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There are three work programmes to explore workforce retention and configuration in healthcare. The first programme will combine and align multiple large datasets from 20 NHS trusts across secondary care and mental health and 10 ambulance trusts. This will enable the analysis of multiple variables and their effect on workforce retention, and how these variables, in combination with workforce retention, subsequently impact patient outcomes. The second work programme will involve designing and testing an infrastructure for the routine extraction, combination and analysis of these large datasets. This will enable the adoption of these techniques across the NHS. The nursing element (NuRS) will start first, with the ambulance staff (AmReS) element following approximately six months later. A third programme will examine the effect of the COVID-19 pandemic on patient safety in terms of reporting behaviours, for example; and will explore how nursing and ambulance workforce configuration in response to a pandemic affects patient safety and quality of care. This project is a unique opportunity to unlock the key underlying drivers of nurse and ambulance retention and determine their impact on care quality, helping to tackle the challenge of supply in the NHS and ensure that high quality, sustainable care is available to all.

Key points Recurrent nurse workforce shortages are a global issue, also in high-income countries. Implementation of safe staffing policy measures largely varies across the world. Mandated patient-to-nurse ratios are the most straightforward policy to ensure staffing levels. Our overview of policies from various high-income countries may guide future decision-making.

Among the results reported by the Scan4Safety demonstrator sites, were: the release of 140,000 hours of clinical time back to patient care non-recurrent inventory reductions of £9m recurrent inventory savings worth nearly £5m across the six trusts.

The full impact of COVID-19 has not yet been realised, but what we do know is that we have been navigating with no roadmap or star to guide us. In terms of the three psychological phases of a crisis, we have worked through the initial state of ‘emergency’ where we have had (largely) shared goals and an urgency that made us feel energised, focused and even productive. However, this phase feels like it is in its descendancy and most of us are now in the next phase of ‘regression’ where the future feels uncertain and we have lost that sense of purpose. In my work with colleagues from across health and social care to understand what phase three ‘recovery’ looks like in workforce and wellbeing terms, it is clear that both aspects are starting to get the focus they always should have had but maybe not in the way we would have expected. It has not been cries of ‘more’ staff or money that have been echoing through the corridors, but the cry for ‘different’ and the freedom to make decisions without the shackles of bureaucracy and hierarchy holding the tide of necessary change at bay. In the past, workforce planning has had little shared meaning, and has often been more recruitment planning for a continuation of the same as opposed to thinking about what we need from our teams in terms of availability, skills, expectations, roles and the delivery of care designed around the person receiving it. Wellbeing seemed to be something that only HR considered if there was a staffing issue or high sickness, or even more cynically a poor outcome in survey results, resulting in lots of workshops, fabulous plans, but very little sustainable change. In the initial stages of the pandemic, I worked with a number of acute teams to look at staffing in the short term to face the initial onslaught of COVID-19. This meant looking at variation and where we could adjust care levels safely, planning to deploy a moderated skill mix of staff, and working through the cost of plugging gaps in largely traditional models of care using temporary and volunteer staff, with the hope that the 20% sickness rate wasn’t breached too often leaving us exposed to the hazards of unblocked holes in the workforce. This was acknowledged as an unsustainable and haphazard way of providing care for both staff and patients, which after the ‘emergency’ phase results in burnout, higher sickness, increased turnover, and certainly lacks in the resilience required to continue to manage COVID-19, non-COVID urgent care, elective care and the wellbeing of staff and carers. So, what do we need to do as we plan for recovery, or more precisely ‘post traumatic growth’? Despite an apparent increase in interest in joining the nursing profession since the start of the pandemic, the reported 40,000 gap in nursing numbers is not going to be closed overnight, so it seems that planning for different and capturing and capitalising on the innovation that has flourished in some areas is the only way forward. How do we do this? As an example, let me turn your heads to colleagues in social care who have known for some time that their current state was unsustainable. This has been compounded by COVID-19 and the (inevitable) delayed recognition by government of the essential role of social care in protecting the NHS and some of our most vulnerable people. Therefore, they chose to do for some what is unthinkable – they took their nurses away from direct patient care. In some of the teams I work with there was an expectation that they would have 50% of staff available to be deployed, and would have slower and more limited access to other services to support – including temporary staffing or volunteers. They collaborated swiftly both within and across organisations, changed models of care completely based on some of the data collated by Establishment Genie, and moved to a model of all registered nurses in a supernumerary supervisory role, providing support to staff in their own care home directly and also in other homes via ‘virtual’ collaboration, and using technology to connect, share, teach and learn ‘on the job’. This of course questions the future role of the nurse in these homes but is also an example of how we all may need to re-think roles and responsibilities to meet the challenges of today and the future in order to keep the people in our care – patients, residents and staff – safe. As we begin to reorient, revise our goals and focus on moving beyond rather than on just ‘getting by’, it is important that we look at all settings of care so we can learn from excellence, build on the best, and support a faster response in the future if required. The response to COVID-19 for many has been an example of how a system succeeds in varying conditions; a ‘Safety-II’ approach where humans are the necessary resource for system flexibility and resilience. We need to take the time to understand where things have gone right, to celebrate and acknowledge this, and then co-create a health and social care system that people want to work and be cared for in.

The key challenges identified are: funding; capacity; rehabilitation; health inequalities; regulation and inspections; system working; and managing public expectations. It puts forward a number of practical solutions for the phase three guidance and beyond, including: An extension of emergency funding across all sectors of the NHS, given significant extra demand across all services. Longer term funding will be needed for rehabilitation and recovery services in the community, including for mental health, to manage patients at home and in the community. Putting in place an ongoing arrangement with the private sector – this will be vital to provide capacity to respond to the backlog of treatment. A review of the impact of COVID-19 on the NHS and social care workforce given the unprecedented pressure staff have been under A delay in returning to the inspection regime of the CQC to take into account the positive changes that have been achieved as a result of the lighter touch approach to regulation that has been in place during the pandemic. A commitment to acknowledge and address health inequalities wherever possible through upcoming guidance and policy reform. Clarity over when there will be a return the greater autonomy local organisations had before COVID-19 returned, as we move from Level 4 to Level 3. This should be considered as part of a wider move to less central command and control when the pandemic has subsided. A call for assurance that there will be a fully operational and robust test, track and trace system, as well as appropriate supplies of personal protective equipment (PPE),as services are resumed.

The COVID-19 pandemic is creating an updraft to do something. Clinical, political, geographical, humanitarian, economical and logistical forces present recognisable pressures that either inspire or dissuade action ... but not for all. Innovators are energised when they see an urgent need to dismantle the status quo. They are well equipped to capitalise on the momentum generated by emergent situations to respond in a way that is collaborative, effective and safe. It is from this whirlwind that the April Letter from America is penned. Innovators can be challenging to be around. They see the world differently and can ruffle feathers with ideas that don’t stay on the well-trodden path. But when there is no normalcy, free thinking presents opportunities, necessitates unique partnerships and motivates organisational willingness to recalibrate. It is the responsibility of leaders and peers to appropriately harness this energy to make the most of opportunities that innovators present as they directly interface with patients. The willingness to innovate to address the COVID-19 pandemic is inspiring. An impressive range of solutions have been devised to meet equipment and care service access challenges. Social media is a robust and widely accessible mechanism to stimulate conversations about these ideas. #MacGyverCare is one of several Twitter streams devoted to sharing unconventional solutions. MacGyver, hub members may know, is an American TV character known to improvise to get things done in difficult circumstances. Similar to the hub's own Coronavirus Share your Tips page, people are using #MacGyverCare for sharing ideas and innovative solutions to help those on the frontline manage the demands of the crisis. Examples include creative solutions to the personal protective equipment shortage across the country. While acting to devise a new “as needed” approach may not be something everyone working directly with patients can do, there are other avenues for supporting clinicians to help them provide safe care and find comfort, resilience and even joy in that commitment. People are coming together to ‘MacGyver’ with peers during the pandemic. For example, unique partnerships with libraries are cropping up provide access to the literature, open WiFi hotspots to provide children access to school programmes and even to produce PPE. Is that a MacGyverism? At Columbia University in New York, a Research and Learning Technologies librarian partnered with a cardiology fellow to modify a freely available pattern to create face shields. Using 3D printer skills, assembly line know-how and teamwork they brought together a team to produce and distribute the equipment to staff at New York Presbyterian Hospitals. The Columbia University library shared their process to spread the innovation and encourage the wide use of their concept. At an organisational level, agile information sharing is the bedrock of crisis management. Flexible, enterprise-wide and individualised communication strategies must be in place to respond to rapidly changing circumstances and keep those touched by the situation healthy and safe. The Johns Hopkins University in Baltimore are using peer support and crisis communication strategies to promote institutional resilience. Leadership commitment to resilience, information sharing to reduce anxiety and support network development all buttress system efforts to assure its workforce and community remain safe and healthy both during and after a crisis. The Hopkins process brings the skills of employee assistance, chaplaincy, workplace wellness and psychiatry to the fore in a multidisciplinary team-based approach to assure staff are well situated to provide safe care while staying safe themselves. In light of the shift of resources to patients with COVID-19, delivery of services to patients with non-COVID-19 conditions must also be redesigned. The University of Wisconsin has used an administrative restructuring approach, building on military and emergency management experiences to make adjustments in surgery workforce and expertise availability to address complex shifts in care processes in response to the COVID-19 pandemic. Adjustments were made to synchronise work cycles to assure clinical expertise was reliably available, develop a single clinical pool to staff from rather than coordinating assignments based on speciality or educational level, and form strike teams to engage highly experienced clinicians as needed. These tactics invigorated information transfer, provided role clarity as situations changed and strengthened process sustainability. Team leaders anchored their work by remaining focused on a declared mission and guiding principles to support that mission. While the uptake of new knowledge and science into healthcare practice is often shrouded under the oft-stated “17-year lag” , it is obvious through these and other examples that care innovations can be recognised, applied and improved upon quickly. Granted, it is important for innovators and the organisations they engage with to seek the advice and council of experts from the human factors, process improvement and safety domains to ensure their new ideas are developed and flow into daily work in the safest way possible. However, after this current crisis, let one of the lessons we learn from the COVID-19 pandemic be to make patient safety progress more rapidly through the use of innovative thinking, partnerships and organisation ingenuity.

Podcast 1 – Interview with Chris Frerk Podcast 2 – Interview with Mark Stacey Podcast 3 – Interview with Stephen Hearns Podcast 4 – Interview with Claire Cox

Sometimes, you have those days where you have had enough. ENOUGH. That’s really where the Genie started. I began my career in the private sector, joining the NHS as an ‘experienced hire’ some five years later through ‘Gateway to Leadership – Cohort III’. I probably should have known that a moniker based on the Roman army was telling me something. I had moved from an organisation where the worst thing that had happened was moving the water machine, to an organisation where the water machines had been removed some years before for "cost improvement" purposes. The organisation was struggling to cope on a number of levels, and there was no single answer to solve any of the issues. Sticking plasters were used to cover gaping holes, and we had significant clinical and financial issues. Please don’t misunderstand. I had a baptism of fire, with many incidents I wouldn’t want to put into print, but my wholehearted support of the healthcare workforce, of their resilience and humour, their ability to innovate, and their willingness to stand up and fight, was sown in those first few weeks as a fresh-faced newbie with a desire to change the world. I was approached to join another organisation in those heady days of ‘turnaround’ which gradually became ‘transformation’, as realisation dawned that death by a thousand cuts wasn’t actually saving any money, was impacting on care quality, and maybe (just maybe) we needed a different approach. I was often asked to work with the nursing and midwifery teams based on experiences in my first NHS trust. The issues were often the same. Finance and HR had data – not necessarily matching data – and nursing and midwifery had ‘professional judgement’. Somehow that didn’t hold as much weight, so working together with nursing from ward to board, we would produce our own data based on care levels, costs and WTE, so we could come to the table to ask some really simple questions: “Would you want to be cared for on this unit based on the care that is available?” It made a huge difference, and started to change the conversation from one of conflict and protectionism to one of collaboration. After seven years of working through the same issues in each organisation it reached that point again. Surely there must be a better way? What would happen if we could extend our single organisation work to one that could look at variation between organisations, and include outcome measures, and look at workforce planning across all settings of care? So, with an idea in our minds and a plan to do good, Creative Lighthouse Ltd was formed. Establishment Genie was born in a shed and has been both kicked and nurtured by some wonderful critical friends and safe staffing experts. The hard work, bloodied knuckles from knocking on so many doors, and the highs and lows of running a tech start-up in a sector that often doesn’t embrace technology started to pay off. The Genie achieved NICE endorsement in April 2017 and was awarded a grant by Innovate UK to develop and test the Genie across all settings of care. We have now worked with front-line staff from more than 500 teams and organisations to review, remodel and report on their workforce, supporting them to meet the challenges of safe and affordable care with a backdrop of clinical and financial shortages, and track their progress using outcome measures to show that they are improving quality of care. However, the journey doesn’t stop there. Dear reader, to paraphrase poorly, I have a dream. I have a dream that one day every health and social care organisation will put workforce at the centre of all their planning processes. A dream that all health and social care organisations will use the same approach to plan their workforce and share outcomes and data for the benefit of all, and the future of health and social care. A dream that our frontline health and social care leaders will work beyond professional and organisational boundaries to ensure that every person has the best and most appropriate care, provided in the most appropriate place, with the safety of every individual at the core of every action and intervention. Thankfully I love to travel and cannot wait to meet more innovative disruptors who share that same dream. Jump onboard – it’s going to be one heck of a ride! Read on the hub case studies showing how trusts are developing their approach to workforce planning.

This powerful info-graphic highlights 15 reasons why action is needed in adult social care:

What we did Sharon Mcloughlin, Ward Manager, Dott Ward: "The Innovation Agency gave us the dialogue to engage with staff and address concerns objectively, without staff taking anything personally. I was able to say this is an outside organisation, and with them we’re going to look at how our team could improve." “It’s been about empowering staff, and staff realising that change has to come from all of us. I’ve gained skills to help staff feel more empowered and get on board, and see it as their responsibility to improve things too." “Hopefully as a result we’ve improved safety for patients as well. I’m more confident now that I know everybody on the team knows which patients need turning, which patients are at risk of a fall, which patients are suffering from an infection – and if staff don’t know, they need to take some accountability for that now.” Kate Wallworth, Sister, Dott Ward: "After the Coaching Academy we've now got a structure in place – we’re organised, very organised. We introduced our Safety Huddle where all staff come in and listen while we run through all the main points on the ward. That’s before every shift. Going forward everyone is aware of what’s happening on the ward that day. If a visitor comes onto the ward, any member of staff would be able to answer their questions. We all know which patients are suffering from an infection, which patients are going into theatre. It just helps the running of the ward. It’s a more pleasant ward to work on.” Lisa Clark, Sister, Dott Ward: "We had to try and figure out a way to measure if teamwork was improving or not. We introduced a simple box where staff can post a smiley face or an unhappy face, or a comment card – it was just trying to make it as easy as possible. At the beginning we’d see a lot of sad faces going into the box and not many suggestions." “Now it takes me longer to type up because there’s so many suggestions. People mention staff who’ve really put themselves out to help out, just to say thank you. You can see a lot more positive feedback, and everyone who sees their name on the board gets a positive feeling." “I don’t think people realise how powerful and uplifting it is to hear how to be positive – that there is a way to think positively, and there are solutions to problems. That’s something we’ve tried here with the team – if things aren’t going in the right direction, why don’t you think of an idea? How could you fix it yourself?” The Coaching Academy The Innovation Agency’s Coaching Academy is a programme that enables health and care professionals to improve culture, quality and safety of health and care through structured, focused interactions. Coaching for a safe and continuously improving workplace culture is a one-year programme for clinical teams focused on developing safe, high-quality and compassionate services. The programme includes accredited coaching training for team leaders; a collaborative action learning programme with other teams, creating a community of practice; an accredited team culture diagnostic to identify key areas of focus; and quality improvement and innovation practical knowledge and skills.