Executive Summary

Government’s 30% agency-cut target is presented as fiscal discipline. In practice, attempts to suppress agency demand have pushed work into banks and overtime, often at the same or higher cost, while stripping away the flexibility services rely on to keep patients safe. The result is longer waits, cancelled lists, and exhausted permanent staff. Temporary staffing is the NHS’s shock absorber and safety net; weaken it, and resilience fails.

The Context: Agency Spend in Perspective

• Scale: NHS agency spend peaked around £3bn in 2022/23, driven by COVID backlogs, rising acuity, and periods of industrial action. It then fell by nearly £1bn after stricter caps and rules in 2024/25.
• Displacement, not reduction: The underlying demand that drove agency spend has not disappeared. COVID backlogs, rising acuity, and industrial action created extraordinary pressure, with temporary staffing keeping services running when no other options existed. The unmet demand hasn’t gone away. Caps and restrictions have displaced it into longer waits, cancelled lists, and hidden costs across banks, premium overtime, MSP fees, and private outsourcing.
• Narrative: Government presents agency use as fiscal excess. Truth: it is a clinical necessity that prevents permanent staff being left to run unsafe wards, take relentless overtime, and sacrifice health, work–life balance, and morale. Without agency support, waiting lists rise, theatres close, and patient safety is put at risk.
• Reality: Agency staff sustain frontline care across the NHS. They keep theatres running, A&E open, and diagnostics flowing; they provide cover in rural/hard-to-staff areas and lifelines in mental health and community services. Crucially, they stop permanent staff shouldering unsafe workloads that drive burnout and attrition.

Agency spend is not the cause of NHS deficits, it’s the visible symptom of deeper failures in workforce planning, supply, and retention. Blaming the symptom while ignoring the disease leaves patients and staff paying the price.

Why Blunt Cuts Are Dangerous

• Elective recovery jeopardised: Weekend/evening activity drops without flexible staffing.
• Workforce attrition: Pushing work into bank/overtime without retention support accelerates exits.
• False economy: Negligence payouts already exceed £2.6bn a year; unsafe staffing today becomes litigation tomorrow, wiping out headline “savings.”

Smarter Ways to Manage Agency Spend

• Retention first: Fund practical retention (safe rosters, breaks, wellbeing, flexible contracts).
• Roster intelligence: Use eRostering effectively, annualised hours, and job planning to match skill-mix to demand.
• Targeted controls, not blanket bans: Stop off-framework/premiums but allow framework agency partners for safety-critical cover.
• Grow banks without perverse incentives: Fair rates/terms that don’t just convert agency cost into more expensive overtime.
• Integrated workforce planning: One system view across permanent, bank, agency, insourcing, optimise total capacity, not silos.
• Funded insourcing where it saves money: Rapidly clear high-harm backlogs (endoscopy, imaging, day-case).
• Transparent reporting: Publish total flexible labour cost (bank + agency + overtime + MSP + outsourcing) so boards see reality, not just one line item.

The Political Narrative vs. Reality

The agency-cut target is sold as grip. In reality, attempts to suppress agency demand have shifted costs into banks and overtime while eroding flexibility on the ward. That may satisfy a spreadsheet, but patients feel the consequence, in longer waits, cancelled lists, and thinner staffing when they need care most.

Ambulance crews now wait so long outside A&E that shifts end before patients are even through the door. Patients are passed from one vehicle to another, not because of clinical need, but because there are no staff available inside to admit and discharge them safely.

Final Word – Altin Biba, MBA, AMBA

“Temporary staffing isn’t the problem; it’s the safety net preventing wider collapse. Demanding a 30% cut without a credible workforce plan is reckless. Shifting spend from one column to another doesn’t shorten waits or ease suffering — only safe staffing does. Patients don’t feel accounting tricks; they feel delays, cancellations, and harm. Without safe staffing, there is no NHS.”

References

1. DHSC/NHSE. Nearly £1 billion for NHS frontline after agency spend crackdown (2025).
2. NHS England. Reducing expenditure on NHS agency staff: rules and price caps (2024/25 update).
3. NHS Providers. Agency staffing and the impact on elective recovery.
4. Health Foundation. Workforce shortages and temporary staffing in the NHS.
5. King’s Fund. How should the NHS manage agency and bank staffing?
6. HSJ. Agency restrictions and the risk to elective lists and safety.