3 Safety and quality issues in the
use of temporary nurses
22. NHS Professionals, the NHS run temporary staffing
service, was established in 2001 to reduce the cost and improve
the quality of using temporary staff. By 2006 it was still used
in only 24% of trusts. There were concerns that there might be
a conflict between reducing demand for temporary nursing and making
NHS Professionals self-financing. The Department acknowledged
that NHS Professionals had a troubled history as a result of managerial
and financial difficulties associated with rapid expansion, but
did not agree that there was a contradiction between the target
for NHS professionals to be self-financing by 2008-09 and its
role to drive down the inappropriate use of temporary staff.[59]
To support the need to be self-financing, the Department was working
on a new service model and a new financial model, but considered
utilisation of NHS Professionals by 25-30% of trusts would be
sufficient to be self-financing at this lower level of workload,
and at the same time have a beneficial impact on quality and cost.[60]
23. In 2002, the Department published a Code of
Practice for the Supply of Temporary Staffing[61]
which set out a framework for the management and performance
of temporary staffing to support providers in ensuring the delivery
of high quality, affordable and safe care. This code sets out
minimum standards required in the supply of temporary staff to
the NHS and applies to all organisations supplying such staff,
including nursing agencies, nursing banks and NHS Professionals.[62]
It includes a framework for the achievement of mandatory training
targets.[63]
24. The National Audit Office found that in the twelve
months prior to September 2005 only 61% of bank nurses had received
basic life support training, and 59% had received infection control
training. Also not all permanent staff had received their mandatory
training, only 70% had received the basic life support training
and 69% had been given infection control training during the same
period. [64]
25. The Department conceded that it has been difficult
for the NHS to achieve the provision of mandatory training across
the board and acknowledged that the current levels could be improved.[65]
It also recognised that there was less evidence of a robust appraisal
process with temporary staff.[66]
Nonetheless, it did not believe that temporary nursing staff provided
a lower quality of care to patients or that lower Healthcare Commission
ratings in the South of England were directly linked to their
higher use.[67]
26. The National Audit Office report found that the
majority of bank and NHS Professional staff did not have performance
appraisals or personal development plans which was also true for
a significant minority of permanent staff. NHS Employers were
using the NHS Purchasing and Supply Agency framework agreements
as a way to ensure that private agencies provided performance
appraisals, including testing aspects such as linguistic ability,
in order to minimise risks to patients. NHS Professionals were
intended to be become a benchmark for trusts to assess their in-house
bank against as a basis for identifying and promulgating best
practice work to trusts.[68]
27. Quality assurance procedures require a series
of checks to be run on individual nurses before they are allowed
to work on NHS nursing banks or for NHS Professionals, including
whether they are registered with the Nursing and Midwifery Council
which has specific standards for membership.[69]
Agency staff are also regulated by the Commission for Social Care
Inspection and must comply with the Department's Minimum Standards
for Nursing Agencies. Agencies on the Purchasing and Supply Agency
framework agreements must also comply with the requirements of
these agreements.[70]
28. In order to provide more certainty about the
quality of staff NHS Professionals have introduced a new clinical
coding system, similar to those used by private agencies. The
system ensures that when an NHS trust asks for a nurse with specific
competencies there is a transparent and consistent process across
the NHS. This in-turn ensures that temporary staff provided to
trusts have the requisite experience.[71]
29. Most nurses engaged in temporary work also have
permanent nursing jobs.[72]
Under the European Working Time Directive nursing staff are allowed
to work a maximum of 48 hours per week.[73]
None of the trusts visited by the National Audit Office during
its investigation, however, had robust systems for monitoring
the number of hours being worked by nursing staff.[74]
The Department was anxious that nursing staff might be working
more than 48 hours a week, potentially putting their health at
risk, but it was difficult to monitor this limit. Poor health
could impact on the performance and attendance of employees, thus
further increasing the pressure on nurses and exacerbating the
existing problems. There was no single database for tracking the
number of hours worked by nursing staff, and whilst trusts are
able to monitor the number of extra hours worked by in-house bank
staff, it is more difficult to do the same for a member of staff
working at a different site or for a private agency.[75]
59 Qq 53, 194 Back
60
Qq 53, 196 Back
61
Code of Practice for the Supply of Temporary Staffing,
Department of Health, July 2002 Back
62
C&AG's Report, para 3.1, 3.32; Qq 63-64 Back
63
Q 185 Back
64
Q 179; C&AG's Report, Figure 23 Back
65
Qq 179-180 Back
66
Q 145 Back
67
Qq 28-30, 121 Back
68
C&AG's Report, para 3.32, Figure 23; Qq 57-66, 144 Back
69
Qq 58, 121 Back
70
C&AG's Report, para 3.12 Back
71
Qq 122-124 Back
72
Q 42 Back
73
C&AG's Report, para 3.33 Back
74
Q 190 Back
75
Qq 14-16 Back
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