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Dr Zofia Bajorek

The NHS Conundrum: Locum Costs vs Patient Care.

Authors: Dr Zofia Bajorek Dr Zofia Bajorek

14 January 2014

The use of temporary staff in the NHS is not a new story, but today it makes the headlines again, with news that locum spending in A&E has risen sharply (by 60% in the last 3 years).   The data obtained under the Freedom of Information Act shows that 1 in 10 consultant shifts, and 1 in 6 junior shifts are now undertaken by temporary staff.  Headlines are angry at the cost this imposes on the system (locums can cost up to 4 times more than permanent member of staff), but what about the knock on effects?  What are the implications for patient safety and service quality, and how does the use of locums affect other staff in the department?

Before starting at The Work Foundation, I completed my PhD on just this topic. Temporary staff have always been used extensively in the NHS, and they remain a key component of a hospital’s ability to maintain fluctuations in demand, to cover vacancies or short term absences and, importantly, to ensure that is adequate staffing levels for the provision of safe and effective patient care.  In 2002, the Department of Health published a code of practice for the supply of temporary staff.  It highlighted that greater consistency in the co-ordination and use of temporary staff in healthcare was needed, not solely for ensuring value for money, but for improving the level of patient care that temporary staff offer.  Yet 12 years later, have we learnt the lessons?

So why do A&Es need temporary staff?

My research highlighted that HR Directors often cited the need for the flexibility in vacancy levels in an attempt to control labour costs and temporary staff were used to cover these vacancies.  Yet, ward level managers and staff often discussed the need for staff, so the A&E was staffed sufficiently to maintain patient care.  Additionally, A&E staff are under particular pressures due to the challenging nature of the work; the pressure and stress that staff were under to meet Government targets on waiting hours meant that staff sickness was often high and importantly, people choosing A&E as a specialty is reducing. 

If temporary staff are needed how can they be managed to ensure quality patient care?

There is a widespread belief that the use of temporary staff equates to poor care, yet my research suggested that this popular perception could not be supported by systematic clinical evidence.  However, a lack of familiarity with the team and the environment, and poor communication with team members can lead to delays in service quality.  Hospitals have procedures in place to reduce these risks however.  For example, my research shows that using an in-house staff bank can not only reduce the cost of external agency fees, but also ensures that the temporary staff hired know the system and have developed working relationships with those they have worked alongside.  In-house staff banks also have stricter regulations regarding training standards to ensure that all temporary staff have their training up to date to provide the necessary care. If external agency staff have to be used, then it is preferable to recruit staff who have previously worked in the department, as they know what is to be expected of them and can be trusted to work safely and sufficiently.

However, an important finding was the impact of the use of temporary staff on permanent staff.  Permanent staff and ward managers frequently discussed their need to increase their supervision, and undertake roles that temporary staff were unable to complete, increasing their workload and the pressure placed upon them, potentially to the detriment of service quality.  When agency staff were used, resentment was expressed by temporary staff at the ‘distributive injustice’ when agency staff were paid more per hour for doing less. Managers can prevent this by using temporary staff known to the department (preferably, in-house bank staff), developing a culture of supervision where staff are encouraged to integrate temporary staff into the department, and develop clear contracts with temporary staff so they know what is to be expected of them when they enter the department.

Due the nature of A&Es, which are busy 24 hour departments, with fast patient throughput, and national difficulties in retaining and recruiting temporary staff, the need for temporary staff to cover shifts is certain to continue.  However, senior managers can put practices in place that can manage concerns regarding costs and quality of patient care.  My concern is that if managers solely focus on the cost of temporary staff than ensuring they are managed correctly, then quality of patient care may be compromised.