Mark Bird can see the arguments about locum work from both sides. As a unit nursing manager in a London trust he has to ensure that his two medical wards are adequately staffed, even if that means employing comparatively costly agency staff.
But as a trained nurse who also does agency work, he knows how vital the extra cash is. Mark, like many of his colleagues, does extra shifts in his own hospital, arranged through the Nightingale agency. He generally works at weekends or takes a day's annual leave, and aims to supplement his£1,300 take-home pay by about£750 per month.
He realises it may sound bizarre for him to be employed through an agency to work on his own wards, but says the practice is commonplace in the NHS. The motivation is as much patient care and supporting colleagues as the money.
'Without us doing this the service would go under, 'he says. 'Nowadays I confine myself to doing work at my own trust, but when I worked elsewhere I used to go to other hospitals.
'It is better to do agency work in your own environment because it is less stressful and you feel you are still supporting your own team. '
Bringing in agency nurses from outside the hospital would be more stressful for the existing staff and would be an unknown quantity, he suggests. He is paid around£15 per hour as an agency nurse on D or E grade - a considerable increase on the£10. 50 he gets in the NHS as an H grade. The cost to the hospital is higher - perhaps 20 per cent more on top, he says.
His trust is moving to a 'bank' system where nurses volunteer to do extra shifts but no agency is involved. Although pay rates have not been finalised, they are likely to be less than an agency will pay.
In an exceptional month - when he takes a week or more annual leave but still works during that time - he may take home£1,500 from agency work. 'I use it to pay for some little luxuries that I can't get with my normal salary, 'he says. 'It is not greed. It is just that you want to go on holiday with your friends, or visit your parents - and why shouldn't you have a new pair of shoes?'
He points out that with six weeks' annual leave and rostering which may mean they only work 14 days per month, nurses have plenty of opportunities to do agency work. Many work more hours than him - in some cases taking home an extra£2,000 in a month.
Mark, who is 33, admits there are drawbacks from working the extra hours. 'You reduce your annual leave and you do get tired over the year - you are sacrificing your own free time, 'he says. 'I know nurses who finish at six in the evening, but because they need the money - they have families - they then do a night shift. '
But he is adamant he would never do a shift if he felt he was not up to it. Doing extra work becomes a way of life: 'From the day I went into nurse training I have always done extra;95 per cent of the nursing people here have more than one job.
Every nurse does agency or has a second job. '
Working in nursing homes overnight is often a popular option as it can be done without the hospital's knowledge. But work within a nurse's own hospital has to be authorised, and there can be some hostility from managers.
However, with one of his wards 10 staff short, Mark insists there is often little option other than employing agency staff. 'You do feel guilty for doing extra work - I don't know why, 'he says. 'To be honest, I'm probably owed£50,000 in back money for the extra hours I have put in for the NHS over the years. '
The health service pays heavily for under-staffing. The thousands of nursing vacancies around the country and shortages of doctors in some specialties contribute to the cancellation of operations and long waiting lists, undermining public confidence in the NHS. But there is also a financial burden as hospitals attempt to plug these gaps by taking on temporary staff at all levels, from porters to laboratory scientists, nurses and locum doctors.
It is difficult to get a breakdown on the numbers and costs of temps in each profession. The Department of Health insists it does not collect such information. But it does admit that in England during 1991-98, the cost of agency staff rose from£121m to£216m. If the annual increases in the more recent years were repeated in 1998-99 and 1999-2000, agency staff could now be costing the NHS£260m per year.
Concern is growing. The Audit Commission is currently investigating nursing agencies, and in February this year an Accounts Commission report said that Scottish trusts spent an estimated£25m a year on bank and agency nursing.
1Use of agency nurses in Scotland has grown from 200 whole-time equivalents in 1994 to 540 in 1998.
Trusts in other parts of the UK will have experienced a similar pattern. Agency nurses have ceased to be looked upon as a top-up pool for unforeseen circumstances, such as sickness or an unplanned rise in demand. They are now an expensive but essential part of the workforce.
Ministers and MPs on the Commons health committee are worried about the rising cost. In its report on future NHS staffing requirements, published in March 1999, the committee accepted that there would always be a role for agencies, but said the service should cut its spending on agency staff by filling the gaps with its own staff and paying 'appropriate overtime rates'.
2In its response to the report, the government agreed that use of agency staff should be reduced but added that it was up to individual NHS employers to decide how best to cover unfilled shifts. This could include using agencies.
It has also set up a working group under the NHS social partnership forum to examine the use of bank and agency staff. But in the short-term it recognises that the NHS will rely on agencies until more nurses and doctors are recruited.
Unsurprisingly, given its high cost of living, London is hit particularly hard. The MSF union claims that 500 pathology locums are working in NHS laboratories in London and the South East of England. Many nurses choose agencies through which they can earn£2 per hour more than they would on a staff contract.
According to one human resources professional, some trusts in the capital have given up advertising nursing vacancies and turned to agencies instead.
With unfilled posts running in the hundreds in many London hospitals, it is believed that trusts there spend millions of pounds per year plugging the gaps with agency nurses.
'There is no end in sight because agency nurses have no incentive to join the NHS full-time because they get paid more and they can pick and choose where and when they work, 'he adds.
Helen Chalmers, finance director of University College London Hospitals trust, says it is important to distinguish between different types of agency usage.
'There are some areas where we are more concerned about using agencies than others. We are particularly concerned about nursing agency costs and asking what we can do to deal with these costs.
'The capital's teaching hospitals are getting organised against exploitative agencies, 'she says.
'We are considering a range of options, including what we can do externally, primarily across the London teaching hospitals.
'We want to take a common approach. If one firm is charging exorbitant rates - and there are firms that do - I don't deal with them, but it may not be a problem for the firm because there are another eight trusts that do.
But if we have a united front and will only pay what's reasonable they won't be able to play us off against each other. Firms over-price significantly, but lack of concerted action allows this to happen. '
Many trusts, such as Chesterfield and North Derbyshire Royal Hospital trust, have signed contracts with agencies in an attempt to hold down costs. Eric Morton, the trust's finance director, says: 'We need to use a limited number of agencies, but we have tried to build up a close relationship with a preferred provider. However, it is not always able to meet our needs and where it can't it is often very difficult and expensive to fill the shift. '
Chesterfield has a different set of problems to those in London. 'Locum doctors are able to pick and choose where and when and how long they work. It is becoming increasingly difficult to get locums. We tend not to use agency nurses but use staff from our own bank, 'he says.
'There are additional problems with agency staff if they don't know the hospital site, how things are done, who to call, so you have to put them through some sort of induction procedure and kit them out with IDs, bleeps etc. But this can be difficult when you need a locum at three in the morning. In some respects staff would rather soldier on than spend time keeping an eye out for a new locum. '
Dawn Jackson, marketing director at BNA, the largest nursing agency with over 160 offices, denies claims that agencies are making huge profits.
'We have calculated that 88 per cent of the£216m spent on agencies in 1997-98 represents staff pay itself and national insurance contributions.
Most of our business with the NHS is under contract that makes charges very cost-effective. We work at or close to the NHS pay rates and the pay rates are usually stipulated by the trusts themselves. '
She adds: 'Some of our agency workers are NHS staff, but a large percentage are people who don't have a substantive post but they come to us because we offer the most family-friendly places and flexibility. From the feedback we get from these nurses, we offer an opportunity to work for the NHS to those who cannot commit to shift work. '
Robert Murgatroyd, chief executive of Thornbury Nursing Services, says those who believe agencies are ripping off the NHS are making 'an easy assumption'.
'It strikes me there is a criticism abroad about nursing agencies that is nothing like the true picture. Nursing agencies have a role to play to support and help the NHS when the NHS is unable to find staff from its own resources.
'It might not be too strong to say we have been able to keep waiting lists down and operations on track that would have been impossible had the NHS been left to itself. '
However, he acknowledges that agencies are not altruistic bodies but are in business to make a profit. 'It is true to say we are commercial organisations, but I think there has been a realisation that the private sector has an important role to play alongside the state sector. There is a lot of scaremongering about the amounts of profit nursing agencies make, but they are a lot more imagined than real. '
But how can he justify such remarks when his agency pays an auxiliary nurse£7. 18 per hour for a morning shift (8am-2pm) but in return takes£12. 45 per hour from the trust?
'There is an infrastructure being put in place behind the provision of that auxiliary, 'he says. 'They aren't recruited and tested for free. They have to be found at the last minute and often asked to drive many miles to the client and do an uncomfortable and unsocial shift. '
Other agencies may provide the auxiliary at cheaper rates but the quality may not be as good, he says: 'Our position is quite specific - we provide highly specialised and particular kinds of nurses up to the last minute. We have had to make a number of significant investments to do that, especially in a marketplace that is more and more difficult because nurses are leaving the profession. We have the same pressures as the NHS in recruitment and we also have a hard job retaining them. It isn't a profession that pays very well, so we have put a lot into retention, such as education, ongoing continual professional development programmes and free study days, for example. ' He argues that the company has invested heavily in information technology, including an interactive website, in order to meet the demand for specialised nurses at the last minute.
'One of the mistakes people make is to look solely at the commission; the cost of the nurse sold as it were. This is not profit. More than 70 per cent of the gross profit is salaries and the net profit is relatively limited by the time you have made these investments.
'The final figures are not very impressive and wouldn't impress investors - a 5 per cent or 6 per cent return on sales isn't a particularly big margin. '
He believes there is an element of the NHS passing the buck in blaming nursing agencies for the costs. 'They are transferring the problem to somebody else. The shortage of nursing resources in the country has occurred because nurses are not properly recognised and respected. '
Many NHS managers would have sympathy with his last point. As one HR director says: 'We can plan for it, we can try to use our banks more efficiently, we can exert pressure on the agencies to hold down costs and we can rely on the goodwill of our staff. But at the end of the day we will always rely on agencies, particularly for nurses, until we can recruit and retain a full complement of NHS staff. '
Working in hospitals across Britain has become a way of life for Dr Abdul Kazi over the last four years. As a locum consultant in genito-urinary medicine he travels around the country, covering for other consultants'holidays, study leave and in some cases filling in until new consultants can take up their posts. Jobs can last from a week or two to 18 months.
It is an unsettling way of life that Dr Kazi hopes will end when he gets a substantive post. 'It is a type of life which nobody would like to do - but which has to be done, 'he says. 'It is difficult to say when I will get a post, but obviously one would want to settle down somewhere. '
Dr Kazi, who is in his 40s, had an appointment as a senior registrar in genito-urinary medicine before working in Zambia for an overseas aid agency. 'I went there for two years and then stayed on for 14 because they wanted my services, 'he says. 'It is always difficult when you have been away from a system and then come back and find it's quite different from what you left. '
After more than four years as a locum much of his work is 'repeat business'and there are a number of trusts which regularly ask him to fill in for consultants on leave, enabling him to plan his diary some months ahead. 'It is always better to work in a place where they know me, 'he says. 'If you go to a new place you have to find out your way about - where the canteen is, where the accommodation is. There are a lot of disadvantages. '
But he is also registered with a number of locum agencies and accepts work through them. Like most locums he does end up with some gaps in his diary, but treats them as unpaid holiday.
One of the main differences between working for an agency and directly for a trust is the pay. Trusts pay a flat national rate for locum doctors, but they are then entitled to contribute to the NHS pension and to build up holiday leave. A locum consultant would normally receive£1,104. 95 per week or£100. 45 per notional half day.
Agencies pay a rate per hour - which is usually higher than the equivalent NHS rate - but there are no such fringe benefits. Locum agencies are currently advertising rates of£32-£35 per hour. Deciding whether a post offered through an agency or a direct one is better can be a difficult juggling act for Dr Kazi. 'It depends on which specialty you are working for - if you are doing a lot of on-call it may be better to go through an agency, 'he says. The agency is paid a commission on top of the doctor's pay, but like most locums Dr Kazi does not know what the overall cost of employing him is for the trust. He agrees it is galling to see commission paid, but adds 'but what can you do?'But even if they are sometimes being paid a higher hourly rate than substantive consultants, even the best locums find it difficult to match their earnings over time.
'Out of the 52 weeks in the year you might only be working for 40 or so, 'he adds. This reduces his yearly earnings to around three-quarters of a permanent consultant's salary, which starts at just under£49,000. He earns£37,000-£40,000. He also has the added disadvantages of living away from home - his family is based in Birmingham - and having to find accommodation, either in hospital or renting or staying with friends in the area. But despite the problems, Dr Kazi believes locums have an important role to play in the NHS and says that his experience of working alongside permanent staff has always been positive. 'I know of locums who have had difficulties and have had remarks made about their work, 'he says.
'Locums are always looked down upon. But we provide a service which is badly needed. '