The NHS is under huge financial pressure. 

If anyone needed confirmation of just how bad things are, NHS trusts recorded the largest ever deficit in the history of the health service according to figures published in May.

The crisis has been blamed on a host of factors, from the demands of an ageing population to the increased cost of drugs and medical breakthroughs.

But another problem is the amount of money the NHS spends on agency staff to plug gaps in rotas, according to a recent survey of NHS finance directors.

This Good Health investigation reveals the extent to which nursing agencies benefit from a lack of NHS staff cover.

For despite a cap on the amount that can be spent on ‘rip-off’ agency fees, we’ve found that the agencies continue to rake in tens of millions from hospitals struggling to cope with staff shortages.

Despite a cap on the amount that can be spent on ‘rip-off’ agency fees, we have found that nursing agencies continue to rake in tens of millions from hospitals struggling to cope with staff shortages

One agency alone charged the NHS nearly £40 million for temporary nursing staff last year. Taxpayers paid five of the major nursing agencies an eye-watering £97 million and some agencies are earning even more than we discovered they did in a similar investigation last year.

And these figures could be just the tip of the iceberg, as about a third of trusts refused to divulge what they spent.


It’s easy to see how agency fees can quickly add up. We found that hospitals are continuing to be charged astonishing rates for some nursing shifts.

Wye Valley NHS Trust and Colchester Hospitals University NHS Foundation Trust paid more than £2,000 for a single nursing shift. Other hospitals told us they had paid similar amounts.

It is not just the cost to the NHS that’s a concern — patients can be directly affected by the use of temporary staff as the standard of care can suffer through lack of continuity.

‘The increased reliance on agency nurses and the shortage of nursing staff is an issue that has generated more and more concern among people who contact us,’ says Joyce Robins, of campaign group Patient Concern.

‘You may never see the same face — the situation can be especially bad at weekends when the majority of the nursing staff seem to be from an agency.

‘It’s not that they don’t care, but if they just come in for one or two shifts or the odd day here and there, can they really deliver the same standard of care?’

Not only that, but agency nurses aren’t allowed to carry out the same duties as staff nurses: some trusts won’t let them take blood for example, or give intravenous drugs or even administer food by a tube.


Our findings are based on Freedom Of Information requests we sent to trusts up and down the country asking how much they had paid for nursing cover from some of the major agencies (108 trusts replied, but some didn’t identify individual nursing agencies, suggesting the real cost to the taxpayer is much higher than our figures show).

For instance, Mayday Healthcare PLC charged the NHS £31.3 million for temporary nurses (across 54 hospital trusts). This is nearly £5 million more than the NHS paid it last year.

Another company, Medacs Healthcare plc, charged £11.4 million (for supplying 43 hospital trusts), up from £9.2 million last year (for 38 trusts).

One of the agencies in the study, Mayday Healthcare PLC, charged the NHS £31.3 million for temporary nurses (across 54 hospital trusts). This is nearly £5 million more than the NHS paid it last year

But they pale into insignificance compared to Thornbury Nursing Services, which charged nearly £39 million for supplying temp nursing cover to 47 trusts — the same company was paid £43.9 million last year across 53 trusts.

It’s a huge amount of money, but it’s easy to see how it could soon add up when you look at the highest fees that some hospitals paid for a single nursing shift. Twenty-seven of the trusts named Thornbury as charging the highest single day rate.

Worcester Acute Hospitals NHS Trust, for example, paid Thornbury £1,500 to cover a 12-hour shift on Good Friday. They say this was an ‘exceptional payment’.

A spokesperson said: ‘The cover was needed at extremely short notice. Since then the trust has put in place controls to ensure that this type of payment can’t happen again.’ 

While the trust says it’s not used Thornbury since April, this ‘exceptional payment’ was considerably more than the highest day rate the hospital paid to Thornbury the year before — back then they were charged a mere £952 for a shift.

Yet some hospitals paid even more. Last year, Thornbury charged Wye Valley NHS Trust £2,016 for one 14-hour shift.


Other trusts willing to reveal what they’d actually paid for a shift (many trusts refused to answer the question) included Hampshire Hospitals NHS Foundation Trust which paid Thornbury £1,858 (for an 11½-hour shift).

Derby Hospitals NHS Foundation Trust paid the same agency £1,794.

In fact, 13 trusts from as far apart as Scotland and Taunton revealed that they had paid more than £1,000 for a single shift.

A spokesman for Colchester Hospitals, which paid more than £2,000 for one shift, said the payment related to a nurse working on a bank holiday, but could not confirm which agency it was paid to. 

‘At that time, we were critically short of staff nurses and, in order to ensure patient safety, we needed to source a nurse from an agency,’ he said.

Wye Valley’s payment of more than £2,000 was also for a bank holiday — in this case to look after a child who required a ‘specialist nurse’.

The £2,000 fee is £200 more than the most paid for a single shift last year, according to a previous Good Health investigation.

It’s an 11 per cent rise — considerably more than the 1 per cent pay rise offered to nurses in full-time NHS roles, whose starting salary is just £21,000 a year.

And it helps explain why three quarters of trusts are in the red, according to new figures published last week by the health charity, the King’s Fund.


But what about the caps introduced last November? These were meant to stop hospitals paying nurses, junior doctors and other clinical staff any more than 100 per cent above the pay levels of permanent staff.

This was meant to taper off, to 75 per cent in February and 55 per cent in April.

But as Jim Mackey, chief executive of the regulatory body, NHS Improvement, warned in May: ‘Some trusts simply aren’t doing enough to reduce their agency costs.’

And our results back up his concerns. Some trusts have been particularly big spenders. For instance, Barts Health NHS Trust in London, tops the board, with a bill of £37.7 million.

The trust told us it that in the past year it had reduced its reliance ‘on expensive agencies by recruiting over 800 more permanent staff’ but admitted there is a ‘shortage of specialist staff’.

The next biggest spender was another London trust, Guy’s and St Thomas’ NHS Foundation Trust which spent more than £17 million, slightly less than a year ago (when it was more than £18 million).

A spokesperson said that although ‘the figure may appear large’ it represents just 7 per cent of the total £257 million it spent on nursing.

Yet it’s not just trusts based in the capital that are spending these large sums.

Abertawe Bro Morgannwg University Health Board in Wales spent £12.8 million — the year before it spent £10.1 million.

From this April each trust has been given its own limit on the total it can spend per year on agency staff. Barts’ cap is £62.2 million on all agency staff, including nurses (last year their spend on all agency staff was £89.9 million).

A spokesperson for Guy’s and St Thomas’ said they had been set a ceiling of £33.2 million on total agency costs for 2016-17.

Meeting it will be ‘a challenge’, they admitted.

There must be serious concerns that these two trusts at least will really struggle to remain within their caps.


What may shock many is that the agency nurses themselves — while better paid than their NHS equivalents — are certainly not seeing as much of the fees charged to the NHS as you might think.

According to figures on Thornbury’s website, for instance, a trained nurse is paid £31 an hour for a basic Monday to Friday shift.

The most they pay is £99 per hour to a specialist nurse in charge of a unit on a Bank Holiday. The good news is that some hospitals are bringing their nursing agency bills down.

For example, Oxford University Hospitals NHS Trust spent £10.7 million last year, significantly down on the £12.4 million it spent the year before.

However, many are flouting the caps — which were meant only to be overridden in the interests of patient safety, according to the guidelines. But the number of times that the caps have been overridden has been rising.

When the first cap was introduced in November the override clause was used more than 35,000 times in a week by 228 trusts.

By April this had risen to more than 53,000 times a week over 210 trusts, according to Freedom Of Information figures released in May.

And one trust, Oxleas NHS Foundation Trust, Kent revealed it spent five times MORE on agency nurses last year compared with the year before (from £2 million to £10.7 million).


The root of the problem is a shortage of nurses. According to the Institute for Employment studies, already one in ten nursing posts is unfilled and as almost a third of nurses are aged 50 or over, and are due to retire soon, the situation is set to get worse.

Although some nurses are quitting the NHS for better pay and working conditions, there aren’t enough of them to begin with.

Josie Irwin, head of employment relations at the Royal College of Nursing, said the Good Health investigation ‘shows just how much trusts around the country are struggling to find enough staff to provide safe patient care’.

According to the Institute for Employment studies, already one in ten nursing posts is unfilled and as almost a third of nurses are aged 50 or over

The problem she says is that the UK has not been training enough nurses and therefore has to use agencies to ensure patient safety.

‘Trusts are absolutely right to prioritise safe staffing levels and patient safety over sticking to the cap,’ she says. ‘Unfortunately, they are often forced to use expensive agency staff to do this because of short-sighted decisions taken at a national level.

‘Agency nurses are doing an important job but if a trust is over-reliant on temporary staff it can impact on continuity of care.’

Two of the trusts most reliant on nursing agency staff were also in the highest spenders: Barts Health and Guy’s and St Thomas’ needed nursing cover for 104,223 and 60,433 shifts respectively.

Some trusts are far less dependent. Salford Royal NHS Foundation Trust for example only needed to cover 1,886 shifts and spent about £700,000 on agency staff.

The Patients Association believes there is a simple solution to the staff shortages that allow the agencies to profit so much.

Josie Irwin, head of employment relations at the Royal College of Nursing, says that part of the NHS’s problem is that the UK has not been training enough nurses and therefore has to use agencies to ensure patient safety

‘If a fraction of the money that’s wasted on nursing agencies was invested in recruiting, retaining and training more nurses — giving them better terms and conditions — we would have a more caring compassionate NHS,’ says chief executive Katherine Murphy.

‘Instead, universities are training fewer nurses and the NHS continues to waste vast amounts of money on agency staff.

‘We must remember that the NHS is paid for by the tax-payer, and it belongs to patients and the public.’

A spokesperson for Thornbury said: ‘We provide a valuable service that helps trusts to guarantee safe staffing levels in the NHS.

‘Thornbury ensures that the right nurses, with the right skills, are available to deliver care to patients whenever trusts need us — round the clock, even at incredibly short notice.

‘Some rates for agency nurses are higher than the NHS rates — reflecting the nature of last-minute requests, out of hours, for flexible workers with highly specialist skills.’

Commenting on the high sums charged for single shifts, Thornbury said: ‘They are likely to have been last-minute requests for a highly experienced, specialist nurse who receives none of the benefits that a full-time, permanent worker would, but is available at short notice and prepared to travel a long distance to keep patients safe’.

Nick Poturicich, managing director of the Mayday Group, said: ‘We have a high number of clients that are both reliant on and extremely happy with our staff and service.’