Electronic rostering is being implemented to save money, but this could be mixed news for midwives, reports Phil Harris.
Computers are like Old Testament gods: lots of rules and no mercy.’
The American author Joseph Campbell probably wasn’t thinking about NHS staff scheduling when he wrote this in 1988, but some midwives might be forgiven for nodding in agreement.
The use of IT systems has brought many benefits to the NHS, but electronic rostering is one area where the jury is still out.
The idea is simple enough in theory: having an electronic system helps to plan staff shifts in advance, ensure fairness for everyone and, through increased efficiency, release more time for direct care.
It should give managers the power to plan, allowing for sickness, leave, different skills and competencies, and removing the problems of under- and over-staffing.
Yet e-rostering has proved more tricky in practice, with concerns raised over how it works and how suitable it is for midwifery services.
For decades, the process of working out which staff were needed to work, and when, was done on paper. Although this approach involved a risk of error, took time and could be misused, it was cheap and could accommodate flexibility when and where required.
E-rostering started to appear more than a decade ago as NHS organisations looked to increase efficiency and save money, particularly on agency costs. In 2006 the National Audit Office called for trusts to use better systems, and noted that very few had them in place.
Things have started to snowball recently. A turning point came when a London School of Economics report called for greater use of e-rostering to cut costs and improve care (Hockley and Boyle, 2014).
Following this, the review of hospital productivity and efficiency by Lord Carter of Coles (Department of Health, 2016) recommended that all trusts should use e-rostering, published six weeks in advance, and pointed out that if trusts took a ‘firmer grip’ of staff rostering this would ‘reduce dependency on bank and agency staff’ and ‘improve the predictability and consistency of staff deployment even where recruitment is still a challenge’.
Shortly afterwards, NHS Improvement in England published its Good practice guide: rostering (2016) to help managers implement Lord Carter’s recommendations.
Although e-rostering has not been mandated across the UK, trusts have been driving widespread usage, looking to maximise every penny of spend.
E-rostering should in theory bring more transparency for staff, economies for trusts and savings for the health service. So why is it proving controversial?
RCM director for England Jacque Gerrard says e-rostering programmes are a difficult fit for midwifery: ‘They are part of a growing system fitting in with wider NHS bed management processes, and midwives tell us they don’t like them. They are contentious as they don’t sit well with the principle of small teams, caseloading and continuity of carer.
‘However, heads and directors of midwifery have a job to do to cover the services 24/7, and some understand they do have a place within the trust’s wider bed management process. It is clear that many have no choice as the trust buys into the systems and then uses them in maternity services.’
Robert Drake, principal lecturer in information systems at Sheffield Hallam University and author of several research papers on e-rostering, says: ‘While manual rostering systems may be unsatisfactory, e-rostering brings its own challenges.’
Robert has identified several dilemmas in e-rostering (Drake, 2016). The first is that it often assumes a static work requirement, whereas this can change frequently and unpredictably.
In practice, midwifery teams need to provide a 24/7 service, with enough skilled staff available to safely manage the workload while maintaining a work-life balance for the staff involved, for whom flexibility is key.
Second, e-rostering means rules for all staff have to be made explicit and coded into the system. This may be good in terms of transparency for staff, but it also means that managers lose the ability to make decisions locally and act with discretion.
Another dilemma surrounds whether e-rostering is fair. In reality, this can be hard to define, and attitudes can vary across workplaces. Robert says: ‘Using standardised bureaucratic rules offers a shallow perspective of fairness within a tight-knit team. In practice, the notion of fairness is rooted in team culture and goes beyond unbiased allocation of requested shifts. What may be considered fair in one team may be seen as unfair in another.
‘In some teams, as staff get older the roster is almost like a bargaining tool or rite of passage. As they have put in the time over the years they may feel they are entitled to more choice.’
Roster policies usually give the manager responsibility for roster fairness, and different managers will have different views on what is fair or otherwise – it is difficult to standardise this.
Robert also points out that, although e-rostering can be empowering for staff, it can also be an instrument for management control, meaning that in the drive to standardise and push for greater efficiency, staff can lose control of when and how they work, which can be disempowering and demotivating.
A flexible friend?
Of these issues, flexibility is particularly significant for midwives.
The majority of midwives work part-time and almost all are women; many have children or other caring responsibilities, so work-life balance and the ability to juggle employment and personal commitments is of great importance.
So is e-rostering leading to reduced flexibility and becoming another source of disenchantment for midwives?
Perhaps unsurprisingly, midwives do not wish to speak out publicly on the subject, for fear of seeming to criticise their employers. Anecdotally, complaints about e-rostering and flexibility are common, particularly among part-time staff.
Jackie Mitchell, national officer for RCM Scotland, says that many midwives are concerned about flexibility, but the picture can be more nuanced. She says: ‘I have heard issues raised by others regarding staff complaints of the system’s apparent inflexibility and not being able to have flexible working previously agreed.
‘But when it is investigated it is then found to be more to do with the ward manager not willing to put in the flexible working patterns for staff members and using the e-rostering system as the excuse.’
NHS Employers does not consider flexibility to be a problem. Its spokesperson says that ‘varied working patterns and service needs can be reflected... e-rostering should not have a negative impact in restricting the way services are run, even those that are more complex and variable.
‘The best examples of implementation see managers and staff working together to ensure that both patient care and staffing preferences are considered when rosters are developed.’
Robert Drake agrees that in general the systems can manage well with flexible working. ‘Regardless of the limitations, provided these are identified within the system, the system will only roster that person on the days and hours specified.
‘However, this requires transparency, and this can prove problematic. On a manual roster a manager may allow an individual to work a certain pattern, but keep this confidential to maintain harmony. Within an e-rostering system, this pattern is recognised on the roster.’But arguably, midwifery can ill afford to put up any barriers to flexible working, or give staff any reasons to leave.
Figures from the NMC (2017) show that for the first time more are leaving the register than joining it, and this is particularly pronounced for staff from the UK – meaning the drop is not because of EU workers leaving the UK after the Brexit vote.
Moreover, the NMC’s survey of leavers found that, excluding retirement, two of the top three reasons given were working conditions, including staffing levels (44%), and a change in personal circumstances, such as caring responsibilities (28%) (NMC, 2017).
Case study: effective resource managing?
NHS Employers considers e-rostering to be a helpful tool for the NHS. A spokesperson says: ‘It can support an organisation to ensure their workforce is utilised in the most appropriate and effective way to support the provision of care to patients.’
NHS Employers is keen to promote case studies of where it has benefited the organisation. One such example is Hertfordshire Partnership NHS Foundation Trust, where e-rostering was brought in to help manage sickness absence and reduce its use of expensive agency staff.
This began with a pilot project on a couple of acute wards, which was then rolled out ward by ward, each time taking on board the lessons learned along the way.
Electronic timesheets were introduced so that staff and managers weren’t spending hours every month calculating staff hours, and this also meant the payroll was more accurate.
The project leads engaged a lot with clinical staff, listening to concerns and their response to the new system. Some embraced the new technology and shared information about good outcomes and experiences. The trust saved £750,000 over three years and increased the amount of information available to help manage staffing resources.
Meeting women’s needs
Another big sticking point with e-rostering is whether it actually helps to meet the needs of women, rather than the service.
Jacque says: ‘Midwifery care is complex-variable, and it can be hard for midwives to deliver care in partnership with busy pregnant women who may have to work and care for family if they are e-rostered to specific hours. Their caseload of women may want an antenatal appointment at 8pm in the local children’s centre, for example.
‘Midwives want to give continuity of carer, so what happens when a woman asks for this outside their rostered hours? Midwives will do what they usually do, which is to give the woman more of their time than they are rostered or paid for. For continuity of carer to work we need to staff the women, not the hospital.’
Jacque also highlights that e-rostering seems to be at odds with the recommendations in Better births (NHS England, 2016), which calls for every woman to have a midwife who is part of a small team of four to six midwives, and who can provide continuity.
‘It does not sit well in terms of safe personalised care, continuity of carer and autonomous midwifery practice,’ she adds.
There are also concerns that e-rostering will not work well alongside the changes set out in Scotland’s Best start maternity strategy, which calls for more midwives working in community-based, more self-managing teams.
Mary Ross-Davie, director of RCM Scotland, says: ‘These continuity-of-carer models will require quite a different, more flexible and individualised approach to working out work patterns.’
One midwife in Scotland, who like many others did not wish to be named, says e-rostering has worked.
‘It took us a few months to get into the new system, but we seem to be settling in now,’ she says.
‘There is a template produced for each area with staffing requirements, such as five midwives on the day shift and three on the night shift. Rules can be made to suit any area, and we have a rule that we never have more than one Band 5 on night duty, so if we try to put two Band 5s on a night shift then the system tells us that these staff should not be on together.
‘We can add a supernumerary shift for newly qualifieds. Flexible working for parents and carers can be put in for each specific person, and reports can be run regarding budgets.
‘Bank shifts are run from the same system, so there is no need to call staff bank any more. As soon as a shift goes on as sickness/carers’ leave, then if we have budget we can put the shift on to bank.’
So it is a mixed picture, as Robert explains: ‘Rostering is an extremely complex process. Today’s systems have been designed to reduce much of that complexity. Consequently, the systems are themselves quite complex and require time, training and patience to implement.’
He adds that the roll-out of any information system relies on several factors being in place, including senior management support, project ownership and staff involvement.
‘Senior managers have to be genuinely convinced of the benefits of the system in order to offer their support, take ownership of the project and motivate their staff to be involved. Mandating e-rostering runs the risk of creating reluctant managers imposing systems on a sceptical workforce.
‘E-rostering is a tool that can be used to liberate or control a workforce – and how it is used says much more about the management of the trust than the system itself.
’Some managers, such as Claire Price, deputy head of midwifery and gynaecology at University Hospitals Coventry and Warwickshire NHS Trust, are very positive about the system. Claire says it is ‘amazing’.
‘Staff requests are fairer: there is a limit based on how many hours you work, so it stopped the inequity of people requesting so much.’
She also thinks that the system can provide continuity of carer: ‘For community midwifery this isn’t an issue as they tend to work set days when their clinics are running. For antenatal clinics there are also patterns to ensure women receive continuity through the same midwife working alongside the consultants each week.’
Claire thinks that teams should not be worried about implementing the system, but advises engaging with staff early so they know what to expect: ‘We love it.’
Counting the cost of agency staff
More than £97m was spent on midwifery agency, bank and overtime payments in 2016 in the UK.
This is enough to pay for 2731 full-time, experienced midwives or 4391 newly qualified midwives. (RCM, 2017)
Jon Skewes, RCM director for policy, employment relations and communication, says: ‘We have found that many midwives who chose to work for an agency did so because they were denied the right to work part-time or flexibly. In turn we have a ridiculous situation when midwives leave an organisation because they can’t work flexibly and then are employed by the same trust as an agency midwife.’
Jon says the best solution to this problem is to eliminate the shortage of midwives by training and employing more, and retaining existing midwives by treating them fairly and valuing them. Granting flexible working requests is key to this, he adds.