House of Commons - Public Accounts

Select Committee on Public Accounts Twenty-Ninth Report

2 Taking a planned approach to the use of temporary nurses

13. Whilst individual trusts collect information to varying degrees on reasons for requesting temporary cover and on vacancy, sickness and activity levels, this is often not brought together in a systematic manner to consider the most appropriate way to staff wards. As a result there is little strategic planning and control of trusts' demand for temporary cover.[35]

14. The Department did not have comprehensive data on the factors that determined demand as it needed to limit the amount of national information it collected from NHS organisations. There was little information nationally, though more information was available locally.[36] Indeed, NHS trusts generally had poor management information and a lack of understanding of the drivers of demand for temporary nursing staff.[37]

15. Although the Department considered that it was more important for NHS organisations to have the information that they required locally, it was beginning to collect national information which it had not sought to obtain previously. This information included details of the numbers of bank staff and the total amount being spent on agency staff, and was being used to generate productivity matrixes which would allow NHS organisations to benchmark their utilisation of temporary nursing staff.[38]

16. In 2001 the Audit Commission report Brief Encounters recommended that all trust boards should have a senior person with overall responsibility and board level accountability for the use of temporary staff.[39] The National Audit Office found that few trust boards had given the issue strategic consideration[40] though the Department believed that it had taken a strategic and planned approach to the use of temporary nurses. Initiatives implemented over the last three years included: the development of NHS Professionals; a series of regional framework agreements set up by the Purchasing and Supply Agency to reduce the cost of nursing staff procured through nursing agencies; and the work carried out by NHS Employers to encourage better management of temporary nursing staff.[41]

17. While aware of the most common reasons for booking temporary staff, the Department found it difficult to understand what was driving the demand for the bookings when using a paper-based ward roster.[42] Organisations using electronic rosters have made significant savings through gaining a better understanding of what is driving their temporary staffing behaviour, but these systems are not widely used.[43] An electronic staff record is currently being rolled out across the NHS which included an electronic staff rostering component. Trusts were waiting to see how effective the system was before seeking to invest in alternative systems.[44]

18. In 1986 our predecessors concluded that the lack of an evidence base on minimum staff levels was leading to wide variations in the average number of nursing staff per bed.[45] Twenty years later there is still no clear method for determining how many nurses are needed on a hospital ward. In America and Australia, standardised and mandatory nurse to bed ratios are used for different specialties.[46] The Department nevertheless believed staffing levels should be determined by local needs as these could vary significantly between hospitals and wards. For example staffing a ward or clinical area is complicated by the complexities of patients with different needs; by different approaches to clinical practice; and different rates of day case utilisation. Also hospitals organise themselves differently. Some have more support staff on the ward and some use central teams for specific treatments. This variability made it difficult to develop a single method for determining the minimum number of staff needed to deliver safe and effective patient care.[47]

19. The NHS spends considerable amounts of money to train new nurses, yet some nurses are unable to find a job, particularly newly qualified or student nurses.[48] An online survey of 530 nurses published by the Royal College of Nursing (RCN) in August 2006[49] found that 48% of recently qualified nurses took up temporary posts because they were unable to find a permanent job.[50] In the Department's view permanent nursing jobs were available, but in many cases the vacancies were for highly skilled and experienced nurses. A gap between the number of applicants and vacancies was held to be a legitimate way of increasing competition for jobs.[51]

20. Many ward managers use temporary staffing cover as a means of flexing the workforce and choose to hold one or more vacancies so that they can bring in temporary nursing staff as necessary. Poor management practices on the ward can lead to excessive reliance on temporary nursing cover, however, for example poor rota management, lack of control over sick and annual leave, and ineffective use of flexible working.[52] At the same time nurses want flexibility over their working hours, and if they are unable to obtain this flexibility in their permanent job, they are more likely to work for a nursing bank, NHS Professionals or a nursing agency. Although the Department's Working Lives initiative was designed to give staff more control over their working lives it has caused difficulties for ward managers trying to reconcile the demands for flexibility with the requirement to run a 24-hour, seven-day a week service.[53]

21. The survey published by the Royal College of Nursing also found that 65% of respondents working solely for banks or agencies did so because temporary working offered greater flexibility.[54] The Department suggested that a survey of 530 nurses from a possible 650,000 was unlikely to be representative.[55] It believed that it had provided nurses with greater flexibility in their working lives,[56] stating that its 2000 initiative Improving Working Lives Standard initiative[57] had been successful.[58]