As a health care provider, describe how income flows into the organisation of your choice (e.g. hospital, community or a Private company);

The National Health Service (NHS) was established on the July 5th 1948, with the primary objective of delivery comprehensive healthcare services to the people of the United Kingdom (UK) (Harker, 2012). The vast majority of the funding in the NHS is through central taxation and other sources includes service charges and healthcare insurance (NHS, 2010). However, this study is aimed at discussing the flow of income into and out of the Sunderland City Hospital. It will describe how the NHS Foundation Trust is funded and how income flows.

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The Sunderland City Hospital is a part of the NHS Foundation Trust that was established in 1994 and serves about 1 million people in Sunderland and the north-east part of England. The facility provides job opportunity to about 5 thousand people in the area and its outreach centres. The Hospital most recent budget is about 306 million according to the 2016/17 annual report. The trust provide a wide range of services to the people from children to adult in the view of meeting the healthcare need of the public. According to the annual report 2016/17, the Trust gets its funding primarily from the treaty with Commissioners from the Clinical Commissioning Group (CCG), which account for about two third its funding. The CCGs gives accountability directly to the Department of Health (DOH), and the DOH reports directly or get approval from  the Parliament through the office of the secretary of state for health (NHS, 2015).The main responsibilities  of the CCG includes planning and commissioning of the healthcare services to the HNS foundation trusts through Payment By Result (PBR), which is apparently a payment, structured according to the number of people using the services or the services provided (DH, 2015).

The level of NHS funding in a given year is controlled by the central government through the expenditure assessment process (NHS, 2017). This method entails the estimation of the income the NHS will obtain from sources such as service charges, national insurance and taxation. If there is a shortage in the generated income from the service charges and national insurance, then fund from general taxation is used to supplement it to ensure that the budgeted fund is appropriately allocated (DH, 2013). Additionally, depending on the demographic arrangement and demands, the NHS commissioning board through the clinical commissioning group assigns funds suitably to the different Trusts including the Sunderland city Hospital. The schematic representation shown below will give a clearer explanation of the structure, flow of fund and accountability. 

THE NHS FUNDING STRUCTURE.

(NHS, 2015).

2. Evaluate the steps you would take when reviewing the skill mix in           the clinical setting of your choice.  Discuss how you might balance the financial implications of your actions?.

The demographic and economic challenges confronting the healthcare delivery system in England is mostly felt by the healthcare professionals and the entire workforce delivering services to the service users (Addicott et al., 2015). It was estimated that about 70% of recurring cost in the NHS is related to staffing, and NHS is believed to be one the worlds’ largest employer of labour, therefore it is important that careful attention be paid to the workforce, addressing the cost pressure and challenges associated with skill mix, and ensure appropriate delivery of care model outlined in the Five Year Forward View of the NHS (NHS, 2014, Addicott et al., 2015).

Social and healthcare need have evolved significantly over the last few decades, the reason being the increasing level of complex and chronic conditions and rising number of older population who needs long-term care (Addicott et al., 2014).  There is a direct pressure to ensure that the workforce is adequate to meet the existing demand, but also, there is a need to evaluate the skill mix to make sure that it can meet the standard needed to deliver the desired healthcare model (Appleby et al, 2014). However, considering the financial and clinical impact of developing a competent workforce, it is vital that we understand skill mix, its short and long term impact (Addicott et al., 2014).

Teams with diverse skill mix is recommended to create synergy and an environment where knowledge and experiences can be shared (Swanwick and Mckimm, 2011).

The decision making process in term of skill mix extends from a wide-ranging macro-level administrative policy level to the smaller micro-level every day regular staffing judgement (ANA, 1999). The available literature have revealed that the role-based methods are used to determine staff mix in most advanced countries (Adano, 2008). The Task-based approach is another method determining skill mix which focuses on the task which can be safely allocated, this ensures that quality and standard is maintained (Buchan et al., 1996, Adano, 2008). Despite variations and different approach employed by different organisation, it is common that several approach be used in combination when making a skill mix judgement (Buchan et al., 2000). Irrespective of how and where the decision was made, safety, quality, cost-effectiveness should be the universal determining factor (Buchan et al., 2008.).

The RNC (2015) expressed concern over the trend and the cost of hiring agency staff to cover shifts in the NHS foundation Trust. According to the RNC’s Freedom of Information request submitted to the NHS providers of mental health services, it was estimated that a total of £980 million was spent in the NHS England in 2014/15 on hiring agency staff. The rising cost of was blamed for being the driver behind declining finances of the Trust and as a result leading to challenges such as low staff morale, poor continuity of care  amongst many others (Keogh, 2013 ). This trend of hiring agency staff have being in upward trend considerable following the Francis Inquiry report (Mid Staffordshire NHS Foundation Trust Report 2013).

Conclusively, Workforce planning is vital due to the complexity of the skill mix requirement in the NHS, ensuring greater consistency in maintaining a competent workforce and quality care delivery entails tackling the challenges of affordability (Addicott et al., 2015). Conversely, Scott and Spouse, (2013) argued that the staffing policy of any organisation is dependent on the financial capability of that organisation. Therefore, in other to successfully implement an effective skill mix, financial consideration is vital.

3. You are required to develop a system which would enable you to audit your staffing expenditure on a monthly basis.  Offer detailed discussion of your rationale underpinning your system;

Staff management in an organisation is an important process to ensure adequate utilisation of the budgets. Having outlined the importance of sustainable skill mix in the NHS, it is paramount that staff auditing be instituted to better manage the available resources (Gray and Mason 2008, Addicott, 2015). Staffing Audit have been described as the evaluation of the clinical performance of the health professionals in other words, auditing entails effective management and organising of the human resources and operations in other to evaluate the standard and quality of care (Fulton et al., 2011, Gray and Mason 2008). Conversely, McCutcheon, (2009) opined that auditing involves a reflective process by which healthcare practice is evaluated meant to proffer improvement of services and care delivered. However, Schon (1983) equally asserted that nursing in its nature entails reflective practice which helps to improve the quality of care delivered.

The E-roster system is a vital planning technological mechanism used in the management of staffing in the NHS Trust. The E-Roster is a Real-time Rostering software that helps NHS hospitals to deliver fairer and safer services to patients and staff at the highest standard, this systems helps to balance the demand of productivity and cost (NHS 2016, Drake 2013). The HFMA (2008) reports, asserted that the E-rostering system offers a faster and more justifiable substitute which reduces cost of temporary or agency staff by better organising permanent staff mix and temporary staff protocol, by means of drafting of staff from less busy wards to the wards were demands are high. (NHS, 2010). This entails the use of computer software and the internet, were the permanent staff can request a particular shift from the software and the nurse manager approves or disapproves the shift picked by the nurses (HFMA, 2008).

The budget statement is essential to ensure a functional staffing expenditure which includes overall spending on staff income payments and other unit’s miscellaneous expenses (Sander, 2009). The staff expenditure auditing when effectively done, creates an appropriate skill mix which reflects on the quality of care delivery of the organisation (McCutcheon, 2009). The NHS England suggested the utilisation of evidence based tool together with professional skills of the managers and/or auditors to carry out the departmental auditing. Analysis of the findings of the audit is mainly done by the stakeholders, the score of the audit is taken into consideration, the degree at which the set standard is being meet is greatly considered and appropriate planning and strategies are instituted to improve the present state of event in the organisation (Atkins et al., 2010, DH, 2011).  The NHS Trust Clinical Audit Policy and Procedure for 2018 – 2021 outlined action plans to be followed in conducting a comprehensive clinical audit, a huge emphasis was placed on the reporting of findings and utilisation of the result to improve the standard of service delivery in the Trust. The results of the audit will play significant role in determining the budget and allocation of resources to various areas that needs improvements.

4. You are required to give a detailed discussion how you would audit non-staff expenditure on a monthly basis in a clinical setting of your choice. What reasonable cost effective strategy would you implement in order to maintain best practice?.

The latest report on the NHS 2017 Autumn Budget indicated that spending in the increased with about £2.8 billion mainly due to the day to day running of the Trust (NHS, 2017). Harker (2012) argued that the expenditure on the NHS have risen exponentially since it was established in 1948, she further asserted that the rise is far above that of the national GDP. However it is estimated that by 2020 the NHS budget will be about £127 billion (DH 2018). The expenditure on medical equipment and goods are the key investments that yields profit and enables the staff to perform their duties effectively. Monitoring and periodic auditing is essential for the nurse manager to ensure that adequate resources are always available for smooth running of the department (Clement, 2011). Medical supplies inventory and auditing is a key factor in ensuring that safety and quality of care is maintain, this process helps to keep track of consumable items that may outlast its expiry and pose harm the patient (Kaur and Hall, 2001).

The unit manager is duty bound to ensure that medical supplies are checked and ordered when in low stock and equipment are checked to ensure that they are in working conditions for the  carer to carry out their duties (clement, 2001).Kaur and Hall , (2001) referred to this process as Planned Preventive Maintenance (PPM) the process is most recommended by the manufacturer of the clinical equipment to be carried out by a trained technician periodically to evaluate the performance and integrity of every parts. PPM keeps the equipment in good condition and avoid breakdowns which can cause injury to the patients. Usually manufacturers of most equipment provides PPM services but in a case where those services may not be available due the equipment being produced in a different country, the technical department or the biomedical engineers may be responsible for the periodic checks.

The nurse manager is expected to be knowledgeable in carrying out period audit and inventory check. The First In First Out (FIFO) policy is used to ensure that the old items are utilised first before using the new supplies, this process is achieved by arranging the old stock close the exit point to enable other staff have easy access to them first (Stefi, 2008). Furthermore, a comprehensive documentation is essential in carry out audit, the nurse manager requires the controlled inventory system (Smith et al 2010). This system ensures that easy access to information about the status of each supplies, the system gives access to the expiry dates of the supplies, the quantity available at a time (Kaur and Hall, 2001). The City Hospital Sunderland as a part of the NHS Foundation Trust is saddled with the responsibility of delivery quality care to the people of around Sunderland and its environs, however, appropriate budgeting and comprehensive auditing will ensure that the tax payers’ money is judiciously utilised for the purpose it was meant and quality care delivered (NHS, 2014).

You are required to describe in detail essential information which would enable you to successfully manage your staff and non-staff budget.  From your earlier information (Questions 1 – 4), what do you consider to be key issues in terms of successful management?

The key to successful management of staff and non-staff budget entails the total the understanding the budgetary objectives and effective skill in appropriate decision making (Kelly, 2009). Correspondingly, adequate knowledge and experience of the nurse manager in the area of budgetary allocations in the clinical setting is an important tool in ensuring appropriate management of available resources (LeGrand, 2007). As earlier stated, there are increasing demand in the services provided by the NHS to due varieties of factors (HNS, 2015), these demands can be met by judiciously managing the staff and non- staff allocations in the wards and strict adherent to the budget when planning to avoid over spending (Mauskopf, 2007).

The staffing budgeting and expenditure is a grey area that greatly burdens the NHS Foundation Trust financially (NHS, 2017) and thus the onus is on the nurse managers to ensure that adequate planning and effective staff management strategy is utilised in a way to maintain the standard of care delivery (DOH, 2015). However, the nurses manager in making staff expenditures needs to consider factors such as the patient-nurse ratio approved by the Trust and the complexity of the cases being managed (LeGrand 2007). The E-rosterING system is a recognised staff management system used across the NHS Trust that have helped the nurse managers to better manage the non-staff and staff budget (RNC, 2013). The rostering policy was implemented to ensure that there are effective utilisation of the workforce and skill mix is greatly improved through efficient rostering which is evident based. The Francis inquiry report after the Mid Staffordshire NHS Foundation Trust event focused on addressing the lack of basic care across the Trust (DOH, 2014). Staffing issues amongst many other issues were highlighted and appropriate recommendations were well implemented and are operational across the Trust (NHS, 2015).

Furthermore, the nurse manager is saddled with the responsibility of conducting an audit on the staff and non-staff expenditures, this is to enable effective and safe care delivery (Sander, 2009). First In First Out system is an effective way of managing healthcare delivery supplies (Shorrock, 2014). This system ensures that wastages are avoided by making sure that old items are kept were they reachable and used first before the new supplies. The E-rostering system is as well useful in this regard in keeping record of the items, and to ensure that appropriate inventory and audit is easy and done without hassle (Drake, 2013). The Schon (1983) reflective model is helpful in channelling the nurse manager’s focus on ways to conduct effective planning and implementation of ward audit, by evaluating areas of strength and weakness and proffering a sustainable solution in managing the budgetary allocations, expenditures and monitoring staff mix issues (NHS, 2017).

Conclusively, The importance of management cannot be over emphasized, the nurse as the leader and a team member in the healthcare scheme plays a major role in  not just providing healthcare services but also being a manager of the tax payers resources made available to them in the wards. Therefore the nurse should possess a good management skill, by adopting the evidence based knowledge acquired in their practices in making financial and human resources management decisions.

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