One of the recommendations from the Carter Report in 2016 was for all trusts to adopt a rigorous policy for managing the demands of enhanced care, meaning the specialist care for specific patient needs. Lord Carterfound vast variation in enhanced care practices and managing demand across acute trusts. The report highlighted e-rostering and recording and reporting staff deployment as key elements trusts had to develop for productivity gains, resource optimisation, and temporary staff management.

Gearing workforce management explicitly around patients’ requirements has significant effects, as East and North Hertfordshire NHS Trust has demonstrated. It has used e-rostering software to prioritise the care of patients with dementia and ensure the right staffing mix is available for its patients, transforming care for patients and reducing its agency spend on enhanced care duties by more than half.


Prioritising patients’ care needs


East and North Hertfordshire NHS Trust made dementia a priority when an internal review highlighted the need for improvements. The trust set up an enhanced nursing care team (ENCT), which has improved patient care, safety and experience, while also saving the trust £144,000 in its first quarter against its forecast.

East and North Hertfordshire NHS Trust identified the following challenges:

  • Trust policy on enhanced care was not always followed
  • Reviews of need and risk assessment were not routinely carried out
  • One-to-one care on 12 hour shifts limited flexibility of staff deployment
  • Agency staff with limited knowledge of dementia were frequently used
  • The demand for enhanced care was increasing and costs were escalating

The trust recruited a group of band three clinical support workers and provided specialist training to provide one-to-one enhanced care to inpatients, as the internal review identified that this area of care required significant improvement. With the support of

e-rostering, patient monitoring software and training, the ENCT implemented a virtual roster, rotating staff every three hours, thereby covering more clinical areas and patients with less staff than previously required.

Wards are now required to undertake patient risk assessments based on their levels of risk, confusion and delirium. These assessments are sent to the ENCT for them to assess how best to care for these patients. The level of care they provide depends on the patient’s risk. Care can range from patients receiving one-to-one care, to being placed in a bay with other high-risk patients who require constant monitoring with additional support, or they will put on Bay Watch, which is managed by ward staff establishing a tagging in and out system for a bay with lower-risk patients. This process is managed through the daily staffing and patient safety meeting, which provides oversight of the highest risk areas and appropriate deployment of staff.

The benefits of the three-hour rotations have been:

  • The patients get to see new staff, which changes the rhythm of their day
  • The staff member has a change of environment, which may help when dealing with particularly challenging patients
  • The team can cover more patients for different time periods throughout the day. If a patient has a carer with them in the afternoon, or they sleep in the morning, other patients can be supported on other wards at these times. Staff can be moved around the hospital to the high-risk patients to meet the demand.

Technology was the key facilitator to this change in approach to enhanced care. Through their rostering system, which employees could access through their smartphones, the trust was able to deploy staff into the three-hour rotations. It also means that staff can review where they are meant to be working, allowing the team to respond in a timely manner.

Matron Emily Watts, from the ENCT, who has analysed the team’s work, says: “Before the enhanced care team was established, the standard procedure was to book an unregistered nurse for a 11-and-a-half-hour shift for a specific patient, on a specific ward when a patient was identified with enhanced care needs.

“The flexibility of an in-house team ensures that members can be moved around the hospital covering more areas with less staff to manage and support our high-risk patients.”

The ENCT undertake a daily patient review to clarify the need for the enhanced care requirement, or advise if there were alternative ways to manage the patient. The flexibility of the team means they can move to where there is greatest need.

Before the introduction of the team, agency staff without specialist training would be booked to sit with the patients and patients were kept in their beds with the cot sides up to keep them safe. The team are now proactive in promoting patients’ independence and prevent deconditioning. They have the time to spend with the patients, ensure patients walk around if it is safe to do so and improve patient dignity.

This closer monitoring and interaction with high-risk patients has resulted in a higher standard of care and has contributed to the reduction in length of patient stay in hospital and patient harm.

The trust has seen a bed days cost reduction of £25,000 between January and May 2017 (based on a cost per bed day of £500) through reducing the length of stay by approximately two days for patients with continuing healthcare needs after discharge from hospital. The ENCT has enabled this through their comprehensive patient documents production, eliminating the need for wards to complete night-time diaries for a minimum period of 48 hours as part of the discharge assessment.

The ENCT’s knowledge of the patients in their care also means they are more appropriately placed into their own home with support, rehabilitation, residential care or a nursing home. This improves the experience of their patients when they leave hospital.

£25,000 REDUCTION (JANUARY 2017 – MAY 2017)

Since the team was established in January 2016, of the 1,538 patients referred to the team there have only been three reported falls to date. The graph below shows the reduction in falls, which is the result of a wider improvement programme that the ENCT were part of.

Overall, the clinical and financial benefits from e-rostering and the introduction of the ENCT include improving the visibility of patient numbers, working staff, available staff, and patient acuity levels. It has enabled efficient deployment and re-deployment of staff at the right place and time, with each member aware of any changes such as admission or discharge of patients and staff can move accordingly, with the help of mobile alerts.

Liz Lees, Director of Nursing at East and North Hertfordshire NHS Trust, said: “The most impressive thing about the team is that while there has been an increase in demand for enhanced care, they have reduced temporary staff spending and even decreased the cost of enhanced care. They have done this by flexibly deploying the team to meet the needs of the patients throughout the day to provide high-quality safe care to some of our most vulnerable patients.”

This can be seen through a reduction in cost per whole time equivalent for the delivery of enhanced care from £2,352 in quarter one 2015 to £1,367 in quarter one 2016.


Regarding the use of temporary staff Matron Emily Watts states: “Where peaks in enhanced care needs occur that cannot be met by the substantive team or ward-based care, there will be the need for additional support from bank staff. To ensure that this demand can be met, work has taken place with NHS Professionals to establish a pool of bank staff with the right skills that can be used as required.”

Creating the extra capacity through the ENCT has seen the trust reduce its agency spend dramatically. In quarter one of 2016-17 the temporary staff spend was £225,322, compared to quarter one in 2017-18 of £83,463. This indicates a cost reduction of £141,859 for the quarter.

The three main learnings from East and North Hertfordshire’s use of e-rostering to focus on patients’ needs have been the tangible cost savings that came from the reduction in agency staff, an improved ability for the trust to plan its resourcing needs, and, most importantly, better clinical care and patient experience.