Topic analysis: NHS agency spending

What we learnt

The total spend of 181 NHS trusts in England was just over £3bn between 2020 and 2023 . If we had received data from all 202 NHS trusts in England, the spend would have been even higher. Spending also increased year-on-year across England and its regions.

Across all 3 years, the average spend of a trust was ‘modest’ at around £15.3m. But it was as high as £82m for one trust, Oxford Health NHS Foundation Trust. The spend of most trusts increased from 2020 to 2023, but around a quarter were able to spend less by 2023. One trust managed to eliminate their agency spend.

*This partly reflects the number of trusts in this region.

For many nursing staff, agency work offers flexibility that substantive roles cannot. This likely benefits nursing staff with caring responsibilities, those undertaking studies and those who prefer to work part-time. Agency workers bring valuable capacity to all types of health and care services, and their perspective and input is essential.

While the option for individuals to work for agencies is important, services should not be over-reliant on agency staff to run essential services. When services are unable to run without agency staff, this indicates a failure to undertake proper workforce planning, and an inability to recruit and retain substantive staff.

If services cannot recruit and retain substantive staff, they are more likely to reach out to bank and agency staff to fill gaps in staffing rotas. Paying for agency overheads is expensive, and this is likely to have a detrimental impact on service budgets in the longer term.

In the NHS in England there is a move to reduce the total spend on agency staff, by encouraging workers into substantive and bank roles. NHS services are required to request an exemption if they cannot fill a role using bank or substantive staff. When services cannot fill a vacancy with substantive or bank staff, there is a price cap for the amount which can be spent recruiting an agency worker. Services do however have a ‘break glass’ option to override price caps if patient safety is at risk.

The findings of our freedom of information request indicate that services are frequently engaging agency workers, and the total overall spend is increasing year on year. While we recognise the efforts of NHS leaders to reduce spending on agency workers, within the context of widespread nursing shortages and vacancies the cap on agency spending becomes increasingly irrelevant.

There are several key factors that improve patient experience, including:

• consistency of staff
• staff familiarity with local process and procedures
• strong multidisciplinary team ethos and close working 

Given that agency staff may only be doing one or a small number of shifts at a time, it is difficult to ensure that this does not disrupt the patient experience. Substantive staff members may need to spend time inducting new agency staff, helping them to understand local processes and introducing team members. This takes time away from the other requirements of their roles.

Review flexibility options for trust and bank staff.

There are many reasons why people work for agencies. Within the context of high agency spend and high numbers of trust vacancies, it’s important that leaders of integrated care systems gather local information from agency workers to understand why they don’t choose to work in other types of roles. This information is vital to improving trust and bank role offers, making them more appealing to workers and more cost-effective for local services. 

Consider local options for improving agency staff inductions.

Trust staff may spend significant time inducting new agency staff. To reduce this, and provide more consistency for patients, services should look at options for inductions, training and familiarisation in local services. This would allow agency workers to get up to speed with local processes more quickly, and may mean they feel more comfortable to repeatedly work in the same services.