The NHS in Wales could move to a model in which most or all nursing care is outsourced to private companies, if its increasing reliance on agency staff continues, a union report has claimed.
According to the Royal College of Nursing, the Welsh health service risks moving to a situation where it no longer directly employs staff to provide patient care.
Agency nursing is becoming increasingly popular as an option for our members”
NHS Wales spent between £133m and £140m on agency nursing during 2021-22, based on different freedom of information (FOI) requests and official figures, the RCN’s report suggested.
It claimed the level of “spend clearly illustrates the heavy reliance on agency nursing and the fact that health boards cannot attract enough nurses to provide safe and effective care”.
The report, titled Agency Nursing, calculated that the £140m figure, if accurate, would pay the salaries of 5,167 full-time nurses, though the spend on agency staff represents less than 6% of NHS Wales’ pay bill.
Based on FOI data, the highest levels of agency spending in 2021-22 was by Hywel Dda University Health Board at between £28.9m and £34.7m.
Three further health boards all spend above £20m on agency nursing staff during 2021-22, according to two separate FOI requests.
Swansea Bay Health Board spent between £24m and £23.6m, Aneurin Bevan Health Board spent £22.8m and Cwm Taf Morgannwg spent between £21.8m and £22m.
The picture was less clear for Betsi Cadwaladr Health Board, which spent between £21m and £17.2m, while Cardiff and the Vale Health Board spent £17.6m and £15.2m.
The lowest level of spend, based on the FOI requests, was by Powys Teaching Health, with both sets of figures agreeing that the board spent just £3.7m.
The RCN report also explored factors on why nurses in Wales might be choosing agency work, including better pay and work life balance.
“Agency nursing staff have better pay, more freedom over location and hours and there is generally less responsibility to address staffing shortages and internal challenges,” stated the report.
It also highlighted that many agencies offered further significant benefits, which helped contribute to making agency nursing “very attractive”.
For example, it said Hoop, a Cardiff-based agency, offered a £250 joining bonus, competitive weekly pay, a fast-track application process, revalidation support and an out of hours support team.
Another, Thornbury, offered a ‘refer a friend’ scheme with a bonus of up to £300, revalidation support and even paid the revalidation fee if a nurse worked 18 shifts for them in their first year.
The report said better pay, more flexibility, revalidation support and training, plus fewer pressures meant agency work had “become a popular alternative to being directly employed by the NHS”.
However, RCN report warned that, from a national finance perspective, agency nursing was costing NHS Wales “a lot of money that would be better placed elsewhere – such as nurses’ salaries”.
It called on the Welsh Government to increase pay and flexibility over hours and work location, and improve access to continued professional development to make working for the NHS “more attractive”.
The report acknowledged that, in 2006, ministers implemented the first All Wales Agency Framework Contract, with capped hourly rates of pay a nursing agency could charge to try and control costs.
Suppliers of agency nurses through the contract are referred to as ‘on-contract’ agencies, whereas those that are not part of it are ‘off-contract’ and can charge a higher premium.
The contract has been renewed on several occasions and a new All Wales Agency Framework Contract was signed in 2021 for the period 2021-24, with the possibility to extend it for an extra year.
It continues to cap the hourly rates of pay for nursing agency staff and there are currently 147 agencies signed up to the framework contract.
But, in spite of initiatives like the contract, the report warned that the use of agencies had become increasingly common due to staffing pressures.
RCN Wales said the NHS was now “displaying a dangerous and growing reliance on agency nursing over its own workforce”.
“If this trend continues, Wales will move to a situation where NHS Wales no longer directly employs staff to provide patient care and instead moves to a model in which most or all nursing care is outsourced to private companies,” it said.
“This is not a shift that should take place without a conscious government policy decision,” the report stated.
The report, published on Friday, comes as the college prepares for strike action over nurse pay later this month in Wales, England and Northern Ireland.
All but one of the NHS employers across Wales currently have a mandate for RCN members to take strike action in the coming months, after meeting the required thresholds in balloting.
Earlier this year the Welsh Government handed NHS nurses on Agenda for Change contracts a £1,400 uplift, in line with recommendations from the NHS Pay Review Body.
However, the RCN has been calling for a pay uplift at 5% above inflation for nurses across the whole of the UK.
Sandy Harding, associate director of nursing for professional practice, said: “Agency nursing is becoming increasingly popular as an option for our members as an alternative to working for the NHS.
“Agency nursing can provide more flexibility in hours, better pay, greater choice over work location and support with professional development,” she said.
“Agency nursing is providing our nurses a better work-life balance,” she said. “The NHS struggles without enough nurses.”
She added: “The Welsh Labour government needs to step up and be as good an employer as the nursing agencies.”
A Welsh Government spokesperson said: “Our NHS workers are under considerable pressure. We greatly value their tireless commitment to serving the public and understand their frustrations.
“We believe they should be fairly rewarded but our current financial settlement falls far short of what is needed to meet the very significant challenges faced by our public services and workers across Wales.”
They added: “There are more staff working in NHS Wales than ever before, and this year we are investing record levels in training and professional education, £262m, including more training places than ever before.
“The Workforce Strategy, published by Health Education and Improvement Wales and Social Care Wales, sets out a long-term vision for the health and social care workforce, and we are developing a shorter-term plan to deal with current pressures,” they said.
“The NHS in Wales offers opportunities for nurses who wish to work more flexibly to sign up to work for the NHS organisations’ banks where they benefit from national pay terms and conditions and can opt to work flexibly at times that suit them and in the familiar setting where they are more comfortable.”