Reduction of Agency Staff Use in a Community Health Service

 10th January 2025

By Julia Mead, Associate Director and Lead Nurse for BCHS (QI Project Lead) and William Diaz, Improvement Advisor

As part of East London NHS Foundation Trust’s strategic outcome of Improved Value, the nursing team in Bedfordshire Community Health Services (BCHS) started a quality improvement (QI) project in July 2024 aimed at reducing agency spend by 30% by March 2025. While the project was established to primarily reduce costs around temporary staffing, it was also aimed at streamlining workforce processes and improving service delivery leading to improved value for money. The project evolved to include colleagues from London Community Health Services to share learning and experience. It was led by Julia Mead, Associate Director and Lead Nurse for BCHS, coached by Sarah O’Hare, Leanne Welch and Jo Moore, with the author as the Improvement Advisor.

The team utilised QI tools to address this quality issue, which include the fishbone and driver diagrams. Primary causes of the rise in agency use were identified as issues around high number of vacancies, expectations in the nursing role, lengthy recruitment processes, lack of Community Bank pool, and workforce-related factors such as flexible working arrangements, reasonable work adjustments, and training and development affecting service delivery. These are illustrated in the fishbone diagram in Figure 1 below.

Figure 1. Fishbone diagram showing causes of rise in agency spend

Barriers to change included high sickness rates, caseload complexity, new care homes development in the area, international recruits not  driving or having access to a car which delayed ability to complete their Band 5 competencies and work independently, impracticality of the use of public transport given the geographical area of the service, demand and capacity discrepancy – the population had increased but there had been no additional investment in establishment, large number of newly qualified nurses with limited experience resulting in higher pressure on more experienced staff to see complex and high acuity patients, and lack of confidence to discharge non-housebound patients without alternative care  in the system.

The following opportunities for improvement were also identified: potential of unqualified staff to undertake some additional tasks, staff professional development, improvement in Single Point of Access triage for housebound patients, review of the admission criteria to community nursing inclusion criteria, gap analysis of the system, caseload reviews and bolstering support in decision making around its management, increasing multidisciplinary team involvement, streamlining the bank booking system to retain leavers, and recruitment of more bank workers.

Once the team understood the problem, they developed the Driver Diagram, which showed the aim, primary and secondary drivers, and change ideas that make up their theory of change. Figure 2 illustrates the change ideas (in bold and blue) that the team decided to start testing using Plan-Do-Study-Act (PDSA).

Figure 2. Driver diagram showing the aim, primary and secondary drives and change ideas, from right to left.

PDSA 1: A letter was sent to Primary Care colleagues providing information about the project, which highlighted testing and potential adaption of a revised referral criteria for district nursing visits. This was prepared by the senior leadership team and was circulated at the end of September 2024. This was widely supported by General Practitioner (GP) colleagues and their teams as well as service users.

PDSA 2: Concurrently, a weekly review by senior nurses started to review the caseloads of all nursing teams in Bedfordshire with workforce planning to cover 2 weeks’ rota. This was extended by the second week of December to cover 8 weeks’ staffing levels.  PDSA ramp in Figure 3 below shows the iterative process of this change idea. The team decided that this will be moving toward implementation by January 2025.

Figure 3. PDSA ramp for the weekly caseload and staffing review change idea

PDSA 3: Introduction of a simple questionnaire to reduce inappropriate referrals for non-housebound patients at the Single Point of Access contact centre. Staff reported that this gave them clear guidance on screening patients and a more standardised approach in assessing the need for a home visit.

As a result of these changes, the team have seen a reduction of 9% in weekly agency costs as shown in Figure 4. This is equivalent to an average monthly reduction of £12,271.40 with an annual potential savings of £147,268.80 based on these figures.

Figure 4. I chart illustrates reduction in costs since the QI project started.

Next steps include working with local university partners to recruit nursing students to join the bank pool. 15 students have so far expressed an interest in joining the Trust as bank workers. The service hopes that once these students have qualified, they will work as Band 5 Nurses. Once the first cohort of new bank staff have started, they will be incorporated into the new starters’ programme with existing induction and teaching programme called Skill & Drills together with other recruits on substantive posts.

There is also a requirement to review bank pay for qualified staff. The current arrangements mean that bank staff are paid at the bottom of the band despite previous experience. This means that when staff leave, they are reluctant to sign on the bank. This appears to be a specific issue to ELFT as staff are signing on the Bank for other organisations. If previous experience was recognised, this may improve recruitment of new bank workers and eventually improve the nursing bank pool.

Lastly, the team plan to test a centralised bank service to lead recruitment and management of all temporary staffing arrangements in BCHS. This is still in consideration by the Trust workforce committee, but if approved would further streamline the bank system within BCHS and potentially the cross-organisational working system to ultimately remove reliance on agency workers and provide a much better experience for both staff and service users.