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

Results

Health visitor staff in post

In order to support the delivery of the UHVP, an increase in health visitor numbers was required to effectively deliver the pathway. In June 2014 the Scottish Government committed to creating an additional 500 (WTE) qualified health visitors (AfC bands 6-9) posts by the end of December 2018. Due to the time taken to register as a health visitor following the completion of training (see notes on Staff in Post), some new HVs may not be included in these figures as band 6-9 until March 2019. In addition, figures should be treated with caution due to the banding being grouped across bands 6, 8 and 9 (in December 2018, it was announced that HVs would move to band 7), and Highland posts not all being included in these data. As can be seen from Figure 1, the numbers of qualified health visitors had been relatively static between 2012 and 2014, when the commitment was made by the Scottish Government to create more health visitor posts. It should be noted that national guidance was given on the AfC categories in order to improve these data, and a national exercise to clean these data was then undertaken. For this reason, data from March 2015 are not directly comparable with data before 2015.

The Information Services Division created an adjusted lower and upper estimate of the number of health visitors in post in March 2014, of 1047.9 and 1,114.7, respectively. From 2015, a clear upwards trajectory of numbers of AfC Band 6-9 is evidanced in the data, reaching 1,554.7 health visitors recruited by December 2018. Using the upper and lower estimates this equates to between 506.8 and 440 additional posts (point 'E' on Figure 1 being the higher estimate). Student numbers are not included in this figure and are examined in the next section of the report. Alongside this, the number of WTE band 5 staff in post (staff nurses, health visitor students) fell somewhat, due to the fact that some staff moved from band 5 to band 6; numbers of band 1-4 staff in post remained consistant.

The majority of Health Boards followed clear upward trends in recruiting additional staff in Bands 6-9. Patterns by Health Board can be viewed in Supplementary Figures 4-17.

Notes to figures

A June 2014: date when the Scottish Government announced a commitment to fund an additional 500 health visitor posts (WTE, AfC band 6-9) by the end of 2018.

B December 2018: target date when 500 extra health visitor posts (WTE, AfC band 6-9) should be in place.

C, D Lower and upper revised estimates of the number of qualified HVs in post (WTE, AfC band 6-9) in Scotland at 31 March 2014 (1,047.9 and 1,114.7 respectively) (see Note 6 below).

E Target WTE number of qualified health visitors (AfC band 6-9) to be in post by 31 December 2018 (1,614.7) (Higher Estimate).

1. These data relate to individuals recorded against the Health Visiting sub job family in the Scottish Workforce Information Standard System (SWISS).

2. AfC bands:

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

3. No AfC Band 1 health visiting staff are recorded, and the numbers recorded in band 5 include interns.

4. Data for health visiting staff in post are presented as both head count and whole time equivalent (WTE). An employee may hold more than one appointment in NHS Scotland. In the head count figure (displayed in Figure 2 below), the employee is counted under each area (i.e. post and/or Health Board) in which they work. Health visiting staff in post (WTE, displayed in Figure 1 above) adjusts head-count figures to take account of part-time working (i.e. one person may work 20 hours a week, so head count could make the workforce appear inflated).

5. Workforce data for health visiting staff in post are not available for 31 December 2014. A national exercise to improve the quality of workforce data relating to community nursing was undertaken in 2014. Updated national guidance on assignment of staff to community nursing AfC sub job families (including health visiting) was provided to Health Boards, and Boards systematically cleaned data to ensure existing staff were assigned to the correct category between October and December 2014. Data before this period (September 2014 and earlier) are not directly comparable with data from March 2015 onwards.

6. In Highland, health visitors are mainly employed by Highland Council, rather than NHS Highland. These posts are included in the additional 500 places to be recruited, but not included in the workforce data displayed in these figures.

7. In June 2014, the Scottish Government announced a commitment to increasing HV numbers (WTE, AfC band 6-9) by 500. The baseline date was taken as 31 March 2014, and the baseline number of WTE qualified HVs in March 2014 used for the target is between 1,047.9 (lower estimate) and 1,114.7 (higher estimate). These figures were provided by ISD in 2016 and represent a lower and a higher estimate for the number of health visitors in post in March 2014, adjusted for assumed undercounting based on the data-cleaning exercise undertaken later in 2014 (Information Services Division (ISD) Scotland 2016). The target WTE number of qualified health visitors to be in place by 31 December 2018 is therefore between 1,547.9 and 1,614.7. Due to the time taken to register as health visitors, the data are displayed with a three-month additional window up to March 2019.

Notes

See Notes to Figure 1 above.

Students

In line with the requirement for increased recruitment of health visitors, from the academic year 2014/15, a substantial increase in the number of health visiting students can be seen (Figure 3). Numbers rose from 99 in 2013/14 to 252 starting courses in 2016/17. This includes students funded by both the Scottish Government and individual Health Boards.

The Scottish Government funded a total of 862 additional new health visiting students over five academic years, split as follows:

• 181 students in 2014/15;
• 217 students in 2015/16;
• 162 students in 2016/17;
• 182 students in 2017/18; and
• 120 students in 2018/19.

The vast majority of students are seen to complete their course and qualify as a health visitor; of students who began their course between 2011/12 and 2017/18, 89.3% completed their course and qualified as a health visitor. It should be noted that more than 500 HVs are required to be trained to account for those that do not complete the course and to accommodate part time working.

Notes

1. These data were extracted from National Education for Scotland (NES) on 30 August 2019.

2. When a student starts, discontinues, restarts or completes a course, NES receives information from the provider university about the student, their course and associated training dates and course outcome.

3. A cohort is based on the academic year and runs from September to August inclusive.

4. Students are assigned to a cohort based on their earliest start date and remain with that cohort regardless of any subsequent change of course or provider. Assigning students to cohorts allows standardised comparisons on intakes and outcomes across years and providers.

5. Students can be categorised into one of three mutually exclusive states, based on their training record: active, inactive (i.e. discontinued) or complete. More recent cohorts may show higher proportions of active students and lower proportions of complete students than earlier cohorts, as earlier cohorts have had more time in which to complete their training.

6. Time to completion will also be affected by whether a student studies full or part time.

7. Courses included in the analysis as 'Registered specialist CPH nurse – health visitor' (R_HV) and 'Specialist pract. public health nursing – generic' (R_PHN) at all providers. Three students on the R_PHN course have been removed from the data after being identified by their university as school nurses rather than health visitors.

8. Cohort numbers may occasionally be slightly lower than the number of students beginning a course in a given year, since a student who started the course in an earlier year, but subsequently re-started or changed university will remain counted as part of as earlier cohort.

9. In June 2014, the Scottish Government announced a commitment to create an additional 500 health visitor posts by the end of 2018.

Vacancies

The number of vacancies for health visiting staff over time can be seen to fluctuate somewhat, particularly when broken down by AfC band (see Figure 4). Data were not collected at AfC band level before the Nursing review in 2014, and thus only total vacancies are available until March 2015. After 2015, vacancies were recorded as occurring in two groups: bands 1-5 or bands 6-9.

The number of vacancies increased sharply between 2012 and September 2014. A clear pattern can be seen for bands 6-9, mirroring the increases in health visitor numbers seen in Figure 1 and

Figure 2 above. Increases in levels of vacancies at bands 6-9 occur between the start of 2016 and the end of 2017, before falling sharply in 2018. By contrast, levels of vacancies for bands 1-5 remain lower than bands 6-9, with the exception of an isolated peak at 31 March 2016.

Figure 5 displays the vacancy rate and demonstrates a similar, albeit flatter, pattern. Vacancies at a Health Board level fluctuated widely, due to small numbers.

Notes

See Notes to Figure 1 above.

1. Vacancies are posts that have been cleared for advertisement by the local Health Board. Vacancies prior to the Nursing review in 2014 were not collected at individual AfC band level; vacancies for this time-period are presented as a total for the sub job family. To aid comparison, total vacancies have been calculated from March 2015 onward and added to Figure 4.

2. No data were recorded for AfC band 1-2 for several quarters after March 2015.

3. Establishment is calculated as WTE staff in post + WTE vacancies.

4. Vacancy rate is calculated as WTE vacancies/WTE establishment.

Notes

See Notes to Figure 1 and Figure 4 above.

Turnover

Clear changes can be seen before and after 2014/15 in relation to the levels of staff joining and leaving the health visiting profession (Figure 6). Prior to 2014/15, and also in 2015/16, the number of health visiting staff (WTE) at bands 6-9 leaving NHS Scotland far outweighed the numbers of staff joining NHS Scotland at this level. Note, however, that leavers may have left the profession or moved outwith Scotland; health visitors who moved position within NHS Scotland are not included in this figure. This trend continued in 2015/16, but in 2016/17 and 2017/18, the numbers of joiners outweighed the numbers of leavers in bands 6-9. For bands 1-5, the numbers of joiners were consistently higher than the numbers of leavers.

Figure 7 explores turnover of staff as a proportion of health visiting staff in post each year: between 2015/16 and 2018/19, turnover for bands 6-9 fell from around 11% to just over 8%. By contrast, turnover for bands 1-5 increased from almost 9% to just over 12%, some of which may related to staff upskilling and moving from band 5 to band 6/7 positions. At a Health Board level, it was difficult to come to any firm conclusions around patterns in turnover due to fluctuations in the figures associated with the relatively low numbers involved.

Notes

See Notes to Figure 1 above.

1. Turnover is a snapshot as at each financial year; any staff member who joined and left within the financial year is not included. The following assumptions have been made in calculating the number of leavers and joiners:

• a. A joiner is defined as an employee who is in post X (band 1-5 or 6-9, HV sub job family) in NHS Scotland on 31 March year n + 1, but was not in post at 31 March year n
• b. A leaver is defined as an employee who was in post X (band 1-5 or 6-9, HV sub job family) in NHS Scotland on 31 March year n, but is not in post in year n + 1

i.e. joiners and leavers are only measured by sub jobs, and changing an AfC band is not considered to be a sub job. HV team members who move location within Scotland, but remain employed as a HV team member (at band 1-5 or 6-9) will not be counted as a 'leaver' or 'joiner'.

2. Data for employees leaving or joining the health visiting team are not displayed for the financial year 2014/15. A national exercise to improve the quality of workforce data relating to community nursing was undertaken in 2014. Updated national guidance on assignment of staff to community nursing AfC sub job families was provided to Health Boards, and Boards systematically cleaned data to ensure existing staff were assigned to the correct category between October and December 2014. Data before this period (September 2014 and earlier) are not directly comparable with data from March 2015 onwards; therefore we were unable to display data for leavers and joiners during that financial year, since a proportion of the 'joiners' in 20014/15 are actually employees staying in the same post, but whose job was reclassified into the HV sub job family.

Notes

See Notes to Figure 1 and Figure 6 above.

Absence

Figure 8 displays the absence rate for different AfC bands. Data are only available from the 2016/17 financial year. Between 2016/17 and 2018/19, the absence rate for bands 6-9 (health visitors and supervisors) was seen to fall slightly from 4.6% to 3.6%, with lower bands fluctuating somewhat.

Notes

See Notes to Figure 1 above.

1. The number of contracted hours includes the hours of permanent staff, staff on fixed term contracts or fixed/temporary contracts.

2. Sickness absence is defined as the following codes: Normal Sick Leave (SL), Unpaid Sick Leave (US), Industrial Injury (II), Accident involving a third party (AC), Injury resulting from a crime of violence (CV).

3. Sickness absence rate is calculated as hours lost due to sickness absence divided by total contracted hours.

4. These data include health visitor nursing sub job family only.