One of the keys to achieving patient safety is the wise deployment of locums and other temporary staff - but this is an art in itself, writes Jennifer Trueland. In association with HCL Workforce Solutions

Extra pairs of hands from outside sources are vital to running the NHS but require careful management

Extra pairs of hands from outside sources are vital to running the NHS but require careful management

Halping hands

Few people would deny that understaffing is a patient safety issue. But getting the right people in the right roles is also vital.

‘It’s like driving to the airport – if you have just five minutes to spare you can end up paying far over the odds in the short stay car park’

That means ensuring that everyone who works with patients meets the required standards - involving anything from having the right qualifications to having up-to-date vaccinations and ongoing training. This is the case whether staff are permanent or part of the flexible army of temporary workers which helps to keep the NHS going.

Temporary workers can be a thorny issue for the health service; firstly, hiring locums is more costly, shift by shift, than filling gaps in-house. Secondly, trusts have to be sure that the people they are bringing in are suitable and have the right to work in the UK. They also need robust reassurance that the flexible workforce is patient safe.

Flexible friends

According to Claire Billenness, managing director for client solutions at HCL Workforce, a leading supplier of medical locums and other temporary staff to the NHS, the flexible workforce can be a real boon for the health service, but only if it is deployed wisely.

“It’s like driving to the airport,” she says. “If you’ve planned it properly in advance, and left plenty of time, you can go to the long stay car park. But if you have just five minutes to spare you can end up paying far over the odds in the short stay car park.”

‘You have to ensure that procurement is done ethically and with the patient in mind’

The best employers will recognise this and want to work with agencies and with temporary workers to ensure that everyone gets the best from the relationship: the trust gets a well-trained, fully compliant temporary worker, the locum gets a proper induction - and patient safety benefits. But how can employers ensure this happens? And what are the risks if it does not?

NHS trusts are encouraged to use agencies and locums who are signed up to one or more national framework agreements, which outline standards on issues such as right to work and fitness to practise. Not all agencies are on-framework, however, and not all trusts insist on this as a requirement when trying to get temporary staff.

Gary Snart is category manager with HealthTrust Europe, a procurement hub and framework provider for temporary staff, working with around 40 trusts. He believes there has been a need to improve the way temporary staff are used in the NHS - and that framework agreements are the way forward.

“Temporary staffing is something that, historically, the NHS has found challenging,” he says. “There’s sometimes been a lack of control and a lack of accountability. And yes, you have to get the value side right, but you also have to ensure that procurement is done ethically and with the patient in mind.”

Safe and compassionate

The key difference, he says, is that the framework gives assurance about compliance, and governance. “It’s more of a safety net, really - it’s an extra layer of governance, which, when it comes to patient safety, is very important.

“I believe that being on-framework should be mandatory - although I know I have a vested interest - because it’s a vitally important area. We’re talking about temporary workers who are looking after patients.”

‘It is the employing organisation’s responsibility to ensure themselves that staff are properly vetted and meet regulatory and professional requirements’

Ensuring patient safety is important in terms of clinical risk for individuals, but also in helping trusts to avoid the costs of litigation. Meeting the requirements of regulators is also vital.

Last August, NHS Employers published updated standards to which trusts are expected to adhere when employing temporary staff. This includes measures to ensure patient safety and quality of care. “NHS Employers recommends that NHS organisations use employment agencies that operate under framework agreements, such as those managed by the Crown Commercial Services, because of the regulatory assurances that can bring about the quality of staff supplied to NHS positions,” a spokesman for NHS Employers says.

“Ultimately, it is the employing organisation’s responsibility to ensure themselves that staff are properly vetted and meet regulatory and professional requirements, whether they use agencies on a framework agreement or not.”

Running into trouble

Those who cannot provide the required information on their temporary staff are, however, likely to run into trouble with regulators, as Mr Snart suggests. The Care Quality Commission is clear that it will take action against trusts that do not take this seriously.

‘There will always be peaks and troughs in demand. You wouldn’t want the same level of staffing in summer as you would in winter’

“When inspecting staffing in health and adult social care services, we want to make sure that people are safe and that their welfare needs are met by staff who are fit, appropriately qualified and are both physically and mentally able to do their job,” a CQC spokesman says. “This applies to staff who have been recruited directly by providers, as well as temporary, agency, bank and voluntary practitioners.

“Our focus is on ensuring services provide people with care that is safe, high quality and compassionate. If we do not find this, we will take action and require the providers to make the necessary improvements.”

Mr Snart believes that the temporary workforce will always be with us, and that the NHS has to get better at managing it. “There will always be peaks and troughs in demand,” he says. “For example, you wouldn’t want the same level of staffing in summer as you would in winter in some specialties. It’s a balancing act.”

Trusting technology

Technology can help trusts get a better grasp of their workforce needs. HCL Clarity, for example, is software to streamline the process, help with planning, and provide vital management information on workforce needs.

Jackie Knowles, head of compliance with HCL, says the agency takes its responsibilities very seriously, and is signed up to the national framework agreements, ensuring all its workers meets the standards. “One of our important roles is as gatekeeper for the client. That means that we have to make sure all our processes are robust.”

As well as making sure that all temporary staff are subjected to a thorough recruitment process, HCL itself ensures that its own internal processes are held up to scrutiny. This includes quarterly audits of each division, and spot checks to look at specific risks, such as identity.

“There is a risk to patient safety if we aren’t putting forward the right people for roles,” she says. “And there’s also a risk to the client, in terms of audit by the CQC, for example.

“Really, however, compliance is about safeguarding the public. And although frameworks are valuable, they shouldn’t be the only guide. Every organisation has to be guided by the highest standards of compliance. And that includes us as an agency.”

Stephen Burke: New hope on patient safety

At last, definitive guidance has emerged from a respected source on how many patients a single nurse can reasonably expect to care for in one shift. The National Institute for Health and Care Excellence has responded to the Francis and Berwick reports, which cited persistent short staffing as a direct risk to patient safety.

The first of its recommendations for adult wards noted that more than eight patients to one nurse “can increase the risk of harm to the patient”.

This guidance will enable that which has long been absent in NHS workforce planning and management - consistency. Looking at three key recommendations - organisational strategy, ward-level determinants of staffing and monitoring and evaluation of the nursing workforce - it is clear that transparency, technology and flexibility are critical to ensuring safe staffing remains just that.

HCL is partnering with many acute trusts to make this a reality. While use of temporary staff is deemed an absolute last resort, the use of flexible staff is simply inevitable to ensure that patients remain safe in hospital. By ensuring that needs are anticipated and, where chronic staff shortages persist, by recruiting overseas, HCL remains aligned with the goals of the NHS. It ensures patients remain safe through the provision of experienced, compliant staff, on time and to framework-negotiated rates, investing continually in the compliance of all candidates, temporary and permanent.

The NICE guidance requires trusts to “ensure there are procedures for systematically monitoring and reviewing nursing staff establishments of individual wards on a regular basis (at least twice a year)”.

Using HCL Clarity - the Skillstream technology and workforce management solution - a large acute trust was able to recruit more than 600 of its own staff to an internal bank, ensuring that skill gaps were identified and plugged, providing patients with safe and compliant care, while simultaneously shaving a tenth off agency rates - amounting to over £1m in savings in one year.

As the trust commented, “a significant learning for the NHS is that without the transparency of a system to manage temporary staff we cannot see the opportunities to improve the quality of provision and at the same time reduce that spend”.

Critically, this was the trust making best use of its own resources by using technology to access real time management information and plan ahead to access compliant temporary staff, thereby increasing patient safety.

Stephen Burke is chief executive, HCL Workforce Solutions.

Patient safety supplement: The locum motive and body of evidence