For decades, agency healthcare professionals have been the NHS’s shock absorber, stepping in when rotas failed, filling hard to fill shifts, and keeping services running through seasonal peaks and the pandemic. During COVID, NHS Employers called agencies “an extended arm of the NHS family.” Today, that family is being told there’s no place at the table.

Over the last two years, the policy line has hardened: eliminate agency spend; push healthcare professionals onto trust banks (often via restrictive terms); claim a victory for taxpayers. The reality on the ground is bleaker: the appearance of choice without the freedom to choose, a false economy that masks costs rather than removing them, and a quiet erosion of the elasticity that has kept patient services safe for decades.

This is not financial housekeeping. It’s a generational rupture.

1. The new orthodoxy and why it’s a false economy

In 2024/25, ministers trumpeted “almost £1 billion” less in agency spend. NHS England simultaneously ratcheted expectations that bank rates should not exceed “average equivalent agency rates” and set a tighter ceiling for agency as a share of the pay bill. The centre’s agency rules and price-cap regime are the enforcement spine of that doctrine.

Expenditure has not disappeared; it has shifted form. NHS England data for medical and dental staffing in England demonstrate the substitution clearly: bank spending increased by approximately £470 million (+18%) year-on-year, from £1.4 billion to £1.9 billion, while agency spending decreased marginally from £1.15 billion to £1.13 billion between 2022/23 and 2023/24. In accounting terms, the outlay has simply been transferred between cost codes, an administrative success more than a fiscal one.

The broader picture reinforces the same conclusion. Across the entire NHS and GP workforce in 2023/24, total temporary staffing expenditure reached £10.4 billion, comprising £5.8 billion on bank staff and £4.6 billion on agency staff. The balance of spending may have changed, but the underlying dependence on temporary labour has not. Presenting this shift as a victory over agency work risks obscuring the fundamental issue: the NHS is still buying the same hours of care, only through a different ledger line.

The BMA has also publicly criticised coordinated attempts to push down bank/agency rates, calling them “unacceptable” and warning systems that blunt price suppression risk damaging resilience and safety. This is not a fringe complaint about pay; it’s a warning that coercion breaks supply.

Bottom line: “Value for taxpayers” cannot be defined by a cheaper ledger line. It must be measured by the quality, timeliness, and safety of care actually delivered. If policy “savings” translate into more unfilled shifts, thinner staffing, fatigue-related risk, growing waiting lists, and declining care quality, the public is paying more for less.

2. Why “bank is cheaper” keeps failing in practice

Two non-negotiable facts are often missing from the “bank-first” soundbite:

1. Employer on-costs sit with the state. When the NHS (or NHS Professionals) is the employer for a bank shift, the public purse pays employer National Insurance (NICs) and employer pension contributions. The employer NIC rate, previously 13.8% in 2024/25, rose to 15% from April 2025, following updated HM Government thresholds and guidance. NHS employer pension contributions remain at a headline 23.7%, introduced from 1 April 2024 and reconciled via NHSBSA/DHSC. Those are real public costs, even when they don’t appear on a trust’s ward ledger.
2. Many “national bank”/vendor models still lean heavily on agency supply chains.
   NHSP case studies and marketing explicitly foreground “reducing agency spend”; at the same time, trusts routinely rely on agency capacity for hard-to-fill shifts and vacancies. If you recreate an agency pipeline inside a bank product, you don’t erase its economics, you obscure them.

Put together, this means a bank hour can cost the state as much as, or often more than, an equivalent framework-capped agency hour, particularly on nights and weekends (where bank enhancements stack). Finance teams know this; political comms often pretend otherwise.

Explainer: The Total Cost of a Shift (Illustrative, like-for-like)

Cost element	Bank (AfC Band 6, weekend night)	Agency (framework-capped)	Comment
Base pay	£23.00/hr	—	Bank pays AfC base directly
Unsocial-hours premium (e.g., 40%)	+£9.20/hr	—	Bank enhancements stack on nights/weekends
Employer NICs	+£4.40/hr (13.8% in 2024/25; 15% from Apr 2025)	Included within capped rate	Public cost on bank route; agency handles employer on-costs inside the cap
Employer pension	+£5.50/hr (23.7% of pensionable pay)	Not a trust cost	Public cost via NHS pension (bank); agency route does not incur this for the trust
Holiday accrual	+£2.30/hr	Included within capped rate	Often omitted in internal comparisons
Admin/rostering	+£1.00/hr	Included within agency service	Bank platforms/teams still cost

Capped total hourly charge:
• Bank: ≈ £45.40/hr
• Agency: ≈ £43.00/hr (all-in, incl. enhancements, employer on-costs & margin)

Agency cap is a single, all-inclusive ceiling set by NHS England.

Illustrative example using 2024/25 employer on-costs and NHSE price-cap logic; local values vary. From 6 April 2025, Employer NICs rise to 15%, increasing the bank “true public cost”.

Beyond headline pay and on-costs, trusts also absorb significant hidden costs to run their own bank infrastructure. Most pay annual platform or licensing fees to providers such as NHSP or third-party vendors, often six-figure sums per year, plus the internal payroll, compliance, and rostering staff needed to operate them. Those expenses rarely appear in national comparisons, yet they are part of the true taxpayer bill. Framework agencies, by contrast, absorb equivalent technology, payroll, compliance/governance, framework participation, and audit costs within the capped rate, so the like-for-like differential narrows further once these unaccounted elements are recognised. With ENIC rising and most trusts paying six-figure bank-platform fees, the public cost gap widens further.

Taxpayer delta (worked example). If bank covers 100–116 million hours annually and costs just £2.40/hour more than an equivalent framework-capped agency hour, the public overpays £240–£278 million for the same labour, with less flexibility. (Scale anchored to published 2023/24 totals of £5.8bn bank + £4.6bn agency; hours estimated illustratively at £50–£58 blended.) These figures exclude the substantial overheads Trusts absorb to run their own banks; staffing, payroll, compliance, systems, estates and platform licences, none of which are reflected in headline comparisons, yet all borne by the taxpayer.

3. The hidden cost of an unfilled shift

Every time a shift goes unfilled, a spreadsheet records a saving. On the ward, it becomes a debt of risk, an overstretched nurse or clinician, and a patient receiving less than the standard of care they deserve.

A 2019–2021 analysis found 11.3% of requested locum shifts went unfilled across trusts; roughly two-thirds of filled locum shifts were covered by agencies, one-third by banks. If you squeeze agency without building real capacity, you don’t remove the need, you increase the probability that a tired permanent colleague stretches further or that work simply goes undone.

The HSSIB’s 2025 investigation is explicit: fatigue among healthcare staff contributes directly and indirectly to patient harm; systems under-recognise the risk and do not consistently design rotas or mitigations accordingly.

The evidence linking lower RN staffing to worse outcomes (including mortality, falls, and missed care) is robust and long-standing. Cutting flexible capacity while safe staffing remains unresolved raises predictable risks.

Unfilled does not mean zero cost. It means risk deferred, transferred onto exhausted permanent healthcare professionals and onto patients who trust them at their most vulnerable time.

4. The appearance of choice without the freedom to choose

The lived experience many healthcare professionals report is forced migration:

• Inflated introductory bank rates, followed by cuts
  • Restrictive return clauses, limiting the option to come back via agency for a year or more
  • Local practices that use market power to suppress alternatives

The BMA has publicly condemned coordinated bank/extra-contractual rate reductions and called on systems to reverse planned cuts, not to protect “profiteering,” but to avoid collapsing supply. The public rhetoric of “fairness” is masking force.

Ask permanent staff whether “winter” is still a distinct season; most will tell you it has blurred into one long surge. That’s not a cultural complaint; it’s a resource signal.

5. Policy by bulldozer, not by peer review

Policy by bulldozer has replaced policy by evidence. Over the last two years, national leaders have tightened rate caps and pushed a “bank-first” orthodoxy largely by letter and guidance, not by formal public consultation, even floating legislation to “eliminate” agency use. That’s the policymaking equivalent of enforcing a clinical treatment before peer review: an experiment run on the service itself.

When the BMA warned against co-ordinated cuts to bank and extra-contractual rates and called for reversals, and when the REC showed bank spend had jumped while agency fell, those signals were dismissed rather than debated. Decisions reshaping billions of pounds of labour spend and hundreds of thousands of healthcare professionals’ livelihoods have been made without transparent engagement with the workforce or its supply partners. That isn’t scrutiny; it’s certainty seeking confirmation. The centre has even threatened legislation if progress stalls, proof that decree is replacing debate.

6. Quality and governance: demand like-for-like transparency

It’s often implied that agency equals risk. The policy reality is more nuanced:

NHS England’s agency rules require use of approved frameworks; off-framework is allowed only on exceptional patient safety grounds with executive sign-off. Price caps apply to total hourly cost.

Framework agencies are audited multiple times each year and must meet the NHS Employment Check Standards and Framework Standards: identity, right to work, registration/qualifications, DBS, occupational health, and references. Trust banks are supposed to apply the same six checks, but there is no routine, public, like-for-like reporting of compliance rates or incident rates by route.

If safety is the rationale for artificially suppressing agency work, then transparent, comparative data is the only credible basis for policy.

If ministers want to argue banks are safer, they should publish comparable quality/governance metrics (NHS/NHSP/bank vs framework agency) rather than spotlighting isolated incidents involving agency workers while ignoring the routine, systemic harms of running below safe staffing.

7. How many hours of care does temporary staffing buy?

Let’s quantify the scale. In 2023/24, The Guardian reported £10.4bn in total temporary spend across NHS hospitals and GP (£5.8bn bank + £4.6bn agency). Even at a conservative £50–£65/hour blended rate across roles and shift types, that funds approximately 160–208 million hours of care, roughly 13–17 million 12-hour shifts. Those are the hours that keep wards open and lists moving. Remove them and the “saving” reappears as unprecedented waiting lists, cancelled activity, unsafe ratios, and rising risk.

How do agency healthcare professionals feel when that work is recast as a problem?
Like many of us would: used in a crisis, caricatured in calmer times. It breaks the social contract, the one that says “step up when needed and we’ll respect your contribution,” not “step up, then be blamed for the bill.”

8. The NHSP push and the monopoly drift

NHS Professionals (NHSP) markets a “National Bank” that “reduces agency spend” and showcases trust case studies claiming 0% off-framework usage and headline hourly savings. Centralising control may simplify optics; it also reduces competition and choice, the very levers that drive service quality, innovation, and value. The case studies rarely present whole-of-labour comparators (enhancements, employer NICs, pension, vendor bank operating overheads cost) against framework-capped agency, which is what taxpayers deserve to see.

That’s the heart of this argument: the optics have become more important than the maths and the safety.

9. When leaders are forced to act down

The drive to eliminate agency use has not removed gaps; it has pushed them upwards. Across the country, consultants are being asked, and often expected, to act down to cover Middle Grade or SHO rota gaps when flexible cover cannot be sourced.

According to the BMA’s 2024 Medical Rota Gaps Report, 37% of consultants said they had been asked to act down, 56% of SAS doctors to act up or down, and 70% of resident doctors reported rota gaps that were never filled. Acting down is extra-contractual, confirmed by both BMA and NHS Employers guidance, yet it is now becoming routine. Each time a consultant covers a junior gap, the NHS pays consultant-rate labour for junior-level work while draining the senior expertise that should be mentoring, supervising, and leading their teams.

Consultants are not just clinicians; they are mentors, stabilisers, and moral anchors of hospital medicine. When they are stretched into back-to-back service cover, teaching time disappears, quality oversight thins, and morale collapses. The message to the next generation is bleak: that experience is a burden to be exploited, not an asset to be protected. Every hour a senior doctor spends firefighting junior rotas is an hour stolen from training, governance, research, and innovation.

The cost isn’t only financial. It is cultural and psychological, a slow unravelling of professional identity that risks driving the very people who hold the system together out of it altogether.

When even those who lead the system are made to act down, the social contract between government and the medical profession begins to fracture.

10. Permanent staff: carrying the burden

Permanent colleagues have been stretched thin for years. The NHS Staff Survey 2024 reports 41.6% felt unwell due to work-related stress in the last 12 months; this is “lowest since 2021,” but remains unacceptably high. Younger staff trends are especially concerning, with authoritative analyses showing lower job satisfaction and higher stress among Gen Z healthcare professionals over the last decade.

“Bank-first” was sold as protection for substantives. Used as a bludgeon, it hardens overtime culture, erodes recovery time, and trades financial optics for clinical risk.

When flexibility is punished and choice removed, clinicians leave. The GMC warns that nearly one in five doctors plan to leave UK practice; many more are exploring overseas or private options. These are not short-term agency fillers; they are the mentors and mid-career anchors the NHS cannot replace quickly.

The government’s narrative has turned the very people who kept the NHS afloat into scapegoats for its deficits. You cannot cut your way to loyalty.

11. Leaders’ impossible brief

NHS leaders are told to cut agency, hit savings, reduce waits, and protect quality, while deficits deepen and demand remains high. The King’s Fund notes system deficits roughly doubled from 2022/23 to 2023/24, illustrating how unrealistic “do more with less” has become. In that context, rhetorical savings that shift cost and risk (rather than reduce them) are not leadership, they’re wishful thinking.

12. Define value properly, publish like-for-like comparisons

If the case against agency is as strong as ministers claim, scrutiny should be welcome. Three simple steps would rebuild trust:

• Publish whole-of-labour cost: per filled hour/shift, by route (bank, framework agency, insource, outsource). Include: worker pay, employer NICs, pension, enhancements, admin/vendor fees, travel/accom where relevant, and VAT treatment. Stop the cost code shell game.
• Publish quality/governance parity: identical, routinised reporting of identity/DBS/reg-status compliance and incident rates for NHS/NHSP/bank vs agency placements. If bank is genuinely safer, prove it.
• Publish requested vs filled: temporary demand and the safety impact (e.g., missed obs, escalation delays). We already know 11% of locum requests went unfilled pre-clampdown; hiding today’s non-fill doesn’t protect patients.

13. A respectful settlement (that actually works)

Treat agency as part of the ecosystem, not an aberration. NHSE rules already enforce frameworks and caps; use them, don’t vilify the people doing the work.

Use staff banks where they really add value: protect permanent staff wellbeing, support continuity, and deliver a lower total cost than alternatives. If those tests aren’t met, be honest.

End coercive migration tactics. Reverse blanket rate ambushes and restrictive return bans; negotiate openly, or workers will vote with their feet, often out of the NHS entirely, around 154,000 hospital & community staff left their NHS employer in the year to September 2024 (10.1% turnover).

Keep competition and choice alive. A monopoly “national bank” is not a modern solution; it’s a single point of failure that invites stagnation.

Anchor “value” in outcomes. HSSIB is clear: fatigue harms patients. Counting saved pounds while ignoring missed care is not value, it’s moral hazard.

Final Word — Altin Biba, MBA, AMBA

“You don’t fix capacity by shrinking the choices of the people who provide it.

 

Agency healthcare professionals didn’t just keep the NHS safe in the past, they still do. Forcing everything through a single channel doesn’t solve shortages; it disguises them. An artificial drop in “agency spend” is not efficiency; it’s a system growing numb to patient harm and to its own staff exhaustion.

 

NHS leaders across the system have an impossible task on their hands, but the NHS can still rebuild a healthier, more future-proof model of flexibility that strengthens, not fractures its workforce.

 

Patients deserve the reassurance that safe care will be there when they need it, and that requires a workforce with real choice and fair support. ProMedical continues to work alongside NHS partners and healthcare professionals to uphold that commitment.”

 

References

NHS England — Reducing expenditure on NHS agency staff: rules and price caps; and Agency rules changes for 2024–25 (price-cap logic, frameworks).
DHSC & HSJ (Sept 2025) — Agency spend down ~£1 bn; legislative option under review.
REC (2024) — medical & dental bank spend up £470m (+18%) to £1.9bn; agency medical fell slightly to £1.13bn.
NHSBSA / NHS Employers — employer pension 23.7% from 1 April 2024.
UK Parliament Research Briefing — employer NICs 13.8% (secondary threshold detail).
NIHR / PubMed — locum usage: two-thirds via agencies, 11.3% unfilled (2019–2021).
HSSIB (Apr 2025) — The impact of staff fatigue on patient safety.
RCN evidence & position statements — lower RN staffing linked to higher risk/poorer outcomes.
NHS Employers — Employment Check Standards (six checks; parity expectation).
NHS Staff Survey 2024 — 41.6% unwell due to work-related stress.
Nuffield Trust analysis — younger staff, higher stress/lower satisfaction trends.
BMA/HSJ — criticism of bank/agency rate cuts; calls to reverse.
NHSP National Bank case studies/marketing (agency displacement claims).
The King’s Fund — deficits roughly doubled 2022/23 → 2023/24.
HM Gov (2025) — Employer NIC 15% rate from 6 Apr 2025.