Every healthcare system seeks to provide the best quality care at the lowest possible cost. When resources are as stretched as they have been within the NHS for much of the last decade, optimising resources is not about making the NHS workforce do more for less, but making sure there is consistency, transparency, and flexibility in the way staff are deployed and managed.

Done properly, the introduction of new systems and techniques to get the most out of the workforce can also help clinical and non-clinical staff gain more control of their work, not less. This is particularly important for those employed from Generation Z, who expect to have flexible working arrangements and who want to experience different working experiences in their chosen field.

In 2014/15, the NHS spent over £3 billion on agency staff, which led to the introduction of new measures. Agency price caps were introduced in October 2015 to support NHS providers to reduce their agency staff spend and to encourage increased use of substantive and bank staff. Prior to the introduction of agency controls, trusts’ agency staff spending had grown at 25% a year for the previous two years.

In February 2017, it was reported that 77% of trusts successfully reduced their agency spend, and over half of these (95 trusts) reduced spend by more than a quarter. It has also been reported that the agency controls have saved the NHS £1 billion since they were introduced.

By reducing the use of agency staff and more intelligently deploying substantive core staff, trusts can provide patients with better care, while using their resources more effectively.

However, despite monthly spend being around 20% less in 2017 than it was at the same point in 2016, the sector is still spending £250 million a month on agencies.

In 2016, NHS Improvement called for more trusts to improve how they manage their existing workforce to help encourage staff back to the NHS, by allowing them to work more flexibly.

E-Rostering software supports trusts to provide flexibility through allowing staff to book their own shifts and leave.

The Carter Report notes the benefits from properly harnessing even quite basic data about the workforce:

“During our visits to trusts we realised that despite the national electronic staff record (ESR), many trusts did not have a full picture of where all their staff are and what they are doing – which is critical if trusts are to optimise their resource.

“A firmer grip of e-rostering will reduce dependency on bank and agency staff and it will improve predictability and consistency of deployment for staff even where recruitment is still a challenge.”

In order to better manage workforce data, the review team made a series of recommendations, including that all trusts use an e-rostering platform and implement changes such as: “An effective approval process be made possible by publishing rosters six weeks in advance and review them against trust key performance indicators such as proportion of staff on leave, training and appropriate use of contracted hours.”

To explore how e-rostering was working, an analysis of roster approvals in 88 NHS organisations by Allocate Software, an e-rostering solutions provider, showed that between October 2015 and March 2017, the average roster approval lead had increased by 85% in this period, from 1.5 weeks to 2.77 weeks (graph below).

Average approval lead in time

An exploration into the e-roster publication and approval lead time across NHS organisations in England

The data also show that the percentage of NHS organisations approving rosters greater than four weeks in advance had increased to 26% from 11% across the same period.

As seen in the table below, the average approval lead time across health education regions ranges from 0.6 weeks to 2.96 weeks in October 2015 with some regions increasing the average approval lead time by over 100% by the end of March 2017.

However, the majority of NHS organisations analysed fell short of achieving the Carter Report’s recommended approval lead-time of six weeks.

Over a 12-month period, Allocate Software took data on approval lead-time and average agency use from 57 trusts to determine a link between the two metrics. The results clearly show that as the lead-time on roster approval lengthened there was a gradual reduction in the use of agency staff.

  • Rosters with approval lead time of 0 – 2 weeks had an average agency use of 5.45%
  • Rosters with approval lead time of 2 – 4 weeks had an average agency use of 5.39%
  • Rosters with approval lead time of 4 – 6 weeks had an average agency use of 4.04%

The top 20 trusts for approval lead time had an average agency use of 3.9%, whereas the 20 trusts with the shortest lead time for publishing their rosters had much higher average use at 6.34%. (Source: Allocate-Insight – The Impact of a Longer Approval Lead Times on Temporary Staff Use, 2017). In part this reduction is because the longer lead time ensures that bank workers and substantively employed pool workers have the ability to see and fill available shifts before they go out for agency fill. To make the most of this efficiency it is necessary for the trusts’ rostering system to interface with the bank provider system to ensure available shifts are open for bank staff use.

This research shows the positive impact longer approval lead times currently have on the average use of agency staff, and the insight offers NHS trusts a practical means of reducing agency use. However, there is an inevitable tipping point for approval lead time beyond which there will be no benefit to increasing the length of the approval lead time any further. This is yet to be defined and more research is needed identify the tipping point.

Eight ways to improve approval lead times:

  1. Make sure all roster approvers understand the importance of the lead time to approval
  2. Share data findings, and the importance of this for staff
  3. Ensure the roster policy sets the target number of weeks for lead time approvals
  4.  Ensure approvers know when they need to approve
  5. Publish a roster approval calendar
  6. Monitor lead times routinely across all wards and units, and distribute this to all staff
  7. Support managers who are not meeting the target
  8.  Understand the reasons why people might leave approvals until it’s too late, and offer help.


South West London Collaborative Staff Bank


The South West London Sustainability and Transformation Partnership footprint will launch a pioneering piece of joint working in the way it deploys bank nurses. The collaborative will join together the nursing bank of five provider trusts in the area: Croydon Health Services NHS Trust, Epsom & St Helier University Hospitals NHS Trust, Kingston Hospital NHS Foundation Trust, St George’s NHS Foundation Trust, and South West London and St George’s Mental Health NHS Trust.

Through a negotiated framework and a cloud-based rostering system, the providers will be able to more efficiently deploy nursing staff from a unified bank.

Sue Winter, one of the project leads and director of workforce at Epsom and St Helier University Hospitals NHS Trust, explained how this process came about: “Our organisations came together to see if there was any joint working that we could do, particularly around bank staff and our bank spend.

“We found we all share the same group of staff – be they our substantive staff working in another hospital on their bank or vice versa. We asked ‘why are we paying money to an agency to give our own staff back to us if collectively as an STP we can work together to make it easy for staff that want to move around to be able to do so?’

“Nurses who participate in the joint bank system only need to register once and will be then available to book shifts with all the providers.”

One of the key enablers for the collaborative has been the harmonisation of pay rates across all participating provider organisations, which Winter described as a “complex and painful process”.

Winter argued that the impact of changes to pay rates could be an initial cost pressure for some organisation in the sort terms where rates had to be increased. However, the financial benefits will come from the area as a whole achieving higher fill rates and savings on agency commissions. It also prevents pay escalating as we are no longer competing with each other.

“If we’re all paying exactly the same, it really is just about convenience for the staff and where they want to work.”

In addition to harmonised pay rates, under the new bank system, substantive staff will not be allowed to work shifts in any of the participating trusts if they try to work through an agency. They will still be able to work that shift, but they must do it through the bank.

“All trusts would say that they would much rather have their regular bank staff working temporary shifts than an agency person who has never worked here before, because the quality of patient care goes up,” Winter explained.

Through the cloud-based rostering software, managers will be able to see all the shift patterns that their substantive staff work, as well as which bank shifts they have opted to do. This process will also help with a number of regulatory issues, such as European Working Time Directive compliance.

With the new cloud system, employees will be able to see their substantive rosters and their bank working on their smartphone. They will also be able to see all of the shifts that are available across the whole of South West London. Winter explained: “If we don’t have a shift that’s convenient for their home life then another trust might and vice versa.

“It’s not that one organisation is going to lose all of its staff, which is often the fear, because it’s swings and roundabouts.”


How East and North Hertfordshire are prioritising patients’ care needs save costs


The introduction of a new enhanced nursing care team (ENCT) at East and North Hertfordshire NHS Trust highlights how workforce optimisation has had a positive impact on patient care. The creation and investment in extra capacity also saw the trust significantly reduce its temporary staff spend.

The chart below demonstrates the trust’s reduction in the use of May 2016 agency staff achieved within the ENCT.

Reduction in agency cover within the Enhanced Nursing Care Team (May 2016 – June 2017)

The trust’s reduction in expenditure on temporary staff, following the increase in establishment of the ENCT, has been dramatic. In quarter one 2017-18 the temporary staff spend was £83,463, compared to quarter one 2016-17 £225,322, a cost reduction of £141,859 for the quarter.

Reduction in temporary staff spend Quarter 1 2016-17 and Quarter 1 2017-18

The trust’s forecast expenditure on temporary staff for 2017/2018 is £318,000. By investing £144,941 to increase the size of the substantive team, the trust is set to save £173,000 per year. With continued investment in the ENCT the trust has an aim of reducing agency spend to zero.


Liz Lees MBE


Two and a half years ago our nurse vacancy rate was significant and difficult to manage on a day-to-day basis.

We upgraded our e-rostering platform and began holding daily staffing meetings between myself, our e-rostering team, matrons from our surgery and medical teams, and a temporary staffing team provided by NHS Professionals.

These meetings helped us identify the main staffing shortfalls in the organisations. We then took this process further and created a staffing hub within our main hospital site.

This enabled us to get a daily view of those in charge that day and who in our teams was temporary staff, alongside the acuity of our patients.

By using the platform in conjunction with our professional judgement we could better tailor patient care and improve our staffing makeup.

With the challenges relating to agency expenditure, we plan our rosters eight weeks in advance. This enables our in-house e-roster team and our heads of nursing go through a risk profile ahead of time.

Through these processes we saw a 50% reduction in agency spend from 16% of our budget in January 2017 to 8% in June.”

Liz Lees has been Acting Director of Nursing at East & North Hertfordshire NHS Trust since 2016 and was made an MBE in the 2016 New Year’s honours list for services to nursing.


Dr Chris Streather


When examining the shape of our workforce, there are three priorities that immediately spring to mind.

Firstly, the key for us is the ability to deliver on our promises about care quality and access targets.

Secondly, ‘proper’ staffing costs a fortune, so the reduction in our agency workforce bill is absolutely essential. Through intelligent workforce management, including the use of e-rostering technology – we have been able to push down this particular cost within nursing.

However, the agency expenditure in other areas of the workforce is still high.

With the introduction of e-rostering, pharmacists could deliver a great deal of urgent primary care provided in the accident and emergency department. While the trust has been able to leverage the benefits of e-rostering technology on our nursing teams, we have yet to roll out the platform across our medical workforce.

We are going to begin using e-rostering in three medical specialties: paediatrics, accident and emergency, and the intensive therapy unit, and then roll it out across the trust.

In the short-term the key focus for me is to reduce my dependency on agency spend in medicine, particularly emergency care. That is likely to have a quality and access target benefit.

I anticipate that introducing e-rostering with doctors will be difficult. Nursing has gone well and it was relatively straightforward to get senior nursing buy-in to these changes.

We have deliberately placed senior doctors in each work stream in an effort to help encourage clinical buy-in.

Changes to our rostering processes will open up opportunities to shift people who currently work with us through an agency into our own bank.

There is an opportunity that has been used in nursing to shift people across the hospital. So there can be an opportunity to take a healthcare assistant from part of the hospital and use them in another part.”

Dr Chris Streather is chief executive of The Royal Free Hospital, the largest of three acute hospital sites operated by Royal Free London NHS Foundation Trust. Dr Streather was previously chief medical officer at HCA Healthcare UK. Prior to this Dr Streather held a number of senior leadership roles across the NHS in London.