Almost all NHS trusts have some form of nursing staff bank, but they will be at different stages in maximising their bank’s effectiveness and use, and deploying different staff bank arrangements – for example, creating collaborative banks, commissioning staff banks or focusing efforts on enhancing in-house banks.
This guidance supports NHS trusts to develop and refine their nursing bank offer as one measure to reduce nurse agency use. It sets out the core elements they should consider in ensuring their bank provides high quality temporary staffing solutions in a timely fashion to support safe, effective care, and identifies resources to help them do so, under 3 sections:
- Bank strategy – aimed at senior leadership
- Governance and deployment – initiatives for ward managers or clinical leads to implement based on strategy
- Flexible staff offer – initiatives for ward managers or clinical leads to implement based on strategy
This guidance has been produced in collaboration with nursing colleagues from trusts, integrated care boards (ICBs) and regions, with input from NHS England’s Workforce, Training and Education directorate, drawing on their experience of what works well to deliver a healthy bank. It is not prescriptive and should be used locally to support improvements as part of a trust wide approach to temporary staffing. Also, although directed at nursing, this guidance is applicable to other professions.
What is a ‘healthy bank’?
Nursing leaders who have adopted different temporary staffing models all identify the need to create what they describe as a ‘healthy bank’.
A healthy bank offers trusts a pool of appropriately skilled, experienced staff who can work flexibly to cover increased demand for or shortfalls in the workforce, including from unplanned absence or vacancies.
A healthy bank fosters a welcoming and inclusive culture and provides staff who, having received comprehensive orientation and training, can work in accordance with trust policies and procedures and are familiar with the environments in which they will be working.
A healthy bank is cost-effective and its offer is well understood from ward to board.Bank strategy
Developing your strategy and action plan
Trusts that are developing a strategy and action plan to reduce their reliance on agency staff tell us that trust-wide recognition of this purpose is essential in driving change. Finance colleagues, HR directors and clinicians all need to be involved for a collaborative approach to supporting maximum use of bank staff.
All partners in this effort need to:
- consider how they can be proactive in enrolling new staff into and encouraging existing staff to join the bank, including by highlighting the benefits of bank working
- regularly engage with the temporary workforce to understand their motivations in choosing to work additional shifts via an agency rather than the bank
- understand deployment requirements, including substantiative and temporary staff patterns, trust approaches to address hard to fill shifts and notice periods for shifts offered to bank staff
- support the creation of an inclusive environment for temporary staffing, one that ensures the equal treatment of all bank members
As detailed below, the key areas to consider are:
- regularly review your data (see maximising data), ensuring you do so holistically, to shape your strategy
- engage with your temporary workforce using, for example, surveys, engagement sessions and 1-to-1s
- review your current policies and procedures to minimise any unnecessary agency use and make bank work more accessible to staff
An action plan for reducing agency use is:
Six Steps for Organisational Initiatives
Identify the right initiatives for your organisation
Develop a strategy with clear workstreams and objectives
- use SMART objectives
- identify key leads
- agree priority actions and objectives
- identify risks and mitigations
- develop key milestones
Agree key performance indicators (KPIs) to measure success
Develop workstream action plans
developing a clear action plan(s) with achievable and measurable KPIs will allow you to track, review and amend your initiatives
Engage multi-departmental teams
securing buy-in from multiple teams, such as finance, clinical, safer staffing and workforce, will ensure your initiatives have considered organisational priorities
Agree governance
successful strategies have an executive sponsor who is responsible for reporting to the board and raising awareness throughout the organisation while aligning objectives with your trust’s wider strategy
Resources
- developing your aims statement
- action planning
- project initiation document guide
- agency rules toolkit
Maximising your use of data
Data sourced and triangulated from multiple teams – clinical, organisation development (recruitment and retention), finance and analytics – should underpin your strategy. Understanding your data, addressing any data gaps and taking a holistic approach are essential to:
- inform your decisions around the management and governance of your temporary workforce while maintaining patient safety and positive staff experience
- implement targeted interventions to address local challenges
- provide a clear foundation on which to agree a baseline for benchmarking and set realistic trajectories to track progress against at trust, system and regional levels, and help identify emerging issues, including performance and quality complaints
The list below of suggested data to consider includes all the areas highlighted in our case study conversations, but will not be exhaustive:
Data Categories for Staffing Analysis
Finance
- areas of high temporary staffing expenditure (agency and bank)
- temporary staffing expenditure as a proportion of total staffing costs
- off-framework agency use
- nursing-specific agency trends
- price cap compliance rate by ward or specialty
Establishment
- vacancy rates
- recruitment activity
- retention rates
- turnover
- shift fill rates
- reviewing unused hours substantive staff
- % of substantive staff annual leave taken
- establishment reviews
- % of active bank workers
Quality and safety
- reasons for shift requests
- different ward or shift pattern trends
- same temporary staff filling shifts trends
- skills gap from bank to substantive
- profile of bank staff (already full time in trust, part-time employed/bank, employed elsewhere)
- safe staffing reviews
Using a driver diagram
Effective real-time data analysis can support the development of your improvement initiatives by identifying the key drivers for you to investigate, for example recruitment and retention if there is both a high temporary staffing use and a high vacancy position.
The driver diagram below maps out the primary drivers and from these the secondary drivers and activities to achieve the overall aim of creating a healthy bank.
Diagram explanatory text
From the aim of creating a healthy bank the diagram shows:
- primary driver – agency use reduction, which requires:
- secondary driver – review existing governance structures
intervention – implementation of agency control board panel
- secondary driver – defined agency policies and procedures
intervention – review existing agency use policies and procedures
- secondary driver – effective deployment of agency staff
intervention – review existing e-rostering practices
- primary driver – substantive vacancy reduction, which requires:
- secondary driver – increased retention of substantive staff
intervention – values-based recruitment
- secondary driver – reduced attrition
intervention – stay conversations (3, 6 or 12 months)
- recruitment activity
intervention – automated bank enrolment for new starters
- primary driver – agency to bank migration, which requires:
- development of an attractive bank offer
intervention – upskilling or CPD offer
Creating additional driver diagrams for each of the initial interventions as aims will inform your action plan by developing more detailed interventions tailored to your organisation’s workforce needs.
Resources
- NHS England has a dedicated page on reducing expenditure on NHS agency staff with toolkits and guides
- Model Health System can be used to benchmark your current situation
- NHS England has developed a tool to diagnose how efficient your bank is
- NHS IMPACT’s driver diagram tool
Engaging your temporary workforce
You need to understand who your temporary workforce are and what informs their decisions to take on additional shifts. This will help you identify ways to support and encourage staff into NHS bank work and to support those already part of your bank to take up shifts. Embedding a strong collaborative culture between your temporary staff and clinicians, ward or temporary staffing managers, HR and finance will also help them feel more supported and recognised for the essential work they do.
There are many ways you can do this – engagement sessions, surveys, online forums, 1-to-1s, for example. We would recommend you engage regularly (once a quarter, in addition to your annual bank survey).
Below are suggested questions you may want to ask.
Understanding your agency workforce:
- what makes nurses join an agency?
- do your agency nurses know what additional support a bank can offer?
- are there agency nurses working the same shifts each week?
- are your agency nurses aware of the professional development opportunities through your bank?
Understanding your bank workforce:
- what makes nurses join the bank?
- what do your bank staff want from this role?
- do you know your bank fill rate?
- are your bank staff respected and valued?
What more can we do as employers:
- do you celebrate your trust’s unique selling points and promote successes?
- do your bank staff feel supported and included?
- what are the benefits of the bank system over agency work?
- what are the common misconceptions of working for a bank?
Resource
- NHS England’s bank development resource includes guides on how to engage your bank workforce
Reviewing policies and procedures
Reviewing bank and agency policies and procedures will give you insights into where possible savings and changes can be made. Consistency in how temporary staff are managed and the infrastructure within which they operate is vital for the trust and the temporary staffing team, to maximise the benefits from running a staff bank, and for bank workers themselves.
Consider the following for bank work, including for night shifts and weekends:
- does your rostering policy preference bank over agency deployment?
- do you review substantive workforce data when creating rosters (for example, unused hours)?
- can you offer agency shifts to bank (‘bumping’) without incurring double charge costs?
- is temporary staffing use regularly discussed at board in conjunction with recruitment and retention?
- do you have robust senior temporary staffing use and mitigation oversight?
- do you talk to your temporary workforce about migrating to substantive work: agency to bank or agency to substantive?
- do you undertake regular data analysis to inform policy and procedure reviews on establishment, recruitment and retention, staff costs and agency booking trends?
Case study: Rotherham NHS Foundation Trust – reducing agency reliance through international recruitment
The Rotherham NHS Foundation Trust wanted to repeat the success it had seen in reducing agency use for healthcare support worker temporary staffing across its registered nursing workforce by developing defined escalation governance:
- Executive leadership team sponsorship: clinical leadership support was critical in driving the cultural shift away from high-cost agency reliance to bank use.
- Supported through a trust-wide communication and engagement strategy to demonstrate the clinical rationale behind the decision.
- 4 defined padlock or golden key escalation trigger points and processes to mitigate agency use and offer assurance for proceeding with escalation.
- Agency ‘bumping’ points built into each escalation process to increase bank fill rate.
Resource
- Newcastle upon Tyne Hospitals NHS Foundation Trust staff bank policy
Governance and deployment
Bank and agency governance
Strong governance that is easily understood and visible is an important element of a healthy bank. This provides clear oversight of and accountability for compliance with trust policies and procedures, including bank staff meeting minimum training requirements, and the necessary feedback loop to continually adapt and improve temporary staffing policies in an everchanging healthcare ecosystem.
Examples of good governance being used in the system are:
- centralised booking to ensure consistency across departments or sites
- temporary staffing control panels to ensure board oversight
- regular agency reviews to ensure quality and value
- defined process flow for temporary staffing engagement, mitigation and sign off
- clear approval and escalation process underpinning process flow
With high agency spend, Sussex Partnership NHS Foundation Trust looked to develop its temporary staffing governance to reduce reliance on high-cost agency through initiatives including:
- agency engagement review
- implementation of centralised booking
- procurement review – this resulted in the use of fewer agency providers and therefore greater efficiency
- executive board oversight through the establishment of an agency control panel
- agency cap review
- engaging with agency providers and staff to align aims and expectations to maintain delivery quality
Early sponsorship from the executive board ensured engagement from both agencies and staff, which had previously proven difficult.
The full case study is available on FutureNHS.Resources
- Newcastle upon Tyne Hospitals NHS Foundation Trust staff bank policy
- NHS England’s agency rules toolkit and guidance
Effective deployment
Effective deployment – ‘right people, right skills, right place, right time’ is key in providing continuous high-quality care and applies to both your substantive and temporary workforce. There is no ‘one size fits all’ approach to deployment as each organisation needs to best respond to its own local requirements.
The National Quality Board’s safe, sustainable and productive staffing guidance sets out a triangulated approach to staffing decisions.
Examples of deployment approaches being used in the system are:
- setting up system-wide collaborative banks
- establishment setting
- e-rostering
- regular safe staffing reviews
- staff upskilling to ensure effective skill mix
- use of NHS reservists
Case study: Norfolk and Waveney Integrated Care System – system-wide bank
Faced with a £32 million agency staff bill and growing competition between system trusts to fill shifts, Norfolk and Waveney Integrated Care System took a proposal to create a system-wide collaborative bank to their bank and agency consortium for consideration.
The 4 key risk factors driving this were:
- current temporary staffing challenges
- growing service requirements
- lack of temporary staffing insights
- reduced workforce visibility
Resource
- NHS England’s bank development resource gives guidance on setting up collaborative banks to support effective deployment
Effective e-rostering
Trusts have found that consistently harnessing all the benefits of e-rostering platforms (ensuring timely and complete rosters and mapping individuals’ skills, for example) allows ward managers and the wider organisation to reduce reliance on last minute bank or agency use by appropriately planning safe staffing levels and deploying their nurses’ skills.
For consistency in e-rostering you need to:
- develop an e-roster policy and KPIs with board-level non-compliance management
- engage staff (communication plan)
- undertake equality impact assessments
- complete health and safety assessments
- ensure appropriate staff training
- consider e-job planning integration with e-rostering
Case study: The Walton Centre NHS Foundation Trust – integrated e-rostering system
The Walton Centre NHS Foundation Trust has seen many benefits since introducing a fully integrated e-rostering system, including:
- over 5,000 fewer unused contractual hours
- over £445,000 reduction in healthcare assistant (HCA) bank spend, while also increasing fill rate
- £450,000 of savings through establishment review (reinvested in HCA numbers)
- efficient rostering, with numbers more consistently balanced and improved skill mix
- fairer shift allocations
- improved staff wellbeing through better visibility of future shift patterns
- live visibility of actual staffing levels triangulated with patient acuity and dependency via SafeCare, enabling improved deployment to meet clinical demand and ensure safer staffing
- improved governance, assurance and reporting practices
- staff feel this has made positive changes for them, including knowing their working pattern further in advance, improved visibility and greater accessibility
Resources
- NHS England’s e-rostering the clinical workforce guidance
- NHS England’s Nursing and midwifery e-rostering: a good practice guide
- NHS England’s e-job planning the clinical workforce guidance
- NHS England’s e-rostering the clinical workforce: levels of attainment and meaningful use standards
- E-rostering policy: Leicestershire Partnership NHS Trust
- National Quality Board’s guidance on safe staffing: nursing and midwifery
Flexible staff offer (improving incentives)
Why develop a flexible staff offer?
Understanding the drivers for your temporary workforce will help you develop the incentives that make your bank competitive. Clinical leaders tell us that, while each organisation will have individual workforce challenges and therefore incentives to fill gaps, these can generally be categorised into 3 overarching themes: career development, attraction and health and wellbeing.
Case study: North Central London (NCL) Integrated Care System – benefits of collaborative banks
In 2020, North Central London (NCL) Integrated Care System created a collaborative bank to support:
- improvements in workforce flexibility
- cost efficiencies
- improvements in quality of care
- improvements in staff satisfaction
- increased collaboration across the system
The collaborative bank’s offer was attractive. It:
- gave staff more choice and flexibility as they could select shifts across different trusts that matched their skills
- enhanced skills by giving staff experience of working in different settings and trusts
- one central booking system made it easier for staff to book shifts
A robust feedback process identified that staff feel empowered to pick up shifts away from their own trust if they know the IT processes of another trust.
The full case study is published on FutureNHS.Upskilling bank staff and continuing professional development
“There should be continued focus on upskilling – developing skills and expanding capabilities – to create more flexibility, boost morale and support career progression” (NHS People Plan, 2020).
All staff should be invested in regardless of whether they are substantive or temporary. Trusts have told us about the value of having a dynamic bank training offer to meet organisational needs. This can incentivise staff to join the bank over an agency, and ensures quality patient care through the provision of a stable temporary workforce and one that may be more willing to take on hard to fill shifts.
Examples of upskilling being used in NHS organisations are:
- a well thought out induction package to include training in specialist areas
- access to statutory or mandatory NHS training
- career development pathways; tailored personal development to support career aspirations
- access to coaching and mentoring
- promoted role competencies at every level to support development and encourage progression
- personal development plans
- in-house training and development: clinical or leadership skills and management development or experience in different wards or departments
- revalidation support
- learning and development policies including parameters for bank staff and how they are included in trust learning and development
Case study: Alder Hey Children’s NHS Foundation Trust – upskilling bank members
Alder Hey Children’s NHS Foundation Trust worked with its bank provider to provide children and young people care certificate training as part of its healthcare support worker (HCSW) Development programme, after identifying a specific training need.
This investment in bank staff resulted in:
- 20 HCSWs joining the substantive workforce
- a 0% HCSW vacancy position
- increased bank deployment
Resources
Resources available to staff to support their development are provided by:
Maximising flexible working
Nurses say they choose agency over bank working because of the choice, flexibility and speed of payment offered by agencies, all of which contribute to a healthy work-life balance.
A fully developed strategy should target these reasons and afford your bank staff comparable benefits. For example:
- shift security: Sussex Partnership NHS Foundation Trust only makes shifts available through its bank; staff joining the bank have increased and agency use has reduced
- wage security: as part of its collaborative bank initiative, North Central London Integrated Care Board engaged with Allocate Pay to ensure fast payment for colleagues working additional shifts
- useability: Somerset NHS Foundation Trust designed its collaborative bank model around useability and developing an app that makes it easier for staff to view and book shifts
- flexible working: offering flexible working as part of a bank offer can support work-life balance and any changing caring responsibilities throughout a nurse’s career
Resources:
- NHS Employer’s flexible working common myths
- NHS Employers How to embed flexible working for nurses guide
- NHS England’s flexible working toolkit for individuals
Health and wellbeing support
How temporary staff perceive your organisation as supporting them to feel well, healthy and happy at work will factor in their decision to join an agency or bank, as well as to become part of the substantive workforce.
Diagnostic tools, such as the organisational diagnostic tool, provide an easy way to self-assess how good your organisation is at protecting its staff’s health and wellbeing.
Case study: Staff retention at Westminster Talking Therapies service
Westminster Talking Therapies wanted to understand whether its organisational culture was driving its higher-than-average retention rates.
Speaking to its longest serving colleagues, several themes emerged:
- a feeling of being truly listened to
- their views and ideas are valued and acted on where appropriate
- the team understood and embraced organisational values
- CPD is supported by line managers
The professional nurse advocate (PNA) role can deliver wellbeing support. A PNA is a registered nurse who protects nurses’ rights and represents their interests, as well as providing clinical leadership, facilitating restorative clinical supervision and leading quality improvement projects.
Wellbeing support they can deliver includes:
- dynamic support conversations covering professional areas such as clinical incidents, team dynamics, stress, burnout, instances of bullying, career progression, interviews and quality initiatives, as well as personal issues
- trauma and stress support: creating the opportunity for reflection after an event to reduce stress and enable learning, limit compassion fatigue and improve confidence
- supporting the development of personal and professional resilience
Resources:
- NHS England’s support available for our NHS people
- NHS England’s health and wellbeing programmes
- NHS England’s PNA resources
Publication reference: PRN01050