Will the cap fit? GWH faces up to the squeeze of recruitment versus capped agency costs
As NHS hospitals across England enter the winter months - and put their plans to work round strikes by junior doctors on hold - staff shortages are still high on their agenda. Staffing - especially nursing staff - is being squeezed from both ends.
There are serious recruitment problems throughout the NHS and finance directors are watching every day's costs. And from November 23 they have the additional pressure of a government imposed cap on how much they can pay agency nurses.
The money spent of agency staff across the NHS in England during July-September was £1.9 billion - or 7.7 per cent of the national NHS pay bill. Great Western Hospitals Foundation Trust (GWH) have been working to cut their agency costs by 30 per cent from last year's level and their spend for October came to to 3.7 per cent of their pay bill.
GWH currently have 87 nursing vacancies. In the first week of the agency pay cap they missed the limit on 87 nursing shifts. But they had only had a weekend's notice that the cap was coming into force.
This intervention by the government in the marketplace for nurses is by no means certain to have the impact ministers want. One director told the Trust's board meeting this week: "I don't think it's going to have the kind of benefits people are predicting."
An experienced senior NHS manager and now a consultant to NHS Trusts, went further - his view featuring in this Health Service Journal headline: Fears agency cap will be 'train crash'.
NHS authorities have said the cap poses 'significant risks' for patient safety and performance, but that the 'balance of clinical risks' support taking action on agency costs.
The difference in pay between the capped hourly rate of £28.80 per hour (for daytime shifts) and the prices paid for some agency nurses can be as much as £10 per hour. GWH managers believe that at November levels they will breach the cap for nurses' pay an average of 62 times a week.
The capping regime will get tougher next year. The cap rachets down from that £28.80 per hour to £25.20 on February 1 and to £22.32 on April 1.
Nurses are not the only agency staff employed by GWH. They are currently employing four consultants from agencies who are breaching the £129.62 per hour cap. Already there are stories about overseas doctors working for agencies seeing their pay reducing and deciding to return home.
GWH's chief executive, Nerissa Vaughan, told this week's board meeting that since 2013 the Trust has recruited 570 nurses, 47 midwives and 102 doctors - which means they have 198 more permanent staff caring for patients.
Marlborough News Online asked Oonagh Fitzgerald, GWH's director of human resources, where those other 521 people had gone. Nurses can retire at 55 without damaging their pensions: "Turnover has crept up over the last years - across the NHS."
One factor has been the one per cent pay rise over the last government and into this one. And that pay rise is not what it seems as increased pension contributions have eroded the one per cent. Some staff do leave to join the higher paying agencies.
Some nurses do get annual increments as their experience increases. But 27 per cent of GWH's nurses are at the top of their pay scale - and so only get the one per cent rises.
When it come to planning ahead Oonagh Fitzgerald has a good local source of newly trained nurses who come through the Oxford Brookes University training college in Swindon. She hopes to recruit about eight in every ten nurses trained there - many of them already living locally.
The NHS (through the Health Education England) buys places at the Swindon arm of Oxford Brookes University: 67 this year, 120 next year and a rise to 132 for 2017 and 2018. Interestingly the average age of applicants for those places is running at 29 - it may be their second career or they are returning to work after having children: "They are making", says Oonagh, "a proactive choice - and so are most likely to become good nurses."
To close the immediate gap GWH is again recruiting overseas. As their economies revive, the EU countries - mainly Ireland, Spain and Portugal - are not proving such good recruitment areas. The relief overseas recruits bring in boosting staff numbers is sometimes shortlived as the pull of families and the strangeness of England lead some to realise they have made the wrong choice and they return home.
GWH 's last visit to Spain and Portugal - where forty NHS Trusts had been over the last two years - was not so productive. They saw 35 applicants and accepted six: "We have," Oonagh explains, "high standards for people working with our patients."
Next year they may go further afield - to India and the Philippines. The Home Secretary lifted visa restrictions in October and put nurses on the shortage occupation list. But Mrs May's decision is now under review - and GWH have been putting their case to the review that visa restrictions should not be put back in place.
Shortages in other areas are not affecting GWH so much. Unlike some areas of the NHS, they are not short of midwives. But the age profile of their midwife team is 'at the high end' - which may bring future problems. And GWH reflects the national shortage of doctors specialising in the care of the elderly.