Staff Recruitment and Retention - Royal College of Nursing - Transcript - 14 September 2015

Health and Social Security Scrutiny Panel MONDAY, 14th SEPTEMBER 2015

Panel:

Deputy R.J. Renouf of St. Ouen (Chairman) Deputy G.P. Southern of St. Helier

Deputy T.A. McDonald of St. Saviour

Witness:

Chairman, Royal College of Nursing (Jersey)

[12:59]

Deputy R.J. Renouf of St. Ouen (Chairman):

Right, this is a public hearing of the Health and Social Security Scrutiny Panel and we are here today to meet Mr. Kenny McNeill who is the Chairman of the Royal College of Nursing, Jersey Bank. This is a public hearing, the meeting will be recorded so for the record we are going to introduce ourselves and perhaps I will ask you to formally introduce yourself or give your name. So I am Deputy Richard Renouf and I am the Chairman of the panel.

The Deputy of St. Ouen :

I see, yes. We are also joined by our Scrutiny Officer. You have kindly given us a written submission already and we are grateful to you for that. Perhaps could you update us on that and outline any particular areas of concern to you?

Chairman, Royal College of Nursing (Jersey):

I think that was a brief resume probably. I think when I first looked at the scrutiny panel had taken the initial evidence there seemed quite old data. I think it was a report back in ... it was 2011 on nurses'  recruitment  retention  which  had  been  cited  as  being  the  document  that  was  being

questioned again. I mean there had been quite a lot of stuff going on within the Health and Social Services over that period of time. We saw big changes in the type of education that is supplied from Jersey directly. So it was quite difficult to actually just pin it down to particular issues and problems. We are aware that there have been longstanding issues and problems with nurses, midwives and recruitment retention on the Island for some time. There would be various factors for that. I think, as I said, it is ... I mean, Jersey is quite a small jurisdiction that did not offer training so we always had to bring all the staff from the U.K. (United Kingdom) or other places in the European Union in here to work. Quite often there were also distractions initially in-house and such like which staff could only stay for certain periods of time. That did change and people come now can stay if they so wish for a long period of time but also another issue on that factor is that demographic has changed but we have not seen nurses join straight from school, go straight into nursing, qualify and then look into coming to gain experience. Quite often you will find that people were coming into nursing now who have a got a second career, they have had a career for a number of years, they have come back ... they have gone and done nursing so they have often got families and children and such like that they bring with them. I would think that has certainly been on factor which has been highlighted to us on a number occasions when recruiting a nurse from the U.K. who has got their own family the issues of coming across to Jersey and bringing their family with them, if there is employment for the husband or wife, whoever the nurse is, the situation around school, if they have got children who are certainly in secondary school they are thinking about university in the situation so there are issues again around what would happen when they go to university because they are in an entirely different situation in Jersey than if they stayed in the U.K. Quite often we have found people will back out and will be coming on that other recruitment side there. Again, I do not have real hard and fast facts because they would come direct from Health but I what I have done is, as I say, I did do a snapshot in the last few weeks when I knew I was going to be coming to speak to you. I just sort of took a flavour of what was going in an area for a number of members. We know there is a problem with recruitment and retention at the moment. There is a worldwide recruitment problem for nurses. There is a U.K. recruitment problem for nurses because the number of training places have reduced considerably for training nurses in the last few years because of what is seen as being a good use of money. I do not know why but I think there was a report done that showed 26,000 places had been lost to nurse training. Now, that would have a residual effect somewhere down the line because you have taken that number of people out of training nurses then you are going to have a problem somewhere down the line because you are not going to have enough nurses. We also saw when the Francis Report was done, which was a major report in the U.K. following the Mid-Staffs crisis that happened up there, we saw a number of the English regions especially almost panic and they took up all the nurses that were available to make sure that they were getting safe staffing levels. So when they were getting inspected by the CQC and various parties they were seen to be addressing some of the problems that Francis had raised that were precipitators to possibly what

went on. That is a very complex report to just identify, but that is just a factor. So we know that is going on elsewhere and Jersey, as just a tiny small Island, we are going to have a problem because that is where we are going to draw staff off from. We had a snapshot - and I am not going to name individual areas - but we had come up with 33 vacancies covering about 9 different areas in Health and Social Services, and that is quite a lot considering. That is a big area. There were 10 waiting to start and the problems that they have for not starting are the slowness of getting the police checks completed, the time it takes for people to then get found the right accommodation, affordable accommodation to move across here, and that is often a time when you can lose somebody, in that sort of waiting period, when they are looking at moving to the Island ... quite often they will get so far down the line and then they will just stop the process and say: "Look, I am not coming now."

The Deputy of St. Ouen :

Is it left to them or do they get any assistance from within the hospital department?

Chairman, Royal College of Nursing (Jersey):

There was an allowance which every nurse got who was coming to the Island to help them with that first initial move, which was stopped. It was £3,000 upfront which nurses received which helped them find that deposit when they first arrived, so almost that first month's rent and just that initial settling in type stuff. But that was stopped and just wrapped in with the whole recruitment retention process and I am not sure if that was a factor, as I say, in why people are not coming but I think financially if would certainly make people think because if they were moving to a new place there is that big initial outlying expense to get here.

Deputy G.P. Southern :

When was that stopped, again?

Chairman, Royal College of Nursing (Jersey):

I am not sure because it was just by chance we found out. There was not a discussion or agreement with us they were going to stop that. There was not a discussion and agreement when they were starting that, it was decided by Health themselves that that was going to be a factor they would bring in. There was some discussions around whether it was the right thing to have done at the time but they thought it could work so give it a go. They have not got anything to lose.

Deputy G.P. Southern :

But you have seen no explanation for either the introduction or the ...

Chairman, Royal College of Nursing (Jersey):

The no explanation for the starting was because there was desperation to get ... we needed to recruit, we needed to make sure that we got nurses here.

The Deputy of St. Ouen : So when was it introduced?

Chairman, Royal College of Nursing (Jersey): It would be a year ago, I think.

The Deputy of St. Ouen : But since gone?

Chairman, Royal College of Nursing (Jersey): But it has gone. It has only gone fairly recently.

Deputy G.P. Southern :

The recruitment goes on presumably?

Chairman, Royal College of Nursing (Jersey):

Well, it would appear ... as I say, just with the snapshot I took ... and the thing is all these jobs that I am talking about are all part of the establishment. These are not new posts that have been addressed in the new easy working. These are old established post, so these are posts that are in general wards across the organisation so that is quite high.

The Deputy of St. Ouen :

As a proportion of the posts, what are 33 vacancies?

Chairman, Royal College of Nursing (Jersey):

Well, again this was only a small ... I think that is something you need to take to Health to get the proper percentage. You could ask them for their workforce plan and manager. But, as I say, there are 10 posts, 10 people, waiting to start. Some of them were quite high. There was one area that has got 8 vacancies. That is one area alone, which was really hard to sustain because ... they get agency staff in there but there is another factor in bringing in agency staff because agency staff are really expensive to the organisation. As well, just in preparing for coming here, I did an investigation to discover there is around 20 agency nurses in the organisation at the moment and 22 locum social workers.

Deputy G.P. Southern : Locum social workers?

Chairman, Royal College of Nursing (Jersey):

Now, I think part of that is the fact that Health are reforming and reorganising so rather than decide is there going to be a need to have all these post permanently or in the short term, so I think it is probably pertinent to decide: "Let us get someone in as a locum" but, again, that is quite an expensive way of doing it. I think or expect we have probably got more than 20 agency nurses coming and going. I think there is a constant need to just keep certain areas up to a level.

The Deputy of St. Ouen :

Do you feel that number has increased over the last 3 years?

Chairman, Royal College of Nursing (Jersey):

It has probably stuck around that. It goes up and down and in between. I think the other factor which comes into it, and another question that I know you were interested in, was the nursing bank. Now, again, I have got the 2014 ... if I go back and look at 2011, 14,812 shifts were covered by bank staff, in 2012 that had gone up to 22,501 and in 2014 there were 25,212 shifts covered by bank staff. Now that could be for a multitude of reasons. That could be where we get a bad winter and we get a flu bug and the staff go down with that as well. You get other staff coming in and working and filling in. It could be the fact that we are not recruiting enough or we are not getting enough nurses in post so it is a matter of having get additional to that. The thing about the majority of these bank staff, they are already staff who have got a contract, they are already full- time staff in Health and Social Services and they hold a zero hours contract and work on the bank, which means they are getting paid at the bank rate as opposed working it as overtime. Which certainly, to the organisation, is much cheaper. Now, nursing banks have been around for a long time everywhere, this is not a unique situation to Jersey but, as I say, it has put a strain on the existing staff because if they are on the bank and they are working extra shifts on the bank then you can only do that for so long before you do start to tire out. But there are sections in which they can do it. It is often difficult sometimes to track that down. If you split it between, there is a difference between, let us say 2014 ... the number in 2015 up until now is 16,864 shifts have been worked that was up until the end of August. So we still have 4 months of the year to go.

The Deputy of St. Ouen : That reach 24,000 then?

Chairman, Royal College of Nursing (Jersey):

That is what I am saying, it is not going to be very much less than the 25, if you look on ... there are varying ... it is varying roughly between, for qualified staff, 832 to 647 shifts per month. That is 2015 if you actually add that up it is not going to be a lot different to 2014. Again, as I say ... I mean, I think we accept we use bank staff because it certainly makes sure that we keep safe numbers in the wards for a start but ...

The Deputy of St. Ouen : Yes, but you understand ...

Chairman, Royal College of Nursing (Jersey):

But I have a concern from a R.C.N. perspective and certainly from a member's perspective on the welfare part to the staff. As I say, there is an expectation of them. People sometimes feel a bit pressurised to take on extra shifts and that would be a concern to us that people are feeling in that position. It would never be cited like that. I think it is certainly something people feel when ... but nurses are a bit like, they do not want to let anybody down.

The Deputy of St. Ouen :

Yes. Sorry, I just want to explore with you, though, is it your understanding that most of the bank staff are employed on zero hours contracts?

Chairman, Royal College of Nursing (Jersey):

The majority of them are, yes. The majority of them have already got a substantive contract with Health.

The Deputy of St. Ouen :

Right, so they are nurses with a full-time contract ...

Chairman, Royal College of Nursing (Jersey): They are nurses with full-time contracts.

[13:15]

The Deputy of St. Ouen :

So how does this differ from being asked to work overtime? Are they asked to work overtime rather than go on the bank?

Chairman, Royal College of Nursing (Jersey):

No, they are asked to join the bank in order to get any extra work.

The Deputy of St. Ouen : I see, okay.

Chairman, Royal College of Nursing (Jersey):

We have already got, in the terms and conditions of service for nurses, an agreement on an overtime level but if we were to pay them overtime I think it would be quite ... you would see a huge expense to the organisation, as I say, and again if you actually looked to pick on ... because you would have to pay them overtime rates which would be enhanced, I think it is time and a half Monday and Saturday and double time Sunday and bank holidays. Whereas in the bank rate they will get paid ... the bank rate is slightly above the normal hourly rate of the grade because that goes into holidays and such like, because people on zero contract do not have any payment for holidays. So what they do is they build it in to that ...

The Deputy of St. Ouen :

Yes. But they enter into a separate contract with the department?

Chairman, Royal College of Nursing (Jersey): They do.

The Deputy of St. Ouen :

Which is to work on the bank, yes, and then they are on ...

Chairman, Royal College of Nursing (Jersey): But that is personal choice.

The Deputy of St. Ouen : Accepted, yes.

Chairman, Royal College of Nursing (Jersey):

Nobody is forced to take on a bank contract. Nobody is made to take one up. As I say, that is something that people advised if they were interested to join the bank then if there is extra work ...

The Deputy of St. Ouen :

But you seem to have concerns about pressures and the amount of work they are doing, taken as a whole.

Chairman, Royal College of Nursing (Jersey):

Yes, I think certainly the nurse workforce is under pressure.

The Deputy of St. Ouen :

Yes, and where does that pressure come from?

Chairman, Royal College of Nursing (Jersey):

It comes from just delivering services, people are using healthcare a lot more. If there are not the right numbers around at the time, if there is not the right number of staff on the wards then they will use bank staff in order to fill the gaps.

Deputy G.P. Southern :

You get a phone call, basically: "We are 2 short on X ward. We need you" and you have a choice of yes or no.

Chairman, Royal College of Nursing (Jersey):

Yes. It is a difficult one but it is clearly an area that we have ... it was an area that was raised when we had major discussions with States Employment Board on the equality of pay for nurses. I was never additional and more pay for nurses, we were looking at the way the nurses were getting treated and the organisation definitely failed us. We looked at recruitment retention, we looked at bank staff, we looked at the use of bank staff at that particular time. As I say, that is when we had these initial figures. I was a bit surprised when I got the latest ... I do not know what 2013 but when we jumped to 2014 and then I saw what we were in 2015, I thought that is still running really, really high, which would indicate to me that there is ... again that longstanding issue around recruitment and retention is still there. We have never really got to grips with that.

Deputy G.P. Southern :

You say that there is a risk that your nursing staff are under pressure and the stress as it were by doing the bank shifts. Is there any implication that there is a health issue ... an estate issue there? Obviously there is a health issue for your nurses if they are overtaxing themselves by doing extra shifts.

Chairman, Royal College of Nursing (Jersey):

There should not be because the nurses are responsible for making that decision. If a nurse takes it on ... nurses are governed by a code as well. If they do not believe they can do it then they should say no. They have got responsibility and I think we have all got that, we have all got that personal responsibility but what I am saying is that I still think some nurses do feel pressure to maybe do an extra bit, even though they are a little bit tired. They would rather come and help than sit back and not help. Then if something goes wrong the buck stops at them. I have sat in situations where people have said: "Well, why did you do that?" and the person said: "I know I should not have but ..." So, as I say ...

The Deputy of St. Ouen :

Can I ask, do any of your members tell you about feeling under any financial pressure to do this extra work?

Chairman, Royal College of Nursing (Jersey):

Yes, yes. We did a survey ... when we were looking at it the last time, many of the survey members were saying they had to do the bank work in order to get by. That made up their extra pay. Because there was an issue and I said: "Nobody forces you to do banks, so why would you do it?" They said: "Well we have to." That came up fairly regularly. As I say, that came up in discussion quite often where staff was ... that the bank does help their pay.

The Deputy of St. Ouen :

So if they are finding that the standard nursing pay is not sufficient to make ends meet in Jersey what is the extra ... what are the pressures on costs?

Chairman, Royal College of Nursing (Jersey):

To be honest, I think Jersey ... a lot of different working groups would say that. I do not think there is a one thing that is particularly attributed to nurses. I know we are here talking about nurse recruitment, and as I say there is a lot more to nurse recruitment than pay, albeit that is important to everybody. I think the nurses are looking ... as I say, it is about making sure that we provide a good, efficient, safe and correct service to the people in the Island. I would say that is a big factor. Nurses have taken quite a big hit with a lot of things that were going on like the Francis Report at Mid-Staffs and such like. I think the nurses should sit up and say: "Look, we are still here, we are the people." Part of the reason why a lot of people in France are so angry with nurses was because that was as much as: "If that was going on why did you not do something about it?" The community expects nurses to stand up and talk up on their behalf. When something falters then quite often they will turn around and they will say to the nurses: "Why did you not do something more?" Because they trust them, they trust in that group of staff and that is ... it is a big responsibility to take on.

Deputy G.P. Southern : It is.

Chairman, Royal College of Nursing (Jersey):

That is something that I have never looked on lightly. Being a nurse myself for years and years, it is something I have never looked on lightly as a factor. Everything we do has an impact somewhere along the line to somebody else.

The Deputy of St. Ouen :

What could we do in Jersey to improve? A big question, I know.

Chairman, Royal College of Nursing (Jersey): If I had all the answers I would be ...

The Deputy of St. Ouen :

Yes, but what thoughts? What are you ...

Chairman, Royal College of Nursing (Jersey):

As I say, there is lots of stuff out there. Health Education England in 2014, they looked at this quite closely and some of the factors that they have come up with like paying customer(?), employment opportunities, that means retraining, that means being able to work in different areas, feel valued, for people to feel valued. Things like flexible retirement, giving people options when people get a bit older and they are maybe less able to do that manual handling, that high stress environment in the middle of A. and E. (Accident and Emergency). There are tasks that nurses can still perform at Health. There is also supporting new entrants, which we do do, because everybody who comes in now gets ... they get a mentorship programme, technically for the first year. They have a mentor attributed to them who is an experienced member of the nursing team and so that first year they have that person to go to and talk to if they have a problem. So we are providing it. I never got that. Back in the 1980s when I walked into the ward the charge nurse said to me: "There are the keys, go away and do the medicines." Things have changed a lot in that period of time, certainly for the better.

Deputy T.A. McDonald:

That is only for 12 months, is it not?

Chairman, Royal College of Nursing (Jersey): Initially.

Deputy T.A. McDonald: Initially.

Chairman, Royal College of Nursing (Jersey):

As I say, you would ... if people need it longer then ... people can have a mentor as long as they like. But, as I say, certainly the mentorship would run ... as well as that, everybody who qualifies in Jersey is granted a job here in the Island if they so wish it. Again, that takes some of the pressure off people when they ... but they do not want the job, you see.

The Deputy of St. Ouen :

You said before that our education and training had improved in the last 3 years, we had more locally ...

Chairman, Royal College of Nursing (Jersey):

Well, improved, it has become live again because before that it was non-existent. We never trained our own nurses ... we stopped training our own nurses because it was deemed to be too expensive and there was clearly, as I said, again the same ... in the report from the U.K. it says that factors that could help the pressure and stress is to deal with it. It is cost-effective to deal with it at the time than to wait until it has happened because that is when it is much more costly to deal with. To recruit and replace staff, having a recruitment programme in place is clearly a positive message. It is certainly good for the Island. It is one thing that gives youngsters an opportunity who would like to go into that field that they can train here in the Island ...

The Deputy of St. Ouen :

Do we give everyone who wants to train as a nurse that opportunity or are there people we have to turn away because there are only a fixed number of places on the course.

Chairman, Royal College of Nursing (Jersey):

Well, there is only a number of fixed places on the course. The school is not that big. Everyone has an opportunity for that course. If they have the entry qualifications to get in, because it is a university qualification now, the education service ... it is tied in with the University of Chester, is the agreement. So in conjunction with them the programme is run. So the students work between Chester and ... but most of the stuff is done here on Island.

The Deputy of St. Ouen :

Do you know if we turn many away who might be eligible to come on the course so that they do not have to pursue another career or they go off to the U.K. for training?

Chairman, Royal College of Nursing (Jersey):

I do not know how many are turned away. There will be some that do not qualify and there is an opportunity for them to maybe ... there will also be some staff who may want to go and do a course up in Highlands which is like a feeder course and then come back a couple of years down the line and try and apply again. I think there is ... we are going to talk to the students a week on Friday ... I am going to talk to the students about the R.C.N., I think there is 14 in the class. I think there was 16 ... there is a core every year coming in. So we will start to see every 3 years there will be a cohort of 13 or 14 new Jersey born nurses, Jersey trained nurses coming out. That will not stop the fact that we need to recruit from the U.K.

The Deputy of St. Ouen :

No, I understand that. We understand as well there are courses to bring in nurses who have left the profession.

Chairman, Royal College of Nursing (Jersey): There is back to nursing courses as well, yes.

The Deputy of St. Ouen :

So in your opinion how has that worked?

Chairman, Royal College of Nursing (Jersey):

It has certainly brought one or 2 back in. I think that is a problem. Again, I was looking through some statistics. There is up to 10 per cent ... in a report again there was up to 10 per cent of nurses were leaving the service, whatever, they were just leaving because they had reached the end of their tether. They said their expectation was that at least 10 per cent of nurses will leave for whatever, they have taken early retirement and people may want to come back and ... again, there needs to be some strategies put in place. I think clearly in that environment ... if you are happy in the environment, a lot of the wards have ... well, some of the wards they do not have proper facilities for the staff to even go and have a quiet coffee, a break there. What used to be a cupboard is a break room. It is not just like sitting in a cupboard, it has a window but it was originally a cupboard and they have had to bring in their own furniture. The hospital canteen is an excellent service for people but, again, that is open to everybody. Anyone could walk in. So when it is really busy if you go in there to try and sit down and have relaxation, there are a lot of people around, it is noisy ... there is nowhere in the hospital you can really go and just sit and have a nice quiet coffee. Again, I will go back to my time at the hospital I was at in Scotland, they had the canteen area but then if you walked through to another room there was an area that was soft comfortable chairs, there was a television in the corner, there was newspapers lying on the desk, there was a table that you could sit down and have your coffee or sit and chat, people would sit and play on their phones, whatever that did because

The Deputy of St. Ouen : Yes, a sort of break-out room.

Chairman, Royal College of Nursing (Jersey):

But nowadays people would advocate, did you but the hospital has been so geared up, more than they used to be able to do that, is now filled with computer tracking system, which monitors people going through it.

[13:30]

There is not really any proper relaxation areas and I think these became the factors I think would certainly help make the environment better but whether that would resolve recruitment retention probably not, but they are factors.

Deputy G.P. Southern :

But that is certainly not going to have an effect on retention, your conditions in which are working are not up to scratch really

Chairman, Royal College of Nursing (Jersey):

Yes, but they are certainly areas that we will look into. If you are looking to retain staff, there are certainly things that would be helpful, to have that kind of facilities around.

Deputy G.P. Southern :

You mentioned the Francis Report earlier and we were talking about having the base set staffing levels for safety sake, do we need the

Chairman, Royal College of Nursing (Jersey): Francis never said "staffing levels", they never came.

Deputy G.P. Southern : Right.

Chairman, Royal College of Nursing (Jersey):

What Francis did suggest is that there should be 24/7 senior nurses available on site. He recommended that and that is something which I think we certainly would adhere to. There is some discussion about trying to distract some of the wards have not the managers working at weekends and in the evenings and I think that would go against what Francis was trying to achieve but that is not in place yet.

Deputy G.P. Southern : It is not in place.

Chairman, Royal College of Nursing (Jersey): No, it is not in place.

Deputy G.P. Southern : We do not need that.

Chairman, Royal College of Nursing (Jersey): We do not do that.

Deputy G.P. Southern : We do not do that.

Chairman, Royal College of Nursing (Jersey):

No, we do not but the staff levels now but it would be a dangerous I think we have certainly raised it with Health and Social Services and it would be a risk and concern if we were to start restricting our senior nurses because they are the people who do the check and balance on behalf of the It is their area, they can go in and check and they can turn around and say: "Well, I have seen this, we need to do this" whether it be in an evening or a weekend or whatever because you want the best opportunity to see your service 24/7 if you need to do.

Deputy T.A. McDonald:

How would you define a senior nurse? In other words, what do you think the Francis Report really wanted? Was it you as a service

Chairman, Royal College of Nursing (Jersey): More ward managers.

Deputy T.A. McDonald:

Ward managers, yes, nurse managers and

Chairman, Royal College of Nursing (Jersey): The equivalent of a sister.

Deputy T.A. McDonald: Right.

Chairman, Royal College of Nursing (Jersey): They are the most senior nurses in the wards.

Deputy T.A. McDonald: Yes, yes.

Chairman, Royal College of Nursing (Jersey):

Then you have got above that as well, you have got your I am talking about ward managers, they are responsible for their areas.

Deputy T.A. McDonald:

It is really saying that there should be somebody 24/7 on those wards.

Chairman, Royal College of Nursing (Jersey):

There was a report supposed to have been done on safe staffing levels by who, it has gone completely out of my head? It may come back.

The Deputy of St. Ouen : Is this in Jersey?

Chairman, Royal College of Nursing (Jersey): No, no, in the U.K.

The Deputy of St. Ouen : Okay.

Chairman, Royal College of Nursing (Jersey):

They were commissioned to do it but the Government pulled the plug and so they stopped it, so we have never got it defined what sort of staffing level it is.

Deputy T.A. McDonald: No, exactly

If you look at what the staffing levels are in the hospital to what they are in the independent sector, they are different as well. There is a lot less trained staff per client in the independent sector than what there is in the hospital. That is for various reasons because most people who go into hospital are going in unwell, that is one factor. There is a need to have a there is also, as I say, an independent sector. There is a need to have your experienced staff around you as well. Of course, we have got the core community services separate, the fact that Health and Social Services and the community services are run by Family Nursing, so it is part of the new way forward work. We are following a model, moving towards community services being the forerunner. I think there is probably still quite a bit of work to be done around there because I am aware that Family Nursing have also had issues with recruitment retention and getting the right level of staff to work in the community because you are going to be sending and there is a whole lot of good stuff being done there, rapid response and such like there where we can take people to the hospital who are really quite unwell and they can monitor them and manage them and care for them at home, whereas these people would normally have had to stay in hospital. There is good stuff happening. There is a lot happening, as I say, health is such a fast-moving area at the moment, we need it to be

The Deputy of St. Ouen :

Are there particular issues surrounding the recruitment of these community nurses or is it just the same issues facing them all?

Chairman, Royal College of Nursing (Jersey):

Yes. They tend to take them to the hospital, so, again, then they will move back from their community to the hospital, so they are still with each other to a certain degree. As I say, it is difficult to get the right quality of staff who come in who have got community experience in the U.K. because people sometimes are afraid to move. Again, as I say, people who are in the community tend to have been in nursing for quite a while, so they are often well established wherever they are, so to shift them from their area is difficult.

The Deputy of St. Ouen : Right, yes.

Chairman, Royal College of Nursing (Jersey):

But that is going to be a problem. Again, I was talking about that earlier on, we also had an agreement where there was an issue with partners of community nurses, they were able to apply for jobs that only the qualified people in Jersey could apply for and that was stopped. Housing seemed to then say, no, that that could not happen. So a lot of the nurses' partners that came

across were not allowed to apply for certain jobs, which would put strain on their survival. Again, and I thought we are really bringing them in to help nursing recruitment and suddenly you are looking to pulling the plug on it. Again, what are the Government thinking about here? You are giving them something to help and you are pulling the rug on the other side.

Deputy G.P. Southern :

That presumably was the control of the Housing and Work Law?

Chairman, Royal College of Nursing (Jersey):

Yes, yes, it would the but there was an actual policy on that which we followed. Again, it was something that nurses were able to if you were at interview you were able to turn around and say: "By the way, Ken, if are married or your partner will be entitled to ...." "Okay, I am going to Jersey, we could go to Jersey and I have got skills and I certainly then could get a job."

The Deputy of St. Ouen : That is right.

Chairman, Royal College of Nursing (Jersey): That was made certainly more difficult.

The Deputy of St. Ouen :

Were you consulted before that change was introduced?

Chairman, Royal College of Nursing (Jersey):

No, it was in 2011, that was a policy the management had undertaken with the Population Office permission for employment of nurses and midwives' partners. That was an actual Health and Social Services policy that was agreed. But still it is supposed to be in place but there has been some people who have reported back that have had some difficulties.

The Deputy of St. Ouen :

Sorry, you say it is still supposed to be in place.

Chairman, Royal College of Nursing (Jersey): Yes, because

The Deputy of St. Ouen :

What is your recent experience of

Chairman, Royal College of Nursing (Jersey):

There has been some experiences of people saying that, no, that their partners have not been able to get jobs when they have gone forward because they are getting blocked by the Population Office to say that: "You have not got 5 years qualification for that job, so you cannot apply for it."

The Deputy of St. Ouen :

Something we will need to investigate what has happened to that policy.

Chairman, Royal College of Nursing (Jersey):

Having that would certainly help in the recruitment side but clearly it was said that that has to be recognised

Deputy G.P. Southern :

If that is the case that it is not working jointly, then that is a knockback, is it not? You mentioned agency nurses with various staff and the fact that the agency nurses are more expensive, in what sort of areas then do we see agency nurses brought in and what is the reason they are brought in?

Chairman, Royal College of Nursing (Jersey):

Probably a sort of high-user area would be I think we have used quite a lot of agency nurses in the theatres but theatres have been for quite a long time a very difficult area to recruit to because experienced theatre nurses are really hard to come by and they have been for a long, long time. They are just general nurses who have moved into theatre and sort of specialise in that area but to get theatre nurses and, again, they cannot work lots of extra ... they work there because if you are tired at the table you if you can drop them off of the table. There are reasons why we need to keep these right numbers in there but

Deputy G.P. Southern : Theatre nurses are

Chairman, Royal College of Nursing (Jersey):

But specialist nurses as well, again, agency staff, we have had some of them in specialist areas to

Deputy G.P. Southern :

Specialism and experience are areas where we have got pinch points and is that linked not just to

Chairman, Royal College of Nursing (Jersey):

Yes, there has been difficulties in older people services.

Deputy G.P. Southern : With the training.

Chairman, Royal College of Nursing (Jersey):

That is another area that we have had agency staff in because they are difficult to recruit, people looking after older people. As I say, it varies across where the agency staff are. The ones that are in medicine, older people services and theatres, this was just a very quick check done. I was going to talk about skill mix, which is the difference between the health care assistants to qualified staff. I asked the question, did they feel that the skill mix was right? There was only about 50/50, it was a small area and I would have expected that to have been higher. I would have picked areas to come back and say: "Yes, we have got the right skill mix or we have not got it for a reason" but, as I said, in fact there was slightly more saying: "No, we did not have the right skill mix." Again, that could be part of us going through this transformation period. We are providing a lot of upskilling into our healthcare assistant workforce. There is a restriction. We can use that. With healthcare assistants in Jersey they have got lots of opportunities to train in as well and I think that sometimes we could use them more effectively and use that training more effectively to make them feel as valued. I think they sometimes feel they go and do training and then they are not recognised for that training. There is a chance that we can do a bit more around that but you still need to have the qualified staff in place there.

The Deputy of St. Ouen :

Yes, yes. How do we assess whether we have got the right skill mix in an area if, as you said before, there is no defined safe staffing level? How do we know whether

Chairman, Royal College of Nursing (Jersey):

All of that is done on a cursory kind of study in the area, how sick are the patients that we are looking after, what are the type of skills that we need for that area and that could be done then over a period of time. We have done some work with that about 3 or 4 years ago where we consulted in the areas completely. People thought it was time in motion because what we had done and I had done some areas myself where we tracked everybody's whereabouts every hour. Again, what were they doing in that hour? But people thought: "Ken, you are following me" and I said: "No, I do not want to know." I said: "Just what task have you been doing? Have you been doing medicines? Have you been looking after a patient? Have you been stocking a linen cupboard? What tasks are you doing, as opposed to and you might have stocked 10 linen cupboards." For somebody that says: "I have been doing medication for the last 2 hours" which would not be unusual but some people thought: "I am taking too long." I said: "No, do not rush it, if you are doing it because you are doing a whole ward, that could take a long, long time."

The Deputy of St. Ouen :

Were the results of that survey collated?

Chairman, Royal College of Nursing (Jersey):

They were collated and that was in training, and it was recognised that there were some staffing issues and certainly areas which were addressed as best as they could be because, again, you cannot just suddenly new nurses and say: "Yes, we are needing 4 new nurses for that area, where are we going to get them from?" All of these are currently established, these are establishment as well. As I say, it is not very scientific recruitment retention and it is a really difficult one for a group to take. As I say, I have concerns that nurses are working really hard, that we were not often sort of recognising that we are potentially getting to a point where we are overworking them sometimes and that is the address ... that I would like to make sure that we have that in place. As I say, there is the issue, we have got the ongoing equality stuff and the modernisation in the hospital. There is a new hospital, which is another factor but very few people know about that.

Deputy G.P. Southern :

In terms of nursing, you just mentioned the modernisation programme, how does that particularly work in relation to nurses? Where is the modernisation?

Chairman, Royal College of Nursing (Jersey):

Probably it started because of the 2012, 2013, 2014 agreement that we reached with the States Employment Board on certainly equal pay for nurses, which was not just being equal pay for nurses because we recognised in that agreement as well that there was an opportunity to modernise, which would make the service much more effective. We believed that we got it right. Health are working mostly in different conditions and service and it would be certainly worthwhile looking at getting some kind of consensus where we were all there but we are still on that road. Again, until we find out where that goes and there are certain factors which I am afraid we see now that we have seen before in 2005, which was a near disaster because that was the last time that they tried to reform nursing.

[13:45]

As I say, it happened at the same time because a bit of austerity come on, there was money taken out of the budget and next thing it was all crammed into a smaller box and everybody was left feeling pretty let down by it. This is a much bigger project where we have been working really quite closely. We thought we were doing really well and we were getting to a real joint consensus of opinion and now we are hearing this £145 million. There are certain politicians seem to be allaying part of the blame to the public sector and nurses. They are allaying it to us, the public sector, they are allaying it to nurses as well. Again, we hear things about Health and I think people feel let down and feel aggrieved. It is not their fault, whatever has happened and, as I say, that people feel aggrieved that and certainly they are the ones blamed for that. Again, I think that tell the politicians to go and look in the mirror. They have been grappling with the finances for a long time and why do they not know? Why has it suddenly come to the public sector?

The Deputy of St. Ouen :

Yes, we must bear that in mind.

Chairman, Royal College of Nursing (Jersey):

The amount of savings that have been announced to be made I think as well, certainly to Health, are getting quite colossal or be a real, real challenge to Health to achieve it before they get any new development money and that is another factor. As I say, I think we need to look at getting that side of it again as well. Health need to develop, they need that money to expand and to get their services designed for the future but they cannot do it under the umbrella that if you do not save then you will not get it. I think it has got to be done in a proper way. Again, everybody can save money, every department when they look at it but to have a set target I think probably should be something that is certainly considered to be, again, say flexible.

Deputy G.P. Southern :

Perhaps sometimes you need to spend in the short term to save in the long term.

Chairman, Royal College of Nursing (Jersey):

But we said that at the very beginning. We said this modernisation plan that was going to start, I said: "Because a lot of it was going to be upskilled workforce as well, that there was going to be a lot of additional training. Of course, you are aware that to go down this road this is going to cost you more money" and the message came back: "Yes, we are."

Deputy G.P. Southern :

As far as specialists are concerned, is there a training problem already? Is it easy to train based in Jersey in specialisms or not?

Chairman, Royal College of Nursing (Jersey):

It is not as easy to train a specialist in Jersey because to get the skills you need you would certainly have to go off Island for a lot of them but can bring them back to here. In Jersey there is a forerunner in some great cardiac stuff, we have very good staff working in that area but they have done things that they have not done in the U.K. yet. They have presented some of their findings to the U.K., which I am pleased to see from a nursing perspective. But we have got a master's programme running in Jersey as well now, and when you are talking about nurses at specialist level then the nurses will want to go ... we often do master's programmes and such like.

Deputy G.P. Southern :

That master's programme runs in Jersey.

Chairman, Royal College of Nursing (Jersey):

There is a master's programme available certainly from Jersey, yes.

Deputy G.P. Southern :

Okay. It is not the case that you come to Jersey and it seems a battle when you may be doing a progression

Chairman, Royal College of Nursing (Jersey):

No, no, somebody could be a recruited into a specialist post and the basis that they could come and complete that, maybe if they have started their training, they are looking at the job, they like the job and they think the job is right and I say: "We have also got the facilities to allow you to complete your master's here. We will just A.P.L. (Accreditation of Prior Learning) you and whatever they do through a university process and naturally "

The Deputy of St. Ouen : Okay, that is good to know.

Deputy G.P. Southern :

I need to focus on the particular area, in terms of Jersey is a high cost of living place, compared to the U.K. and we are recruiting largely from the U.K., to what extent is there a margin between basic payment levels between Jersey and the U.K., which accounts for the extra cost of living here or not? Where are we now?

Chairman, Royal College of Nursing (Jersey):

There are pay negotiations going on at the moment with the States Employment Board or non-paid negotiations, it is a matter of how we want to put it. Yes, but I think that is something that is a live issue at the moment. As I say, for nurses and midwives I think the situation was certainly much bigger than pay because it was a big part of modernisation. It was a big part of the modernisation and, as I say, we had ... other than the first 3 years and then, as I say, that is honouring our agreement at the second 3 years. But considering that we were supposed to have reached a consensus by June 2014 and we are now a further year down the line because they extended that and I can see the reasons why. But they have certainly left nurses still wondering, is this ever going to happen, then we are still seeing some levels of inequality? I think once we get to that level that we can see the equality ... but that is a long road away. Again, conditions for nurses ... let us look at annual leave. A nurse in the U.K. can get 33 days annual leave now after 10 years' service, again, which is 5 days more than they are ever going to achieve in Jersey, to speak to an experienced nurse in the U.K. I spoke to some in the congress, I was across at the R.C.N Congress in Bournemouth in June and I was talking to nurses and I said: "Come to work in Jersey" as I always do and they say: "Will we get our annual leave?" I said: "Yes, you will get your full quota of annual leave" and they say: "How much is that?" Because like a salesman I think I am being rumbled here. [Laughter]

Deputy G.P. Southern :

This is the package, as it were, the pay and conditions.

Chairman, Royal College of Nursing (Jersey):

But certainly the pay looks on paper higher in Jersey than what it is in the U.K. for most grades of staff. As I say, I would not have questioned that but, as I say, as when people have left because of that cost, when you throw in all these additional costs of the house, when you throw in that that makes a big portion. Even comparing it to central London, then if you look at central London, which is probably the highest-cost area in the U.K., as I say, we are not recruiting our nurses from that area but south of England, that is a big area that we tend to recruit from. It is getting that balance right. There is lots of new work being done on them because, as I say, recruitment retention in nursing staff ... because it is identified as certainly one of the professions that there is a shortage. We go to an all-degree profession as well, may have to change the number of people that can come in to it because people then were not able come in to it. There was a big question mark around, do you need to have a degree to be a nurse? Still, that might be a question that will be asked in 10 years' time. When you have got a degree it helps that analytical type of thinking, that is what it does for nurses and moving into health services has become much more technical nowadays. Of course, as we move into that route then we will want more analytical thinkers and every nurse will have that quality and we certainly want to get them here in Jersey. We want to retain them in Jersey and so it is a better retainer. If we can just retain as many as we can get, if we can retain our staff, say if we are retaining the staff we are training here on their own that would be a big factor than then having to keep going to recruit new members of staff.

Deputy G.P. Southern :

There is a cost in not retaining them. I have been told and I have been aware that a vacancy rate of 5 per cent in a hospital, in nursing levels, is some sort of marker that people look at and say: "Hang on, you are looking at 5 per cent" and they know that that institution is under stress and that they will be working all the hours that God sends. Will you accept that that is a valid sort of marker that says if your vacancy rate goes up above 5 per cent you are in trouble, you need to keep it below 5 per cent in order to recruit

Chairman, Royal College of Nursing (Jersey):

Yes, as a marker, that is the marker we use at the moment that we are running ... I think when we had gone back we used that. We never personally used it but the hospitals, we had done it together and we came up to find out where we lay. I think we were running at almost 9 per cent at that particular time, which got us into the red. Again, as I say, you are talking below 2 per cent would be an acceptable level of vacancies to carry in any organisation. Between 2 per cent and 5 per cent you should be thinking about some sort of strategic thing in place. If you go above 5 per cent then you should really be pushing the boat out a bit to make sure you get in again, that sort of factor is why we might see an increase in the bank use, as if

The Deputy of St. Ouen :

If all vacancies were filled there would be no recourse to the bank, is that the situation?

Chairman, Royal College of Nursing (Jersey):

No, you will always need to use the bank because you need to cover set mass, you need to cover times where there is extra need for the wards. If we get a flu bug, let us say

Deputy G.P. Southern : This winter, for instance, yes.

Chairman, Royal College of Nursing (Jersey):

This winter we get a if we get wrong thing, if we pick the wrong flu injection we can only guess and then we are all getting a different one, all get the wrong strain of flu.

The Deputy of St. Ouen :

But in setting staffing levels

Chairman, Royal College of Nursing (Jersey):

What if we get norovirus, if we got a bout of norovirus comes in, there is always going to be the need for bank staff?

The Deputy of St. Ouen :

Okay, maybe there are highs and lows but in setting staffing levels for any area within the hospital, would they not take account of annual holidays and usual levels of sickness among staff to say we need so many posts on a permanent basis?

Chairman, Royal College of Nursing (Jersey):

My belief there and, again, I am not talking through any factual level but it is another high what was built into staffing budgets in the wards to accommodate annual leave, training, all that kind of stuff. It means that though we used that up fairly quickly, which they can then use bank, bank would be the next cheapest thing to make sure because we have got mandatory training of all nurses, which all the nurses and healthcare assistants have to go away and do anyway, as well as other types of training. You have got to allow time for people to go away and you have got to give people time. They are going to do that in their own time as well.

The Deputy of St. Ouen :

Yes, yes. Without the bank the hospital just could not function, even if it was fully staffed

Chairman, Royal College of Nursing (Jersey):

If everyone had stopped working in the bank it would collapse very quickly.

The Deputy of St. Ouen : Yes, yes.

Deputy G.P. Southern :

In Jersey, to your knowledge, do you know if we have had ward closures because of staffing issues, staff on wards, is that something that happens or happened?

Chairman, Royal College of Nursing (Jersey): We have closed beds. We have closed

Deputy G.P. Southern : You used it for the wards.

Chairman, Royal College of Nursing (Jersey): Yes.

Deputy G.P. Southern : Right.

Chairman, Royal College of Nursing (Jersey):

It was just the capacity of wards because there has not been the staffing to cover that number of beds.

Deputy G.P. Southern :

Is that fairly common or rare?

Chairman, Royal College of Nursing (Jersey):

It is not that common, it has happened a few times recently, not

The Deputy of St. Ouen :

Does that mean cancelled operations?

Chairman, Royal College of Nursing (Jersey):

I do not think it was in a surgical area, it was mainly in medicine. You tend to find the highest capacity goes because surgery is very much more symptom-structured. You can cancel surgery long before it gets to a stage you are needing a bed, whereas medicine tends to be something that people can get an infection and they have to come in to hospital. Surgery is usually planned, again, you are going to go and get your knee joints done or your hip joints done and if there is a problem with recruitment then what happens is they just push that back. I do not know what hospital waiting lists are like, I have not had certainly I cannot comment on that. But, as I say, that would be purely from a national perspective. There will always be a need for the bank but I think sometimes people feel that the bank gets used

The Deputy of St. Ouen : Okay.

Deputy G.P. Southern :

Can I just ask you, you mentioned there have been more acting-up opportunities in the workforce, it suggests that maybe some control is needed in there because you cannot rely on people acting up a

Chairman, Royal College of Nursing (Jersey):

I think there is a problem with acting up. As I say, my experience is that certain colleagues feel that they go into acting-up roles and they seem to be in them for ever in an acting-up role and then they are doing their job and they never get the chance to again, when it comes down to it they say: "Right, well I am not going to do that now, we have decided we are going to do something differently." If they get paid the proper rate for acting up they are getting paid a lesser amount for taking on more responsibility and then they end up with not getting the job, yes.

Deputy G.P. Southern : They come back to ...

Chairman, Royal College of Nursing (Jersey): They come back to it

Deputy G.P. Southern :

... experienced level staff and specialist staff, so he is acting up

Chairman, Royal College of Nursing (Jersey): Acting up just seems to go on for ever.

Deputy G.P. Southern : Yes, yes.

Chairman, Royal College of Nursing (Jersey):

Like somebody comes to me and they say: "I have been acting up for a year and a half" and I think: "Why? Surely in a year and half you must know, you need to fill the place or not?"

[14:00]

Deputy G.P. Southern :

Yes, they are doing the job or they are not doing the job.

Chairman, Royal College of Nursing (Jersey):

If you are not doing that properly after acting up for a year and a half there should have been somebody else.

Deputy G.P. Southern :

It links to the recruitment and retention

Chairman, Royal College of Nursing (Jersey): Yes, if that person gets fed up they will leave

Deputy G.P. Southern :

You have recruited but have not retained, then, yes, you could be acting-up for quite a while, yes.

Chairman, Royal College of Nursing (Jersey):

But, as I say, I think it is certainly a cheaper route acting up but they are good as well because it gives people experience to go into that level, potentially to scale up. I would not deny that we should do away with that but I think we need to make sure that it is much more structured than that. If people are going to do it for, say, 6 months then we are going to make sure that we are paying them properly for doing it for taking because when you are acting up you still take on the responsibility. You are not going to take on any less of a responsibility if people are acting-up. They are experienced nurses when they go in there and they have often done it for senior staff- nurse level, so it is just going to that next board up.

The Deputy of St. Ouen :

Yes. We have come to the end of our allotted time, Mr. McNeil. Is there anything that you would like to mention at the very end of this to do with retention and recruitment?

Chairman, Royal College of Nursing (Jersey):

How long have you got? No, I do not. [Laughter] It is a big portion certainly of the role of nursing, as I say, we are always keen to participate and talk about how do we recruit and retain nurse, how do we make things better for nurses because nurses are the backbone of any health service.

The Deputy of St. Ouen : Yes.

Chairman, Royal College of Nursing (Jersey):

That is why often when things go wrong nurses often get a bit of the brunt from the community because people are saying they trust nurses to support them. They trust nurses to be there. They think: "You have let us down on this occasion" and that is what happened a bit in the U.K.

Deputy G.P. Southern :

Can I just take you through I realise we have not spoken about this, overall the new plan, the P.82 and the site of the new hospital still not decided, has that caused problems in terms of staffing and changes not happening that you have been expecting?

Chairman, Royal College of Nursing (Jersey):

To be honest, very few people ... the people I was speaking to, they know that they have agreed to build a new hospital but nobody has really come and asked that much about it. Most people think, is it going to happen in my lifetime? Probably not. We are going to carry on with the same facilities. We are going to see it getting worse. There are a lot of problems in that hospital as it stands. Again, there has been huge issues with the structural stuff inside, as I say, but it was just allowed to go that way. Another factor that I did not mention was accommodation wise and that is probably something that could be certainly thought about is the staff accommodation. The hospital still has some staff accommodation, that has moved over into Jersey Property Holdings' care. Often when staff come across that is not in very good condition and it is at the bottom of the pile for Jersey Property Holdings for putting money into it to bring it up to standard. If that is your first experience of coming into Jersey and going into an accommodation that is not very nice, the chances are such that in keeping them automatically slip again

Deputy T.A. McDonald:

Yes, and the damage that can be done when they go back to the U.K. and

Chairman, Royal College of Nursing (Jersey):

Yes, they can go back and they say: "I have been across and the place was falling about on me that. I am not moving into it". Again, that is something I think that is very low priority to Jersey Property Holdings because it is staff accommodation.

Deputy G.P. Southern :

Again, it is one of those mechanisms by which you can

Chairman, Royal College of Nursing (Jersey):

But that is one area, at least if there is being work done in the States staff accommodation then it could be done in a more timely manner where people do come and see: "This is quite nice. Yes, this is modern, this is at least up to date" and that is certainly something that has been cited by people, which I did not mention earlier on. But the new hospital, and I have said this publicly in the press, they need to make a decision and get on and do this project. It is just going to cost us more and more money. We have a big deficit. They need to get on and make their mind up, already it has been delayed way longer than it should have been.

Deputy G.P. Southern :

Way beyond, yes, in terms of the recruitment and fresh staff to get into the community.

Chairman, Royal College of Nursing (Jersey):

I cannot understand why the States allowed it to be delayed so long.

Deputy G.P. Southern :

2015 and 2016 I think, they are already saying. The point was not being made because the whole thing has stalled and it is a shame.

Chairman, Royal College of Nursing (Jersey):

The amount ... it is just going to be a colossal ... and the bill is going up and up and up and that is what I mean, that we are talking about, again, structural austerity problems now then for building a new hospital those bills are just going to go through the roof and I think that is why people

The Deputy of St. Ouen :

Rest assured, we are doing what we can to press for a decision on that, yes. Okay.

Chairman, Royal College of Nursing (Jersey): Okay.

The Deputy of St. Ouen : Thank you so much.

Chairman, Royal College of Nursing (Jersey): Thank you very much for your time.

The Deputy of St. Ouen :

What you have said has been of great help to us and most interesting. Thank you coming to speak to us.

[14:05]