NATIONAL AUDIT ECE

Report by the Comptroller and Auditor General

National Health Service Administrative and Clerical Manpower

Ordered by the House of Commons to be printed 8 March 1991

London: HMSO E6.60 net 276

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

This report has been prepared under Section 6 of the National Audit Act, 1983 for presentation to the House of Commons in accordance with Section 9 of the Act.

John Bourn Comptroller and Auditor General National Audit Office

22 February 1991

The Comptroller and Auditor General is the head of the National Audit Office employing some 900 staff. He, and the NAO, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies use their resources.

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

Contents

Summary and conclusions

Part 1: Introduction and background

Part 2: Determination of manpower requirements

Part 3: Meeting manpower requirements

Part 4: Monitoring and control

Pages

1

7

11

18

24

Annex

Breakdown of Administrative and Clerical Staff numbers and costs by Health Authority 29

NATIONAL HEALTH SERVICE ADh4INISTRATIVE AND CLERICAL MANPOWER

Summary and conclusions

1. Administrative and clerical staff are employed throughout the National Health Service. They provide management support and undertake general administrative functions ranging from routine clerical and secretarial duties to professional services, for example accountancy. Their work contributes, both directly and indirectly, to the quality of service provided to patients.

2. In 1988-89 administrative and clerical staff costs were about El billion in England, 8.0 per cent of total Hospital and Community Health Services’ revenue expenditure. Currently, there are 121,000 administrative and clerical staff (including 4,600 NHS senior managers), 15 per cent of the total National Health Service workforce in England. About one-third of administrative and clerical staff are classified as being engaged on clinically related work. The proportion of NHS revenue expenditure devoted to administrative and clerical staff has fallen slightly in recent years.

3. This report presents the results of an examination by the National Audit Office of administrative and clerical staffing arrangements within the Hospital and Community Health Services in England. The report examines three main issues relating to health authorities’ current procedures for:

(a) determining administrative and clerical manpower requirements;

(b) meeting these requirements; and

(c) monitoring and controlling manpower numbers and costs.

4. The examination took into account the following changes which are likely to impact on the demand for, and supply of, administrative and clerical staff:

(4 implementatron of the National Health Service reforms from April 1991 which will separate purchasers (for example, health authorities) from providers (for example, hospitals) of health care and introduce contracts for health services between the two. The reforms will also devolve responsibility for recruitment and grading of staff and provide opportunities for more individual employment packages.

(b) demographic trends, resulting in fewer school leavers during the 199Os, although this is likely to be offset by an increase in the 25 to 54 years old age group especially women returning to work, and higher numbers of graduates.

5. The National Audit Office’s main findings, conclusions and recommendations were:

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NATIONAI. HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

On determining manpower requirements

(a) responsibility for the planning and control of the manpower group is devolved to individual health authorities (paragraph 1.6);

(b) administrative and clerical staffing levels are historically based and health authorities generally have no formal assessment procedure for determining staffing requirements (paragraph 2.2);

(c) in 1988-89 district health authorities’ expenditure on administrative and clerical manpower varied horn 6.7 to 12.4 per cent of their revenue spend. Differences between districts, particularly in London, reflected more the impact of higher unit labour costs than staff numbers (paragraphs 2.6 and 2.6);

(d) higher administrative and clerical staff numbers and costs were usually associated with higher numbers of frontline staff (for example, medical and nursing) and higher levels of patient activity. However the extent of these relationships varied widely between districts: administrative and clerical costs ranged from E9 to 1632 per patient episode; the ratios of total administrative and clerical staff to front- line staff ranged from 1:2 to 1:8 (paragraphs 2.7 and 2.8);

(e) health authorities have generally, not assessed the time spent by professional staff groups, such as nurses, on work that may be more appropriate to administrative and clerical staff. The Department of Health have however asked health authorities to review the roles of support staff, including administrative and clerical, to facilitate the introduction of the post of Health Care Assistant (paragraphs 2.9 to 2.12):

(f) the grading of posts through job evaluation is widely used in health authorities for senior managers but little used for the vast majority of administrative and clerical jobs (paragraph 2.13);

(g) some health authorities are re-examining their administrative and clerical staffing requirements as part of wider manpower exercises. This is partly in response to the Resource Management Programme. Additionally, the NHS reforms are prompting health authorities to re-examine staffing balances within and between manpower groups (paragraphs 2.18 to 2.20 and Tables 8 and 91.

6. The National Audit Office conclude that administrative and clerical manpower numbers reflect “top-down” health authority resource allocation decisions but, nevertheless, are broadly related to health authority activity levels. Whilst taking some assurance horn this, the National Audit Office cannot be sure whether health authorities are appropriately staffed for their administrative and clerical needs. This is due to the absence of any defined yardsticks for determining manpower requirements.

7. The introduction of the NHS reforms is likely to lead to a greater concentration of administrative and clerical functions at hospital level. From April 1991, contracts, based on agreed levels and quality of patient care, will determine the amount of money received by hospitals, rather than the previous system of “top-down” resource allocation by health authorities. Manpower will be the major cost element of these contracts.

2

NATIONAL HEALTH SERVICE ADMINISTRATIVE AN,, CLERICAL MANPOWER

There is consequently a need for health authorities to make more explicit assessments of their manpower requirements, with a view to both minimising labour costs and maximising benefits of skill mix within and across staff groups. Failure to address this issue might reduce the potential to achieve increased manpower efficiency. In making this assessment the National Audit Office acknowledge the positive steps already being taken and outlined in this Report.

8. The National Audit Office believe that health service employers could improve value for money in determining manpower requirements by:

Action required on determining manpower requirements

evaluation. This would assist managers in their determination of appropriate administrative and clerical staffing structures and associated pay costs for set levels of workload.

On meeting manpower requirements

(h) the rate of turnover of administrative and clerical staff employed by health authorities in England averaged 25 per cent in 1988-89. Recruitment and retention was most difficult in South East England where turnover rates reached 44 per cent (paragraph 3.8):

(i) health authorities visited by the National Audit Office accept that there is a need to ascertain the financial cost of turnover, but few had done so (paragraph 3.11);

(j) the Department of Health’s 1989 pay award for administrative and clerical staff included a provision for health authorities to approve local pay supplements where there were proven difficulties in recruitment and retention. As at June 1990, however, only eight district health authorities had implemented such supplements but most Health Service employers visited planned to do so (paragraphs 3.12 and 3.13);

(k) regions are well aware of the growing impact of demographic changes on the labour market and generally have developed imaginative schemes to attract and retain the main staff groups including administrative and clerical. There was little evidence however of health authorities monitoring the cost-effectiveness of these schemes (paragraphs 3.16 to 3.18);

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NATIONAL HEALTH SERVICB ADMINISTRATIVE AND CLERICAL MANPOWER

(1) agency staff costs in regional and district health authorities in 1988-89 were E50 million, 5 per cent of total administrative and clerical staff expenditure, and in London, where most agency staff usage occurs, reached as high as 22 per cent. The decision to employ agency staff is based on the operational judgements of individual line managers and control is exercised through manpower budgets (paragraphs 3.21 and 3.22);

(m) in general, health authorities are using preferred or sole agencies, the latter appointed following competitive tendering exercises. This is advantageous both financially and in terms of the quality of staff supplied (paragraphs 3.23 and 3.24);

(n) a number of specialist administrative and clerical functions, for example computing, are contracted out by some health authorities. There is however little evidence of districts considering the contracting out of routine administrative and clerical services (paragraph 3.25).

9. The Department of Health have acknowledged the problems faced by health authorities in recruiting and retaining administrative and clerical staff. And health authorities themselves have developed imaginative schemes to aid staff recruitment and retention. However some areas left room for improvement, such as health authorities’ failure to monitor the cost-effectiveness of recruitment and retention schemes, and general lack of knowledge of the financial cost of turnover. There appeared to be scope for health service employers to examine the feasibility of contracting out some administrative and clerical services.

10. The National Audit Office believe that health service employers could improve value for money in meeting manpower requirements by:

Action required on meeting manpower requirements

On monitoring and control

(0) all health authorities visited consider the Department’s Health Service Indicators for manpower so far provided to be of limited use because they are not comprehensive, complete or up to date (paragraph 4.4);

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NATIONAL HEALTH SERVICE ADMINISTRATIVS ANJI CLERICAL MANPOWER

(p) regional health authorities facilitate the monitoring of administrative and clerical staff through the provision of region-wide information to their districts. Monitoring however, is generally focused on staff numbers rather than indicators of performance, for example costs and activity levels (paragraphs 4.5 and 4.6);

(q) errors in occupational coding and an out of date coding list for administrative and clerical staff mean that the accuracy of reported staffing figures is undermined (paragraphs 4.8 to 4.10);

(r) manpower budgets act as the spending cash limit on administrative and clerical staff. All attributable manpower expenditure (essentially salaries, overtime payments, and agency staff costs] is charged and controlled against these budgets. Few administrative and clerical staff are required to work paid overtime (paragraphs 4.13 to 4.15):

(s) a lack of detailed knowledge of vacancy levels within some health authorities makes it more difficult for them to review current - and better inform future - manpower funding decisions. This situation is now however being addressed by the health authorities concerned (paragraphs 4.16 to 4.19);

(t) the sickness rate for administrative and clerical staff in most health authorities is between 3 and 5 per cent, representing a cost nationally of about E30 million. The National Audit Office found that health authorities visited did not routinely assess sickness data (paragraph 4.23).

11. The introduction of the NHS reforms will strengthen local control over resource areas such as administrative and clerical manpower. The National Audit Office conclude, however, that there will still be a role after 1991 for central and regional dissemination of good practice and well-presented manpower information. This will require a flow of accurate source data to enable the Department of Health and regions to act effectively as “facilitators” in disseminating manpower facts and figures.

12. The National Audit Office conclude that managers require improved management information, as part of a strengthened budgetary control system, to better inform them of the cost implications of their manpower spending decisions. The need for effective cost control procedures at local level will grow with increased devolved responsibility and accountability. A key indicator for monitoring and control will be unit labour costs linked to contracted activity levels. The National Audit Office consider that an understanding of, and the ability to successfully control, the relationship between manpower numbers, costs and activity levels will be a key to increased efficiency under the NHS reforms. To help in achieving this, the personnel function, particularly at hospital level, will need to be developed and strengthened.

13. The National Audit Office believe that health service employers (or, where specified, the Department of Health] could improve value for money in the monitoring and control of administrative and clerical staff by:

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NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

Action required on monitoring and control

i . ,. ,~ “ P i I, i 9 ‘.

‘T ;; ,, _ ; . updating and streamlining the &i&k& list ,of o~~uj@3cih 23des { 1 * for administrative and clerical staff (Department-ofHe&lth];

l upgrading the range and quality of manpower management : information at local level;

l implementing appropriate arrangements for the m:onitoring and control of sickness absence;

l encouraging the use of targets for managers based ‘on ,key ,.” _ manpower indicators such as turnover, absence ar?d.vacancy a levels;

: ,,, l developing a methodology for identifying and using’ unit labour

costs linked to activity levels as a key,indicator-of,performance;

l strengthening the personnel function, particularly at hospital”level.

General conclusion

14. The National Audit Office conclude that the introduction of the National Health Service reforms in April 1991 will emphasise the need for better assessments of staffing requirements across and within manpower groups. To maximise value for money it will be essential for manpower levels and costs to be related directly to contracted patient activity. The challenge now facing health authorities as purchasers, and more especially, Units, Trusts, and individual hospitals as providers of services, is to develop and introduce the arrangements necessary to ensure that such relationships will exist. The need for these arrangements, as outlined in this Report, goes therefore beyond just administrative and clerical staff and applies to all major National Health Service manpower groups.

6

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

Part 1: Introduction and background

1.1 The National Health Service is one of Europe’s largest organisations and the biggest single employer of staff in Great Britain. In 1988-89 staff costs in England totalled X9.5 billion, 75 per cent of total NHS revenue expenditure. The main staff groups are shown in Figure 1. Currently there are 121,000 Administrative and Clerical staff (including 4,600 NHS senior managers), representing 15 per cent of the total NHS workforce in England and costing about El billion a year.

Role of administrative and clerical staff

1.2 Administrative and clerical staff are employed within regional and district health authorities, in hospitals and the community (the “Hospital and Community Health Services”]; and by family health services authorities (approximately 4 par cent of total administrative and clerical staffj. They provide management support and general administrative services ranging from routine clerical and secretarial

(covering ever 50 per cent of staff) through to professional, for example accountancy and senior management. Over 80 per cent of staff are female, approximately 40 per cent working part-time.

1.3 Administrative and clerical staff contribute, both directly and indirectly, to the quality of service provided to patients. The Department of Health make a distinction between those whose work is closely related to patient care (clinically related staff), and those whose work is not (non-clinically related staff) (Table 1). Currently, about one-third of total administrative and clerical staff are classified as clinically related, most of whom are employed within hospitals.

1.4 Administmtive and clerical staff numbers increased by 15 per cent between 1980 and 1989. Staff numbers of other manpower groups also increased over this period, with the exception of those groups (Ancillary, and Works and Maintenance)

Figure 1 NHS Directly Employed Staff by Main Staff Group [England] - September 1989

Ancillary

I Professional and Technical

Administrative and Clerical, /

Medical and Dental

Works and Maintenance

Ambulance

Nursing and Midwifery

Source: Department of Health Note: Total staff 795,000 [whole-time equivalents).

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NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

Table 1

Administrative and Clerical (A&C) NHS Staff

Medical Secretaries Ward Clerks Medical Records Officers Health Educationalists Other

7 Senior Management 3 Finance

12 Computing 1 Personnel 8 General Administration

Support Services Other

31

Numbers of staff: 38,540 Numbers of staff:

Total of all A&C staff: 121,450

69

82,910

Source: Department of Health (data as at September 1989). Staff numbers are expressed as whole-time equivalents.

Note: There are currently a total of 84 separate occupational groups within the overall category of administrative and clerical staff. Many of these groups are, however, very small in size.

where contracting out of work has taken place (Figure 2). The proportion of NHS revenue expenditure devoted to administrative and clerical staff (8.0 per cent in 1988-89) has remained relatively constant in recent years, even falling slightly (Table 2).

Table 2

Costs of Administrative and Clerical Staff

$&j ?.f (:‘l ;‘&& .$&;;;3+t;g; : .~pkL(;&;f~ ..~ ., .$&&es md,‘,;gfy~otd ‘. gcfis ..:

wages ,’ HCHS(S) ReVellUe G Million[Z) Salaries and Expendit&

Wages(4)

1985-86(‘) 773 11.0 8.0 1986437 841 11.2 8.2 1987-88 915 11.1 8.1 1988-89 1010 10.8 8.0

Source: Annual HCHS Summarised accounts

Notes

(‘1 Cost data not readily available prior to 1985-86.

(2) Includes salaries of senior managers but not agency costs.

(3] Hospital and Community Health Services.

(4) Does not include agency costs.

Planning and control framework

1.5 The Department require health authorities to plan and manage health care services within a defined planning framework. Each year district health authorities prepare short-term operational progxunmes which take account of changing local needs and the sources of finance available. These are approved and aggregated at regional level and then submitted as individual regional plans to the Department of Health. In the past the Department scrutinised the regional programmes prior to approval to ensure that they were consistent with national policies and priorities, feasible in resource terms, and coherent as far as plans for activity, manpower and finance were concerned. Regions would subsequently account for their performance, and would review district performance in the same way. However, under the Reforms this system will change because regions will not be expected to exert such tight control over providers of service - it will be a market (purchaser/provider) relationship rather than a management one.

1.6 Manpower planning for administrative and clerical staff operates mainly at a local level. This is because most administrative and clerical staff are recruited in competition with other employers from local labour markets. They often bring their skills with them. The Department of Health are taking increasingly less responsibility for setting the framework of pay and conditions of service through

NATIONAL HEALTH SERVICE ADMINISTRATWE AND CLERICAL MANPOWER

Figure 2 Main staff groups percentage change 1980-89 England

Nursing and Midwifery

Professional and Technical

Works and Maintenance

Administrative and Clerical

Ambulance

Ancillary

Medical and Dental

Total Employed staff

-60 -1” ”

Percentage change

Source: Department of Health

the Whitley machinery. Individual health authorities, NHS Trusts and individual hospitals will play a progressively larger role in the planning and development of their own manpower needs.

1.7 Consistent with this devolution, the Department of Health do not set health authorities targets for administrative and clerical manpower numbers. The Department have however stated that health authorities should concentrate on those groups which deliver services to patients and their immediate support staff, and to exercise close scrutiny of numbers of non-clinically related staff.

National Health Service Reforms

1.8 The Government’s White Paper “Working for Patients” @nuary 19891, proposed a range of NHS reforms from April 1991. The proposals were enacted by the NHS and Community Care Act (1990) which separates the purchasers of health care services (for example, health authorities) from providers (for

example, hospitals) and introduces service

agreements between the two, based on an agreed level of charges.

1.9 Hospitals and other providers of service also have the option of applying to the Secretary of State for Health to run their own affairs as NHS Trusts, free from the direct management of health authorities. Subject to honouring existing NHS staff contracts, trusts will be able to determine their own staffing levels, rates of pay and conditions of service. The introduction of the NHS reforms will therefore alter the planning and management framework within which health authorities determine and meet their administrative and clerical manpower requirements.

Scope of National Audit Office examination

1.10 This examination is restricted to administrative and clerical staffing arrangements within the Hospital and Community Health Services in England. In particular it concentrates on the manpower planning and control arrangements for administrative and clerical staffing within regional and district health

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N.4TIOli.U HEALTH SERVICE ADMlNlSTRATIvE AND CLERICAL MANPOWER

authorities and in hospitals, where most staff are employed. The National Audit Office set out to establish the procedures for:

(a] determining administrative and clerical manpower requirements;

(b) meeting these requirements; and

(c) monitoring and controlling manpower numbers and costs.

The Report takes into account the revised planning and management framework for administrative and clerical staff arising from the NHS reforms. In particular, the National Audit Office recognise that, in future, the control of administrative and clerical staff numbers, work performance and organisation will be the responsibility of individual health service employers. And the present definitions of staff groups and their work are likely to become less rigid. Thus, whilst necessarily focusing on current procedures, the examination concentrates on manpower issues whose importance will continue in 1991 and beyond. The Report’s conclusions and recommendations aim therefore to be forward-looking in their application to the management and control of administrative and clerical manpower.

1.11 In the course of their examination the National Audit Office visited six regional and 12 district health authorities [Table 3). Evidence from these visits was supplemented by a questionnaire sent to the 14 regional health authorities, seeking information on a district basis. In presenting this Report the National

Audit Office have included examples of good manpower practices within those health authorities examined. The National Audit Office visited appropriate branches of the Department of Health, particularly to seek statistical information. They also took advice from the Institute of Manpower Studies and consulted the National And Local Government Officers Association.

Table 3

Health Authorities Visited by the National Audit Office

,.. ,,,, ., ., . .

East Anglian

Mersey

South Western

West Midlands

North East Thames

North West Thames

Cambridge Wirral south Sefton Southmead

Wolverhampton

City and Hackney Bloomsbury Southend West Essex

HZFOW P&side

The National Audit Office also visited the Guys Acute Unit, Lewisham and North Southwark Health Authority.

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NATIONAL. HEALTH SERVICE ADMlNlSTRATNE AND CLERICAL MANPOWER

Part 2: Determination of manpower requirements 2.1 This part of the Report deals with the determination of administrative and clerical manpower requirements for the hospital and community services. It also considers the procedures for job evaluation which should play an important role in managers’ assessments of need.

2.2 As paragraphs 1.6 to 1.7 explain, the determination of administrative and clerical staff numbers is made by the individual health authorities. The National Audit Office therefore sought to establish, by visits and by questionnaire, the methods used by heal

%% Health authorities informed the National Audit Office that staffing levels reflect managers’ judgements based on experience of workload in their departments. They also had to take account of financial constraints.

2.3 The National Audit Office’s enquiries showed that very few health authorities used a “zero-based” approach to manpower planning. This involves looking anew at the administrative and clerical work necessary within a department, along with the staff numbers and associated skills required to do this work. Health authorities accepted that a “zero-based” approach would be feasible in principle, but the effort involved would be very expensive. Nevertheless in the National Audit Office’s view, without such periodic reviews of staffing requirements, health authorities cannot be sure whether they are employing too many (or too few) staff.

Analysis of manpower numbers and costs

2.4 In the absence of formal assessment procedures, the National Audit Office set out to determine whether manpower levels had become distorted over time. Although there is no agreed “appropriate” level of spending on administrative and clerical staff, the National Audit Office took the view that some consistency of spending should be expected, at least between regional health authorities having broadly similar demographic and other characteristics. The National Audit Office compared and analysed staffing levels, costs and patient activity in the six regions visited. National data obtained by questionnaire were

also examined. A detailed breakdown of the results obtained is shown in the Annex to this Report,

2.5 The overall results showed a considerable measure of consistency in the proportion of revenue expenditure devoted to administrative and clerical staff by Thames and provincial regions (Table 4). At the majority of district health authorities (67 per cent), administrative and clerical staff costs accounted for between 6.5 and 8.0 per cent of revenue expenditure. However, the results also showed a wide range in the level of resources being incurred on administrative and clerical staffing by individual districts within each region and across the country (Table 4 and Annex). Northumberland District Health Authority spent the least of its revenue expenditure on administrative and clerical staff (5.7 per cent) and Camberwell District Health Authority the most (12.4 per cent). The National Audit Office therefore analysed these ranges in the health authorities visited.

2.6 District extremes appeared to be at least partially attributable to the special problems of inner-city districts, especially in London, through having to pay higher basic wages to attract administrative and clerical staff. This finding was also reinforced by the wide variation in unit labour costs shown in Table 5. Nationally, costs ranged from f6,700 to El2,400 per member of staff, with the majority of districts falling within a narrower range (%OOO to S9,OOO). The results indicated that unit labour costs had a greater impact on districts’ relative spending on administrative and clerical manpower than staff numbers. There was therefore no clear evidence that differences in relative expenditure on administrative and clerical manpower pointed to significant imbalances between staffing levels at individual districts.

2.7 Based on data from regions visited, the National Audit Office also examined the relationship between administrative and clerical manpower numbers and costs, sizes of frontline staff groups (for example, medical and nursing), and levels of patient activity. The results indicated that higher administrative and clerical staff numbers and costs were usually associated with higher numbers of frontline staff and higher levels of patient activity. The relationships were generally stronger in the provinces than in London and were most marked in the Mersey and East Anglian Regional Health Authorities.

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NATIONAL HEALTH SERVICE AlXWNlSTRATIVE AND CLERICAL MANPOWER

Table 4

Costs of adminis~ative and clerical staff as a percentage of health authorities’ revenue expenditure: 198849

Percentage range frequency by district numbers

below 6.0 3 6.0-6.4 10 6.54.0 26 7.0-7.4 49 7.5-7.9 53 8.0-8.4 22 8.5-8.0 12 0.0 and above 15

100

Notes: (I) Table excludes regional headquarters. Total administrative and clerical staff costs of regional headquarters in 1988-89 were Cl18 million. 35 per cent of their revenue expenditure. The national range was 24 to 63 per cent; comparison is however dficult as the skuchm of headquarters’ operations varies significantly between different regional health authorities.

Iz) Table excludes Special Health Authorities. c3) Total administrative and clerical costs include salaries of senior

managers and agency costs.

Table 5

unit Labour costs

P) PI E E Staff Numbers unit Labour costs

East Anglia Mersey south western W Midlands NE Thames NW Thames

All Thames NidiOd

34.200

45.000

55,900 78,300 02,100 71,000

287,400 845.400

3,681 5,084 6.324 9,048 9,861 7,620

30,276 94,653

9.300 8.+xlo-l”.l””

8,800 8.40~10.000 8.800 8,20& 9.400 8.700 8.100- 9.700 9.300 6,700-11.000 0,300 7.000-11.400

SSOO fvoo-I*,400 8,000 6,700-12,400

No obvious impact No obvious impact No obvious impact No obvious impact

Positive impact Positive impact

No obsious impact Positive impact

No obvious impact Positive impact

Strong positive impact strong positive impact

Range frequency by district numbers (“1

below 7000 3 700~7400 5 750~7090 8 80004499 40 8500-8909 5s 0000-9409 30 0500-9099 21 above 10.000 10

182

Notes: (1) Total administrative and clerical costs exclude agency costs and staff employed at regional headquarters and Special Health Authorities.

(‘1 Staff in post, as at September 1988 (whole-time equivalents). (3] Data were unavailable for acme districts. (4) The last two columns of the table show what impact staff numbers and unit

labour costs have on an authority’s spending on administrative and clerical manpower as a proportion of its total expenditure. Where no impact is shown it indicates that spending on other areas of

! revenue expenditure is the major intluence on an authority’s relative spend

I an administrative and clerical manpower.

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NATIONAL HEALTH SERVICE ADMNISTRATIVE AND CLERICAL MANPOWER

2.8 Other analyses undertaken by the National Audit Office however, identified wide variations across districts in the relationship between administrative and clerical numbers and costs and the output measures identified above. Allowing for a small distortion caused by London allowances, administrative and clerical costs per patient episode ranged nationally from f9 to f32 (Table 61, although 85 per cent of districts were in the range of El1 to SZO. The ratios of total administrative and clerical staff to frontline NHS staff ranged from 12 to 1:8 (Table 7). At regional level the results showed a greater consistency, because district extremes tended to be evened out. Overall, the numbers and costs of administrative and clerical staff broadly related to health authority activity levels. Nevertheless the National Audit Office were unable to conclude from their analysis whether health authorities were appropriately staffed for their needs.

Administrative and clerical work undertaken by other staff groups

2.9 The National Audit Office asked health authority managers whether in their view “frontline” staff groups, particularly nurses, were spending time on

Table 6

administiative and clerical work at the possible expense of direct patient care. Managers informed the National Audit Office that, in their view, a problem did exist in this area, although they were unable to quantify it.

2.10 A number of recent studies and exercises had examined or considered this issue (Table 8), in particular the amount of time typically spent by nurses on non-nursing duties. Such duties were seen to include, amongst other things, “house-keeping tasks” such as cleaning and making beds, as well as administrative and clerical jobs, for example the paperwork involved in patient admissions. The studies generally confirmed the existence of a problem and raised the issue of whether greater use should be made of support workers (including clerical staff) to assist professional staff groups. In particular, the Report produced by Mersey Regional Health Authority “ But Who Will Make The Beds?“, estimated that whilst only 5 per cent of nurses’ time was being spent on routine clerical duties, in total, almost a quarter of working time was being devoted to tasks appropriate to support workers in general [Table 8).

Administrative and clerical costs by patient activity (1988-89)

East Anglia 35,000 2,131 16 14-20

Mersey 45,100 3,230 14 12-22

South Western 57,200 3,456 17 12-32

Midlands 92,800 6,167 15 11-21

NE Thames 102,900 5,342 19 13-28

NW Thames 80,100 4,066 20 11-26

All Thames 334,900 17,338 19 11-28

National 923,500 57,174 16 9-32

Cost range frequency by district numbers

3

87

16-20 75

21-25 18

26-30 6

Above 30 1

Notes: (‘) Table does not include costs of administrative and clerical

staff employed at regional headquarters or Special Health Authorities.

(2) Total administiative and clerical costs includes agency costs. (s) Patient episodes comprise inpatients, outpatients, day cases,

and accident and emergency cases.

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NATIONAL HEALTH SERVICE ADMUWXRATIVE AND CLERICAL MANPOWER

Table 7

Ratios of administrative and clerical staff to frontline staff [I)

E Anglia 3,856 18,940 1:5 1:4-1:6 Mersey 5,461 28,185 1:5 l:P1:6 south Western 6,609 34,117 1:5 1:4-1:6

W Midlands 8,753 41,156 1:5 1:3-1:6 NE Thames 10,017 41,806 1:4 1:2-1:6 NW Thames 8,047 34,634 1:4 1:3-1:5

All Thames 31,501 134,603 1:4 1:2-1:7 National 97,817 508,522 1:5 1:2-1:8

Notes: (1) Staff in post as at September 1989, (whole-time equivalents). (2) Total administrative and clerical staff excludes regional headquarters. (3) “Frontline” staff comprises medical, nursing, professions allied to medicine (PAMs) and professional

and technical. (4) Data were unavailable for some districts

from commercially available packages to methods adapted in-house. _“... @fi~~~gi?$g@“$ii littl&ad,fc&ha ,/,*,. ‘x;I, .$, ,‘* .&

clerical jbbs. Poss either newly established or shortly to be refilled.

‘iluti& in&i&~ administrative &d clerical. ?&is made it more difficult for managers to determine the appropriate level of any required remedial action.

2.12 In January 1990, the Department of Health announced the introduction of Health Care Assistants to act as support workers to health care professional staff. To facilitate this initiative, they asked health authorities to review, by the end of May 1991, the roles and functions of existing support staff. If following this review, employing authorities created jobs which did not accord with existing pay grade definitions, they would be free to determine tha pay and conditions of service for this group of staff locally.

Job evaluation

2.13 Determining manpower requirements is concerned not only with job numbers, but with the relative content and responsibilities of those jobs. The National Audit Office found that the objective grading of posts through job evaluation is widely used in health authorities for senior managers as part of their pay arrangements. The National Audit Off%x noted at health authorities visited that a number of different methods of job evaluation were being used, ranging

2.14 The National Audit Office did find however that administrative and clerical staff generally had job descriptions. These can assist in management’s control of grade drift if regularly reviewed. Grade drift occurs where, for a variety of reasons, including market pressures, job contents bear a decreasing relationship to the salaries paid for them. Such grade drift can work in either direction, resulting in employees being relatively underpaid or overpaid for their current job responsibilities. However, only job descriptions of senior staff were subject to a formal reassessment each year.

2.15 Health authorities visited told the National Audit Office that a significant cause of grade drift was the need to grade jobs artificially high so as to pay higher wages to attract staff, particularly in inner-city areas. Evidence of this was reinforced by analysis undertaken by the National Audit Office (paragraph

review how much extra money is being paid in

14

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

Table 8

Recent Studies undertaken on nursing and other staff groups’ activity

Nursing Policy Studies Savings of up to 6.4 per cent in the staffing costs of hospital wards could be Centre, Warwick University made by reorganising work so that more routine tasks are done by support

workers rather than qualified nurses.

Mersey Regional Health Authority

Estimated that a significant proportion of trained and student nurse time was being spent on work that could be undertaken by the following support worker groups: care assistants (10 per cent); hotel workers (8 per cant); clerical staff (5 per cant].

Plymouth Health Authority Skill mix exercises* were currently being carried out by each district within South Western Regional Health Authority. Such an exercise undertaken by Plymouth Health Authority had identified a number of areas where additional clerical staff would assist in improved utilisation of skilled nurses’ time. Plymouth plan further work on skill mix to explore the extant of this problem.

Oxford Regional Health Authority

Study undertaken by the Institute of Manpower Studies on Professions Allied to Medicine (PAMs) and related therapy professiuns. Results indicated that between 2 and 15 per cent of qualified speech therapists’, and orthoptists’ on-duty time was spent on clerical/receptionist work appropriate to administrative and clerical staff.

* The purpose of skill mix exercises is to identify the optimum staffing balance within and between manpower groups to deliver a defined level of service. These exercises would typically take into account the required balance between qualified and unqualified staff within a particular area of activity.

salaries as a result of recruitment difficulties. Secondly, they cannot be sure that the existing distribution of grades is appropriate for present organisational responsibilities. An important consideration is whether acceptable levels of productivity could still be achieved with a less expensive staffing structure.

2.16 The introduction of even quite simple methods of job evaluation can be a costly and time-consuming process. Health authorities visited, however, recognised that there was now a need for more widespread job evaluation and many were in fact at the implementation stage. The introduction of flexible pay for administrative and clerical staff and a likely increase in local control over pay and grade definitions (particularly by NHS Trusts) will bring into sharper focus the need for clear assessments of job values and required manpower structures.

Impact of National Health Service reforms

2.17 The introduction of the NHS reforms will impact on administrative and clerical manpower numbers and costs at all levels of the National Health Service:

Regional Health Authorities

The 14 regional health authorities currently employ about 10 per cent of total administrative and clerical staff. As part of the White Paper proposals, all regions had to identify their headquarters’ “core” and “non-core” functions. Core functions are those which will continue to be provided in-house, whilst non-core can be contracted out or delegated to districts. All regional health authorities have now made assessments of their future organisational arrangements and some reduction is expected in the number of directly employed staff. The overall impact on total NHS administrative and clerical staff numbers will, however, be small.

District Health Authorities

Districts will become much smaller organisations, no longer concerned with running hospitals or managing large numbers of staff. There will however, be a strong need at district level for management, financial and legal skills

15

NATIONALHW.LTHSER"XEADMINISTRATWEANDCLERICALMANPOWER

to assess population health needs, draw up contracts and supervise their implementation, and to monitor hospital performance.

Hospitals

Implicit within the new arrangements is that, in the longer term, all operational systems and services will be provided by hospitals themselves without recourse to district or region. NHS Trusts will additionally be able to determine their own rates of pay and conditions of service. All hospital managers will need to know the fall cost of services provided, in order to determine charges to be set and new work will include recording, costing and billing for transactions. These factors will result in a greater concentration of administrative and clerical functions at hospital level.

Table 9

2.18 Costs of staff employed by hospitals will in future form part of contract service levels, agreed between hospitals and client districts. Contracts, based on agreed levels and quality of patient care, will determine the amount of money received by

undertaken by each district within South Western Regional Health Authority.

2.19 The National Audit Office noted also, that scana health authorities were already re-examining their administrative and clerical staffing requirements, usually as part of wider manpower exercises (Table 9). This has arisen in part by the desire to minimise

Examples of manpower reviews by health authorities (1989-90)

Mersey Regional Headquarters Reviews of staffing levels in all staff groups have been undertaken based on the Introduction of zero-based budgeting designed to achieve payroll reductions of El

million each year.

NE Thames

NE Thames

NW Thames

Southend

Ealing

The authority has undertaken a human resource planning exercise covering all staff groups and is now moving towards a zero-based approach to determine optimum administrative and clerical staffing levels.

City and Hackney In determining its manpower input to business plans, the authority has issued guidelines for a comprehensive analysis of future demand and supply requirements across all relevant staff groups. The demand analysis includes scope to assess both numbers and grades (and associated costs) of required staff. To facilitate the review process a multi-disciplinary district manpower planning group has been established.

A staff strategy is being developed to ensure that the demand and supply of human resources are brought into balance. On the demand side the stiategy recognises the importance of an accurate assessment of manpower requirements to achieve the right balance between costs and quality of service provision after the introduction of the NHS internal market.

16

staffing costs, although a major new impetus has also been the Resource Management Programme. This Programme, launched in 1986, aims to improve the planning, delivery and costing of patient care in acute hospitals. The White Paper “Working for Patients” spelt out the Government’s commitment to extend the Programme by the end of 1991-92 to all major acute hospitals.

2.20 Central to the Resource Management Programme is the concept of clinical directorates, based on specific care groups and each headed by a clinician. Each directorate has to prepare an annual business plan as a basis for determining charges for hospital services within the fntihroming NHS internal market. These plans will include an assessment of manpower numbers and costs required to deliver specified levels of service. Many clinically related administrative and clerical staff will be directly managed within, and charged as a cost to, clinical directorates. This should lead to numbers and grades of administrative and clerical staff being determined more explicitly than in the past.

2.21 Additionally, at hospital level, the introduction of Health Care Assistants may absorb some of the work currently undertaken by administrative and clerical staff, nurses and other professionals, and should lead to more explicit judgements on the balance of work between professional and support staff. Such judgements would likely include consideration of whether investment in appropriate information technology could reduce the amount of clerical time for both frontline and support staff.

2.22 The new arrangements will also mean that the distinction between clinically related and non- clinically related administrative and clerical staff is likely tn herome less impnrtant than managers’ assessments of the role played by all these staff in meeting hospitals’ contracted service commitments. Within this framework, managers will be seeking to maximise the relationship between staff deployment (for example, flexible working hours, use of part-time staff), productivity (for example, accuracy and timeliness of clerical work) and desired quality of output.

17

NATlONAL HEALTH SERVICE ADh4lNlSTRATIvE AN0 CLF.RICAL MANPOWER

Part 3: Meeting manpower requirements

3.1 Administrative and clerical staff have skills and experience which are sought after by employers other than the National Health Service. In attempting to meat their administrative and clerical staffing requirements therefore, health authorities have to be particularly aware of local labour market conditions and the extent of competition from other employers, such as local authorities, banks and insurance companies.

3.2 Traditionally, many administrative and clerical staff have been recruited directly from school or college. Demographic changes resulting in fewer school and college leavers during the 199Os, will mean greater competition for such recruits. However, the projected fall in the number of young people aged 16 to 24 will be more than offset by an increase in the number of 25 to 54 year olds. There is also a predicted rise in the number of graduates entering the labour market. Furthermore, the total working population, if present trends continua, is likely to increase over the next ten years, as more women return to work after raising a family. These changes in the working population will be subject to regional variation. For example, working populations are expected to decline in London and Merseyside, but to increase in East Anglia and the South West.

3.3 At the same time as a traditional source of recruitment is diminishing, changes to the National Health Service, resulting from the introduction of the NHS reforms [paragraph 2.17). will generate new demands for administrative work. Against this background the National Audit Office set out to find how health authorities were planning to maintain au adequate supply of administrative and clerical staff.

Recruitment and retention of administrative and clerical staff

Pay and conditions of service

3.4 Pay and conditions of NHS support staff groups, including Adminisirative and Clerical, are approved by the Secretary of State for Health who takes into account the outcome of negotiations in Whitley Councils. These apa national negotiating forums comprising representatives of management and staff in the NHS and set up following implementation of the 1946 National Health Service Act. There are six Whitley Councils carrying out negotiations on pay and conditions of service for individual NHS staff

groups. All administrative and clerical functional staff groups (excluding Senior Managers, below) are covered by the Administrative and Clerical Staffs Whitley Council.

3.5 NHS Senior Managers are grouped with Administrative and Clerical staff for the purpose of manpower returns but they constitute a separate staff group. They come from a variety of professional backgrounds and disciplines. Their basic pay is set by the Secretary of State for Health and not negotiated through the Whitley Council machinery. Senior managers also receive performance-related pay supplements (up to a maximum of 20 per cent of basic pay) based on their achievement of locally- determined objectives. The salaries cost of Senior Managers in 1988-89 was fi31 million, 0.24 per cent of total Hospital and Community Health Services’ salaries’ expenditure. Until 1989 performance-related pay was available to only the top tier of management within health authorities. Similar pay and grading arrangements have since been introduced for other NHS managers under the Senior Managers Scheme.

Turnover

3.6 The annual turnover rate gives the percentage of staff who, for any reason, leave an organisation. A certain amount of turnover is inevitable and may be welcomed by management as an opportunity to bring in new ideas. A high rate of turnover, however, can be organisationally damaging and may mean that a substantial amount of time and money has to be spent on the recruitment and training of new staff. Temporary replacement staff may also have to be engaged from a commercial agency at additional cost. This cost may be significant where recruitment of permanent staff is difficult.

3.7 The nature of a turnover problem centres on its causes, which can be either internal or external. External factors such as competing employers’ pay rates are clearly outside the direct control of health authorities. However, factors such as quality of management and opportunities for career development have internal solutions. Health authorities therefore need to know why people are leaving, for instance by using exit questionnaires. The reasons why staff stay are equally important and can be identified through the use of retention questionnaires. Analysis of such information can identify common causes and patterns of turnover (for

18

NATIONAL HEALTH SERVICE ADMINISTR.4~ AND CLERICAL MANPOWER

example how long, on average, a person who resigns has worked for the authority). Appropriate action can then be taken to address controllable aspects of any turnover problem identified.

3.8 The National Audit Office found that the rate of turnover of administrative and clerical staff employed within regional health authorities ranged from 15 to 33 per cent and averaged 25 per cent in 1988-89

(Table 10). In South East England, district turnover rates reached 44 per cent and in central London were also associated with much higher than average agency costs, indicating difficulties in recruitment. Evidence from one Thames Region showed that almost half its administrative and clerical leavers had been in post for one year or less, also indicating a general retention problem.

3.9 The Department of Health commissioned two independent studies in 1988, to assess the extent of labour turnover problems in the National Health Service. A study by the Institute of Manpower Studies, identified the major cost components of staff

turnover in three staff groups, including administrative and clerical, as:

- separation costs (for example providing references and updating personnel records); - temporary replacement costs (for example overtime or agency cover); - recruitment and selection costs (for example advertising); and - induction/training costs.

They also developed a methodology by which line managers within the National Health Service could cost staff turnover.

3.10 The second study, by York University Centre for Health Economics, estimated that, in 1987-88, the cost of turnover for all non-clinical staff at five district health authorities ranged from &?Z~,OOO in Grimsby District Health Authority (0.7 per cent of revenue expenditure), to g1,630,000 in Parkside District Health Authority (2.5 per cent of revenue expenditure).

Table 10

Administrative and clerical staff. Turnover rates by region 1988-1989

Region

Trent 15

East Anglia 18

NOt?hUll 18

Yorkshire 120

West Midlands 20

Mersey 25

Wesse.X 127

south western 27

South East Thames 127

North East Thames

South West Thames

North West Thames

Oxford

I

I

28

28

32

33

I I I I 0 6 12 18 24 30

Turnover % Source: NAO Questionnaire (One region and not all districts were able to supply data)

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NATIONAL HEALTH SERVICE ADMWISTRATIVE AND CLERICAL MANPOWER

health authorities were unable to assess how much money should be spent to minimise their turnover costs. Furthermore, health authorities visited did not routinely assess why staff were leaving. All authorities saw turnover as something to be monitored, but only South Western Regional Health Authority had made it a specific indicator of districts’ performance. The Region informed the National Audit Office that it was setting district targets on turnover which would initially be applied to nursing and medical staff as well as professions allied to medicine, but not to administrative and clerical staff. Other regions told the National Audit Office that they were aware of the need to cost turnover and some planned to do so.

3.12 The Department of Health informed the National Audit Office that the findings of their commissioned studies provided evidence of staffing difficulties within health authorities. The 1989 pay award, negotiated between the Management and Staff Sides of the Administrative and Clerical Whitley Council, made provision for health authorities to approve local pay supplements to groups of administrative and clerical staff, where there were proven difficulties with recruitment and retention. Health authorities in the four Thames Regions were permitted to pay higher supplements than other authorities. The award also involved the restructuring of the administrative and clerical grades and pay scales, as well es improving pay on entry to the service end on promotion. This development will gather momentum after April 1991, when NHS Trusts will be able to negotiate pay rates independently of Whitley agreements.

3.13 Regions had welcomed these initiatives which they believed would have a beneficial impact on the recruitment and retention of administrative and clerical staff. Nevertheless, the Department of Health informed the National Audit Office that, as at June 1990, only eight district health authorities had implemented local pay supplements. However, most health authorities visited by the National Audit Office planned to implement them. Factors delaying implementation included the need to evaluate local labour markets in order to assess the level of supplement required, industrial relations issues, and the need to prepare local guidance.

3.14 All the regions questioned by the National Audit Office stated that severe difficulties still existed in recruiting and retaining the following groups of administrative and clerical staff:

- medical secretaries;

- general secretaries;

- finance staff;

- computer staff: and

- personnel staff.

Problems are most acute in London, particularly in inner London district health authorities, and the South East.

3.15 The Department of Health have recognised that the introduction of the NHS reforms will increase the demand for finance, personnel and information technology staff in particular. They estimated that around 3,000 such additional staff will be needed on a permanent basis and allocated f15.5 million to regional health authorities for this purpose in 1989-90. A further f1.6 million was allocated during 1989-90 to the National Health Service Training Authority to support an initiative to upgrade the finance function through a comprehensive training and career development strategy.

Recruitment and retention schemes and their impact

3.16 Regions visited by the National Audit Office were well aware of the growing impact of the demographic changes on the labour market and most had developed imaginative schemes to attract and retain the main staff groups, including administrative and clerical. The National Audit Office found that in addition to trying to maintain their traditional source of recruitment for administrative and clerical staff, by forging links with schools and colleges, health authorities were now targetting older candidates, I particularly women who wished to rejoin the workforce.

3.17 Schemes employed by health authorities recognised that recruitment and retention issues such as career development, pay and flexibility of working hours, required a different emphasis for differing I categories and grades of administrative and clerical staff. The National Audit Office established from health authorities which schemes, designed to improve recruitment and retention, appeared to be the most successful. These were:

- flexible working arrangements such as job sharing, part-time working, and the ability for staff to choose the hours they work;

20

- the use of administrative and clerical staff banks. These provide an internal agency service to health authorities and offer employment to staff who want to work on an occasional basis. The banks not only provide cover for vacancies and absences but also can act as a pool for the recruitment of permanent staff;

- the provision of creche facilities and other schemes designed to attract working parents, such as term-time only employment or school holiday play schemes:

- better opportunities for the training and career development of staff.

The National Audit Office noted that practical guidance on implementing such schemes had been produced by West Midlands Regional Health Authority in their Department of Health sponsored, and commercially available publication “Vacancies Ahead!“. South Western Regional Health Authority had supplied a copy of this publication to each of its districts.

3.18 At the health authorities visited, the National Audit Office asked managers how they assessed the cost effectiveness of recruitment and retention schemes. There was little evidence of formal monitoring of schemes although the National Audit Office did note one example. West Essex District Health Authority operate a recruitment and retention committee with a number of sub-committees responsible for specific initiatives. The district were proposing to undertake an exercise in 1990-91 to assess which recruitment schemes had been most successful in attracting staff to work for the authority.

3.19 The National Audit Office found that major private sector employers were also well aware of the impact of demographic trends on the labour market. A survey of eight such employers in January 1990, commissioned by the National Audit Office for their Report “Clerical Recruitment in the Civil Service” (HC487), indicated that the private sector was using similar recruitment and retention schemes to those used by health authorities. However monitoring of the impact of recruitment schemes was more prevalent in the private sector than in the National Health Service. Seven out of the eight firms surveyed monitored costs and effectiveness of schemes through performance indicators (for example numbers of job applications, shortlistings, withdrawals, and job offers made) and often against recruitment budgets.

IJJffof agency administrative and clerical

3.20 Agency staff are generally used where health authorities have difficulties in filling vacancies, and to provide cover for staff absences due to sickness and leave. They can also be used to provide additional support during times of peak workload activity. Such usage, if short-term, can make economic sense when compared to the employment of permanent staff, who may only be busy at certain times of the year. However, when agency staff are employed in a less controlled way, as cover for long-term vacancies, their cost effectiveness invariably diminishes compared to directly employed staff doing the same work.

3.21 Agency staff costs in 1988-89 were f50 million (regional and district health authorities), 5 per cent of total administrative and clerical staff expenditure (Table 11). Most agency staff usage occurred in London, with a significant proportion of spending on typing and secretarial services (57 per cent of total agency costs in 1988-89). The two highest district health authority spenders on agency staff in London (and nationally) were Bloomsbury and Riverside who each spent more than f3.5 million during 1988-89 (about 22 per cent of their total administrative and clerical costs). In contrast, 78 per cent of districts spent less than 5 per cent of their total administrative and clerical costs on agency staff and 18 districts, mostly in the north of England, incurred no agency costs at all.

procedures to recruit agency staff varied. At some authorities, line manag& were able to approve the use of agency staff directly. At others, the Director of Personnel normally approved requests for agency staff.

3.23 The National Audit Office noted that in general, health authorities were using preferred or sole agencies. This was advantageous both financially and in terms of the quality of staff supplied. Most authorities also had informal procedures to monitor agency staff usage. For instance, line managers were periodically asked by the personnel department to justify their continuing need for any agency staff employed on a longstanding basis.

21

NATIONALHEALTHSERVICEADMINISTRATNEANDCLERlCALMANPOWER

Table 11

Agency costs 1988-89

East Anglia 35,000

Mersey 45,100

South Western 57,200

W Midlands 92,800 NE Thames 102,900 NW Thames 80,100 All other regions 510,400

National 923,500

824

151

1,277

1,575

10,824

9,141

17,213

41,005

0.7- 5.3

0 - 1.7

0.5- 5.7

O.l- 5.4

0.7-22.4

2.P21.7 -

0 -22.4

Regional HQs 118,100 8,782 7.4

Total: English Health Authorities 1,041,600 49,787 4.8

Percentage range frequency by district numbers

0 18 O.l- 4.9 131

I Note: Table excludes adminisimtive and clerical and

3.24 On examination, the National Audit Office found that during 1989-90 Bloomsbury District Health Authority had been facing a potential overspend of f5 million, much of it attributable to the use of agency covm across major staff groups, including administmtive and clerical. Consequently the district intmduced controls in September 1989 aimed at reducing such costs. Those which might have wider application are listed in Table 12. At the same time, the district negotiated through competitive tendering a sole contract for the supply of its administrative and clerical agency staff.

Alternative ways of P

roviding administrative and c erical labour

3.25 The National Audit Office noted that some health authorities had contracted out specialist administrative and clerical functions, such as

agency costs of Special Health Authorities.

3.26 New technology offers alternative ways of providing administrative and clerical services. One example is the opportunity for typing services to be provided through remote working, either by directly employed staff working at home, or commercially by remote secretarial services. The National Audit Office found that a unit personnel department in Bloomsbury District Health Authority used a commercial secretarial agency based in Gloucester. The unit informed the National Audit Office that annual savings of f27,000 had been achieved by using this service and reducing the number of permanent and agency staff. Such arrangements are used by both public and private sectors. In the public sector, the Department of Social Security use long distance commercial services. The National Audit Office also found that a major clearing bank had set up a remote word processing centre in Durham to serve its major departments and branches in London. The system was very successful and was capable of turning round work in 80 minutes by using voice and data transmission networks.

22

NATIONAL HiWLTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

Table 12

Controls introduced in September 1989 over the use of administrative and clerical agency staff: Bloomsbury District Health Authority

l Managers had to ensure that the costs of agency staff could be met from within their staffing budget.

l Agency staff could only be booked through the Personnel Department.

l The number of hours to be worked by agency staff were not to exceed that worked by the regular post holder.

l Agency staff were not to be used on public holidays.

l The continuing need for agency cover would be discussed between the Personnel Department and the line manager after eight weeks usage.

l The Finance Department would only pay invoices that had been coded and authorised by the Personnel Department.

3.27 Currently, a range of administrative and clerical level, it may not be economical for each hospital to services, such as the administration of salaries and provide these services directly. Hospitals may wages, is provided by districts on behalf of their therefore, wish to consider developing consortia as a hospitals. From 1991, as more administrative and cost effective way of providing certain administrative clerical services become concentrated at hospital and clerical services.

23

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

Part 4: Monitoring and control

4.1 Responsibility for planning and control of administrative and clerical staff is devolved to health authorities. This reinforces the need for effective monitoring and control procedures at appropriate levels of management. Therefore, the National Audit Office examined the extent to which mechanisms exist to monitor and control the growth of staff numbers and contain manpower expenditure within approved budgets.

Manpower information

4.2 The Department of Health undertake a twice- yearly census of all NHS non-medical manpower, based on numbers of staff in post at March and September. Analysis of the data is generally undertaken in response to specific requests, such as may arise from Parliamentary questions, or to support any relevant current Department of Health studies or K%it?WS.

4.3 The Department also publish “Health Service Indicators” annually, representing an analysis of a wide range of NHS facts and figures, including various manpower data. The scmrce of the data for these indicators is the standardised (Khmer) returns submitted by each health authority. The manpower indicators include a range of information by district health authority for each staff group, such as turnover rates, absence rates and numbers of part-time employees.

are district-based: hospital and community-based indicators would be more useful for comparative analysis, since districts themselves are not particularly homogenous units. The Department told the National Audit Office that there were particular problems in producing the 1987-88 indicators; in future they aimed to publish the indicators within 11 months of the year to which they related. They are also reviewing the scope of the indicators to ensure that they meet the needs of the post-reforms NHS.

4.5 The National Audit Office found that Regional He&b Authorities’ main role in the monitoring of administrative and clerical staffing levels is a

facilitating one through providing region-wide information to districts, so that they can make comparisons between themselves and other districts. Such information is provided at regular intervals throughout the year. A good example was found at South Western Region who have also for some time produced occasional statistical papers on manpower, for the benefit of districts, to complement their standard information reports.

4.7 In their use of staff numbers as the indicator for monitoring purposes, regions and districts are dependent on the accuracy of the underlying source data. These data show staff numbers by occupation code of which there are currently 84 within the overall administrative and clerical classification.

4.8 The National Audit Office found that in all health authorities visited the quality of monitoring had been affected by errors in coding, although a number of them were introducing procedures to improve the accuracy of input and processing. The National Audit Office further noted that the standard list of occupation codes for administrative and clerical staff, produced by the Department of Health, had not been updated for several years. Consequently, an increasing number of administrative and clerical staff were being coded under the catch-all category “other” in the absence of up to date job title definitions. Additionally, the reported numbers were being distorted through the categorisation into the administrative and clerical staff grouping of non- administrative and clerical staff, such as Operating Department Assistants. This had occurred because their pay had been purposely aligned to administrative rates, in an attempt to ease difficulties in the recruitment and retention of such personnel.

4.9 Health authorities visited informed the National Audit Office that the major impact of coding errors was on the reported split between clinically related and non-clinically related administrative and clerical staff. This appeared to be supported by the National Audit Office’s findings, which revealed significant differences: the district range was between 15 and 69 per cent (Table 13).

24

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERKXL MANPOWER

Table 13

Clinically related adminisirative and clerical staff as a percentage of total administrative and clerical staff

Total A&C Staff

East Anglia 3,856 1,551 40 3746 Mersey 5,461 2,050 38 31-44 South Western 6,609 2,360 36 29-46 NE Thames 10,017 3,099 31 22-ll NW Thames 8,047 2,528 31 2442

All Thames 30,121 10,295 34 20-52 National 80,059 30,665 38 15-69

Source: National Audit Office questionnaire. Notes: (1) Staff in post as at September 1989. Figures exclude staff employed at regional headquarters.

(2) Data were unavailable for some districts. (3) West Midlands excluded as it uses a different basis for categorising its clinically related

administrative and clerical staff.

4.10 The National Audit Office concluded that it was not possible for the Department of Health and health authorities to assess accurately the extent of changes in the deployment of administrative and clerical staff. The Department of Health, however, consider that they have no role in the monitoring of administrative and clerical staff numbers and costs following the introduction of the NHS reforms. They see this as being consistent with the aims of the reforms for maximum control to be exercised at local level. However, both the Department and health authorities visited agree with the National Audit Office that local managers would still benefit from being made aware of good practice and receiving informative data on national and regional manpower. As such, the need for accurate source data will still remain necessary to enable the Department of Health and regions to act effectively as “facilitators” in disseminating manpower information. A joint Department/NHS working group is currently reviewing the codes for administrative and clerical staff which should lead to a considerable improvement in the quality of manpower data.

Regional review

4.11 Previously, regional health authorities had responsibility for approving their districts’ short-term programmes. These programmes represented districts’ annual intentions for planned service expansion or contraction, along with the manpower implications. As part of this process, changes in staffing levels were reviewed by regions to ensure they were consistent with available funding and planned activity levels.

Additionally, as part of the review process, South Western Region has introduced what it calls “critical success factors” to assess districts’ performances. These included, for manpower, indicators for turnover, absence rates and vacancy levels. Outside of such review processes, however, detailed responsibility for control over administrative and clerical staffing arrangements was left to individual districts.

4.12 From April 1991 the regional role in manpower planning will alter. Regions’ prime responsibility in future will be to ensure that sufficient numbers of trained staff are available to meet assessed demand. To fulfil this role, both Directly Managed Units and NHS Trusts will provide, for each staff group, forecasts of demand for training, which regions will aggregate. For Directly Managed Units, regions will in future monitor manpower strategies, as distinct from planning manpower regionally. They will act in much the same way as the Management Executive of the Department of Health, that is by keeping a watching brief, assisting and supporting units, and only intervening when necessary. However, since they oversee the shape and direction of future services they will also have to consider whether planned activity changes are feasible in the light of service contracts.

Budgetary control

4.13 All attributable administrative and clerical manpower expenditure is charged to, and controlled against, managers’ budgets. These budgets are usually

25

NATIONAL HEALTH SERVICE ADMINISTRATI”E AND CLERICAL MANPOWER

calculated net of an assessed vacancy factor. This factor is included in budgets to reflect the reality that, at any one time, staff in post are likely to be less than estimated, particularly where staff turnover is high. The vacancy factor thus represents an estimate of savings that are achievable against the salary costs of planned staff numbers. As a corollary, however, where vacancy factors are applied to manpower budgets of small departments with stable staffing arrangements, this probably means that budgets will be exceeded.

4.14 The manpower budget acts as the cash limit on administrative and clerical manpower expenditure and therefore determines the accuracy of the balance between planned and actual manpower spend. Health authorities acknowledge however that there are weaknesses in their budgetary control systems. This is often due to the timeliness and quality of budgetary information supplied to managers, who may not be informed quickly enough of the ongoing cost implications of their spending decisions.

4.15 The National Audit Office noted that, apart from annual pay awards which are outside the control of individual line managers, the main factors likely to determine whether manpower budgets are overspent (or underspent) are the prevalence of overtime, agency costs, vacancy levels, and appointments to new or existing posts. The National Audit Office found that few administrative and clerical staff are required to work paid overtime and investigation revealed that such costs were minimal and therefore did not materially affect the budget outturn. Control over agency costs was examined in Part 3 of this report.

vacancy levels

4.16 Vacancy levels, particularly in authorities with high turnover rates, can distort planned manpower expenditure. For managers to control the manpower element of their budgets they need accurate and timely information on the financial implications of their current and ongoing vacancy levels. This information is also essential to determine the “net cost” of staff turnover based on payroll savings from unfilled vacancies.

4.17 In a wider context, without knowledge of the levels and pattern of an authority’s vacancy levels, personnel departments are unable to review properly the appropriateness’ of present levels of manpower funding. Health authorities may still achieve planned levels of service even with a number of longstanding unfilled vacancies and this may indicate that certain posts are no longer required. Furthermore, if these

vacancies go undetected they may continue to be funded as part of a manager’s budget.

4.18 The National Audit Office found that, in certain health authorities visited, the quality of manpower information available did not allow budget holders, Personnel or Finance Departments to routinely monitor vacancies against funded manpower budgets. This affected these health authorities’ ability to assess and analyse the numbers and types of vacancies they were holding, so as to better inform future manpower funding decisions.

4.19 The National Audit Office noted, however, that all authorities visited had now introduced or were planning to introduce more sophisticated manpower control systems. On the basis of the planned introduction of such a system, City and Hackney District Health Authority had drawn up a Manpower Information Strategy aimed at producing a comprehensive manpower information and monitoring system.

New posts and vacancy filling

4.20 Another major factor impacting on the balance between manpower expenditure and the funded establishment, is the appointment to additional or existing posts. The National Audit Office found that the creation of totally new posts was normally linked to service developments and controlled, both at regional and district level, through the planning process, as a result of bids from line managers.

4.21 The decision to fill vacant posts occuring within funded establishments was generally the prerogative of line managers although the National Audit Office noted some authorities where vacancies were vetted and recruitment approved centrally. The continued need for a post is usually reviewed when it becomes vacant. In filling vacant posts, however, line managers have considerable discretion as to how they use their staff budgets. Such freedom extends to the type of staff appointed, for example, a secretary could be recruited to replace a clerical officer.

Sickness Absence Control

4.22 An important consideration in the management of any workforce is the amount of time lost through sickness. It is necessary therefore for authorities to enaure that adequate arrangements exist for the monitoring and control of these absences. Although some degree of absenteeism is inevitable, high levels of absence represent a considerable cost to an organisation, as well as affecting judgements on staffing levels.

26

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

that, where information was available, most district health authorities’ annual sickness rates for administrative and clerical staff were between 3 and 5 per cent. The reported range however, was from under one per cant to 12 per cent [or 27 working days per administrative and clerical staff member). There were also significant regional variations in average sickness rates ranging from 2.7 per cent (Yorkshire] to 5.6 per cent [Northern) (Table 14). These levels exceed the Confederation of British Industry’s identified national average of 2.2 per cent for white collar workers. The National Audit Office estimated that the national sickness level for administrative and clerical staff represented a salary cost to the NHS in 1986-89 of at least E30 million.

Table 14

Sickness rates by region 1968-1989

4.24 Health authorities and individual managers need to know and monitor staff sickness rates for the same reasons as they need to know and monitor vacancy levels. If planned levels of service are being achieved even with high sickness rates, this may indicate that staffing levels are set too high, or that the quality of the administrative and clerical service is being compromised. Conversely, if sick absences are adversely affecting planned levels of service then managers need to monitor these as an aid to determining appropriate remedial action. Additional costs undoubtedly arise if substitute labour is unnecessarily obtained through overtime working or agencies. The National Audit Office analysis did indicate, however, that overtime working was minimal and agency staff were primarily used to cover for unfilled vacancies rather than for sick absences.

4.25 An exercise undertaken by Cornwall and Isles of Scilly Health Authority had shown that counselling of staff by line managers could reduce the percentage rate of future absences by up to one percentage point. At a

Yorkshire 2.7

Trent 2.8

West Midlands 2.8

East Anglia 2.9

South West Thames 3.0

Oxford 3.3

Wessex 3.3

MW%Y 3.3

South Western 3.5

North Western 3.9

North East Thames 3.9

South East Thames 4.6

NOlth~lll 5.6

b ; ; i I 4 ;

Sickness rate %

Source: NAO Questionnaire. NW Thames excluded as its data are not produced on a directly comparable basis. Not all districts in each Region were able to supply data.

27

NA’“ONAL HEALTH SERVICE ADMINISTRATI”E AND CLERICAL MANPOWER

national level this could reduce unproductive administrative and clerical salaries expenditure by about El0 million per annum based on 1988-89 figures.

There appeared to be a case for the introduction of routine monitorine of absenteeism. mobablv bv

;t;rl;xt control: Implications of NHS

4.27 The introduction of the National Health Service reforms will further increase the need for strong cost

control procedures and management information systems at hospital level. Health authorities visited informed the National Audit Office that a key indicator for monitoring and control will be unit labour costs linked to contracted activity levels. The National Audit Office consider that an understanding of. and the ability to successfully control, the relationship between manpower numbers. costs and activity levels will be a key to increased efficiency under the NHS reforms.

4.28 The National Audit Office believe, as do health authorities visited, that the personnel function will have an important role in assisting managers to minimise their labour costs. To achieve this the personnel function, particularly at hospital level, will need to be developed and strengthened. The control environment at local level could also be developed through a greater emphasis on setting targets for key manpower indicators such as turnover, absence and vacancy levels.

NATIONAL HEALTH SERVICE ADMINISlXATI”E AND CLERICAL MANPOWER

Annex

Breakdown of Administrative and Clerical staff numbers and costs by Health Authority

Clerical of Revenue slff costs Expenditure

(198849) ~000

Northern Hartlepool North Tees South Tees East Cumbria South Cumbria West Cumbria Darlington Durham North West Durham South West Durham Northumberland Gateshead NW.W&le

North Tyneside South Tyneside Sunderland

Yorkshire Hull East Yorkshire Grimsby Scunthorpe Northallerton York Scarborough Harrogate Bradford Airedale Calderdale Huddersfield Dewsbury Leeds Western Leeds Eastern Wakefield Pontefract

217 1,888 8.0 11 1:5

348 2,950 8.6 17 1:4

665 5,409 6.6 13 1:5

317 2,808 6.2 14 1:5

296 2,489 7.8 12 1:4

236 2,060 7.0 1.5 1:5

293 2,609 7.5 17 1:5

262 3,186 8.4 17 1:5 173 1,489 7.1 14 15

264 2,404 6.3 19 1:6

613 4,133 5.7 19 1:6

269 2,396 6.3 15 1:6

1,297 10,179 6.3 11 1:5

298 2,148 7.3 13 1:4

230 2,148 7.7 12 1:5

648 5,357 7.3 12 1:5

6,466 53,653 6.9 14 1:5

716 5,320 6.7 12 1:4

315 2,950 6.6 20 1:5

273 2,362 6.6 10 1:5

312 2,455 7.3 11 1:5

141 1,305 7.7 16 1:4

531 4,479 7.0 16 1:5

217 2,090 7.7 13 1:5

258 2,293 7.3 14 1:5

647 6,067 7.6 13 1:5

282 2,677 7.2 16 1:5

282 2,550 6.3 11 1:6

412 3,795 7.2 15 1:6

254 2,366 8.0 13 1:5

844 7,271 6.6 13 1:5

842 6,953 6.7 14 1:5

428 3,942 7.4 17 1:5

269 2,462 7.9 12 1:4

7,023 61,337 7.1 14 1:5

29

NATTONAL HEALTH SERVICE ADMINISTRATWE AND CLERICAL MANPOWER

Cl&Cd of Revenue staff costs Expendihue

(1988-89) E’OOO

Trent North Derbyshire South Derbyshire Leicestershire North Lincolnshire South Lincolnshire Bass&M Central Nottinghamshire Nottingham Barnsley Doncaster R&wham Sheffield

East Anglia Cambridge Peterborough west Suffolk East Suffolk Norwich Great Yarmouth West Norfolk Huntingdon

North West Thames North Bedfordshire South Bedfordshire North Hertfordshire East Hertfordshire North West Hertfordshire South West Hertfordshire Barnet HXTOW Hillingdon Hounslow E&g Riverside Pa&side

477 4,043 6.8 14 1:6 1,004 9,162 8.0 17 1:5 1,619 14,169 7.2 16 1:5

518 4,546 6.7 16 1:5 505 4,384 7.5 15 1:5 153 1,498 7.8 12 1:5 511 4,220 6.8 14 1:6

1,463 12,231 7.1 15 1:5 369 3,081 7.0 12 1:6 482 3,850 6.1 11 1:7 370 3,333 7.0 12 1:6

1,521 12,334 6.5 14 1:5

8,992 76,851 7.0 14 1:5

669 7,132 8.3 20 1:4 445 3,860 7.7 14 1:4 365 3,182 7.1 16 1:5 547 4,950 6.8 16 1:5 763 7,744 6.8 17 1:6 357 3,201 7.9 14 1:5 313 2,825 7.9 15 1:5 222 2,095 7.1 17 1:5

3,681 34,989 7.4 16 1:5

391 3,587 8.2 20 1:4 475 4,101 7.9 15 1:5 243 2,262 7.0 11 1:5 418 3,091 7.0 19 1:3 619 5,944 7.1 25 1:5 325 2,905 8.2 15 1:4 765 7,793 8.6 22 1:4 414 3,835 7.9 17 1:4 558 5,747 7.8 16 1:4 627 5,300 7.9 13 1:4 399 4,561 6.6 26 1:5

1,153 16,724 10.1 26 1:4 1,233 14,276 9.7 22 1:4

7,620 80,126 8.6 20 1:4

30

NATIONAL HEALTH SERVICE ADMllrlISTRATIvE AN,, CLERKAL MANPOWER

costs Expetiditure (1988-89)

S’OOO

North East Thames Basildon Mid Essex North East Essex West Essex Southend Barking Hampstead Bloomsbury Islington City and Hackney Newham Tower Hamlets Enfield Haringey Redbridge Waltham Forest

South East Thames Brighton Eastbourne Hastings South East Kent Canterbury Dartford Maidstone Medway Tunbridge Wells Bexley Greenwich Bramley West Lambeth Camberwell Lewisham

515 4,499 7.6 13 1:5

479 4,449 7.0 19 1:4

646 5,396 7.9 19 1:5

409 3,737 7.5 13 1:6

600 4,594 7.9 16 1:4

982 6,648 7.3 14 1:5

647 7,902 10.6 28 1:4

1,126 16,186 10.4 23 1:4

501 6,655 10.6 23 1:4

864 9,915 9.5 23 1:4

386 4,198 8.0 16 1:4

792 9,407 10.7 20 1:4

373 3,736 7.6 17 1:4

534 4,765 8.4 21 1:2

390 4,120 8.2 19 1:4

617 6,475 9.3 20 1:4

9,861 102,882 8.9 19 1:4

734 -

351

403

605

449 -

-

444

514

612 -

846

970

1,347

7,470 10.1 21 1:4

3,419 6.6 17 - 3,172 8.6 17 1:4

3,853 8.2 15 1:5

5,301 7.3 15 1:5

4,241 7.9 16 1:5

3,191 7.1 15 - 4,664 7.6 17 - 4,251 7.7 17 1:5

5,112 11.0 23 1:3

6,007 8.2 16 1:4

5,652 8.1 18 - 10,640 10.5 24 1:3

11,469 12.4 25 1:3

15,052 10.9 22 1:3

7,275 93,494 9.2 19 1:4

31

NATIONAL HEALTH SERVlCE ADMINISTRATIVE AND CLERICAL MANPOWER

and Percentage Episode to Frontline Clerical of Revenue E staff costs Expenditure

(1988-89) E’OOO

South West Thames North West Surrey west Suney south west Surrey Mid Surrey East Surrey Chichester Mid-Downs Worthing Croydon Kingston Richmond Wandsworth Merton

376 4,117 8.5 22 1:5 378 3,313 7.9 18 1:4 412 4,197 7.6 17 1:5 301 3,069 6.1 24 1:7 364 3,984 6.9 23 1:5 356 3,077 7.8 16 1:5 394 3,721 6.7 15 1:6 391 3,250 7.3 15 1:5

517 5,603 7.4 17 1:5 345 3,857 7.7 15 1:5 289 3,695 8.2 28 1:5 786 10,215 8.8 26 1:4 609 6,306 7.4 17 1:5

Wessex East Dorset West Dorset Portsmouth soutbampton Winchester Basingstoke Salisbury Swindon Bath Isle of Wight

5,369 50,892 7.7 17 1:5 Oxford East Berkshire 491 4,847 7.1 13 1:6 West Berkshire 709 6,290 7.1 17 1:5 Aylesbury 356 3,268 6.4 16 1:5 Wycombe 343 3,421 8.9 15 1:4 Milton Keynes 335 2,422 8.5 15 1:3 Kettering 364 2,903 6.8 13 1:5 Northampton 580 5,252 7.6 18 1:5 Oxfordshire 1,162 10,039 7.2 18 1:5

5,520 58,404 7.6 19 1:5

747 6,905 7.4 15 1:5 322 3,109 7.1 17 1:6 841 7,360 7.2 15 1:5

1,080 9,548 7.8 17 1:5 363 4,689 9.9 26 1:5 386 3,652 7.6 20 1:5 308 2,818 7.5 16 1:5 427 4,377 8.3 18 1:5 672 6,099 7.2 16 1:5 223 2,335 7.9 18 1:5

4,340 38,442 7.3 16 1:5

32

NATIONAL HEALTH SERVICE ADMINISTRATIVE AND CLERICAL MANPOWER

costs

(1988-89)

i?ooo

Expenditure

South Western Bristol Frenchay Southmead Cornwall Exeter North Devon Plymouth Torbay Cheltenham Gloucester Somerset

West Midlands Bromsgrove Herefordshire Kidderminster Worcester Shropshire Mid Staffordshire North Staffordshire South East Staffordshire Rdv North Warwickshire South Warwickshire Central Birmingham East Birmingham North Birmingham South Birmingham West Birmingham Coventry Dudley Sandwell Solihull Walsall Wolverhampton

1,144 9,992 8.8 17 1:4 564 5,058 8.1 32 1:6 484 4,450 7.6 21 1:6 572 5,208 5.6 14 1:6 664 6,158 7.2 19 1:6 254 2,159 7.3 14 1:5 653 6,141 6.9 15 1:5 442 3,936 7.7 15 1:5 312 3,026 7.6 12 1:5 601 5,383 7.6 16 1:5 634 5,662 6.7 15 1:6

6,324 57,173 7.4 17 1:5

303 272 239

434 623 451 892

470 -

309

401 -

474 361 705 617 623 621 390

289 -

574

2,552 8.1 14 1:4 2,383 7.5 14 1:3 2,061 6.8 16 1:6 3,768 7.3 17 1:5 5,371 6.7 15 1:5 3,812 7.1 19 1:4 7,350 6.5 14 1:6 3,867 7.7 14 1:5 1,136 7.7 12 -

3,023 7.2 16 1:5 3,917 7.4 21 1:5 8,165 7.8 13 -

4,017 8.8 16 1:4 3,255 8.1 17 1:4 6,593 8.3 16 -

5,944 8.1 17 1:3 5,397 7.1 14 1:5 5,341 8.4 14 1:4 3,569 7.9 15 1:5 2,716 7.8 19 1:5 3,886 7.6 17 -

4,686 7.5 11 1:5

9,048 92,809 7.6 15 1:5

33

NATIONAL HEALTH SERVICE ADMINISTRATNE AND CLERICAL MANPOWER

ana Percentage Episode. to Frontline Clerical of Revenue f: staff costs Expenditure

(198849) s?ooo

Mersey Chester Crewe

Halton Macclesfield Warrington Liverpool St Helens southport south Sefton

wiiral

North Western

401 3,603 6.8 13 1:5 376 3,228 7.0 14 1:6 189 1,886 9.2 19 1:4 327 2,954 7.3 22 1:5 397 3,767 7.0 16 1:6

1,378 12,158 7.1 13 1:5 567 5,036 7.4 17 1:5 264 2,432 7.5 14 1:6 534 4.561 6.2 12 1:5 651 5,477 7.1 13 1:5

5,084 45,102 7.1 14 1:5

Lancaster 434 3,293 6.5 18 1:6 Blackpool 536 4,455 6.8 13 1:6 Preston 586 5,274 6.7 16 1:5 Blackburn 602 4,613 8.7 14 1:5 Burnley 457 4,298 5.8 17 1:8 west Lancashire 254 2,097 7.9 14 1:5 Chorley 156 1,449 6.4 16 1:5 Bolton 454 3,812 7.2 12 1:5 B=V 242 1,858 6.1 9 1:6 North Manchester 601 5,356 7.7 16 1:6 Central Manchester 712 6,044 7.8 11 1:4 South Manchester - 7,891 7.5 14 - Oldham 364 3,282 7.9 13 1:5 Rochdale 288 2,395 7.0 11 1:5 Salford 720 6,680 7.1 17 1:6 stockport 490 4,099 7.3 13 1:5 Tameside 345 2,949 6.9 12 1:5 T&ford 260 3,015 8.6 14 1:4 Wigan 529 4,459 7.6 10 1:5

8,050 77,319 7.3 14 1%

Notes 1. Columns 14 based on 1988-89 data. Column 5 is based on staff numbers as at September 1989. 2. Total administmtive and clerical costs include senior managers and agency staff costs. 3. Patient episodes comprise inpatients, outpatients, day cases and accident and emergency cases. 4. Frontline staff comprises medical, nursing, professions allied to medicine (PAMs) and professional and

technical. 5. Data from some districts were not received in time for inclusion in this Report.

34