Flexibility and workforce innovation: The key to overcoming staffing challenges in the NHS

Even accounting for the crippling pandemic pressures, nationwide staffing shortages and what many highlight as chronic underfunding, the NHS undoubtedly remains one of the greatest institutions the world has ever seen. This is a testament to the resilience and dynamism of the people who work in it – and yet the wants and needs of the healthcare workforce are consistently overlooked.

There were an estimated 100,000 vacancies in hospital and community services at the onset of the pandemic - equivalent to one in twelve roles. The structural deficit of a skilled medical and clinical workforce is enduring. Attrition has only been exacerbated by COVID-19, with rising sickness levels applying more pressure to overstretched services.

NHS trusts have had to continue to turn to temporary staff from both staff banks and agencies to address these labour and skills gaps. This reliance on temporary workers is the result of a perfect storm of systemic, social, political and economic factors.?

It’s an environment that has seen agency staffing often cited as the cause, rather than a solution to the NHS staffing crisis. This is despite framework agencies offering healthcare staff the type of employment the workforce want, and in many cases need. There will always be an ongoing role for agency supply – and without it, the NHS will not have access to enough staff to keep patients safe.

‘Work’ is not one size fits all

People leave permanent positions in the NHS for a host of personal and professional reasons, from caring responsibilities to employee burnout. An ageing workforce also threatens to exacerbate current staffing shortfalls. 47% of NHS staff are aged 45 and over, with 20% already at an age they could access their pension. For many, a career in healthcare is a vocation, and it’s one some wish to continue with greater flexibility after a change in life circumstances, such as having a family or moving into retirement.

The NHS has not yet been able to maximise the societal shift towards increased flexible working, effectively blocking people from adding value as and when they can or want to. The flexibility agencies provide ensures expertise and skills are not lost, allowing them to be deployed into critical open vacancies.?

In short, agency work ‘works’ for healthcare professionals. Increased flexibility empowers those with caring responsibilities to fit work around their personal commitments. Others benefit from a single PAYE reference and tax simplicity when looking to pick up extra shifts to boost earnings to build a deposit for a first home or work off student debt. Some simply enjoy the freedom, variety and professional development opportunities that come with working across multiple hirers which would not be achievable working for a local staff bank.

While other industries have embraced the ‘gig economy’ and employees’ preference for flexibility by partnering with specialist recruitment process outsourcing, managed workforce and master vendor agencies to drive value, the NHS continues to hold this sector at arm’s length. This approach is further compounded by a lack of workforce data which leaves trusts and Clinical Commissioning Groups working in silos, competing for the same resource.?

The NHS system lacks the ability to accommodate flexible working. This inflexibility, the damage it causes and the growing acknowledgement of the challenges outside of policy making circles is not new. In the 2019 NHS Interim People Plan, there was a clear call for a more flexible workforce, which was reinforced in the NHS People Plan in July 2020.?

Politicised policy making

Historically, the cost of agency staff was expensive relative to substantive employment. This made the sector an easy target for policy makers looking to explain away financial deficits. This is evident in a repeated narrative of ‘extortionate pricing and profiteering’ which can be seen throughout the period of the Francis Report’s publication in 2013 and the introduction of the Agency Rules in 2016.?

Agency staffing - the true cost?

The perception that agency staffing is expensive continues to be pervasive amongst policymakers and executive organisations. Agency spending caps have been widely deemed successful, with NHSEI figures confirming the level of agency spend over recent years has decreased from ￡3.63 billion in 2015/16 to ￡2.38 billion in 2018/19.?

Conversely, spend on unregulated and uncapped staff banks have increased from ￡2.98 billion in 2016/17 to 3.78 billion in 2019/20. These figures reveal that while Agency Rules and fee caps have delivered reductions in agency spend, overall workforce costs have increased.

The 2019 NHSI (now NHSEI) document, ‘Performance of the NHS Provider sector’ confirmed that the provider pay bill is the NHS’ single largest area of expenditure. In 2019, spend on staff pay was just short of ￡55 billion compared to a budget of ￡53 billion. It identified increases in spend on temporary staff as a key driver of the overspend, stating that spending on bank staff was ￡666 million (24% higher) more than planned. Comparatively, agency spend was ￡201 million higher than planned (9% higher).?

The report stated, “This continues the previous identified trend of providers increasing use of temporary (especially bank) staff to manage workload in the face of record demand pressures, high levels of vacancies, sickness/absence and staff turnover”.?

‘Exposing the true cost of workforce’, a paper published by NHSP procurement in 2015, illustrated that business cases supporting an in-house bank arrangement can underestimate annual cost by as much as 40%. This has only been exacerbated in the pandemic where staff banks have further increased rates beyond those of agency to entice agency workers to work with them on a more regular basis.?

In summary, rising bank costs have been obscured by the ongoing anti-agency rhetoric. While trusts are being proactive and successful in their objectives to reduce agency spend, this is a false economy as they’re ultimately spending more. Until the core challenges around workplace flexibility are addressed or the negative sentiment around agencies is challenged, trusts will continue to see rising staff costs with little benefit to patients or staff.?

‘Break glass’ in case of emergency

The NHS People Plan reports ‘incomplete data on both NHS and Non-NHS source of supply’, highlighting a ‘historic negligence of workforce planning’. This is in part due to the way the NHS is fragmented into trusts and CCGs where decisions and processes are largely devolved.?

Without a holistic view of this data, it is difficult to get a complete picture of the NHS’ workforce challenge. This has allowed for the use of expensive off-framework supply to become more prevalent than ever. In many cases these off-framework suppliers are not being used ‘last minute’ as intended and are able to gain commitments to long term assignments due to a lack of workforce planning.??

The implementation of the Agency Rules saw a divergence in agency strategy.?Whilst many hundreds of suppliers signed up to frameworks and complied with the rules, others either refused or subsequently entered the market without access to a framework.??

This has only further damaged the perception of agencies, with less ethical providers creating a second brand, seeking to trade under the framework agency rules as well as in the ‘off-framework’ space. They have proved to be disruptive and excessively expensive as they trade under their own terms and conditions.??

Some businesses that operate in both the on and off-framework space utilise shared candidates and infrastructure between brands in a way that seeks to maximise financial returns.?Unlike reputable suppliers who operate entirely different databases, it is these behaviours that cause concerns over market manipulation, with nefarious agencies looking to ‘game the system’ for their financial advantage. Where there is a place for off-framework supply, it should be used in critical circumstances ‘when no one else can’ and the candidate base and structure should be reflective of this.

Reducing high cost off-framework suppliers is not easy and requires a long-term plan and coordinated approach. Reputable suppliers should seek to work with trusts proactively to execute plans to firstly capture supply via frameworks and then achieve a step down in rates of pay and charges in a coordinated manner.?

Collaboration is key?

Ultimately, it is a holistic workforce approach that can help tackle the lack of workforce supply and temporary staffing overspend. By properly engaging with ethical framework suppliers, the NHS can address the lack of flexibility which excludes swathes of qualified professionals from the workforce. The formulation of 42 integrated care systems presents an opportunity for greater collaboration, empowering boards to respond to staffing and workforce challenges at as regional level.

By acknowledging the needs of the workforce and evolving temporary staffing partnerships in a strategic way, trusts and CCGs can create a system that accommodates both greater flexibility and longer lines of work, providing a constant provision of care for patients at less costs. This will ensure they only need to turn to off-framework suppliers when all other options have been exhausted.?

If the negative misconceptions around agency staffing can be overlooked, the opportunity could be pivotal. Calls to ‘encourage agency staff back into more cost-effective NHS Bank and substantive employment’, as seen in the 2017 Health Education England (HEE) report, are misguided. Although the NHS employs some 316,000 nurses for example, this is no more than 50% of the total nurses employed in the UK, with vast numbers having never worked for the NHS.?

A long term, collaborative approach seeks to support all parties, improving outcomes for healthcare professionals, trusts and patients alike.

About Acacium Group

Acacium Group is the world’s first global health care solutions provider, delivering high quality care and treatment for patients and service users. We are the UK’s largest healthcare solutions partner for both staffing and healthcare services and have been a trusted partner to the NHS for over 35 years, delivering care to over 3.3 million patients in 2021 alone.

Acacium Group is uniquely placed to support the sectors labour supply challenges, operating at all levels of the workforce supply chain. We do this through the provisions of managed workforce solutions, staff bank management, international recruitment, recruitment process outsourcing, agency master vendor solutions and the supply of doctors, nurses and allied health professionals via frameworks. We also offer off-framework ‘last minute staffing’ in critical situations when no-one else can.