10 / 07 / 2012
High Impact action 1: Increase understanding of the issue
In 2010, the trust commissioned an external report to provide recommendations for reducing temporary medical staffing costs. The report showed that agency locum usage during 2010 equated to 20,000 hours per month and added up to an £18m overspend.
The high usage of agency locums was largely down to the difficulties the trust faces with recruitment due to its location. The organisation covers three main sites which are each approximately 30/40 miles away from each other and the travelling time between sites can be considerable.
The trust is often not the top choice for many doctors, preferring to work at a large teaching hospital where they trained. This leaves the trust with a high proportion of vacancies which need to be filled using agency locums. Location based issues are also evident in the process of booking locums. The trust experienced difficulty particularly with A&E and Paediatrics in filling shifts.
Directorates were managing the demand for locums through multiple processes and using multiple agencies (the number of agencies used totalled 35 plus), many of which were not on the national Government Procurement Services (GPS) framework. There was little use of the agreed internal locum rates – the agencies and the locums were able to set their own prices which the trust had little choice but to pay when faced with last minute shifts to fill. There was also a distinct lack of management information for use when planning.
The trust learnt that poor practice was accepted practice. Extra duty pay and on-call rates were paid with little challenge. In terms of agency staff, bookings might be made for a week but without the actual shifts necessarily being confirmed – the expected timesheet for 40 hours would then be submitted for 72 hours worked, because the locum had requested a couple of nights “to make it worth their while”. In many cases, framework agencies were unable to fill assignments, which were then filled by their non-framework sister agencies at higher rates.
The only management information we had was largely financial. The trust had little or no data on why the money was being spent on agency locums.
High impact action 2: Manage the process and take control
In conjunction with the introduction of a new clinical management structure, which transferred accountability to newly established business units, United Lincolnshire Hospitals Trust piloted a new locum booking, authorisation and monitoring system and policies. Our aim was to make 10 per cent savings on agency spend and reduce the number of agencies we worked with.
They set themselves the tasks of:
- Gaining control by linking all the information together in one automated system
- Gaining visibility through real-time systems
Performance management via detailed management information
- Establishing a tiered supply chain
- Automating the supply chain cascade
- Reducing commission rates with the agencies
- Single set of rates in the system which are non-negotiable.
To accomplish this they needed to gain:
- Buy-in from our board
- HR and business unit agreement
- Medical staff buy-in
They also recognised that they would need to:
- Set out an initial investment
- Create a rigorous visibility and control environment for locum bookings
- Move from a reactive state to proactive planning
- Engage with a partner to reduce time to benefit from systems experience
The project started with a comprehensive data collection exercise. By May 2011 all the trust booking information, agency and names of the locums had been uploaded to the system and the pilot went live on 8 June 2011.
The trust decided to work in partnership with NHS Professionals (NHSP) for booking medical locums – NHSP had the benefit of already having a system in place for booking temporary staff. The intention was to reduce the time it would take to see a benefit from using the system and the hope of minimising the risk of implementation.
High impact action 3: Manage your workforce, establish a sustainable supply
As ULHT is set over five hospitals, geography posed a challenge in implementing the pilot. However, it was decided to roll out the pilot to all directorates and locations at the same time.
The organisation was undergoing comprehensive restructuring at the same time which caused some problems with the implementation. However, the trust registered all its existing doctors on the system as multi-post holders and operated an opt out system for those who did not wish to be considered for additional work. All bookings at any of our sites are now visible to eligible doctors at all sites, rather than solely their own site.
In order to reduce the number of agencies the trust worked with, they invited their highest spend framework agencies to bid to become one of initially six preferred suppliers with the intention of reducing cost, but also increasing and improving the supply and quality of locum doctors. Reduced commission rates were negotiated with the six chosen agencies and with SLAs in place from October 2011 this cohort became the trust’s Tier 1 suppliers. The trust continued with a further 16 Tier 2 agencies and a number of non-framework Tier 3 agencies, which were regular suppliers and where it was felt there may be a clinical risk if the trust were to stop using them.
Tier 1 agencies were given a few weeks to migrate their regular ULHT locums from their Tier 3 sister agencies to the Tier 1 agencies in order that they could continue to work for ULHT. The trust then gave notice to all Tier 3 agencies at the end of December 2012 and are in the process of removing the Tier 2 agencies, as the Tier 1 agencies are meeting virtually all locum requirements.
High impact action 4: Work collaboratively
The trust decided from the earliest stages to work in partnership with an external organisation and selected NHS Professionals, which had experience of implementing systems for the management and control of temporary staff spend, taking advantage of both their expertise and their online system. A project team was established consisting of internal trust staff and NHSP staff, who worked together through the implementation stage and who continued to work collaboratively during the pilot, which included the appointment of an NHSP on-site trust liaison coordinator.
Doctors already working for the trust are now able to look at the system to view and book assignments which are available to them outside their own location. This has reduced the number of agency locums that the trust needs to book. As the rates are already agreed and non-negotiable, and on the system it has enabled a saving on the amount spent on locums.
The booking system measures demand and spend. This means that the trust is now more informed on its agency locum usage and can be held accountable by auditable management information.
High impact action 5: Engage with staff
The trust developed a communications strategy which involved both written and electronic communications to business units, doctors and agencies. There were also presentations to various trust bodies and roadshows were held, to which all doctors were invited. Training was arranged for HR and business unit staff responsible for placing bookings and for internal doctors, who would be accessing the system to obtain additional work. The trust’s project manager and NHSP client relations team also held numerous one to one meetings and attended monthly meetings with the business managers.