience and how they bring these together to influence their professional judgment. (Buchan and O’May, 2000). Skill Mix also connects ‘needs’ with skills available and outcomes in a particular working environment.

The unit manager who is mainly in charge of allocating shifts usually has some funds allocated and must give account of how it was used at the end of the fiscal year. Taking these into consideration as well as the patient’s needs, being the manager, I will have to prepare the Rota, mixing all categories of nursing staff(Trained Nurses including newly qualified inexperienced nurses, Nursing Associates and Healthcare Assistants) per shift. The various banding are from band two up to band six on my ward. For example, I cannot have 2 band six and 2 band fives on a shift instead of 1 band six and 2 band fives and 1 band two.

 I will therefore have to consider some factors which include:

Staffing: Safe and effective nursing is crucial for patient safety. For this to happen, we need a sufficient number of nursing staffing at any given time. That is, the right numbers with the right skills in the right place at the right time. This leads to improved patient outcomes, reduced mortality rates and increased productivity (Royal College of Nursing, 2017).

Training: Nurses need continuous training and development to keep up or improve their competencies, productivity and performance to meet up with current needs.

Experience: We need nurses with the expertise or skill in particular areas on every shift.

Competency: This is the ability to do something successfully and efficiently and all nurses need this for patient safety.

Qualification: We need qualified nurses and not nursing assistants or healthcare assistants to do certain types of skill.

Patient Need: In recent times, patient needs are continuously rising because of increasing technology and media, as well as increasing patient awareness of their rights.

Staff to Patient Ratio: There has to be a suitable staff to patient ratio.

However, the staff to patient ratio cannot always be maintained. A survey data from over 30,000 shifts shows that a shortfall in planned staffing levels is present across the UK, and spans the full range of clinical settings and providers – both NHS and non-NHS. (Royal College of Nursing, 2017). Although nurse patient ratio depends on what type of ward or setting, patient acuity, number of beds etc., the above survey depicts that every shift suffers nurse shortage hence patient ratio will increase, affecting nursing output and patient safety. In the UK, the normal ratio on a ward is 1:8 as compared to Australia 1:4 (Dawson et al, 2018).

Other factors affecting effective skill mix involve shortage of staff and absences due to too much workload pressures, which then affect morale, retention and standards of care for patients. Further causes like poor access to continuing professional development, a sense of not feeling valued, ongoing pay restraint, the impact of Brexit and the introduction of language testing are making more nurses leave the professional register than those entering it. There is currently a total of 36,000 to 40,000 nursing vacancies in the NHS (House of Commons Health Committee, 2018). Hence staff mix will continue to be a problem.

Some helpful solutions will include:

Proper planning and good teamwork, taking into consideration the Francis Inquiry Report Feb 2013 which looked into the failings in care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009. A lot of recommendations were made which included openness, transparency and duty of candour, changing the culture in the NHS. This means there should be adequate staffing with the right expertise for patient safety. Patient has the right to know the care he is receiving, meaning the nurse must be knowledgeable-training. Nurses can also voice out their problems and the manager listens and finds ways of solving their problems. These will result in work satisfaction reducing sicknesses, fatigue, absences among others, reducing the number of agency staff, increasing productivity and efficiency, saving cost.

According to Maslow’s Hierarchy of needs, the nurses’ needs must  be met  both within the working environment and home, i.e. physiological needs (food, water shelter, clothing), safety needs as well as all the other needs met – Love and Belonging needs, esteem and self-actualisation (McLeod, 2018). This brings greater job satisfaction and retention of staff.

Another point is Flexible working time policy. The manager must give staff the flexibility in choosing which working times are best for them since some may have very young children or other commitments that clash with the usual working hours.

3. An audit is an inspection of business accounts that is carried out by an accountant in order to make sure that they are correct. (Collins English Dictionary)

Staffing in this context refers to nursing personnel, ward clerks and ward housekeepers employed to work in a particular healthcare setting.

Expenditure here refers to the act of spending money, time and energy.

Staff expenditure refers to the amount of money spent on staffing only e.g. Salary, holiday, sickness, absenteeism, covering shifts with temporary paid staff, overtime pay, internal bank staff, private sector agency staff and individual direct contract workers.

Meeting patient’s needs will be enhanced by allowing ward sisters to decide the number and mix of nurses, care assistants and ward housekeepers. It will be the job of matrons to support ward sisters and charge nurses to discharge these functions. The NHS in Wales employs almost 80,000 full-time equivalent staff, excluding General Practitioners and those employed directly by General Practices, spending £3.62 billion on pay in 2017-18. (Nhsemployers.org, 2019). In addition to the above, staff supplied by agencies tend to be the most costly source of temporary staff causing NHS bodies in Wales to collectively spend over £160 million on agency staff in 2016-17, more than four times the equivalent figure for 2012-13. There have also been large increases in agency expenditure in other UK countries.

As the ward sister, I must be fully equipped with the necessary skills and information into budgeting and budgeting control as well as leadership skills essential for managing the budget effectively. I must also be able to assess the various skills of my staff, compared to the workloads in the ward/clinical area to effectively manage the staffing resource. These enable patient costing, provide information for audit and assist in care planning and rostering (Duncan (1991) in Dunne (1991)). These also give a link between expenditure and quality of care.

I will therefore adapt a system of Electronic Rostering (as paper Rostering is facing out) where skills and availability are matched. This is an effective tool which brings together, in one central place, management information on shift patterns (including individuals’ preferred shift patterns-self rostering), annual leave, sickness absence, staff skill mix and movement of staff between wards. (Nhsemployers.org, 2019). This enables managers to quickly build rotas to meet patient demand. Employees are able to access the system to check their rotas and make personal requests. This brings more flexibility to staff and they are sometimes able to choose who they want to work with, for a better staff output. This when implemented successfully, allows improved workforce management of both substantive and temporary staff.

Some advantages of are

1. Staff cannot just change their shifts without contacting the manager

2. Flexibility solves family issues and social lives confirming Maslow’s Hierarchy of needs as staff’s Physiological, Safety, Belonging, Esteem and Self Actualisation needs are met.

Another system I will adapt to is the biometric clocking system (face, eyes, fingerprints) where staff clock in and clock out. (Clockingsystems.co.uk, 2019)

This is usually linked to payroll and so saves time and money as it calculates employee hours and overtime.

This prevents employees from clocking in and out for each other.

Disadvantages will include problems with or breakdown of network.

4. An audit is an inspection of business accounts that is carried out by an accountant in order to make sure that they are correct (Collins English Dictionary)

Expenditure here refers to the act of spending money, time and energy. Also means outflows, using up of assets or incurring liabilities from delivering or producing goods, rendering services or other activities that relate to the firm’s core business operations.

Non-Staff Expenditure is any form of spending other than on staff e.g. Medical Supplies (syringes, gauze etc), Drugs, Furniture, Office Equipment.

As the ward manager, I will put some systems in place to help me audit as well as use the allocated funds properly.

I will employ one staff who will be in charge of inventory, stocktaking, record keeping and ordering of ward stock and disposables. This person will have to compare and check orders against supply to ensure everything ordered have been received.

Expenses on drugs are usually very high. Most drugs sit in the cupboards, fridge etc and get expired and thrown away. I will therefore hold a meeting with the pharmacist and consultant about the drugs which are needed on the ward and how the cheaper versions can be sourced(Brand name and Generic name) and put this topic on the ward meeting agenda to make everybody aware of what is going on and why we are doing this.

I will also adopt inventory control measures of FIFO (first in first out) FEFO (first expired first out) to reduce waste. FIFO is where old stock are brought forward and used first, and new ones rolled behind. This term is also called Last In Still Here (LISH). FEFO is date sensitive and so regardless of date of acquisition, stock with earliest expiry date or shortest shelf life must be handled first. (International, 2019)

I will also take into consideration ‘best before’ and ‘use by’ dates. This is only a rough guide rather than a strict rule and it mainly applies to medication especially Vitamins. (Anon, 2019).

I will also put some systems in place where I can monitor my ward equipment when borrowed by another ward so we can track them and they do not go lost. Systems like beeping systems, coding systems as well as putting the ward name with stickers that are not easily removed or irremovable on all ward equipments. Also ensuring a log in book where equipment are logged in on borrowing and logged out on return.

Record keeping is very important as stated in NMC Code of Conduct which advises that good note taking is a vital tool of communication between nurses. (contributor, 2019). There is the faithful saying that if it isn’t recorded, it hasn’t happened.

5. Budget simply put is the amount available to spend.

Budgeting is the process of designing, implementing and operating budgets.  (Your Article Library, 2019).

75% of NHS spend is on staff budget and 25% on non staffing budget.

Budgeting entails planning, communication, coordination, control, evaluation, motivation and conflict management etc. As the ward manager (budget holder), I must have good leadership and management skills. I will have to involve key people like accountant, pharmacist, doctor, my manager, to help in budgeting (planning), as well as involve my staff in implementing the plan. This is done through good communication, coordination, good team work, being in control of all situations, motivating staff by improving working environments, pay rise and training amongst others, managing conflicts well as well as evaluating the outcome. Budgeting must be seen as the whole department’s responsibility and not just the budget holder’s. (Nursingleadership.org.uk, 2019).

This brings my leadership skills into play (democratic, participating, and delegating) as well as using change model to make the change stay. Using Lewin’s change model –unfreezing (letting go of an old pattern), change (process of change in thoughts, feeling and behavior) and refreezing (establishing the change as the new habit). (Nursing Theory, 2019).

For me to successfully manage my staff and non staff budget as the ward manager, I must understand how money flows into the ward. Funds is usually allocated from HMRC (Taxation) to DOH, to NHS England then to CCG, to my hospital and then to my ward.

This will enable me to use good skill mix taking patient need into consideration as in Francis Report. This also helps to cut down cost.

I will also adapt to E-Rostering instead of paper rostering which empowers staff, gives more flexibility, reduces absenteeism and hence less usage of agency staff. This takes into account Abraham Maslow’s Hierarchy of Needs. E-rostering also linked to payroll will remove all confusions about salaries.

Also adopting systems like FIFO, FEFO, Coding and Record Keeping will all help me manage my ward successfully and effectively.

REFERENCES

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