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In praise of agency nurses

November 18, 2014

There is a special circle of Media Hell reserved for agency nurses. Staff on permanent contracts don’t exactly have it easy. Log onto any news feed and you’ll soon learn that when we’re not citing our educational attainments as the reason we can’t help Granny to the loo, we’re letting her drown in her own wee while we bid for Jimmy Choos on eBay. But for agency nurses, this is nothing. On top of all the usual garbage, they also have cope with being portrayed as gormless liabilities who are more of a hindrance than a help. And that’s before anyone mentions that funding their wage bill is the main reason the NHS has run out of money. I don’t know how they sleep at night.

Trawl through the on-line archive of even a liberal-minded newspaper like the Guardian, and you’ll find the demonisation of agency nurses stretches back at least sixteen years. As long ago as January 1999, the paper reported that ‘Britain’s biggest nursing agency is hiring out nurses…despite complaints that they are incompetent or even mentally unstable’.

The years since have produced little to challenge that perception. The use of agency nurses has allegedly ‘demoralised’ staff in ITU (2002), wasted permanent staff’s time (2005) and been a predictor of higher-than-average mortality rates (2008). Recent panics about the NHS’s ability to deliver safe care has thrust agency nurses even more firmly into the media spotlight. In particular, 2014 has witnessed the birth of £1800 Nurse.

£1800 Nurse first saw the light of day in a widely-reproduced Press Association report last July, when it was claimed that ‘one Bristol hospital paid £1800 for a nurse on May Day Bank Holiday’. And while it’s repeatedly been pointed out that the nurse in question will have seen nowhere near that much money once the agency deducted its booking fee, it’s a figure that’s proved remarkably reluctant to die. So much so, that it’s become the media’s agency nurse pay-rate benchmark.

The Guardian trundled it out again as recently as November 1st, along with a comment from Labour’s shadow health secretary Andy Burnham. Burnham said that ‘the soaring bill for agency staff, now bleeding the NHS dry, is a direct consequence of David Cameron’s disastrous NHS reorganisation’ (my italics – and actually, Andy, it’s got just as much to do with piss-poor workforce planning, as I’m sure you well know). Meanwhile, Royal College of Nursing General Secretary Peter Carter, responding to the original Press Association report in July, said that ‘agency nurses do not provide good value for money’. With friends like these, who needs enemies?

The reality is that without agency nurses the NHS would collapse. Instead of dissing them, we should be bigging them up! So why don’t we? For one thing, because old attitudes haven’t gone away. Scratch beneath the surface and they’re still there: nurses should work for love; gratitude should be reward enough; pay too much, and you’ll attract the ‘wrong sort’.

Anonymous of Aberystwyth contacted the Daily Mail the other week to make exactly this point: ‘at weekends less efficient nurses would appear…they were agency staff, working shifts at £55 per hour, who then take the rest of the week off’. Ironic, isn’t it, that this is the polar opposite of arguments routinely trotted out about managers: if you don’t pay top whack, you won’t get the best people. Applying the same logic to nurses would see agency staff emerge as the crème de la crème!

But what’s really disheartening are Peter Carter’s comments. When he moans about agency nurses not providing good value for money, it’s like he’s looking down the telescope from the wrong end. What he should really be flagging up is not how much agency staff are paid, but how cheaply, by comparison, the NHS is getting its permanent staff. And in any case, value for money is relative. If the presence of an agency nurse means your mother’s deteriorating condition is spotted in time to save her life, that’s beyond value.

So it’s all very well for Health Secretary Jeremy Hunt to stand in front of an audience at the King’s Fund last week and demand ‘action’ to tackle the £2.5 billion a year that the NHS is now spending on agency staff – ‘mainly nurses’. But what action is possible? The ‘supply side’ options – train more nurses, import more nurses, re-instate more nurses, let people who aren’t really nurses call themselves nurses (that last one isn’t official policy) – will doubtless ease some of the pressure. But none is without problems – and there’s not a hope in Hell that even all of them put together can plug the whopping 47,500 nurse shortfall that the Centre for Workforce Intelligence has predicated will be upon us as as early as 2016.

There are only other two other solutions. One, erode NHS/agency rate differentials by paying NHS nurses more – but Mr Hunt has already ruled that out; or two, cap how much agencies can charge NHS customers – but this would amount to an admission that free markets can’t always be trusted to operate for the common good. And in the political climate currently surrounding health care, that would be a very big admission indeed.

Agency nurses are an easy target. But the roots of the mess we’re in are a toxic combination of cost-cutting and head-in-sand planning and are entirely the result of government policy. If agency nurses can turn it to their advantage – good for them. In other circumstances, there’d be a word for it: enterprising.

  1. Barbara Bradbury, Halland Solutions permalink

    Well put! The poor workforce planning is very concerning,not only for nurses but medics. How the NHS is expected to introduce a full 7-day working plan with current staffing levels is a joke, and the future looks even more hilarious (irony, I know you will ‘get’.)

  2. Thanks Barbara. I do ‘get’ it! If I say so myself, I am particularly pleased with this post. Most agency nurses do a fabulous job in what are often difficult conditions (sometimes made more difficult than they need be by permanent staff who are prejudiced and unwelcoming) and I am sick to death of seeing them get the blame for other peoples’ mess-ups.
    The UK nursing workforce conundrum has no easy answers. I just wish politicians would be honest about that, instead of claiming that, for example, everything would be OK if only we didn’t have to shell out all this money for agency staff. The reason we are having to shell it out is down to their corner-cutting policies and their lack of foresight.

  3. Marieke permalink

    Your point is certainly a valid one and the vilification of agency nurses must stop. It is not their fault they are in such demand. However, it is not surprising that there are issues around care as well. Not being familiar with a patient means you are less likely to spot a change from their baseline. Working for long times unsupervised (for example in district nursing) can mean your skills may not be as up to date as they should be. Many NHS trusts have a (good) habit of demanding nurses go on all kinds of courses and some would say they are constantly nagged about not yet having had this update or another. NHS trusts will put staff on these courses for free. Agency nurses have to pay top dollar for similar courses in the private sector. So it is not surprising that some agency nurses may not go on as many of these courses as they ideally should because they may not be aware they need to update their skills. I think many NHS nurses go on these courses thinking they don’t need an update and then are surprised about the new thing they learn. It is human nature.
    Agency nurses may not be familiar with the ward or caseload. This can cause delays in referrals or when contacting doctors or other experts. This is a similar problem when working a shift with a lot of bank staff. It would be nice if the media reports the issue more accurately as a consequence if poor workforce planning rather than suggesting agency nurses are bad nurses.

    So although agency nurses are not individually to blame (as I assume they all provide care as best they can), there are certainly patient safety issues around using too many agency nurses that can not be denied.

  4. Hi Marieke! Thanks for commenting, and for articulating a slightly different viewpoint, which is always welcome.
    I think it’s easier for nurses to complain about agency nurses than it is for them to complain about their permanent colleagues. If someone is an outsider whom you may never see again, raising concerns about their practice costs you nothing. I think this is one reason why agency nurses make such easy targets. If a nurse’s practice or attitudes raise concerns, of course you should take action. But I wonder if, even subconsciously, we require a lower burden of proof where agency nurses are concerned.
    I take your point about the risk that agency nurses may be less up-to-date, and the difficulties, not to mention costs, they may encounter if they want to update themselves. But all nurses have to undertake continuing education in order to remain on the register. If some people are staying on the register without complying with these obligations, they should not be able to re-register. If they are doing so anyway, but not being found out, then the regulator is also at fault.
    But I think we are in danger of falling into the trap of being overly-negative. Many agency nurses have wide experience, much wider experience than, for example, someone who has only ever worked in a single speciality. And that can be very valuable.
    On the point about not being familiar with the patients, I think this is not just a problem for agency staff – ward staff can also feel that handovers don’t always tell them what they need to know, Background information on the patient’s pre-morbid condition is a frequent lacuna. If, as seems likely – pace Jeremy Hunt – we are going to be seeing increasing use of agency staff, maybe a more positive response would to look at how handovers can convey appropriate information in ways that can be quickly assimilated by staff on the go.

  5. I most certainly don’t think it is the fault of the agency nurses themselves. Much of the issues around the use of agency nurses are very similar to using any staff that is not part of the normal team (i.e. bank staff). Yes, handovers should be better but I believe that knowing patients well due to having regular contact with them makes it much more likely that nurses will be able to spot things ‘on a hunch’. Bank staff and agency nurses are perfectly capable of doing that, given the chance. The ‘danger’ is not the agency or bank nurse, it is, if anything, the ‘wandering nature’ of the way they work: they might only be somewhere for a day or a few days. This is in no way a reflection on their skills or quality. And yes, I do think it is easier to report concerns about agency staff. If nothing else because nurses might feel the agency nurse does not work ‘the way we do’, and not realise that the agency nurse is actually more up to date.

    You are of course right that many agency nurses have a wealth of experience. Many nurses leave the NHS with years of experience to become a free agent and work for agencies. Their knowledge is invaluable and should be harnessed.
    The idea that agency nurses are mercenaries just because their fees are considered to be high is utterly infuriating. As you said, free lance managers are paid for their expertise and we are fine with doing so… Yet nurses should work for the love of it without having to worry about their overhead costs?
    The NMC should be stricter in enforcing the CPD checks on everyone. Am I right in thinking that in theory I can do a load of modules on the Nursing Times website and call that CPD? That does not seem a good way of checking how good I am as a nurse. I do think that NHS-employed staff are more likely to be more or less forced by their employers to go on refresher courses due to their great fear of being liable in case of something going wrong. I suppose that is a good outcome of that fear. There is so much info to keep up to date with, I might not know there are new ways of doing things unless my employer tells me. However, instead of saying that agency nurses are not good enough, we should make sure they have all kinds of avenues open to them to keep their skills up to date.

  6. PS: The fact that in my cohort a large number of students are writing their dissertation about some kind of improvement to the handover process is enough evidence that even students can see there is much wrong with the way it is done now (Don’t get me started on shift changes that no longer have an overlap and demand that handovers are done in a nurse’s own time)

  7. Hi Marieke! I didn’t reply immediately in case anyone else wanted to jump in. Handovers: a massive issue. How can we make ensure that all relevant and accurate information (and ONLY relevant and accurate information) is handed over in the short time available to devote to each patient? If any of your cohort who have done the research here want to distil their thoughts into a blog for me, put us in touch!
    In the original blog post, I chose to focus on media images of agency nurses, but as @AlyxPeters1 pointed out to me over on Twitter, one possible answer to the conundrum of agency nurses not getting sufficient access to updates and training is an NHS-run agency. Unfortunately, Jeremy Hunt is reportedly thinking of selling off NHS Professionals, which provided just such a service. (This news item from October 2014 is quite instructive:
    What this shows is that there is a lot of double-think going on around the use of agency staff. On the one hand, the Coalition is happy to moan about the ‘waste of money’ it represents, but on the other, they want to increase opportunities for and involvement of their friends in the private sector. The ultimate (but still thankfully very distant aim) might be for the supply of ALL nursing staff to be contracted out to the private sector. From the employers’ point of view, this could go a long way towards realising the dream of a completely flexible workforce. We shall have to wait and see what the benefits to staff will be.

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