Conclusions and Recommendations
1. Between 2000 and 2005 the number of nurses
working in the NHS in England increased by 55,000, but expenditure
on temporary nursing staff has remained at around 9% of the NHS's
total expenditure on nurses.
The Department believes that 6-7% may be a reasonable level for
most trusts, but that there will be some, for example in London,
where 15% is reasonable. Currently some spend less than 5% while
others spend as much as 29%. The Department needs to outline its
strategy for the use of temporary nursing staff as part of wider
workforce planning and, in conjunction with NHS Employers, should
set out guidelines on what it believes are acceptable levels of
temporary nursing for the different types of trusts.
2. Trusts have not taken a strategic and managed
approach to controlling the demand for temporary nursing.
Each trust should develop a local strategy to improve its understanding
and management of demand for temporary nurses. The strategy should
be underpinned by a clear understanding of the requisite establishment
levels needed to provide safe and effective care, which IT based
workforce management and rostering systems could help to determine.
Trusts should use a standard system for recording the reasons
why booking temporary cover was deemed necessary. Directors of
Nursing should compare booking information with information on
staffing needs to determine compliance with the trust strategy
on controlling demand.
3. When booking temporary cover, ward staff
do not have sufficient information to determine the most cost-effective
procurement route. Trusts should have
arrangements in place to obtain temporary staff at best value,
underpinned by performance measures to assess all suppliers (both
in-house and external). Trusts should provide guidance to wards
on the preferred route for booking temporary cover based on an
objective and evidence based assessment of the cost and quality
of the different options including: using nurses from its own
bank; whether NHS Professionals might provide a more cost-effective
option; and the cost and quality of staff from the different nursing
agencies.
4. Trusts do not monitor, in a systematic
way, the full costs of using temporary nursing staff. Trusts
should allocate responsibility for monitoring expenditure on temporary
nursing to one of its trust board members, including quarterly
reports to the strategic health authority on this expenditure.
Strategic health authorities should assist trusts to compare their
use of temporary nurses and share good practice locally. The National
Audit Office's Good Practice in managing the use of temporary
nursing staff provides practical examples and checklists to
help improve aspects of both supply of and demand for temporary
staff.
5. At least 30% of permanent nurses and at
least 39% temporary staff are still not receiving mandatory basic
life support training. Other mandatory
training for nurses such as Infection Control and Fire Training
is also not being refreshed annually. Strategic Health Authorities
should manage local NHS Trusts so that all nursing staff receive
mandatory training. Trusts should schedule mandatory training
at times that encourage maximum attendance or consider, where
applicable, alternative ways of delivering training, for example
through e-learning. Trusts should maintain accurate training records
which show whether nurses they employ, on both a permanent or
temporary basis, have received their mandatory training.
6. There are no systems or safeguards to enable
a trust to know whether a temporary nurse has exceeded the safe
level of hours set under the European Working Time Directive.
Long working hours can put at risk the health and ultimately the
performance and attendance of employees, thus further increasing
the pressure on nurses and exacerbating the existing problems.
NHS trusts should have systems to enable them to control and monitor
the total number of hours worked by each nurse, whether in direct
employment or working for other employees. Specifically the Department
should expedite implementation of its electronic staff record
so that it can be used to monitor the hours worked by temporary
staff.
7. NHS Professionals faces a tension between
its strategic role to improve the quality of the temporary labour
market and its operational requirement to make temporary staffing
more cost effective. The Department needs
to clarify to NHS Professionals and trusts how the new service
model and new financial model that it is working on will reduce
this tension. One of the key aims in developing NHS Professionals
was to improve the quality of temporary staff. Trusts should therefore
compare the performance of their in-house banks with NHS Professionals,
in terms of cost and quality standards, to determine whether the
bank is operating effectively.
8. The NHS Purchasing and Supplies Agency
(PASA) agreements have moderated the cost and improved the quality
of agency nursing staff, but trusts continue to use agencies that
are not on the framework agreements. PASA
should use its negotiating powers to obtain greater volume discounts
by consolidating its framework agreements. Trusts should only
use agencies that are on the PASA framework agreements to assure
the quality of temporary nurses and achieve control over their
local temporary staffing market.
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