NHS Funded Nursing Care Review 2018

Healthcare market intelligence experts, LaingBuisson, have been awarded the contract by the Department of Health and Social Care to review the NHS-Funded Nursing Care (‘NHS FNC’) Rate in England.


The project will consider the following factors in coming up with a fair calculation of the 2018/19 NHS FNC rate:

  • Cost to nursing homes of providing registered nursing staff per resident per week
  • Proportion of nursing care provided by registered nursing staff that should be included in NHS FNC rate, according to the legislation
  • Share of nursing home residents who qualify for NHS FNC.

There will be a universal survey of all nursing homes in England and this will roll out from 12 November onwards, alongside a focused survey which will be aimed at a 10% sample of nursing homes. The survey will be supported by online forms and a mobile app which we believe will offer a more reliable way of collecting and collating data from the survey than traditional methods, with the result of producing a robust dataset for England and its regions to support the Department in its decision making.

If you would like to be involved in the survey, to ensure we have the correct contact details for your nursing home, please enter your details in the form below.

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An outline of the method is summarised in the Figure.

Project initiation and preparation

Following confirmation of tender success, we will engage with DHSC and key stakeholders to finalise the project plan and establish mechanisms for engagement and communication.

Under DHSC guidance, we will arrange focus groups to present our proposed method to stakeholders and seek feedback on the general approach and technical challenges. Stakeholders may include national and local care home membership organisations, NHS England, Clinical Commissioning Group (CCG) representatives, the Care Quality Commission (CQC) and the Association of Directors of Adult Social Services (ADASS).


Survey Method

The project requires the consultant to produce three reliable sets of numbers as a basis for calculating a 2018/19 NHS FNC rate.

  • Cost to nursing homes of providing registered nursing staff per resident per week.
  • Proportion of registered nursing staff time that qualifies as an NHS FNC cost according to the law.
  • Share of nursing home residents who qualify for NHS FNC (e.g. excluding those in receipt of continuing healthcare and personal care only.

Two provider surveys will be undertaken to achieve these objectives, a Cost Collection survey and a Nurse Time Analysis survey.


Cost Collection survey

Questions relating mainly to the costs of employing registered nursing staff will be consolidated into a webform (on-line survey form) to be answered for the latest available payroll or accounting period, with discretion over the length of the period. A composite, multi-home response template will also be provided for the convenience of care home groups. The survey questions will include:

    • Actual payroll information for the payroll period ending in the target week, including registered nurse hours, gross pay and itemised on-costs.
    • Additional payments that may count towards NHS FNC costs (e.g. professional registration fees).
    • Actual agency costs incurred (if any) for the supply of registered nursing staff for the period including the target week.
    • Number and timing (day or night) of registered nurse shifts.
    • Numbers of residents at a point of time, separating out those who qualify for NHS FNC and those that do not.

Nurse Time Analysis survey

As regards questions relating to the division of nursing activities into those which do and do not count towards NHS FNC, we will enable registered nursing staff to answer the questions via an on-line Data Collection Tool (DTC). Nurses will be asked to state what category of activity they are engaged on at a randomly generated set of times during their shift (see details below). The list of activity categories is likely to be fewer than 10.

Questions will be compiled in the light of guidance from DHSC and advice from stakeholders. We will seek sign-off of the final questions from DHSC.

To keep within the resource and time constraints, it will be necessary for nurses to self-record their activities. The approach we propose draws on experience from a similar NHS FNC exercise in Wales, where we found that many nurses had difficulty in maintaining complete diaries and that making contemporaneous paper-based entries interfered with the tasks themselves. Together with other internal inconsistencies, this meant that data from many shifts had to be discarded as unreliable.

The alternative approach we recommend is the on-line DTC to enable nurses to self-record their activities on a spot sampling basis, with the minimum disruption to their work activities and the maximum recall of the activity. The process can be summarised as follows:

  • The home manager gives each registered nurse on duty during the survey week (each that has access to a smart phone) simple LaingBuisson drafted instructions to record their activities via the DTC which guarantees them total confidentiality.
  • Each participating nurse logs in to the DTC (hosted on a secure, dedicated website), using the unique LB home identifier. The nurse will enter the finishing time of the shift and the app will generate [N] randomly timed texts alerting the nurse, at the next opportunity, to enter the activity she/he was engaged on at the time of the last alert.
  • The nurse will choose from a list of activities displayed on the DTC - based on the Supreme Court judgement in the case of Forge. This list will be further refined at the initial engagement stage with DHSC and other stakeholders, and we will seek sign-off from DHSC on the final wording of the activities list.

Each registered nurse (employed and agency) working at each sampled home will be asked to record activity in at least one shift during the survey week, with an appropriate balance between day versus night shifts.

Registered nurse responses will be recorded in a secure SQL database, building up a probability distribution of spot sampled activities which are, in principle, equivalent to a diary-based division of relative time spent on those activities, and likely to be more accurate in practice.


Intensive follow up of 10% sample

Invitations to participate in the surveys will be sent by mail and email to the entire universe of approaching 4,400 nursing homes in England, either at group or individual home level.

In addition, it is proposed to take a 10% sample of homes to be subject to more intensive follow-up.


Secure handling of data

We are aware of our responsibilities as a data processor and will implement the following steps to ensure that GDPR is effectively upheld for this assignment and that it is delivered in line with our data protection policy. This means that we will review the implications of any sensitive information we received in the light of the Data Protection Act and GDPR and what steps may consequently result.

We will ensure that team members know which data is likely to require an enhanced level of security, taking all possible steps to remove identifiers or personal information from the data, storing data solely on our secure drive, having password protection and transferring the data using secure email platforms (e.g. Egress Switch). A key facet of our proposal is that all survey data will be entered in the secure SQL database in real time, meaning that there is reduced risk of data loss in transfer.

LaingBuisson has up-to-date CyberEssentials certification and, in readiness for the launch of GDPR, senior management updated all data management protocols.


Quality assurance of response and dealing with outliers

We will write SQL queries to compare individual cost survey responses with recognised sector benchmarks.

These queries will identify potential outliers which can either be challenged or excluded (according to a protocol to be agreed with DHSC).

Challenging will take the form of asking respondents to account for disparities between their responses and sector benchmarks. For example, focusing on the most important drivers of exceptional costs:

  • Nurse hours per resident per week can be challenged by asking respondents to explain the staffing rota which gives rise to exceptionally high or exceptionally low numbers.
  • (Exceptionally high) agency costs can be challenged by asking the respondent to explain what circumstances give rise to them (e.g. recruitment, turnaround, etc.). Provisionally, we would set a reported agency use rate of 20% as a trigger for challenge. A protocol will be developed for approval by DHSC.


Monitoring response and development of reporting outputs

Following sign-off of a definitive list of survey questions, we will write SQL queries designed to:

  1. Monitor response rates.
  2. Output provisional results showing:
  • how key results are building up, and to give early warning of any issues arising.
  • provisional calculations of how NHS FNC calculations vary according to a number of parameters which are linked to individual homes on the LaingBuisson database, including: region, client type, home capacity, ownership status, whether group owned, CQC rating.

Query results will also allow us to take action to correct any significant under-response in the stratification segments, by mobilising extensions to the 10% intensively followed-up sample.


Management and delivery risks

We will deal with management of key delivery risks as follows:

Failure to deliver a fully working mobile app. We have substantial experience in the field and confirm that a simple mobile app, as described, can be developed within the required timescale of the project. We do not believe this is a significant risk to the project.

Failure to deliver an acceptable response rate. This is the main risk to the successful completion of the project. We have addressed this by proposing intensive follow-up of a 10% sample of nursing homes.


Liaison with DHSC throughout the project

 In line with Section 6 of the Service Description, we will attend fortnightly meetings with DHSC to review progress.

At the planning and preparation stage we will report on achievement of key preparatory tasks.

Thereafter, we will report on response rates and output provisional results as survey data becomes available, using the same SQL queries as used to produce the final outputs. This will enable DHSC to see results as they emerge, rather than waiting for the surveys to close before an analysis of results is prepared.


Quality assurance

Our approach to quality assurance is as follows:

  • A quality assured proposal, reviewed by a senior member of staff to ensure we are confident of our suitability for the project and our ability to deliver your requirements to time, specification and budget.
  • Heidi Nicholson, Chief Operating Officer, is the designated contract manager and will have overall responsibility for ensuring the project is delivered as agreed. She will be your main point of contact for the project and will deliver the key partner liaison activities.
  • Further internal overview, challenge and quality assurance will be provided by project director, William Laing.
  • Our work is guided by policies on quality assurance, research governance, data protection and customer care. Copies are available on request.


Credible defined dates for each key output

We confirm we can meet the key dates for delivery of the draft report (18 December 2018) and of the final report (18 January 2019) and have a robust project plan to enable us to achieve this.