Universal Health Visiting Pathway evaluation - phase 1: report - routine data analysis - workforce

Methods

Years of available data

For the first phase of the UHVP Evaluation RDA, in which workforce data have been analysed, nationally available data relating to health visitor staffing for the period January 2011 to March 2019 were used. This sought to cover the period prior to the investment in additional qualified health visitors by Scottish Government, to the period of time that the pledge of creating an additional 500 posts was due to be met (by December 2018). The time point of up to March 2019 is included as it can take some time for new health visitors to gain their registration and subsequently be included on the workforce data system at the correct band, the additional three months allows for this process to be accomplished. January 2011 was selected as the start date, as children born in January 2011 were the first group eligible to receive the 27-30 month review in April 2013.

Data source

Routine data for the Phase 1 workforce data analyses have been provided by NHS National Services Scotland (NSS) Information Services Division (ISD) (now Public Health Scotland) in the form of disclosure-controlled aggregate bespoke data extracts. The workforce data are mainly SWISS (Scottish Workforce Information Standard System) quarterly workforce census data (extracted from NHS Board HR systems and returned to ISD). Additional data on vacancies (returned by NHS Boards to ISD) and health visitor students (returned by NHS Education for Scotland (NES) to ISD) have also been explored. Data for phase 2 will be provided by NES Digital Data Group, which is now responsible for sourcing workforce data, following the creation of Public Health Scotland (PHS).

Health Visitor staffing

A national exercise to improve the quality of workforce data relating to community nursing was undertaken during 2014. Updated national guidance on assignment of staff to community nursing sub job families (including health visiting) was provided by ISD to health boards, and health boards systematically cleaned data on the SWISS national NHS HR system to ensure existing staff were assigned to the correct category. Consequently, data for the periods up to September 2014 and from March 2015 onwards are not directly comparable. However, this time period coincides with the recruitment of the additional 500 health visitors pledged by Scottish Government and therefore needs to be considered in this analysis.

In order to provide an estimate of health visitors in post at 31 March 2014, ISD produced retrospectively adjusted figures to provide a baseline that could be compared to data for March 2015 onwards (Information Services Division (ISD) Scotland 2016)⁴. ISD estimated that, at 31 March 2014, the whole-time equivalent (WTE) number of health visitors was between 1,047.9 (lower estimate) and 1,114.7 (higher estimate) (Information Services Division (ISD) Scotland 2016). For the purposes of the implementation evaluation, the higher estimate has been used as a baseline, with the lower estimate referred to additionally where appropriate.

Descriptive statistical analyses

The analyses are as follows: in the main text of this report, the results for Scotland as a whole are provided; supplementary figures displaying the number of (WTE) staff in post for individual NHS Boards are included in the appendix; and raw data (including additional data for individual Boards) are also provided through a set of supplementary data tables for transparency.

The analysis of workforce data is descriptive. Data around health visitor staffing have been presented using bar and line charts. In particular, we aimed to establish the extent to which additional staff have been recruited to HV teams to support delivery of the UHVP. Indicators of staff wellbeing, such as turnover and absence, and the profile of health visiting workforce are also presented. The number of staff in post and recruitment rate by health board were also detailed (see the appendix and supplementary tables respectively).

Staff in post

Staff are allocated to specific job and sub job families on the SWISS system, indicating the clinical area in which they work. The results in this report relate to staff allocated to the Health Visiting sub job family, which includes qualified HVs, HV students, and other staff working in HV teams. Within this, staff are allocated to different bands, known as Agenda for Change bands.

There are nine Agenda for Change (AfC) bands:

• AfC band 1-2 includes healthcare assistants
• AfC band 3-4 includes early years workers, family support workers, nursery nurses
• AfC band 5 includes staff nurses, health visitor students
• AfC band 6-9 includes health visitors, team leaders, practice teachers, HV managers, family nurses, family nurse supervisors.

As shown above, qualified health visitors are included in AfC band 6-9. The inclusion of additional roles within bands 6-9 means that we cannot be entirely clear that any increase shown in this band is solely down to an increase in HVs alone, and should therefore be treated with caution.

Student health visitors employed by a host health board while undertaking the health visiting programme are also included in the health visiting staff in post data as band 5s. It should be noted that registration as a health visitor following the end of training can take 2-3 months. Thus immediately at the end of training a HV might be working as a fully qualified HV but may not have been moved over to the HV job family, and would not have been counted in the reporting period up to December 2018 (when the Scottish Government had pledged to provide an additional 500 health visitor posts). For this reason, the December 2018 workforce figures are likely to be a slight underestimate, due to the January 2018 intake of HV students having just completed their course and likely waiting on their final registration to allow the post to be correctly categorised on the system to the appropriate AfC band and job family. For this reason the workforce data within the subsequent data extract (March 2019) is also shown in the results.

Results, for Scotland, are presented for health visitor staff in post, both in terms of whole-time equivalent (WTE) and head count, and vacancies; they are broken down into band and year quarter. Analyses of the WTE staff in post data, stratified by health board, are included in the appendix. In the appendix, we have also included plots for WTE staff in post in three additional sub job families (public health nursing, community nursing general, and staff nursery), solely to understand the degree of misclassification.

It should be noted that Highland Health Board has a different model for employing HVs, whereby the majority of HVs are employed by Highland Council rather than NHS Highland. This means that, although Highland HVs were included in the 500 additional HV posts commitment, they are not included in the workforce figures, either for the whole of Scotland or for Highland Health Board.

In terms of timelines, SWISS and vacancy quarterly census data are available for 31 March 2011 to 31 March 2019 (phase 1); HV student data are available for academic years (September to August) 2011/12 to 2018/19 (phase 1).

Health Visitor Students

Students have been categorised into three mutually exclusive states, based on their training record: active, inactive (i.e. discontinued) or complete. The results in this report shows the status of HV students at 30 August 2019 (the end of the academic year that included December 2018 – the date by which the 500 new HV posts should be in place). As would be expected, more recent cohorts of HV students show higher percentages of active students and lower percentages of complete students than earlier cohorts, as earlier cohorts have had more time in which to complete their course. Time to completion is also affected by whether the student is studying full or part time.

The courses that those studying to be health visitors can undertake include; Registered Specialist Community Public Health Nurse – Health Visitor (R_HV) and Specialist Practitioner Public Health Nursing – Generic (R_PHN), where students studied at Glasgow Caledonian University, Queen Margaret University, University of Edinburgh , Robert Gordon University, University of Stirling , or University of the West of Scotland. These are the courses included in the analysis. Those studying outwith Scotland are not included in the data.

Vacancies

Vacancies are defined as health visiting posts that have been cleared for advertisement by the local NHS health board. There are graphs displaying the number of vacancies at each quarter, and the vacancy rate, which has been calculated as follows:

Vacancy rate = WTE vacancies / WTE establishment

where

Establishment = WTE staff in post + WTE vacancies.

Before the review of nursing roles 'Transforming nursing, midwifery and health professionals roles' in 2014, WTE vacancies were not collected at AfC band level, and thus overall Scotland totals for WTE vacancies are provided between March 2011 and September 2014. From March 2015, vacancies are displayed as AfC band 1-2, 3-4, 5 and 6-9; the total numbers of vacancies during this period have also been calculated to enable comparison with the earlier period.

Turnover

When exploring turnover, the number of leavers and joiners in each financial year were examined, and then the turnover rate was calculated as follows:

Turnover = Number of leavers in financial year n to n+1 / Staff in post as at 31 March year n

Leavers are defined as employees who were in post as a health visitor (band 1-5 or 6-9, HV sub job family) as at 31 March year n, and not in post at 31 March year n + 1; joiners are defined as employees who were in post as a health visitor (band 1-5 or 6-9, HV sub job family) as at 31 March year n + 1, but not in post at 31 March year n. HV team members that moved location within Scotland, but remained employed as a HV team member (at band 1-5 or 6-9), were not counted as a 'leaver' or 'joiner'. Turnover is a snapshot for each year: any staff member who joined the HV team and left within the same financial year would not be included in the turnover.

Absence

Sickness absence is defined as normal sick leave, unpaid sick leave, industrial injury, accident involving a third party, and injury resulting from a crime of violence. The sickness absence rate is calculated as follows:

Absence rate = Total hours lost through sickness absence / Total contracted hours

Absence rate is displayed for AfC band 1-5 and 6-9.

Additional AfC sub job families

There are three additional AfC sub job families: public health nursing, community nursing general, and staff nursery nurses. The community nursing general sub job family was no longer in use after the Nursing review in 2014. Analyses relating to these three sub job families were conducted only to understand the degree of misclassification (e.g. if health visitor numbers went up, did they appear to be associated with a drop in numbers from another sub job family due to original misclassification), and a figure for each sub family is included in the appendix.

Missing data

As the analyses in this part of the evaluation are descriptive, instances of missing data will be reported, but multiple imputation will not be performed.

Descriptive analyses have been conducted in the Statistical package R, version R3.6.2.