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Increased patient demand and untaken annual leave contributed to some district health board's nursing budgets blowing out last year, according to nursing directors. More at risk patients requiring 1:1 watches and shorter patient stays were also contributing to pressure on nursing budgets, the directors of nursing told Nursing Review.

Their comments were in response to a Ministry of Health report showing that nursing hours had been under-budgeted by the equivalent of 474 fulltime equivalent (FTE) nursing personnel across the 20 DHBs, according to the boards' interim financial results for 2015-16. (NB nursing personnel FTEs and budgets include nurses, midwives and health care assistants.)

The report also showed that total staff costs across all the 20 DHBs were $144 million higher than budgeted for – with higher than expected patient volumes and/or nursing costs reported to have contributing substantially to that blowout*.

Nursing Review approached seven district health boards (including the six largest) for more details and comment on their 2015-16 nursing budgets in September, shortly after the release of the Ministry report on the DHBs' unaudited financial performance. The sixth of the seven DHBs approached, Canterbury DHB, has just released the information to Nursing Review under the Official Information Act (OIA).

Margaret Dotchin, chief nursing officer for Auckland DHB's nearly 3,500 FTE nursing staff, said its nursing personnel budget was overspent by six per cent last year for a number of reasons but was largely driven by higher patient volumes than budgeted for. She said matching the "right nursing resource to the right place at the right time" had been met through balancing its permanent staff with nursing bureau staff where required.

 The Ministry report said that Auckland reported that "high usage" of bureau nurses was one of the primary reasons for ADHB's total personnel costs (including medical, allied health and other staff) being overspent along with reevaluating employee entitlements like long-service leave.

Overtime due to increased presentations at ED,  high acuity admissions and shorter length of stays was one contributing factor to Waikato DHB overspending its nursing budget by $1.8 million in 2015-16, says chief nursing officer Sue Hayward. "There was an increased number of discharges against planned which is an indicator of the increased throughput of patients in the wards."  She said it was still examining its acuity data but acuity levels seemed to be similar to the previous year and the shorter length of stay of patients appeared to having more of an impact on the nursing HPPD (hours per patient day) required than the patient acuity.

Hayward said Waikato had also budgeted and expected for more annual leave to be taken by its nursing staff then had eventuated and the budget had also assumed that vacancies would not be filled as quickly as they had. "While the nursing budget is overspent what should be acknowledged is the amazing work the charge nurse managers do to ensure that the nursing resource is matched in a timely way to patient need and demand," said Hayward.

Higher patient volumes and the greater use of 1:1 patient watches contributed to Counties Manukau Health's nursing personnel FTE being 3.5 per cent above budget in 2015-16.

Director of nursing Denise Kivell said it had set an "ambitious but considered" nursing budget and, while overall the DHB had delivered on budget, the nursing FTE was 92 above the budgeted for 2589 FTEs. She said the increase was mainly due to higher patient volumes and acuity requirements together with growth in new models of care, particularly in community. Kivell added that the changing profile of the population and resulting increase in emergency care visits was impacting on staffing levels along with people now presenting with multi-factor diseases, for example diabetes, obesity, renal and skin infections.

A significant factor in higher bureau demand for health care assistants (HCAs) was greater use of 1:1 patient watches for older and frail patients at risk of harm or disorientation.

Accumulated annual leave and an increased usage of patient watches also contributed to Capital & Coast DHB's nursing budget being $5.4 million (3.2%) over budget in 2015-16. Andrea McCance, executive director of nursing said factors included annual leave balances being higher than the previous year, NZNO MECA pay increases, increased penal costs due to statutory holidays (including the Monday-isation of Waitangi Day) along with increases in overtime and patient watches.

Waitemata, Waikato, Wairarapa and West Coast DHBs were the only DHBs to have budgeted for more nursing personnel FTEs than they actually employed in 2015-16.

Waitemata DHB director of nursing Jocelyn Peach said the DHB's overspend for total personnel costs were due to exceeding elective surgery targets and higher than anticipated acute demand volumes. "Despite this Waitemata DHB was actually under budgeted FTE overall and for nursing we were 12 FTE under across the year," said Peach. A DHB spokesperson also added that the nursing personnel expenditure was within budget and the DHB was one of only a few around the country to post a surplus in 2015-2016. 

The biggest variance between budgeted and actual nursing personnel was 8.8 per cent at Bay of Plenty DHB which ended up with 95 FTE above its budgeted for 1069 FTEs. The Ministry report said that the DHB reported that its overall personnel costs (not just nursing) were above budget due to higher than budgeted levels of both personnel and "outsourced" (bureau) personnel which had been driven primarily by a very high acute workload at both Tauranga and Whakatane hospitals.

Carolyn Gullery, the planning and funding general manager of Canterbury DHB, said in the DHB's OIA response that the interim results for 2015-16 show that the DHB slightly underspent its $273 million budget for nursing personnel. The DHB, which employs the highest number of nursing personnel of the 20 DHBs – did employ

49 more FTEs (1.3%) more than the budgeted for 3639 FTEs, which Gullery said could be attributed to a different staff mixed used for setting the budget. It had slightly overspent its bureau/temporary nursing staff budget of $2.8 million by $0.48 million but when combined with the slight surplus in the nursing personnel budget that had lead to a small overspend of 0.08 per cent. 

*NB: All but one of the boards overspent their personnel budgets but overall eight of the 20 DHBs looked likely to manage a break-even or better result for the 2015-16 year. The combined bottom line for all 20 DHBs was estimated to be $54 million in the red – $35.2 million worse than budgeted for.