NHS vacancies, temporary staff, and why it matters for care

The increase far outstrips any change in staffing, however.

Yes, the nursing and midwifery workforce did shrink, but only by 0.9 per cent - equivalent to roughly 558 full-time nurses or midwives dropping out.

The vacancy rate for nurses and midwives peaked at 9% in December 2021, but fell to a (still very high) 7.9% by March 2023.

READ MORE: Rural patients at risk from 'dangerous and worsening' doctor shortfall

Yet the expenditure on agency nurses went up by a staggering 91% last year.

For bank nurses - a pool of flexible NHS staff who can volunteer to fill shifts at short-notice - the rise was a more modest 19.6%.

Spending on agency/bank nurses over time (top) and on medical locums (Image: Turas/NHS)

Spending on medical locums also reached a record high of £119.6m last year - up by 17% compared to the previous year - despite the number of consultants in post actually increasing.

Vacancy rates vary substantially by region, but overall the shortfall of medical and dental consultants has fluctuated around the same level since 2015 - ranging from around 320 to 540 empty posts.

It is currently hovering around 450 (a vacancy rate of around 7%).

Both the number and rate of consultant vacancies were actually lower during 2022/23 than they were in 2021/22.

The vacancy rate for consultants has been similar since 2015, while the rate for nurses and midwives appeared to fall last year despite a reduction in the workforce (Image: Turas/NHS)

Yet, like nursing and midwifery, the health service saw its bill for agency doctors climb.

This raises a few alarm bells.

One is how accurately vacancies are counted. In the case of consultants, official statistics omit any posts which are temporarily filled by locums, have yet to be advertised, or where they have been empty so long that recruitment efforts have been abandoned.

BMA Scotland estimates that the true shortfall of consultants is probably double what official statistics claim.

READ MORE: Nurses warn over 'catch-22' in staffing shortages 

It is possible then that a growth in consultant vacancies could be partially 'hidden' if enough of these posts were being filled by locums. The same may be true for agency nurses.

Another thing to consider is that vacancies are not the only reason health boards turn to medical agencies or the NHS bank.

Covering for sickness absence is another - and this appears to be on the rise.

On average, 6.2% of NHS staff were off sick in the year to March 2023, up from 5.7% in the previous year and a low of 4.7% in the first year of the pandemic.

This would appear to tie in with the easing of social distancing and other measures in 2022, which was associated with a sudden rebound in levels of viral and respiratory illnesses.

There were also concerns that the cumulative effects of stress and burnout were resulting in many more NHS staff ending up on long-term sick leave.

However, the figures for the most recent financial year include Covid-related absences for the first time (as of September 2022) which were not previously included among the general sickness absence statistics.

The sickness absence rate is higher than it was pre-pandemic but there is uncertainty over how Covid has altered the figures in the most recent year (Image: Turas/NHS)

As a result, it is difficult to say for sure whether the number of NHS staff off sick really has increased year-on-year, or by how much.

It is also worth noting that by far the highest absence rates were found among ambulance and NHS 24 staff, whose posts would not generally be filled by medical agencies.

Another clue, as Audit Scotland notes, is that year on year spending figures are "not adjusted for inflation".

Like pretty much everything else in 2022, the cost of staffing hospital wards went up. 

The agency expenditure figures only tell us what the NHS paid, not how many temporary staff were hired. 

While health boards can strike deals with healthcare agencies to supply nurses and doctors on a long-term basis on rates that are closer to the norm, supply-and-demand means there are plenty of reports of exorbitant fees.

These can range from shifts costing double what a permanent member of staff might earn to the extreme outliers like the recent case of a locum doctor in England who cost his NHS hospital £5,200 for a single shift (a hefty percentage of which goes straight to the agencies).

READ MORE: More than £26m spent on agency staff in three months 

The potential for higher earnings is not the only factor driving NHS staff to swap permanent posts for freelance work.

In many cases, flexibility is the bigger draw.

Nurses in particular are known to retire early only to sign up to the bank or with agencies because it is the only way they can alter their hours - a situation which means they end up costing more.

The problem is more than financial, however.

Research repeatedly shows that hospitals with lower ratio of permanent to agency staff are less safe.

Research shows that an over-reliance on agency nurses to fill rota gaps is associated with higher patient mortality on wards (Image: PA)

A 2019 study, from the University of Southampton, estimated that the risk of death increased by 12% for every day that a patient spent on a ward with high levels of bank and agency nurses.

Another, from January this year, analysed 53 wards in a single NHS trust in England during 2017 to track how nurse understaffing dovetailed with patient mortality.

On days where a team lacked the equivalent of 24-hours worth of registered nurse cover (roughly two to three nurses), they found that the risk of death went up by 37%.

By contrast, the odds of a patient dying on a ward during their stay were cut by an average of 9.6% by adding an extra 12-hour shift from a registered nurse to the team.

Crucially, however, this was only the case where the nurse was a permanent member of staff (including a permanent nurse doing overtime via the bank).

No benefit, in terms of reduced mortality, was seen if the shift were filled by an agency nurse.

Compared to a decade ago, the NHS has roughly twice as many nursing and medical vacancies and with that has come a growing reliance on temporary staff.

That's bad value for taxpayers - and worse news for patients.