Acute trusts in England have overridden government-enforced caps on hourly rates of pay for agency nurses more than 60,000 times since they were introduced at the end of last year, an investigation by Nursing Times has revealed.
Experts warned that the number of breaches was higher than expected and looked set to get worse as the phased tightening of the caps on spending kicked in, noting that the national nursing shortage was the root cause of the problem.
“There will be even more overrides because people won’t be able to get the staff”
Most trusts that took part in our investigation (85%) have exceeded the hourly pay limits in the past few months, which are allowed to be breached on “exceptional safety grounds”.
More than 20 have breached the cap – set at 100% more than the hourly rate paid to permanently employed nurses from the end of November to the end of January – an average of more than 100 times a week.
Meanwhile, ceilings for overall spend on agency nurses that were set by regulators for each individual trust have been challenged by around a quarter of trusts. A total of 25 applied to raise their ceiling, with 76% of those being granted an increase.
Nursing Times sent out Freedom of Information requests at the end of January to find out how far trusts were complying with the new rules for agency staff payments, brought in to crack down on increasing spend on temporary workers.
Almost 75% of trusts responded, with the majority stating they had overridden the rules. Only 16 trusts said they had not used agency nurses at rates above the cap.
Our Headline Findings:
- 85% of trusts have overridden the rules more than 60,000 times
- 25% of trusts have applied to increase their ceiling on total agency nurse spending
- 96% of all overrides were for band 5 nurse shifts
In general, the overrides were not limited to specific periods during the winter and instead occurred across an average of nine weeks.
Based on the 83 trusts that provided a breakdown of the data, 96% of all overrides were for band 5 nurse shifts, with 3% for band 6s, and the remaining 1% for band 7s – just one trust broke the rules for three band 8 nurses.
When the rules were introduced on 23 November by Monitor and the NHS Trust Development Authority, the caps were set at 100% above the hourly rate paid to permanently employed nurses.
This meant the maximum hourly rate paid by a trust for a band 5 nurse in an area with no high cost supplement was £28.80 for a day shift, or £37.44 for a night or Saturday shift.
- Regulators reveal new hourly pay rates for agency nurses
- New agency staff charge caps apply to NHS from today
- Agency staff survey raises fears cap will be ‘train crash’
At the start of February, this changed to 75% above substantive nurse pay, and from April the cap will be tightened again to 55% above an equivalent wage for a permanently employed nurse.
On average, trusts exceeded the caps around 60 times a week, but some saw this happen far more frequently.
Nottingham University Hospitals Trust reported 427 overrides per week on average over a period of three months.
“Our spend on agency, bank and locum staff continues to rise”
A spokesman for the Nottingham trust said: “Our spend on agency, bank and locum staff continues to rise. So far in this financial year we have spent £34.6m. This compares to £26.5m in the same period last year.
However, he said the trust was working to “rapidly reduce” its reliance on agency staff, adding: “One of the ways we are achieving this is through our proactive recruitment strategy, which includes attracting nurses from overseas and taking an ever more imaginative approach to recruitment and retention of new nurses.”
Meanwhile, Wye Valley NHS Trust exceeded the caps an average of 262 times in a week over nine weeks.
When asked by Nursing Times the reasons for such a high number of cap overrides, Wye Valley said it would “not compromise on patient safety”.
But the trust’s deputy director of nursing Paul Hooton said the agency staff rules in combination with a shortage of nurses had “undoubtedly made the issue of safe staffing even more challenging”.
He noted other trusts were also in a similar position and that Wye Valley had responded by increasing recruitment efforts and expected reliance on agency staff to reduce in the coming months.
Despite the trust lacking the “big-city” draw that other hospitals have, he said it was experiencing “reasonable success” in attracting new employees.
Meanwhile, Royal Surrey County Foundation Trust overrode the rules an average of 214 shifts per week over nine weeks.
A trust spokesman said the reason was a “critical” shortage of nurses in permanent posts, particularly in specialist areas such as intensive care and chemotherapy.
He said patient safety was the priority and that agency staff were required to ensure this.
However, he noted the trust was improving its compliance with the caps over time – with just 131 overrides in the past week –alongside bringing in more nurses from abroad.
Recent data from Monitor – including acute, community and mental health trusts – suggested the caps have had some impact in helping to bring down spending on agency staff.
Six weeks after the rules were introduced, the number of nursing, midwifery and health visiting shifts that breached the caps had fallen by 47%, it said, from 14,913 breached shifts a week to 7,848.
But one expert questioned how far these savings could be delivered as the caps were tightened. He said it was “striking” how hard it was already proving for trusts to fully comply with the rules, even when rates were limited to a more generous level of 100% above substantive pay.
Richard Murray, director of policy at the King’s Fund think-tank, said: “If there are this many overrides already, how credible is it to continue to tighten the rate?”
Exclusive: Challenged trusts commit to recruiting nurses
“This [data] suggests it has been harder for trust to live within these rules [than was expected]. Once those rates continue to tighten and go down, there will be even more overrides because people won’t be able to get the staff,” he told Nursing Times.
He suggested the underlying problem was a shortage of nurses, rather than agencies overpricing their staff.
“Until something is done about the shortage of nurses – if you push these rates down – the danger is organisations will not be able to get the staff they need,” he warned.
Howard Catton, head of policy and international for the Royal College of Nursing, said: “The over-reliance on short-term staffing in the NHS has been getting worse for years and won’t be fixed overnight.
“The reliance on short-term staffing is because the numbers being trained in the UK have been reduced, for short-term financial reasons,” he said. “Remedying the root cause involves time and money, which is why so much focus has been on managing the symptoms.
“What these figures show is that NHS trusts are making the right short-term decisions in prioritising patient safety over sticking to the cap,” said Mr Catton.
“When patients need nurses in the here and now, they should get them but the very real worry is that short term decisions are now the only ones the NHS is able to make,” he said.
He added: “Leaving the health service in this perpetual loop of short term decisions, each one of which costs unnecessary money, makes it all the harder to get long term workforce planning right and leaves the health service even more stretched.”
A spokesman for Monitor and the NHS Trust Development Authority reiterated the policy was in its “early days” but was already having a “positive impact”.
“Overuse of agency staff is unaffordable for the NHS and unfair on other staff and patients,” he said. “We want trusts to be able to rely on a more stable supply of staff, paid on standard NHS terms and conditions and not the rip-off rates charged by agencies in recent years.”
Trusts with high numbers of weekly overrides:
- Nottingham University Hospitals NHS Trust: 427 overrides per week on average
- Wye Valley NHS Trust: 262 overrides per week on average
- Royal Surrey County NHS Foundation Trust: 214 overrides per week on average
- Northern Lincolnshire and Goole NHS Foundation Trust: 193 overrides per week on average
- The Princess Alexandra Hospital NHS Trust: 183 overrides per week on average
- Medway NHS Foundation Trust: 176 overrides per week on average
- University Hospitals of Leicester NHS Trust: 172 overrides per week on average
- Pennine Acute Hospitals NHS Trust: 168 overrides per week on average
- East Kent Hospitals University NHS Foundation Trust: 158 overrides per week on average
- Worcestershire Acute Hospitals NHS Trust: 150 overrides per week on average
- North Bristol NHS Trust: 143 overrides per week on average
- University Hospital Southampton NHS Foundation Trust: 142 overrides per week on average
- County Durham and Darlington NHS Foundation Trust: 138 overrides per week on average
- Warrington and Halton Hospitals NHS Foundation Trust: 139 overrides per week on average
- Mid Yorkshire Hospitals NHS Trust: 132 overrides per week on average
- Ashford and St Peter’s Hospitals NHS Foundation Trust: 130 overrides per week on average
- Frimley Health Hospital NHS Foundation Trust: 125 overrides per week on average
- Torbay and South Devon NHS Foundation Trust: 122 overrides per week on average
- Royal Cornwall Hospitals NHS Trust: 119 overrides per week on average
- Calderdale and Huddersfield NHS Foundation Trust: 115 overrides per week on average
- Great Western Hospitals NHS Foundation Trust: 114 overrides per week on average