Art & science | acute care Feature
MANAGING RELIANCE ON TEMPORARY AGENCY STAFF Maria Nicholson examines how care providers in England can comply with newly approved agency staff procurement routes while maintaining high-quality care and staffing levels Correspondence maria.nicholson@ nhsprofessionals.nhs.uk Maria Nicholson is head of workforce insight at NHS Professionals Date of submission February 1 2016 Date of acceptance February 1 2016 Author guidelines journals.rcni.com/r/ nm-author-guidelines
Abstract Amid spiralling agency staff costs, in November 2015 Monitor and the Trust Development Authority placed caps on the hourly rate that NHS trusts can pay agency staff, and informed all NHS and foundation trusts that they are required to procure agency staff through approved frameworks. This article suggests ways in which management can maintain these requirements while ensuring safe staffing levels and high-quality care delivery. Keywords agency staff, temporary staff, workforce, safe staffing, management, leadership
Introduction TEMPORARY STAFF make up a bedrock for NHS trusts across England, and care providers rely on them to ensure safe patient services, whether through in-house banks, outsourced providers or agencies. In the wake of the Francis Inquiry report into care failings at Mid Staffordshire NHS Foundation Trust, NHS trusts have attempted to increase their staffing levels but, with fewer substantive nurses looking for work, they have become reliant on staffing agencies to fill the gaps. While there is an argument for using temporary staff to cover unplanned absences and vacancies, and to meet unexpected spikes in demand, an increasing reliance on agency staff to fill permanent posts raises financial and quality concerns. Between October 2013 and September 2015, NHS Professionals, which provides temporary staff, has seen demand for bank nursing in England grow 22 March 2016 | Volume 22 | Number 10
by 35% in acute trusts, and 38% in community and mental health trusts (NHS Professionals 2014). This has led to greater use of staffing agencies to make up the shortfall in bank staff. The scarcity of registered nursing staff in the recruitment market has led to increased competition between trusts for resources, and a consequent growth in agency rates for available nurses. To add to this, there is no consistent agency rate across health economies and many agencies are not on a recognised procurement framework. Trusts are expected to select staffing agencies from agreed NHS procurement frameworks but this is not always possible if specific skills and experience are in short supply. Most procurement frameworks specify the maximum rates that can be charged by the staffing agencies that have applied to operate under their protection. However, agencies not on frameworks can charge what the market will pay and will arrange for nurses to travel considerable distances to workplaces, which often involves several hours’ drive time. Moreover, people can choose to work across a range of agencies, making it impossible to keep track of their compliance with working time regulations, which presents a potential risk for patients and trusts. Increased hourly agency rates for registered nurses have also attracted substantively employed people who would normally work additional hours through local nursing banks to support their own trust. In some cases, it has led to people leaving substantive NHS employment in favour of agency work. This is particularly true in certain specialist NURSING MANAGEMENT
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NURSING MANAGEMENT
March 2016 | Volume 22 | Number 10 23
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Art & science | acute care Feature It is vital to engage with staff and encourage them to join the bank so that nurses can continue to be part of the NHS family roles, including theatres, critical care, emergency care, paediatrics, midwifery and community psychiatric nursing. For the first time in many years, some trusts are allowing their substantively employed staff to work additional hours through an agency in their employing trust, rendering the trust’s nursing bank a poor second choice for registered nurses. This is not good practice and unfair to substantive staff who are committed to working additional hours through the bank.
Cap on agency spending In 2014/15, the NHS spent more than £3.3 billion on agency staff, prompting Monitor and the Trust Development Authority (TDA) to put controls in place to support trusts in deficit, many of which face spiralling agency costs. Monitor and the TDA has written to all NHS trust and foundation trust chief executives setting individual ceilings for the proportion of nursing expenditure their organisations can spend on temporary staffing agencies. Trusts are also required to procure all agency nursing and care staff through approved frameworks. Off-framework arrangements are permitted only in exceptional circumstances, for example to protect patient safety. On November 23 2015, caps were placed on the hourly rate NHS trusts can pay agency staff. The price caps apply when: ■ An agency fills a shift directly. ■ An agency finds a worker to fill a shift, but the trust pays the worker directly for that shift and pays the agency a finder’s fee. ■ Staff are paid through their own limited or personal services company. The maximum trusts can pay for agency nurses as of November 2015 is 100% above basic pay, with an aim to bring this down to 55% above permanent staff pay rates by April 2016. While the cap marks a clampdown by the government to prevent agencies ‘ripping off the NHS’ (BBC News Online 2015), there has, unsurprisingly, been some resistance to the cap among care providers.
Solutions It is a challenging time to be a director of nursing or senior nurse. They are under intense scrutiny 24 March 2016 | Volume 22 | Number 10
to save money on staffing costs, but at the same time need to provide safe staffing levels on wards. The critical shortage of qualified and specialist nurses has led trusts to become reliant on agencies to fill their shifts at whatever cost it takes to ensure patient safety. However, it is important that trusts hold a firm line; nurses working through agencies will migrate to where the work is, whether an in-house bank or cheaper on-framework agencies. There will be a short period where shift coverage might be tight, but it is important that trusts assess where risks are and mitigate them by making good use of workforce planning tools. In addition, rostering well in advance, and always using the bank in the first instance, will enable bank staff to plan ahead too, which usually results in a higher bank shift fill. Most organisations have information that provides reports and analyses of their substantive workforce data. However, often detailed management information reports that highlight temporary workforce activity across a trust are missing. These reports should cover all temporary assignments, including bank and agency spend, and shift fill rates. They should also highlight essential workforce information, such as clinical governance compliance and hours worked through the bank, for compliance with working time regulations. Patterns of demand are visible only when recorded at source. All management information collected by NHS Professionals’ booking system, NHSP:Online, is used to manage demand and reduce agency use. NHS Planning Guidance, issued at the end of 2015 to deliver NHS England’s Five Year Forward View, makes it clear that NHS organisations have to demonstrate the use of e-rostering, and how they use it effectively to manage their workforce. All providers will be expected to evidence the effective use of e-rostering for nurses, midwives, healthcare assistants and other clinicians. This will help ensure the right staff are in the right place at the right time to guarantee patients receive the correct hours of care, and that as little time as possible is wasted on bureaucracy. This approach will enable providers to reduce their reliance on agency staffing, while compliance with the agency staffing rules will reduce the rates paid (NHS England 2015). For NHS trusts to make banks more attractive options for staff, it is important that they re-engage with the workforce. If we want skilled, experienced people to join the NHS and the bank, we have to showcase the health service and make it the most NURSING MANAGEMENT
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attractive place to work. Trusts need to value their bank staff and look at pay rates and pay modelling to attract and retain their workforce.
Agency partnership programme By introducing other workforce programmes, such as the agency partnership programme (APP), NHS Professionals has helped trusts manage their agency expenditure by working with a small set of approved staffing agencies at agreed rates. Each trust selects their preferred staffing agencies based on quality, and NHS Professionals negotiates with these agencies to ensure that the trusts gain favourable rates. The rates are often better than those the trusts would receive under established procurement frameworks, due to enhanced buying power. Trusts will use their banks in the first instance, but can be reassured that they will not be overcharged when they need to use agencies to fill shifts that cannot be filled with substantive or bank staff. Before the agency cap came into effect, NHS Professionals supported rate capping across a consortium of five NHS acute trusts in the North West of England: Central Manchester University NHS Foundation Trust, Stockport NHS Foundation Trust, Salford Royal NHS Foundation Trust, University Hospitals of South Manchester NHS Foundation Trust and Tameside Hospital NHS Foundation Trust. Working with NHS Professionals, these trusts provided data on rates and hours worked by a variety of agency staff between bands 2 and 5. The data were analysed by NHS Professionals and shared with the APP consortium. The hourly rates paid to nursing agencies by trusts across the region were collected, normalised and compared with those charged to the five trusts in the consortium. The data have enabled an open, honest and professional discussion, led jointly by senior nursing and procurement staff, who championed patient safety and care, and effective use of resources. When measured against four control groups, the five trusts in the APP consortium made significant savings. The comparison showed that rates in the APP consortium were between £5.66 and £11.12 an hour lower than the average rates charged across the control groups. From this comparison, total savings of between £3.5 million and £5 million were derived in the five trusts compared with the four control groups. Following changes to the agency frameworks covering the north west, the APP exercise was NURSING MANAGEMENT
repeated in 2015 to revise the preferred agency list and review the rates. A number of challenges were encountered during the process. For example, some procurement framework agreements had expired and six of the original agencies were no longer on an approved framework. The market rate for agency nurses had increased considerably and not all agencies wanted to participate in the revised programme; some planned to increase rates that had been set in, and held since, 2012. The north west APP Consortium also explored a number of other staffing options alongside agency rate caps, such as attracting staff back to the NHS by increasing bank pay to encourage more people to work through the nursing bank.
Conclusion Trusts have a rich supply of workforce data and, used effectively, this information can help reduce reliance on agencies. By analysing substantive staff demographics, employers can see who is coming up for retirement and the skills that need to be retained. It is a time to be creative and consider new ways of working to attract and retain highly skilled staff, and develop other staff so that they attain the skills that are essential to good patient care in various settings. It is also vital to engage with staff and encourage them to join the bank so that trusts can continue to make use of their skills, and nurses can continue be part of the NHS family and supplement their retirement income. We look forward to seeing the national rate caps implemented, as these will drive real benefits for NHS trusts. We expect that, with the right incentives in place, many people working through staffing agencies will return to full-time substantive or flexible bank employment for the benefit of patients, taxpayers and the NHS.
Find out more More information about the NHS Professionals agency partnership programme is available at tinyurl.com/jnenyu7
Online archive
References
For related information, visit our online archive and search using the keywords
BBC News Online (2015) NHS to Target ‘Rip-off’ Staffing Agencies. tinyurl.com/pajhyd9 (Date of last access: January 28 2016.) NHS England (2015) Delivering the Forward View: NHS Planning Guidance 2016/17-2020/21. tinyurl.com/zm78f87 (Last accessed: January 28 2016.) NHS Professionals (2014) National Trends Quarterly Report. www.nhsp.co.uk/national-trends (Last accessed: January 28 2016.)
Conflict of interest None declared
March 2016 | Volume 22 | Number 10 25
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MANAGING RELIANCE ON TEMPORARY AGENCY STAFF Maria Nicholson examines how care providers in England can comply with newly approved agency staff procurement routes while maintaining high-quality care and staffing levels Correspondence maria.nicholson@ nhsprofessionals.nhs.uk Maria Nicholson is head of workforce insight at NHS Professionals Date of submission February 1 2016 Date of acceptance February 1 2016 Author guidelines journals.rcni.com/r/ nm-author-guidelines
Abstract Amid spiralling agency staff costs, in November 2015 Monitor and the Trust Development Authority placed caps on the hourly rate that NHS trusts can pay agency staff, and informed all NHS and foundation trusts that they are required to procure agency staff through approved frameworks. This article suggests ways in which management can maintain these requirements while ensuring safe staffing levels and high-quality care delivery. Keywords agency staff, temporary staff, workforce, safe staffing, management, leadership
Introduction TEMPORARY STAFF make up a bedrock for NHS trusts across England, and care providers rely on them to ensure safe patient services, whether through in-house banks, outsourced providers or agencies. In the wake of the Francis Inquiry report into care failings at Mid Staffordshire NHS Foundation Trust, NHS trusts have attempted to increase their staffing levels but, with fewer substantive nurses looking for work, they have become reliant on staffing agencies to fill the gaps. While there is an argument for using temporary staff to cover unplanned absences and vacancies, and to meet unexpected spikes in demand, an increasing reliance on agency staff to fill permanent posts raises financial and quality concerns. Between October 2013 and September 2015, NHS Professionals, which provides temporary staff, has seen demand for bank nursing in England grow 22 March 2016 | Volume 22 | Number 10
by 35% in acute trusts, and 38% in community and mental health trusts (NHS Professionals 2014). This has led to greater use of staffing agencies to make up the shortfall in bank staff. The scarcity of registered nursing staff in the recruitment market has led to increased competition between trusts for resources, and a consequent growth in agency rates for available nurses. To add to this, there is no consistent agency rate across health economies and many agencies are not on a recognised procurement framework. Trusts are expected to select staffing agencies from agreed NHS procurement frameworks but this is not always possible if specific skills and experience are in short supply. Most procurement frameworks specify the maximum rates that can be charged by the staffing agencies that have applied to operate under their protection. However, agencies not on frameworks can charge what the market will pay and will arrange for nurses to travel considerable distances to workplaces, which often involves several hours’ drive time. Moreover, people can choose to work across a range of agencies, making it impossible to keep track of their compliance with working time regulations, which presents a potential risk for patients and trusts. Increased hourly agency rates for registered nurses have also attracted substantively employed people who would normally work additional hours through local nursing banks to support their own trust. In some cases, it has led to people leaving substantive NHS employment in favour of agency work. This is particularly true in certain specialist NURSING MANAGEMENT
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NURSING MANAGEMENT
March 2016 | Volume 22 | Number 10 23
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Art & science | acute care Feature It is vital to engage with staff and encourage them to join the bank so that nurses can continue to be part of the NHS family roles, including theatres, critical care, emergency care, paediatrics, midwifery and community psychiatric nursing. For the first time in many years, some trusts are allowing their substantively employed staff to work additional hours through an agency in their employing trust, rendering the trust’s nursing bank a poor second choice for registered nurses. This is not good practice and unfair to substantive staff who are committed to working additional hours through the bank.
Cap on agency spending In 2014/15, the NHS spent more than £3.3 billion on agency staff, prompting Monitor and the Trust Development Authority (TDA) to put controls in place to support trusts in deficit, many of which face spiralling agency costs. Monitor and the TDA has written to all NHS trust and foundation trust chief executives setting individual ceilings for the proportion of nursing expenditure their organisations can spend on temporary staffing agencies. Trusts are also required to procure all agency nursing and care staff through approved frameworks. Off-framework arrangements are permitted only in exceptional circumstances, for example to protect patient safety. On November 23 2015, caps were placed on the hourly rate NHS trusts can pay agency staff. The price caps apply when: ■ An agency fills a shift directly. ■ An agency finds a worker to fill a shift, but the trust pays the worker directly for that shift and pays the agency a finder’s fee. ■ Staff are paid through their own limited or personal services company. The maximum trusts can pay for agency nurses as of November 2015 is 100% above basic pay, with an aim to bring this down to 55% above permanent staff pay rates by April 2016. While the cap marks a clampdown by the government to prevent agencies ‘ripping off the NHS’ (BBC News Online 2015), there has, unsurprisingly, been some resistance to the cap among care providers.
Solutions It is a challenging time to be a director of nursing or senior nurse. They are under intense scrutiny 24 March 2016 | Volume 22 | Number 10
to save money on staffing costs, but at the same time need to provide safe staffing levels on wards. The critical shortage of qualified and specialist nurses has led trusts to become reliant on agencies to fill their shifts at whatever cost it takes to ensure patient safety. However, it is important that trusts hold a firm line; nurses working through agencies will migrate to where the work is, whether an in-house bank or cheaper on-framework agencies. There will be a short period where shift coverage might be tight, but it is important that trusts assess where risks are and mitigate them by making good use of workforce planning tools. In addition, rostering well in advance, and always using the bank in the first instance, will enable bank staff to plan ahead too, which usually results in a higher bank shift fill. Most organisations have information that provides reports and analyses of their substantive workforce data. However, often detailed management information reports that highlight temporary workforce activity across a trust are missing. These reports should cover all temporary assignments, including bank and agency spend, and shift fill rates. They should also highlight essential workforce information, such as clinical governance compliance and hours worked through the bank, for compliance with working time regulations. Patterns of demand are visible only when recorded at source. All management information collected by NHS Professionals’ booking system, NHSP:Online, is used to manage demand and reduce agency use. NHS Planning Guidance, issued at the end of 2015 to deliver NHS England’s Five Year Forward View, makes it clear that NHS organisations have to demonstrate the use of e-rostering, and how they use it effectively to manage their workforce. All providers will be expected to evidence the effective use of e-rostering for nurses, midwives, healthcare assistants and other clinicians. This will help ensure the right staff are in the right place at the right time to guarantee patients receive the correct hours of care, and that as little time as possible is wasted on bureaucracy. This approach will enable providers to reduce their reliance on agency staffing, while compliance with the agency staffing rules will reduce the rates paid (NHS England 2015). For NHS trusts to make banks more attractive options for staff, it is important that they re-engage with the workforce. If we want skilled, experienced people to join the NHS and the bank, we have to showcase the health service and make it the most NURSING MANAGEMENT
Downloaded from RCNi.com by ${individualUser.displayName} on Jul 18, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
attractive place to work. Trusts need to value their bank staff and look at pay rates and pay modelling to attract and retain their workforce.
Agency partnership programme By introducing other workforce programmes, such as the agency partnership programme (APP), NHS Professionals has helped trusts manage their agency expenditure by working with a small set of approved staffing agencies at agreed rates. Each trust selects their preferred staffing agencies based on quality, and NHS Professionals negotiates with these agencies to ensure that the trusts gain favourable rates. The rates are often better than those the trusts would receive under established procurement frameworks, due to enhanced buying power. Trusts will use their banks in the first instance, but can be reassured that they will not be overcharged when they need to use agencies to fill shifts that cannot be filled with substantive or bank staff. Before the agency cap came into effect, NHS Professionals supported rate capping across a consortium of five NHS acute trusts in the North West of England: Central Manchester University NHS Foundation Trust, Stockport NHS Foundation Trust, Salford Royal NHS Foundation Trust, University Hospitals of South Manchester NHS Foundation Trust and Tameside Hospital NHS Foundation Trust. Working with NHS Professionals, these trusts provided data on rates and hours worked by a variety of agency staff between bands 2 and 5. The data were analysed by NHS Professionals and shared with the APP consortium. The hourly rates paid to nursing agencies by trusts across the region were collected, normalised and compared with those charged to the five trusts in the consortium. The data have enabled an open, honest and professional discussion, led jointly by senior nursing and procurement staff, who championed patient safety and care, and effective use of resources. When measured against four control groups, the five trusts in the APP consortium made significant savings. The comparison showed that rates in the APP consortium were between £5.66 and £11.12 an hour lower than the average rates charged across the control groups. From this comparison, total savings of between £3.5 million and £5 million were derived in the five trusts compared with the four control groups. Following changes to the agency frameworks covering the north west, the APP exercise was NURSING MANAGEMENT
repeated in 2015 to revise the preferred agency list and review the rates. A number of challenges were encountered during the process. For example, some procurement framework agreements had expired and six of the original agencies were no longer on an approved framework. The market rate for agency nurses had increased considerably and not all agencies wanted to participate in the revised programme; some planned to increase rates that had been set in, and held since, 2012. The north west APP Consortium also explored a number of other staffing options alongside agency rate caps, such as attracting staff back to the NHS by increasing bank pay to encourage more people to work through the nursing bank.
Conclusion Trusts have a rich supply of workforce data and, used effectively, this information can help reduce reliance on agencies. By analysing substantive staff demographics, employers can see who is coming up for retirement and the skills that need to be retained. It is a time to be creative and consider new ways of working to attract and retain highly skilled staff, and develop other staff so that they attain the skills that are essential to good patient care in various settings. It is also vital to engage with staff and encourage them to join the bank so that trusts can continue to make use of their skills, and nurses can continue be part of the NHS family and supplement their retirement income. We look forward to seeing the national rate caps implemented, as these will drive real benefits for NHS trusts. We expect that, with the right incentives in place, many people working through staffing agencies will return to full-time substantive or flexible bank employment for the benefit of patients, taxpayers and the NHS.
Find out more More information about the NHS Professionals agency partnership programme is available at tinyurl.com/jnenyu7
Online archive
References
For related information, visit our online archive and search using the keywords
BBC News Online (2015) NHS to Target ‘Rip-off’ Staffing Agencies. tinyurl.com/pajhyd9 (Date of last access: January 28 2016.) NHS England (2015) Delivering the Forward View: NHS Planning Guidance 2016/17-2020/21. tinyurl.com/zm78f87 (Last accessed: January 28 2016.) NHS Professionals (2014) National Trends Quarterly Report. www.nhsp.co.uk/national-trends (Last accessed: January 28 2016.)
Conflict of interest None declared
March 2016 | Volume 22 | Number 10 25
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