Intended for healthcare professionals


The locum cap is working but we still have a long way to go

BMJ 2016; 355 doi: (Published 18 October 2016) Cite this as: BMJ 2016;355:i5632
  1. Kathy Mclean, executive medical director
  1. NHS Improvement
  1. enquiries{at}


Kathy Mclean considers the progress made by the NHS a year after the first locum agency caps were introduced but warns that trusts are still using too many expensive agency staff

Before NHS Improvement introduced controls aimed at reducing expenditure on agency staff in the NHS, trusts’ spending on such staff had been spiralling out of control, growing 25% on average year on year.

A year after the caps were introduced, we have made a difference and are starting to reap the benefits. Trusts up and down the country have worked hard to save a total of just over £600m to date. It’s a solid start, and we expect agency costs to continue to fall.

However, despite all this hard work the sector is still spending £250m a month on agencies. We believe that this is because trusts continue to rely heavily on agency staff.

Using agencies is an expensive solution to staffing shortages. The 2015-16 bill for medical agency staff in particular in the NHS in England was £1.3bn, more than a third of the total agency spend, and representing a cost per tax payer of £51.

We recognise how challenging the workforce market can be and that there are staffing shortages in many specialties and geographical areas. This makes it even more important that trusts take this opportunity to manage their existing workforce better, because we have found that they are still spending too much on medical and dental agency staff. For instance, sample data have shown an 18% reduction in nursing agency prices but only a 13% reduction in medical prices since October 2015. We have seen the progress made by trusts in reducing nursing agency prices, but clearly we are not seeing the same shift in medical staff.

Furthermore, we’re hearing that some agency staff will not even consider accepting work if it’s not negotiated at a starting point well above the cap. This is unacceptable. It puts employers in an impossible position that they have to accept to ensure that patient care isn’t compromised. This type of negotiation isn’t fair or sustainable and shouldn’t be taking place in the NHS.

NHS Improvement has developed a guide to reduce reliance on medical agency staff and to point trusts to ways they can improve their workforce management ( But part of what NHS Improvement plans to do next is to explore what could be done to bring down the costs of individual shifts that are paid above the cap. Some estimates indicate that, if we can get medical and dental shifts over the cap down by £10 an hour, there is a potential saving of over £100m a year.

We want to help trusts manage how they deal with individual agency staff with high fees and to make sure that boards have the right level of oversight when their trusts are agreeing these costs. Some trusts are getting it right on reducing their medical agency spend. For example, Barnsley Hospital NHS Foundation Trust reduced its weekly spend on agency doctors by 40% in just over half a year, through excellent leadership on the part of its medical director. But there needs to be wider movement to make sure the NHS is doing what it can to avoid paying over the odds.

This year has given us great promise as to what the NHS can achieve without compromising the care of patients, but this work must continue.


  • Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interests: I work as executive medical director at NHS Improvement, the organisation responsible for managing the NHS agency staff controls.