WORKFORCE PLANNING: The NHS has contributed to the boom in agency work - by ignoring the needs of its staff. Jan Hesketh explains

Agency nursing has traditionally been seen as a short-term option, a way of earning money while awaiting permanent employment or a way for those in permanent employment to earn a bit extra.

Today, this situation is changing, with increasing numbers of nurses choosing to work permanently for an agency. The conditions and opportunities offered by the larger agencies are on a par with those available in the NHS.

In addition, pay rates are far in excess of those in the NHS. A nurse working extra hours on an NHS bank would earn£7.94 an hour. Nurses working the same extra hours for an agency would be paid£15.50 an hour.

If those extra hours were worked at weekends or on a bank holiday they could earn£39 an hour, and ifthey had specialist experience, such as in theatres, intensive care or accident and emergency, they could earn as much as£50 an hour.

Nurses working full-time for an agency can easily double their NHS salary.

Nursing agencies have been finding work for nurses for more than 50 years. The conditions under which agency nurses could be employed by the NHS were set out in a Department of Health circular in 1976, by the then social services secretary, Barbara Castle. The circular established guidelines for calculating the maximum payment for an agency nurse that would be allowed by the DoH. On this calculation, the cost to the NHS of employing an agency nurse was lower than that charged by the agency to non-NHS clients and was lower than the cost of employing permanent staff.

The conditions set out in the circular were negated when acute trusts were established in the 1990s. As independent bodies, they were not bound by circulars to health authorities and were free to pay the market rate for staff.

In the current crisis, it is not uncommon to hear of trusts paying up to£90 an hour for nurses. The forces of supply and demand determine the price.

To recruit nurses, agencies have to pay high rates, which they then pass on to their customers as costs.

Research suggests that the NHS is losing two nurses for every one it recruits.

1The main reasons given for leaving are dissatisfaction with pay and conditions which has its origins in the political and managerial changes of the 1980s and 1990s.

In 1979, a Conservative government was elected, determined to cut public expenditure and improve the efficiency of public services like the NHS. By the late 1980s and early 1990s, a general recession hit the country and, for probably the first time, nurses faced the possibility of being unemployed.

Those in work were reluctant to leave and those without work were grateful for any they could get.

This situation fed into the hands of managers, who made use of short-term contracts and bank staff to reduce their wage bill. Employing bank staff was cheaper than paying overtime to permanent employees.

This policy may have made sound financial sense to managers in the short term, when work was short, but it had implications for staff loyalty and morale if maintained indefinitely.

Nurses have become used to short-term contracts and working on the bank to earn extra money. They no longer feel loyalty to trusts that treat them as a commodity and have fewer concerns about selling their services to the highest bidder.

2Nurses' pay has remained low compared with the private sector and other public service employers, such as teachers, firefighters and police. For many nurses, pay is a major source of dissatisfaction.

Results from a number of surveys suggest that there has been a substantial deterioration in nurses' satisfaction with their pay during the last decade.

The high rates of pay offered by nursing agencies are an enormous recruitment incentive, and if the current rates reflect the true market value of nurses the NHS is going to find it very difficult to compete with the independent sector.

In the drive to make the NHS more efficient, the needs of nurses to gain rewards from their practice have been overlooked.

This is particularly important in the acute sector, and it is nurses working in this area who have expressed most concern about the standards of care they are able to provide.

3The pressure to treat more patients in response to government targets, but with fewer resources, has led to increased levels of stress among nursing staff. In the 10 years from 1988 to 1998, the number of wholetime equivalent nursing and midwifery staff working for the NHS fell by 13 per cent, but their caseload, as measured by finished consultant episodes, discharges and deaths, increased by 62 per cent.

4 Nursing resources are not given the same priority as medical resources. The Last Straw report, published last year, reported the anger and frustration felt by many nurses at not being able to give an adequate standard of care to their patients.

2Particularly frustrating was the lack of relatively inexpensive items such as pillows.

Another important factor was the lack of time nurses could devote to meeting individual patients' needs.Though the amount of time patients spend in hospital has been reduced, the amount and complexity of the nursing care they require has not.

And though senior managers and clinical directors may have seen this increased productivity as a positive consequence of the policy changes introduced during that period, those at the coalface, particularly nursing staff, experienced the changes in a very different way.

Nurses spend more of their time in direct patient contact then any other professional group in the NHS. It is to nurses that patients address their complaints, anger and frustrations. In most instances nurses are powerless to do anything to rectify the situation.The management changes of the 1980s replaced nurse managers with general managers, and effectively removed nursing's influence on policy-making.

Nursing is too often seen as unimportant or irrelevant in comparison to medicine.Nurses' concerns for the well-being and comfort of their patients were removed from the policy agenda.

Nurses working in the NHS are trying to cope on a daily basis with the conflict between the demands of their profession to deliver high standards of care and the reality of working in an under-funded, under-resourced and understaffed NHS.When the conflict becomes too intense, nurses either leave or search for a compromise.

One that increasing numbers are settling for is to work for an agency.The public do not hold the agency nurse accountable if there are insufficient pillows, if the bathrooms have not been cleaned or if there are an inadequate number of staff or beds for the patients who need them.And it has also been suggested that agency nurses may actually have time to nurse patients, whereas those on the staff are taken up by activities such as quality circles and team-building sessions.

5Providing nursing staff to the NHS has become a multi-million pound industry.Companies which have invested heavily in staff and resources will not be persuaded to go away easily. But the reasons for this expansion lie in the complex interaction of political and managerial change and market forces.

Though the current government is trying to address many of the issues that have contributed to the nursing shortage, it may be too late.

Nurses who have discovered the advantages of working for a third party may be reluctant to return to the NHS. l