The use of temporary agency staff in the NHS is not a new story, but recently re-appeared after Simon Stevens, chief executive of NHS England, admitted that hospitals were over spending on agency staff to the tune of £1.8 billion in 2014 – twice the the amount that was budgeted for.
It is understandable why this provokes some outrage. The NHS is attempting to make £22 billion in “efficiency savings” and ministers have failed to rule out cuts to doctors, nurses and other staff. Yet at the same time, agency and locum staff are often drafted in at expensive additional cost to fill staff gaps. Then there are the other concerns often raised in relation to this – their risk to patient care.
But if agency staff are so costly and perceived as potentially risky to patients, why does the NHS rely on them so much? And what would happen if the NHS didn’t use temporary staff at all?
The NHS, in common with public health services in many other countries (including the US, Canada, Australia and New Zealand) is experiencing staff shortages. Attempts have been made to identify the causes of these shortages, and have highlighted factors common to other organisations such as short-term illness and maternity leave. Other issues that have been identified in the NHS include problems with recruiting, retaining and motivating trainees and graduates.
These may outwardly appear to be solvable problems, but underlying factors such as poor pay, increased expectations on the clinical workforce (and scrutiny over meeting targets), the increased intensity of work and (often) poor working conditions provide are continuing challenges to the profession.
In addition, the NHS also has to consider changes to the demographic profile of its working population. As the workforce ages, policies and practices to encourage older employees to remain in the workforce will become even more important.
The 2009 Boorman Review of the health and well-being of NHS staff recognised that good health was key to good business and that a well workforce contributes to the organisation’s success. Despite reporting generally good health and well-being in the NHS, the review reported that NHS employees displayed high levels of sickness absence – an average of 10.7 days, which compares unfavourably with staff in other government departments including the public sector as a whole.
A recent article in the Nursing Standard highlighted that stress and depression were the leading causes of long-term sick leave in two-thirds of NHS trusts, with work-related stress particularly high among nurses. Yet in the NHS 2014 staff survey, only 56% of staff reported that their line manager took a positive interest in their health and well-being and only 44% indicated that their organisation took positive action in this area. In its 2010 report on use of locums, Audit Scotland concluded that NHS spending on locum and agency staff could be saved if the workforce was planned and managed strategically – a challenge that the NHS must begin to take seriously.
Worryingly, the Boorman Review also indicated that NHS staff came to work when ill, because they were worried about the affects of agency staff use on patient care. In 2006, the National Audit Office reported that when staff vacancies increased, agency use also increased and reports of reduced service patient satisfaction and quality of patient care. Reasons for this perceived drop in care include limited familiarity with specific wards, policies and hospital procedures by temporary staff as well as potential disruption to team communication and the work of permanent staff.
Damned if you do, damned if you don’t
From all this, you might think that the solution was to minimise the use of temporary staff to reduce costs and concerns over quality of care. However, it is not quite so easy.
The NHS has a duty to provide high-quality care for all – yet there is a large body of literature that suggests that staff vacancies and inadequate staff-to-patient ratios can negatively affect patient safety and service quality. Hospitals with good working environments, improved staffing and suitable staff-to-patient ratios have improved patient satisfaction ratings. Patients in hospitals with higher ratios of patients to nurses (increasing staff workloads) were less likely to rate the hospital highly for patient care.
So why is there a perceived drop in quality of care when temporary staff are used? Some may argue that temporary staff do not have the ward experience necessary to act in what could be a stressful and pressured context, that they may not have been inducted appropriately and may not have knowledge of staff protocols. The Audit Commission report noted that any member of staff, however qualified, is unlikely to perform to their best standard in an unfamiliar setting. The Audit Scotland report also said that there are few policies relating to performance management, despite calls previously being made to monitor the skills and professional development of temporary staff when used to support professional practice.
Temporary staff can also have indirect implications for patient safety as a result of their impact on the workload of permanent employees. Permanent staff, for example, may undertake tasks that temporary staff are unable or unwilling to perform or conduct inductions without any adjustments in work allocation to compensate for time away from official duties – often putting these staff under more pressure to complete ward duties.
Although some permanent staff realise that on some occasions they would have difficulties running wards without temporary staff, reduced morale has been reported with regards to the difference in pay between permanent staff and agency workers.
The NHS then has an unwelcome conundrum: if there are risks (and high costs) in both using agency staff and not using them, what can the NHS do to manage this? It is clear that greater consistency and coordination of the use of temporary staff is needed not solely for minimising costs, but for ensuring patient safety and care. However, if the focus becomes solely on costs rather than workforce planning and productivity, then ultimately both the workforce’s well-being and the quality of patient care will remain at risk of being compromised.