Patient First, the UK's largest patient safety event, will return to London's ExCeL on 21-22 November 2017
Collaboration with staffing suppliers is now more critical than ever in ensuring NHS trusts can weather the recruitment storm of the coming months, says the REC’s Vicky O’Brien.
The recent caps and controls introduced to reduce agency spend are illogical and counter‑productive in their design, and risk jeopardising patient access to high quality care across the NHS, as well as escalating agency spend in the long term. Over the past six months, NHS Improvement has introduced a variety of caps and controls to reduce NHS trusts’ agency spend, and dis-incentivise healthcare professionals from choosing locum work over bank or substantive roles. For all these highly disruptive interventions, they have still failed to tackle the fundamental driver of agency spend in the NHS: the shortage of staff willing to work to standard substantive pay and conditions.
While REC members continue to supply staff to cover last minute sickness and spikes in demand, they are also increasingly being called upon to cover longer-term vacancies and staffing gaps caused by years of poor workforce stewardship by the government. As many as 82 per cent of agency bookings by 54 NHS trusts in Q2 2015/2016 were to fill substantive vacancies, an increase from 66 per cent of bookings in Q3 2014/15.
Ensuring our wards are safely staffed is becoming increasingly challenging not only for NHS trusts but also their temporary staffing suppliers. The lack of nursing, medical and care staff available for both perm and temporary placements is consistently flagged in the REC’s ‘Report on Jobs’ survey, the most up-to-date monthly picture available of recruitment, employment, staff availability and employee earnings in the UK jobs market.
While we fully support recent efforts to improve booking procedures at trust level, as one acute trust neatly surmised in a recent Kings Fund’s NHS Quarterly Monitoring Report: ‘We need a workforce solution to ensure that we can recruit sufficient nurses and doctors. The increase in temporary staffing is not just down to a lack of controls’.
Stakeholders across the NHS are having to concede that government cuts to training places, high attrition rates due to unfavourable substantive pay and working conditions, and barriers to overseas recruitment are really starting to bite. Nearly everyone, it seems, except the Secretary of State for Health.
Sadly, the recently introduced caps and controls on NHS agency spend will only exacerbate the escalating recruitment and retention crisis facing the NHS. Since November last year, the healthcare professionals who provide crucial front-line services to NHS patients – often at short notice, during unsociable hours, and having travelled vast distances – are having their pay progressively cut to the point that working for the NHS is no longer affordable for either substantive or agency staff. The REC does not believe that these price caps are safe, sustainable or cost‑effective. In their current form they undermine existing framework agreements, leading to an escalation of rates and off‑framework usage (the stated targets of these reforms). They are also driving many existing agency staff out of the market, further exacerbating staff and skills shortages within the NHS.
Filling in at short notice
Three quarters of REC members we surveyed in January said that restrictions on NHS spending on agency staff have made it more difficult to find doctors and nurses willing to fill temporary vacancies. While demand continues (a third of recruiters we surveyed say they are receiving on average more than 100 requests for staff per NHS trust, a similar level to the demand recorded in an REC in the summer), eight in ten told us they were only able to fill up to half the requests they receive from NHS trusts, due to a drop in the number of doctors and nurses willing to fill in at short notice on NHS wards.
At the time of writing, Monitor is yet to reveal whether or not this shortfall is being picked up by substantive staff, despite having a statutory obligation to ensure patient safety. What we do know is that, only a month into the first November caps, 92 per cent of acute hospitals in England reported that they were unable to find enough nurses to staff their wards. A survey conducted by the Nursing Times found that three quarters of nurses feel they are being forced to leave patients without the care they need at the end of shift due to staff shortages, unsurprising when half feel there are rarely or never enough staff on their wards.
NHS agency workers are highly skilled professionals who trade job security and many of the perks enjoyed by substantive staff in return for greater flexibility. Our members tell us that the overwhelming majority of their candidates are formerly long-time, substantive employees of the NHS, or alternatively, or they combine locum work with existing substantive posts to supplement their poor pay or gain experience in different areas. These workers are keeping some of our remote and most challenging health services going.
The idea therefore that by cutting what they earn they will clamour to return to the NHS as permanent employees is misguided – especially in light of current negotiations on pay and conditions for substantive staff. Inevitably some agency workers will go to work overseas, others will move into the private healthcare where the caps won’t apply and some will find flexible and better paid employment in another sector all together.
Another significant cohort of agency workers are overseas migrants, who come to work in the England for a fixed period (usually 2-3 years) in order to gain experience of working in the NHS and earn a certain amount of money. Many of these candidates have fed back categorically to REC members if the pay caps are introduced, England will no longer be a destination of choice. And for the large share who supplement substantive positions with locum work, they may choose to avoid bank work and evaluate their careers in the NHS completely. The real impact is that we could see the care of millions of patients who depend on the NHS being put at risk over the coming months.
REC members fully recognise that there is an urgent need to make savings, and improve the cost-effectiveness of temporary staffing in the NHS. However, current design and implementation timescales of these caps and controls are unsustainable and potentially dangerous. Many NHS trusts appear to agree – just over half of the chief executives, HR, finance and clinical directors recently surveyed by Health Service Journal felt their Trust was ‘unlikely’ or ‘uncertain’ to meet the capped rates for Band 5 nurses, staff grade doctors and for consultants.
To add to this landscape of disruption and uncertainty, various stakeholders are still pressing NHS Improvement for immediate clarity on several outstanding questions including: will the new set of framework agreements due for tender address design flaws that made previous incarnations commercially unsustainable – for both trusts and their staffing suppliers?; and will pay uplifts in critical skill shortage and remote regions be back on the cards as NHS Improvement moves to specifically cap worker pay?
Get back to basics with workforce reporting
Unless data collection is radically overhauled, any long-term impact assessment of these caps and controls will be impossible. The Health and Social Care Information Centre lacks the ability to measure how many temp workers there are in the system. Meanwhile, far too many NHS trusts are struggling to adhere to any standardized procedure for measuring and tracking their staffing costs.
A recent Monitor audit found that 49 per cent of Foundation Trusts made ‘materially inaccurate’ data submissions, including on staffing costs. Bad practice highlighted included calculating staff costs based on subjective codes, and the use of inaccurate job plans.
And even more worrying, the weekly monitoring form used by Monitor to capture the frontline impact of these caps and controls does not allow trusts to describe the impact on patient safety and service quality. Poor workforce reporting was both a symptom and driver of escalating agency spend. With NHS Improvement slow to prioritise poor workforce reporting, the REC is happy to facilitate regional and local roundtables for NHS HR managers to feedback suppliers insights on how to better manage and monitor local supply chains.
Consider your regional brand
With the removal of regional pay enhancements, and diminishing candidate pool, both recruiters and NHS trusts are learning the importance of considering their brand.
The REC’s Good Recruitment hub contains a wealth of case studies, research and data on good recruitment practice for employers, and the latest developments in recruiting and resourcing, collated from over 90 business organisations that have signed up to the Charter. The self‑assessment tool enables employees to benchmark their company’s recruitment processes. While trusts’ hands are tied when it comes to long-term pay incentives, Good Recruitment Campaign research such as ‘The Candidate Strikes Back’ shows how getting the initial recruitment process right in a fiercely competitive market, has long-term dividends in terms of retention.
Diversity not monopoly is the key to long term stability
With Monitor and the TDA telling NHS trusts to lever their collective purchasing power, surely it makes sense for them to encourage a diversity not monopoly of suppliers. The majority of REC members that operate off-framework do so not by choice. Rather, many new start-ups or SMEs have faced numerous challenges in gaining access to existing frameworks agreements. If customers choose only framework agreements that are commercially viable for SME healthcare recruiters, they will be in a better position to ensure suppliers buy in.
The REC is working hard to seek clarity on these and many other points, champion the vital (and all too often miscast) role healthcare recruiters play at the frontline of the NHS, and steer NHS Improvement away from further disastrous interventions – such as the proposed April cap rates. In the meantime, our members are keen to step up and help their clients navigate the immediate fall-out. We hope you’ll join us.