NHS Grampian

2003/04 Audit

Staff Governance

31 March 2004

Anne MacDonald CA – Senior Audit Manager

Audit Services Audit Scotland

Summerhill Education Centre

Stronsay Drive

Aberdeen AB15 6JA

Tel: 01224 346246

Fax: 01224 346247

NHS Grampian / Contents
2003/04 Audit
Staff Governance
Section 1 /
Page

Executive Summary

/ 1

Section 2

Action Plan

/ 4

Section 3

Introduction

/ 18

Section 4

Main Findings / 20

Appendices

1a. Summary of 2003/04 progress / 27
1b. Summary of audit review of qualitative indicators submissions / 29
2. Summary of audit review of mandatory statistics submissions / 34
3. Mandatory statistics selected for national benchmarking / 37
4. 2003/04 Progress Report (action plan agreed in 2002/03) / 45
5. Staff Survey summary output – the key 21 questions survey results / 65
Audit Services – Audit Scotland / 31 March 2004
NHS Grampian / Section 1
2003/04 Audit
Staff Governance

Executive Summary

Introduction

1.1Staff Governance introduced the third component of governance combining with financial and clinical governance to complete the governance framework within which NHS Boards and Special Health Boards are required to operate. Each Board has three standing committees covering these three critical areas. The Performance and Accountability Framework for NHS Scotland will ensure that Boards are equally accountable for how they behave as employers as well as their existing accountability for finance and clinical matters. Boards are expected to demonstrate that they are exemplar employers.

1.2The aim of the Standard is to improve the way staff are treated in NHS Scotland, to be clear on what staff should expect wherever they are in Scotland and to improve accountability for making this happen. This will be achieved by focusing on how staff are managed and how they feel they are managed. Staff across the whole of the country will be asked every two years in a systematic and professional way about how their employer runs their organisation and the quality of their working lives and environment.

1.3The NHS Reform (Scotland) Bill provides a legislative framework to enact the various commitments outlined in the White Paper, ‘Partnership for Care’. These commitments have recently been extended to make additional provision in the legislation for staff governance. Once the legislation is implemented, it is expected that NHS Boards will require to have arrangements in place to ensure compliance with the Staff Governance Standard.

Audit objectives

1.4With regard to the 2003/04 audit, the auditor had the following objectives in respect of staff governance :

  • To validate and assess progress made against the action plan agreed at 31 March 2003.
  • To confirm the robustness and credibility of the action plan agreed in March 2004 having ensured that the NHS body had considered progress made against the previous year, the self-assessment process and output from the staff survey.
  • To provide assurance that in future the action plan is being delivered (year-on-year).
  • To provide a summary status report of mandatory statistics collected by NHS Grampian and details for six data sets to enable benchmarking to be undertaken at a national level.

Audit approach

1.5Staff Governance has five key standards which employers are required to deliver, entitling staff to be:

  • well informed
  • appropriately trained
  • involved in decisions which affect them
  • treated fairly and consistently
  • provided with an improved and safe working environment.

1.6Depending on each NHS Board’s progress with integration, these arrangements could be considered for each of the NHS bodies or for the NHS Board. With regard to Grampian, the action plan agreed at 31 March 2003 reflected planned activities at NHS Board level and therefore it was appropriate to continue on this basis in the current year.

1.7This review involved a series of four meetings with the Director of Human Resources, members of his management team and lead officers responsible for taking forward the five staff governance standards. As a result of these meetings, a range of evidence was identified for audit review which is considered in more detail in Section 4 of the report. In addition, one of the meetings was used to consider the results from the staff survey and arrangements were made for the collection of data with regard to the mandatory statistics.

Summary of Main Findings

Background

1.8On 1 April 2004, NHS Grampian will become a legal entity following the dissolution of the two Grampian NHS Trusts. It was helpful that an integrated Human Resources service was introduced with effect from 1 January 2003. However, the service has experienced a heavy agenda over the past 12 months in the transition towards single system working. In addition, many staff across Grampian have been heavily involved in the necessary preparatory work for the implementation of the Pay Modernisation Agenda (i.e. the new pay arrangements for medical consultants and general medical services i.e. general practitioners; and for non-medical staff through ‘Agenda for Change’). It is therefore important to take into account this backdrop of activity when considering NHS Grampian’s progress against the staff governance action plan.

Delivery of action plan agreed at 31 March 2003

1.9In total, 21 actions were agreed as part of last year’s plan. A summary of progress made by NHS Grampian against these actions is as follows:

  • Number of planned actions completed (action achieved) – 11.5
  • Number of actions partially achieved – 5.5
  • Number of actions were work has been progressed but there is still much to be done to complete the task (Limited progress) – 4

1.10The main emphasis in NHS Grampian over 2003/04 has been the development of strategies, policies and frameworks across the spectrum of staff governance standards. In several cases, this involved the integration of documentation which has previously existed in the three NHS Grampian entities. While there has been clear action in the majority of cases, approximately half the actions have been completed with the remainder still in progress.

1.11At this stage, it is not possible to assess the impact of the above actions. The next stage is for NHS Grampian to implement the different strategies and policies across the organisation. Thereafter, it will be possible to give consideration to the impact of the new framework on the organisation.

Auditor Assessment

1.12Overall, good progress has been made but there is still much work to do to complete last year’s action plan. Thereafter, the many strategies and policies require to be implemented across the organisation. We are however pleased to note that these activities form the main focus of the action plan agreed in respect of 2004/05.

1.13Due to the nature of the work undertaken to date, it is too early to assess its impact. Once the different strategies and policies have been implemented and rolled out, their impact and an assessment of whether desired outcomes have been achieved will be clearer.

1.14The programme of work in 2003/04 has been led and co-ordinated by the Director of Human Resources and his team. This arrangement has been both appropriate and effective for the nature of work involved in developing strategies and policies. The next tranche of work however relates to the implementation of the frameworks which have been developed. This will require devolvement of responsibilities to managers across the new organisational structure. In addition, it will be those managers who will be required to demonstrate their success in implementing the various strategies and policies. It is therefore strongly recommended that these requirements are fully communicated to relevant staff at the outset so that appropriate mechanisms can be put in place for monitoring the staff governance action plan. In addition, managers should be reminded that the staff governance action plan links with the Performance Assessment Framework and forms part of the Scottish Executive Health Department Annual Accountability Review.

1.15This year’s self assessment provided an opportunity for the Human Resources Directorate and lead officers to re-consider the Self Assessment Audit Tool (SAAT). This ensured that work in progress from the previous year and the results from the staff survey could be incorporated in the assessment.

1.16We believe all the significant matters have been addressed in the updated action plan and note NHS Grampian’s commitment to a challenging plan of work for the next 12 months.

1.17Where available, the specified mandatory statistics have been produced in accordance with the Scottish Executive Health Department’s instructions. It should be noted that detailed information was only available in respect of 4 of the 6 requested mandatory statistics which will form the benchmarking exercise.

Action Plan

1.18The agreed action plan which forms Section 2 of the report is the combined outcome of:

  • actions identified from the self-assessment process this year
  • matters from last year’s action plan which have not yet been fully addressed
  • the 2003 Staff Survey.

The main findings in Section 4 outline progress made during the year with appropriate cross references to the action plan in Section 2 where further work is required to implement actions. In addition, a progress report showing the organisation’s assessment of action taken during the year is included as Appendix 4.

Acknowledgements

1.19The contents of this report has been discussed with the Director of Human Resources of NHS Grampian to confirm factual accuracy.

1.20The assistance and co-operation afforded to us by all staff during the course of our audit is gratefully acknowledged.

Audit Services – Audit Scotland / Page 1 / 31 March 2004
NHS Grampian / Section 2
2003/04 Audit
Staff Governance

Action Plan

1. Brief description of the current situation that needs to be improved. / 2. Brief description of what the improved situation will be. / 3. Brief description of the improvement actions/ projects that will be used to close the gap between 1 and 2 and who will be responsible for the actions/ projects. / 4. What are the key milestones for this improvement and dates by which those milestones will be completed?
A. WELL INFORMED
A.1 We make sure we communicate effectively with our employees
1.NHS Grampian visions and values require to be revised in the context of single system working. / Corporate identity and new vision and values of NHSG to be incorporated into corporate organisational culture. / Revision of visions and values.
Responsibility: Chief Executive and Grampian Management Team (GMT) / Revised vision and values approved by NHSG Board by July, 2004.
Revised visions and values communicated throughout the organisation.
Responsibility: Director of Corporate Communications, GMT and GAPF / Communicated throughout the organisation by August, 2004.
2.The NHSG over-arching, 2-way, internal communication strategy needs to be implemented. / An efficient internal communication strategy in place. / Launch of new Team Brief arrangements, continuation of staff newspaper and continuation of Management Information Exchange.
Responsibility: Director of Corporate Communications, GMT and GAPF / Team Brief arrangements launched by April, 2004.
Distribution of staff newspaper at regular intervals and continuation of Management Information Exchange – throughout the year.
Monitoring and evaluation of internal communication strategy.
Responsibility: Director of Corporate Communications and GAPF / By January, 2005.
Devolve responsibility for communication, within a framework, to operational units.
Responsibility: Dir. of Corporate Communications, Directors and General Managers. / By October, 2004.
A.2 We Make sure we listen to our employees.
See A1 – Team Brief Launch
2003 Staff Survey results require translation into actions. / Improved understanding of staff views. / Development of Action Plan through focus groups.
Responsibility: Director of HR and GAPF. / Focus Groups completed by October, 2004.
Action Plan developed by January, 2005.
Action Plan implemented 2005/2006.
A.3 We make effective use of technology.
Less than half of NHSGrampian Staff have easy access to ‘IT’ at the desktop.
IT training across NHS Grampian lacked coordination. / Better access to eLearning
Co-ordinated IT Training with close working links to HR L&D / An e-learning package covering all IT training needs has been procured. This is available across the internet and can be accessed from anywhere there is an Internet connection.
A manager has been appointed in Informatics with responsibility for co-ordinating IT Training to meet the requirements of the Strategy.
Working with HR L&D to identify sites for ‘internet cafes’ for NHS Grampian to give all staff the opportunity to access IT resource in NHSGrampian. (Dependent on funding and suitable accomodation) / Promoting use of e-Learning – ongoing
Manager in post – achieved
Truly integrated IT Training system in place – December 2004
Identifying and securing sites or ‘Internet Cafes’ – ongoing
Securing Hardware for ‘Internet Cafes’ – Dependent on funding
Less than half of NHSGrampian Staff have easy access to ‘IT’ at the desktop.
IT training across NHS Grampian lacked coordination. / Better access to eLearning
Co-ordinated IT Training with close working links to HR L&D / Single Training booking system being implemented for IT and HR L&D training.
Working with HR and L&D to develop e learning materials ‘in-house’ to be delivered through the Intranet and tracked within the booking system
Responsibility: IM&TGeneral Manager and Head of Learning and Development / Procure system – Achieved
Implement pilot– July 2004
System identified, training required and then key training needs identified, materials produced and delivery piloted.
Initial implementation December 2004
1. Brief description of the current situation that needs to be improved. / 2. Brief description of what the improved situation will be. / 3. Brief description of the improvement actions/ projects that will be used to close the gap between 1 and 2 and who will be responsible for the actions/ projects. / 4. What are the key milestones for this improvement and dates by which those milestones will be completed?
B. APPROPRIATELY TRAINED
B.1 Our goals are realistic given the people we have.
Implementation of the Learning and Development Strategy. / The implementation plan for 2004/5 will be achieved / Develop strategic partnerships with universities, Local Authorities etc.
Responsibility: Directors and senior managers
Integrate with workforce development framework.
Responsibility: Head of L&D and Head of Workforce.
Agree process for learning plans with planning.
Responsibility: Head of L&D.
Support managers to identify training needs.
Responsibility: HR Managers.
Review leadership and management programmes.
Responsibility: Head of L&D. / Relationships established and on-going.
Evidence of integrated approach.
Local service areas are developing local learning plans.
Training and coaching has occurred.
Agreed way forward for Grampian leadership and management development.
Target Date for all - by March 2005.
1. Brief description of the current situation that needs to be improved. / 2. Brief description of what the improved situation will be. / 3. Brief description of the improvement actions/ projects that will be used to close the gap between 1 and 2 and who will be responsible for the actions/ projects. / 4. What are the key milestones for this improvement and dates by which those milestones will be completed?
B.2 We make sure we that there are clear links between: what the employer wants to achieve; what departments/functions and teams have to achieve; and what our employees have to achieve.
Continually strengthen individual, team and service level learning plans with links to workforce plans.
Implementation of pay modernisation through people management. / Improvement in number of staff with PDPs and clear links to service plans.
Staff feel supported and processes are in place. / Learning and Development Implementation plan.
Workforce Plan.
Develop tracking system for monitoring.
Responsibility: Head of Learning and Development and Head of Workforce Development and Redesign. / Monitor and support Managers and staff with appraisal and development processes. HRMS and Learning and Development Managers.
Use feedback from Staff Survey.
B.3 We have assessed the numbers, skills and mix of people we need and we have identified actions needed to achieve this.
1. We are reasonably well staffed for today’s service needs, although there are some staff groups to which recruitment is difficult. / Services are changing and we need to review numbers and skills required. / Service Strategy Change and Innovation Plan.
Pay Modernisation.
Workforce plans.
Special recruitment and retention effort.
Also see D3.
Responsibility: Director of HR, Director of Strategic Change and Head of Workforce Development and Redesign. / Workforce plans linked to service plans by March, 2005.
2. A non-fragmented approach, linked to current and future service objectives, needs to be improved. / Implementation of a coherent Workforce Development Strategy embracing workforce information, workforce development and workforce utilisation / Implement a strategy for workforce information development and utilisation
Responsibility: Director of HR, Head of Workforce Development and Redesign, line managers and management groups e.g. BMG / Workforce Information Strategy pilot to be evaluated. Thereafter to be rolled-out across the organisation.
In line with the results of the pilot evaluation.
1. Brief description of the current situation that needs to be improved. / 2. Brief description of what the improved situation will be. / 3. Brief description of the improvement actions/ projects that will be used to close the gap between 1 and 2 and who will be responsible for the actions/ projects. / 4. What are the key milestones for this improvement and dates by which those milestones will be completed?
B.4 We have a clear understanding of the development needs of our people and how this contributes to our goals and targets. Resources have been identified to support those needs.
Historical budget base. Better implementation of learning plans linked to workforce plans. / Budgets better utilised to meet requirements of learning plans. / Learning plans developed as part of planning process. Resources for training reviewed and used more equitably.
Responsibility: Head of Learning and Development. / Links to planning process will commence in 2004 but will take time. Training budget review to happen by January 2005
B.5 We actively encourage continuous performance improvement.
See B1 and B2
1. Brief description of the current situation that needs to be improved. / 2. Brief description of what the improved situation will be. / 3. Brief description of the improvement actions/ projects that will be used to close the gap between 1 and 2 and who will be responsible for the actions/ projects. / 4. What are the key milestones for this improvement and dates by which those milestones will be completed?