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Staff unavailability and safe staffing: are headroom allowances ‘realistic’?

02 April 2020
17 min read
Volume 29 · Issue 7



‘Hours per patient day’ (HPPD) is an internationally recognised resourcing metric used to measure direct nursing care hours. However, hospitals often underestimate indirect time (unavailability) and specify unrealistic targets for planned unavailability (‘headroom’).


To investigate the disparities between planned unavailability (‘headroom’) and actual staff unavailability.


Data were collected from the e-rostering systems of 87 NHS trusts. This was compared with published data from 35 roster policies.


Many hospitals use headroom as a key performance indicator (KPI) and set targets for its components in their roster policies. This research highlights large variations in unavailability (15.8% to 33.6%) and lower variations in headroom (16–26%).


Hospitals operationalise headroom around an idealised ‘target’ value. This may be detrimental. Compelling a unit with unavailability of between 28% and 30% to adopt an institution-wide headroom of 22% (for example) may, at best, increase spending on bank/agency staff, or, at worse, jeopardise patient safety.

The use of ‘hours per patient day’ (HPPD) plus planned unavailability (‘headroom’) for staff resource budgeting is almost ubiquitous. This approach can be found in many countries, including Australia (Government of Western Australia, Department of Health, 2020), the Republic of Ireland (University College Cork, 2018), Malaysia (Drake, 2013), the USA (Fike and Smith-Stoner, 2016) and the UK (NHS England and NHS Improvement, 2019a). HPPD is a long-established, easy-to-use metric for determining unit budgets and comparing staff resourcing across organisations (Kirby, 2015). It is a measure of direct hours per patient day; however, in a 24/7 care environment there are indirect staff costs (annual leave, sickness, study leave, parental leave and non-clinical work) that must be included when calculating the staffing budget for a unit. In the budgetary process, these indirect costs, often called ‘unavailability’, are offset using a ‘headroom’ allowance (Hunt, 2018). It is crucial that this allowance is ‘realistic’ (NHS England and NHS Improvement, 2019b:12).

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