NHS organisations must now rise to the challenge of improving patient care while safely reducing costs.

A bank and agency quality improvement programme implemented at Salford Royal Foundation Trust provides an example of how trusts can reduce spend while also improving patient care. 

NHS chief executive David Nicholson has stated that we need to move away from the NHS being built for growth to being able to sustain itself in a prolonged limitation of resources. Therefore the NHS will need to make efficiency savings of £15-20 billion from 2011-14. By considering ways of working differently, at lower cost, we can ensure that we continue to have the resources to provide quality patient care.

Nurses are the linchpins in providing high-quality patient care. We must develop systems where patient safety is assured, quality of care is paramount, and staff are satisfied with and actively supported in their roles.   

Booking bank and agency staff has often raised concerns about the consistency and quality, as well as the cost, of health careprovided by temporary staff. The morale of nurses employed directly by the hospital could also suffer when they work alongside agency nurses who earn higher wages and enjoy more flexible scheduling.

Aim of the project

The bank and agency project was centred on nursing staff leading the way in terms of changes to the management and scheduling of staffing. The aim of the project was to reduce bank and agency spend by 30 per cent by the end of November 2009. 

The pilot project covered 12 wards (including A&E & EAU) which were chosen due to their high levels of bank and agency shift bookings. By the end of November the project achieved a 27 per cent reduction in spend which equated to £132,500.

While the end result was three per cent off the target the progress was significant, particularly considering that one of the wards had a significant number of vacancies which were waiting to be filled. 

The latest figures show that the project has reduced bank and agency spend by £200,000.

How was this achieved?

Secondary authorisation

Lead nurse or Matron can only authorise shift bookings. This system has been set up through NHS Professionals.

Locum nurse policy and audit programme

The audit programme helps to ensure that locum nurse staffing is primarily used to support the flexibility of clinical activity and insufficient staffing levels.

Roster compliance

Ward managers are required to complete an online roster and submit this on a six weekly basis.  

Booking difference shifts 6-2 / 10-6 / 11-7 and day shifts rather than night shifts and weekday rather than weekend shifts  

For example, booking 10-6 shifts helps to cover the times on the wards which are particularly busy without needing an extra shift. This means that there is a sufficient number of staff on the ward at hand over time.

Unqualified rather than qualified staff management of specialling

Ward managers and ward staff to examine patient needs on a daily basis to ascertain the need for specialling. 

Reporting of data and review of ward position

Reporting of bank and agency booking and spend reviewed on a weekly basis.

Electronic bank spreadsheet

Providing ward managers with tools to help them to monitor and predict spend. This provides staff with ownership of their budgets and helps to track how much is spent on bank and agency staff.

HR training 

All ward managers to review the HR courses which have been attended on a monthly basis. This will help staff to feel more comfortable with HR issues, for example, managing absence.

Ward managers and occupational health meetings

Ward managers and occupational health to meet and work through details of new starters on the system. This helps to speed up the recruitment process.

The project which was initially piloted on 12 wards has now been spread across the Trust and progress will be closely monitored. 

Important considerations

It is perfectly acceptable to rely on agency and bank nurses in emergencies, but it is essential that we are not booking bank and agency staff when permanent staff could provide a solution to staffing problems.

Although reduction in spend is crucial in the current economic climate, effective staffing can also be critical to efficiency, staff satisfaction and patient care.  

The increasing use of locum nursing staff is not simply an issue of higher staff costs for the organisation, but it can also have a negative impact on the efficiency and quality of patient care that is provided.  Healthcare Commission surveys have shown that the higher use of agency staff is often linked to lower levels of patient satisfaction. 

The deployment and scheduling of permanent staff more efficiently can help to reduce the use of agency or temporary staff. If all NHS trusts were to bring their agency spend down to the average across the NHS that would reduce agency costs by approximately £350 million.

Peter Murphy is assistant director of nursing, quality improvement, Carianne Hunt is a research associate, quality improvement, David Melia, is deputy director of Nursing and Morgan Michele is assistant director of nursing, Corporate Services at Salford Royal Foundation Trust