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Agency Ignorance

June 4, 2015

By Basket Press

Oh dear, Jeremy Hunt has been making his mouth work again about agency nursing costs, and showing his ignorance yet again. Mind, he’s not the only one.

What is it that these supposedly clever and most definitely very well remunerated people don’t grasp about NHS staffing? It’s almost as if they are wilfully ignoring the bleedin’ obvious.

Do I need to spell it out in very simple terms? Looks like I must…

But first some disclaiming: I dabbled in ward management for a few years, writing duty rotas, sorting out staffing problems, authorising bank, over-time and agency expenditure; I also worked for a couple of agencies when I stepped off the ladder in order to protect what passes for my sanity; I have read all manner of policies, papers, National Service Frameworks (NSFs) and the like on staffing; I have occupied a service development role; I have mentored many, mostly final year, students. I don’t believe, as conversations with friends and family confirm, my experiences are out of the ordinary.

Really, it isn’t hard: ward managers do not set out to spend money on agency staff. It is a last resort.

When I was a lad, I put quite a lot of effort into balancing staff requests against the needs of the ward, current patient needs, skill mix, gender mix, experience mix, student needs, staff needing to be present on particular shifts and the like, and mostly I did it well. But, to borrow a line, events, dear boy, events would get the better of me, whether that be staff sickness or emergency, a couple of high dependency admissions throwing out last week’s calculations or whatever and you have to respond. The response would move through begging favours for shift changes, offering over-time, through contacting the bank and lastly agencies to get a shift covered and maintain patient safety.

Likewise when I did agency work I was always, but always, covering the unforeseen: sickness; specialling a high dependency patient who had been urgently admitted or who required a qualified specialist nurse; specialist escort.

Use of agency staff is never just the easy way out.

Underpinning this is the inconvenient fact that for a host of reasons most wards have no spare staffing capacity or are running under recommended compliment, so there is NO SLACK…

Now, ask why this is the case.

The answers haven’t changed since I was a student in the ’80s: the advent of trusts brought pressures for “efficiency savings”, meaning staffing was under the hammer as it is always the largest part of a budget and nurses the largest body of staff. This in turn meant pressure to freeze vacant posts, then ultimately to remove posts, which as we have seen has only worsened in the last 5 years. This was exacerbated back in the day by short-term managerial contracts with performance linked to financial rather than clinical targets, so managers hated it if you blew the budgets by spending on more staff. More recently it meant no jobs for newly qualified nurses, who were often lost to the profession – my old trust for several years would only offer bank posts to the newly qualified and then wondered why they could not recruit even to that.

It also meant services commissioned with stupidly low numbers of staff. I turned down one ward management post because the service manager would not tell me what the staffing complement would be; I had been primed by the consultant that it was too low to ensure safety and the manager did not deny that this was the case. I arrived for another interview as ward manager on a new unit with sample off duties showing that the proposed staffing levels were unworkable. Despite this being discussed at length during the interview, I was offered the job. Foolishly, as it turns out, I accepted, thinking we would fail for a while then renegotiate with the commissioners…Oh no, we ran on over-time, on-call, and bank and agency staff in order to cover shifts adequately. Agency expenditure increased as permanent staff became unwilling and unable to do more over-time. In just over 2 years we lost over half of the original set of qualified staff, including me.

We have had policies and NSF recommendations on minimum staffing levels coming out of our ears for years, and more recently the fallout from Francis 1, but commissioners have not appreciably altered their behaviour in light of these.

And then look what happened to nurse education: numbers of places cut, with the predictable drop in available nurses a few years down the line…

And what about how many trusts manage their banks? My old trust, and many of its neighbours, put all qualified nurses on the bottom of Band 5 with no annual increments. Oddly many folk found this unappealing and financially unviable, compared to either over-time or agency work with inevitable consequences for bank recruitment.

Now, how hard is it to have predicted that any and all of the above would happen? I did, my sister did, many of our friends and acquaintances did, but, hey, we were only Band 5, 6 or 7 nurses: what do we know? Or more importantly who listens to us? Y’know, the people who have been running wards or community services for years, who grapple daily with staffing issues, who see first hand every single day of our working lives what is actually required, who use the best available tools to work out staffing for the patients we have, who have to pick up the pieces when something goes wrong and conjure up staff from somewhere to stop the whole shebang from falling apart…To take it a step further, my payroll officer wife predicted much of that as she sees changes in staffing via payroll…

Tell me, please, Jeremy and Simon, with your salaries that are multiples of what any nurse will ever earn, why do you not know these things?

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