Staffing crisis pushes NHS staff into agency working

It has been said many times that the NHS is at breaking point. Talk of bed shortages, wasted resources, understaffing and missed targets saturate the media. A Government Adviser has even said recently that hospitals are in a ‘state of war’.

High rates of use of agency workers are seen as a symptom of a sick NHS but the reasons for their spiralling use are poorly understood. New research conducted by the National Institute of Economic and Social Research (NIESR) with the support of the Recruitment and Employment Confederation (REC) set out to explain why agency workers seem to be keeping the NHS alive. The research diagnoses the root causes of high agency spending, revealing that agency working is only the symptom of a much larger, chronic problem around NHS staffing.

Media coverage of agency working persistently focuses on sky-high staff day rates and extortionate agency fees, and the impact these have on the public purse. Only last week the Daily Mail reported health regulators as complaining that ‘greedy’ doctors and nurses are abandoning the NHS to work for ‘rip-off agencies’

The cost of agency workers was also the main concern of  NHS England’s own flagship programme to reduce their use. Launched in September 2015 and known as the ‘agency rules’, the programme obliges NHS trusts to procure all agency staff via NHS-approved framework agreements, and at rates set at or below a specified price cap. And this seems to have had some effect – we found the new ‘agency rules’ have streamlined trusts’ recruitment of agency workers and as a result, the agency rules have succeeded in reducing agency spending. Recent data released by NHS Improvement shows some quite substantial falls in agency spending.

However, costs remain high and NHS trusts continue to be highly dependent on agencies and agency workers. The frameworks and agency rules were designed to put trusts are in a strong bargaining position, where they can force agencies into accepting lower fees by driving a hard bargain.  But as long as demand far outstrips supply, agencies and workers are able to hold out for the best deals.

Despite caps on agency pay rates, trusts are able to exceed caps where safety issues are believed to be at stake and our research shows that this happens quite frequently. When faced with the possibility of understaffed A&E departments, trust managers – whose overriding obligation is to maintain patient safety – will inevitably be forced to invoke this provision and accept higher fees. As a result, it is trusts, not agencies, which ‘blink first’. The problem, therefore, seems to be about simple economics –  NHS trust managers’ persistent difficulties in keeping down agency costs are grounded in the imbalance between demand and supply. Put simply, there are not enough nurses and doctors to go around.

The perspective of employers, however, only tells one half of the story. What motivates agency workers themselves? Are they simply ‘greedy’ and out for all they can get from an ailing NHS? Our research shows many agency workers are motivated far less by money than other issues. Their  decisions to enter agency work are often based on a desire to escape NHS permanent employment and experiences of poor and worsening working conditions. We heard numerous accounts of unmanageable workloads, excessive  bureaucracy and paperwork, too little flexibility and poor work-life balance. For some, the decision to sign up to an agency was often described as a last resort, as a way of staying in work but getting out of permanent employment in the NHS.

It’s clearly important that the use of agencies is controlled by strict rules on procedures and spending, but these seem to only address the symptoms of the problem. What they fail to do is tackle the underlining issue of inadequate supply of staff amid rising healthcare needs. The NHS has, and always will, need temporary staff to cope with peaks in demand, but we might reasonably expect the NHS to be able to predict and manage these fluctuations much better than they do and to plan ahead. But staff shortages are often chronic, rather than acute and the NHS needs to not only address the symptoms of agency working but the underlining causes. These include  staff shortages, training, workforce planning, recruitment and retention and, importantly, the issues that drive committed staff into agency work – unmanageable workloads,  lack of work-life balance and excessive bureaucracy. Only by addressing these issues will the NHS reduce its dependence on agencies and return their workforces to a stable condition.

You can read the full report here. The report also contains findings into the use of agency supply teachers in public schools.