Investigation report

Investigation report: Temporary staff – involvement in patient safety investigations

A note of acknowledgement

We would like to thank the healthcare staff who engaged with the investigation for their openness and willingness to support improvements in patient safety.

About this report

This is one of several investigations that HSSIB is carrying out to explore the theme of workforce and patient safety. This stream of work is looking at how working conditions in the NHS can be optimised to support patient safety.

This report is intended for healthcare organisations, policymakers and the public to help improve patient safety in relation to the involvement of temporary staff in incident investigations. This is a legacy investigation completed by the Health Services Safety Investigations Body (HSSIB) under The NHS England (Healthcare Safety Investigation Branch) Directions 2022.

Executive summary

Background

The NHS regularly uses temporary staff to fill gaps in its workforce. This investigation explored the challenges of involving temporary clinical staff (bank only staff, agency staff and locum doctors working within trusts) in local trusts’ patient safety investigations. Trust-level investigations are important because they are a way to identify learning to improve healthcare systems, with the aim of reducing the potential for harm to patients. Identifying learning requires staff to be engaged in an investigation; if temporary staff are not involved, learning may be lost, posing a risk to patient safety.

HSSIB identified this risk following analysis of serious incident reports provided by acute and mental health NHS trusts. To explore the issue further, the investigation carried out site visits and engaged with NHS trusts, providers of bank staff, agencies that supply staff to NHS trusts, substantive (permanent) NHS staff, bank and agency staff, and a range of national stakeholders.

Findings

  • Limited engagement of temporary staff in patient safety investigations may limit the potential for learning and undermine an investigation’s ability to influence future safety improvements.
  • Patient safety investigations are being concluded without vital information because of observed and perceived barriers to engaging with temporary staff.
  • Temporary staff are not always able to report patient safety incidents, and this impacts on the development of an open reporting culture and the ability to learn from patient safety incidents.
  • The extent to which patient safety investigation findings are fed back to temporary staff varies, limiting the ability for all of those involved to learn.
  • Support is not always provided for temporary staff following a patient safety incident; this can have an impact on staff members’ welfare and on patient safety.
  • NHS England’s approved framework agreements for agency staff do not specifically refer to patient safety, or to support for staff following patient safety incidents.

HSSIB makes the following safety recommendations

Safety recommendation R/2024/020:

HSSIB recommends that NHS England includes guidance on engaging temporary staff in learning responses within their 'engaging and involving patients, families and staff following a patient safety incident'. This should be developed in collaboration with providers of temporary staff to the NHS to help assist healthcare providers being able to fully investigate incidents from a systems perspective, enabling learning that can improve patient care.

Safety recommendation R/2024/021:

HSSIB recommends that NHS England updates the agency worker framework agreement criteria to explicitly require framework agreements to adhere to the staff support principles of the NHS England Patient Safety Incident Response Framework. This will improve patient safety as there is a recognised link between staff having wellbeing concerns and the delivery of patient care.

HSSIB makes the following safety observation

Safety observation O/2024/019:

Agencies providing temporary staff to the NHS can improve patient safety by facilitating the involvement of temporary staff in investigation processes, including interviews. This is to enable the investigation of patient safety incidents in line with the Patient Safety Incident Response Framework.

Local-level learning

Healthcare providers can use the findings from this investigation as prompts to help them consider how they involve temporary staff in patient safety investigations:

  • How do you ensure that temporary staff are aware of how to record patient safety incidents?
  • If an incident takes place, how do you ensure that temporary staff are able to record it?
  • How do you engage temporary staff in a learning response?
  • Do you have processes in place so you can conduct interviews with temporary staff?
  • Can you work with employment agencies to create agreed methods of including temporary staff in learning responses through your contractual arrangements?
  • How do you ensure that learning is fed back to those staff involved, including temporary staff?

1. Background and context

1.1 Introduction

1.1.1 This investigation report is part of a wider programme of work being carried out by HSSIB on the theme of workforce and patient safety. To identify topics for investigation within this theme, intelligence was reviewed from service and professional regulators, national reports, the Parliamentary Health and Social Care Select Committee, academia and research. Discussions also took place with a large number of national stakeholders to understand their emerging concerns in this area. As a result of this work four investigations were launched in June 2023 looking at temporary staff, the digital environment, prioritising patient care, and skill mix and integration.

1.1.2 This investigation focused on temporary clinical healthcare staff who work in the NHS in England and sought to identify the challenges this cohort of staff experience that may impair their ability to deliver safe patient care. While temporary staff are present throughout the NHS, including in non-clinical roles, the scope of this investigation was limited to clinical staff only.

1.1.3 The investigation analysed and identified commonalities across 30 serious incident reports (investigation reports by local trusts into patient safety incidents) that had been conducted between May 2022 and May 2023, where temporary staff had been involved in the incident. More details about how the analysis was carried out can be found in the appendix. One risk that emerged from the analysis was around the involvement of temporary staff in trusts’ patient safety investigations. This investigation report focuses on this risk, with future reports planned to consider other risks identified.

1.2 Background

Healthcare professionals in a busy hospital corridor.

The NHS workforce

1.2.1 The NHS has a shortfall of staff which has been recognised to impede patient safety (NHS Providers, 2022). Many of the gaps in staffing left by this shortfall are filled using temporary staff, with ‘an estimated four in five registered nurse vacancies and seven in eight doctor vacancies … being filled by temporary staff’ (Nuffield Trust, 2022).

1.2.2 There are various contractual arrangements under which clinical staff work for or are employed by the NHS. Staff who have a permanent contract with an NHS trust are known as substantive staff. This investigation focused on three specific types of temporary staff; bank only staff, agency staff and locum doctors. These are defined below.

Bank staff

1.2.3 Bank staff are flexible workers who can be contracted directly by a provider or through an outsourced organisation to take on shifts which are available due to planned or unplanned gaps in rotas. Some substantive staff work extra shifts as bank staff. Other bank staff do not hold substantive posts and take on available shifts on an ad hoc basis in line with their individual choices – these are known as bank only staff.

1.2.4 Trusts will often have a local bank of staff they can offer shifts to and there are also regional or collaborative banks which can be drawn upon to fill rota gaps.

1.2.5 In this investigation the term Bank staff is used to refer to non-doctor clinical staff, such as nurses or healthcare assistants.

Agency staff

1.2.6 In this investigation the term agency staff is used to refer to non-doctor clinical staff who are contracted through an agency, such as agency nurses or healthcare assistants.

1.2.7 NHS healthcare providers may use agencies to secure temporary staff to cover gaps in rotas. HSSIB understands that approximately 5% of Nursing and Midwifery Council registrants work for an agency, equivalent to around 16,000 staff. The use of agencies in the NHS is monitored by NHS England, which collects data on the number of shifts undertaken by agency staff and the associated costs. Current data indicates that the shifts completed by agency staff in 2023 cost £3.4bn, which is approximately 2.3% of the overall workforce budget.

1.2.8 There are attempts at a national level to reduce the spend on agency staff (NHS England, 2023a). However, it has been recognised that while shortfalls in staffing exist in the NHS ‘they will continue to be largely covered by use of temporary staffing, including a mixture of bank and agency’ (NHS England, 2023b).

1.2.9 Many agencies provide staff to the NHS and each healthcare provider will have individual arrangements with the agencies they use to provide staff. Temporary staff may work for a number of agencies and may work just one shift at a particular provider, or for a set number of shifts over a period of time, depending on the needs of the provider and choice of the staff member.

1.2.10 NHS England has mandated that trusts should use only agencies which are governed by an authorised framework agreement (NHS England, 2023a). At the time of drafting this report, two such framework agreements had been approved by NHS England for use in the provision of clinical staff. These framework agreements provide a level of assurance by stipulating certain requirements which the agency must adhere to. The organisations who have designed and manage these frameworks are known as the framework operators. These organisations undertake audits of elements of their framework in order to provide assurance that the required standards are being adhered to.

1.2.11 Some agencies operate ‘off-framework’ which means that they are not signed up to a framework agreement but still offer staff to the NHS. While use of such agencies is discouraged (see 1.2.9) the NHS England ‘Agency rules’ do allow the use of such agencies ‘on exceptional patient safety grounds only’ and subject to executive sign-off (NHS England, 2023a). Trusts that use an off-framework agency must follow strict reporting requirements, reporting to both their integrated care board and to NHS England.

Locum doctors

1.2.12 A locum doctor or ‘doctor in locum tenens’ is defined as ‘one who is standing in for an absent doctor, or temporarily covering a vacancy, in an established post or position’ (NHS Executive, 1997). Locums may have a contract directly with a healthcare provider, or work through a locum agency. In this investigation the term locum doctor is used to refer to those working within NHS trusts rather than in primary care settings.

1.2.13 The most recent data available from the General Medical Council shows that in 2017 there were 43,346 licenced doctors working as locums, which equated to 18.3% of the total doctor workforce (General Medical Council, 2018). This data includes ‘locum only’ doctors (those who work only as locums) and also those who undertake locum work while also maintaining a full-time or part-time contract within the NHS.

1.2.14 It has been recognised that there are challenges for those working as locums in relation to ‘continuing professional development, appraisal, revalidation, and governance’ (NHS England, 2018). Guidance has been issued in recognition of this, entitled ‘Supporting locums and doctors in short term placements: a practical guide for doctors in these roles’ (NHS England, 2018).

Incident investigations

1.2.15 Staff, patients, and families involved in a patient safety incident will want to know ‘what happened and why and what can be done to prevent the incident happening again’ (NHS England, 2015). Investigations are undertaken to seek to answer these questions, the findings of which ‘will form the basis of an action plan to prevent the accident or incident from happening again and for improving your [the healthcare provider’s] overall management of risk’ (Health and Safety Executive, 2004).

1.2.16 In 2010 the National Patient Safety Agency published the first national framework for Reporting and Learning from Serious Incidents Requiring Investigation. This was followed by the Serious Incident Framework, which was published in 2013. It set out the approach to the investigation of patient safety incidents in the NHS where there was the potential for significant learning or where the consequences of the incident were significant.

1.2.17 In August 2022 NHS England published the Patient Safety Incident Response Framework (PSIRF) as a replacement for the Serious Incident Framework. The PSIRF is now the approach being used by healthcare providers and has four key aims:

  • compassionate engagement and involvement of those affected by patient safety incidents
  • application of a range of system-based approaches to learning from patient safety incidents
  • considered and proportionate responses to patient safety incidents
  • supportive oversight focused on strengthening response system functioning and improvement (NHS England, 2022b).

1.2.18 The investigation acknowledges that with the move to PSIRF there are other learning responses available in addition to a patient safety incident investigation and this is reflected in the language used in the local level learning and recommendation.

2. The investigation

The analysis of the serious incident investigation reports (see 1.1.3) identified that in 18 of the 30 reports the temporary staff (locum/bank/agency) who were involved in the incident were not involved in the investigation of that incident. In a further four reports it was unclear whether there had been such involvement. The findings were also in contrast to substantive staff, who were routinely involved in the same investigations. Not involving temporary staff members in an investigation means that factors affecting patient safety may not be analysed and this can impact on the effectiveness of any learning and future improvements in care for patients.

The identification of this risk across the serious incident investigations prompted exploration of the challenges of involving temporary staff in patient safety investigations with national stakeholders, healthcare providers, substantive and temporary staff. The investigation considered each step of the local investigation process from reporting the incident to the sharing of learning.

2.1 Incident reporting

A female and male nurse work side by side on a tablet device at a nurse station.

2.1.1 It is recognised that the reporting of patient safety incidents is necessary in order for organisations to learn effectively from them (Department of Health, 2000). The investigation was told that the electronic systems for reporting incidents in trusts were not always available to temporary staff. This included when the temporary staff member was in charge of a shift, such as a nurse in charge. A common reason given for this was that the electronic reporting systems were only accessible through a trust’s intranet and so required a computer log-in, which may not be available to temporary staff.

2.1.2 The investigation was told of adaptations that had been made to enable temporary staff to report incidents. For example, a temporary staff member may ask a substantive colleague to report an incident on their behalf. While this ensured that the incident was recorded, it relied upon another staff member accurately recording the details of what had happened. The investigation also heard that the substantive member of staff who reported the incident may be contacted about the incident but may not be able to provide further information. Temporary staff being unable to report incidents is a barrier to developing an open reporting culture, and to the identification of learning to help address patient safety risks.

2.1.3 The investigation was told by national stakeholders and healthcare providers that temporary staff not having access to electronic systems was a wider issue than just for incident reporting. Challenges for temporary staff in accessing electronic systems more widely and the impact on patient safety will be explored in a subsequent HSSIB report within the workforce and patient safety theme.

2.2 Involvement in investigations

Contact with temporary staff

2.2.1 In most of the patient safety investigation reports reviewed no rationale was given for the lack of involvement of the temporary staff and there was no indication of whether the local investigators had tried to contact these staff members. Only two reports gave reasons for temporary staff not contributing to the investigation; in both cases they related to the staff member being uncontactable.

2.2.2 The Parliamentary and Health Service Ombudsman has recognised that relevant staff not being interviewed or engaged in an investigation affects the thoroughness of the investigation and can contribute to additional or ‘compounded’ harm for the patient or family involved (Parliamentary and Health Service Ombudsman, 2023).

2.2.3 Trusts told the investigation that the ease with which a temporary staff member could be engaged in an investigation varied. This variability was influenced by whether they were agency or bank staff. For example, bank staff were described as often easier to contact and engage with as they were employed either directly by the trust or by a provider that was sub-contracted to manage temporary staff. In these scenarios contact was either through the trust holding the staff member’s contact details or there being someone present at the trust who had direct communication with the staff member. However, trusts told the investigation that there were still some challenges in engaging bank staff in investigations because of the ad hoc nature of their working arrangements.

2.2.4 Trusts told the investigation that involving temporary staff who had been engaged through an agency was generally more challenging than involving bank staff. This was said to be because the contact details of agency staff were not held by trusts and all communication had to go through the agency. Patient safety teams said that having to go through the agency to contact a staff member added an “extra layer”, and engagement with agencies was variable depending on the relationship with the agency and its relative size and infrastructure.

2.2.5 Patient safety teams described the investigation of incidents involving temporary staff as “less thorough” because of the difficulties in engagement and the resulting gaps in information. Patient safety teams told the investigation that “time” was the biggest challenge in involving agency staff as there could be a significant delay in getting the information needed to investigate an incident. The investigation was also told that the response to a request for information was not always forthcoming and so investigations would have to be concluded without input from that staff member.

2.2.6 The investigation heard that such gaps in information affected trust investigations but also other processes. For example, the Parliamentary and Health Service Ombudsman (PHSO) told the investigation that when it had investigated complaints which involved agency staff there was often little information available via the healthcare provider as the staff had moved on. The PHSO said that this affected its ability to investigate and respond fully to the patient or family who had made the complaint.

2.2.7 The Nursing and Midwifery Council (NMC) told the investigation that it recognised from its own processes the difficulties in engagement between the healthcare provider, the agency, and the individual staff member. It said concerns about fitness to practise involving agency staff were more difficult to investigate because referrals were often made by trusts, but often no local investigation had been completed. In these circumstances the agency was not in a position to complete such an investigation due to lack of information and this left the NMC with limited information to be able to consider whether it needed to take action.

2.2.8 Trusts and the PHSO told the investigation that temporary staff not being involved in investigations meant that system-level problems which may have contributed to the incident may go unrecognised. Therefore, the risk to patients of a similar incident happening again would remain.

2.2.9 Trusts gave the investigation different reasons for not holding agency staffs direct contact details. The Conduct of Employment Agencies and Employment Businesses Regulations 2003, which set out information which needs to be passed between agencies and businesses, do not require temporary staff members’ contact details to be made available, but also do not expressly prohibit it provided that consent from the staff member is obtained.

2.2.10 The investigation identified that some trusts held direct contact information for temporary staff, but where this information was held, and whether others knew it was held, varied. For example, in some trusts curriculum vitae (CVs) of prospective agency staff, which include the staff members’ contact details, were reviewed by senior managers. Once reviewed, the CVs (and contact details) were not passed to internal temporary staffing teams and so the opportunity to record them for future contact was lost.

2.2.11 The investigation was told by one trust that it had successfully included all the agency staff it uses on its staff roster, as a way of helping with the governance of these staff members. The trust had made inclusion on the roster a condition of being able to work at the trust; this had been agreed by agencies and their staff. The process of adding staff to the roster included recording their individual contact details. The Trust said that as well as enabling direct contact in situations such as non-attendance or late attendance, having these details would enable direct contact with staff in the case of incidents. Stakeholders told the investigation that access to contact details may assist in more effective investigations but may also risk agencies not being included in discussions.

2.2.12 The investigation found a disconnect between the accounts of some healthcare providers and those of the agencies with whom they engaged. Agencies stated that they were responsive to requests for information and followed up with their staff to ensure that the required information was provided. The agencies said that their staff members wanted to be involved in investigations and engaged when they were contacted.

2.2.13 One trust had invested in the support of temporary staff through a specifically developed role. The person in this role had “yet to come across a bank or agency worker who didn’t want to be involved in an investigation” and identified that the problem appeared more to be the temporary staff “not being engaged by the trust”. Reflective of this, patient safety leads questioned whether the preconception that agency staff would be difficult to contact led to attempts to do so being limited. As an example, the investigation was told that a trust’s investigation had been discontinued because a doctor who was involved in the incident no longer worked at the trust. No attempt to contact the doctor had been made and the investigation was told that the organisation had assumed that attempts would prove unsuccessful.

National guidance

2.2.14 The investigation reviewed what national guidance was available in relation to the involvement of staff in incident investigations. The serious incident reports analysed were published when the Serious Incident Framework was in place, which has now been replaced by the Patient Safety Incident Response Framework (PSIRF). Compliance with PSIRF is mandatory under the NHS standard contract and so applies to a variety of services including acute, mental health and community healthcare providers. As the NHS standard contract does not relate to agencies or bank providers who deploy workers into the NHS, there is currently no requirement for these organisations to comply with the PSIRF. Indeed, the agencies or bank providers engaged with during this investigation had limited awareness of the PSIRF.

2.2.15 One of the four main objectives for change by moving to the PSIRF is ‘Compassionate engagement and involvement of those affected by patient safety incidents’ (NHS England, 2022b). Guidance on ‘Engaging and involving patients, families and staff following a patient safety incident’ was published alongside the framework and this has been supported by training for providers on effective engagement.

2.2.16 The investigation engaged with NHS England in relation to the PSIRF and its accompanying guidance. The investigation learned that agencies and providers of bank staff had not been engaged with during the roll-out of the framework or in the development of the guidance. NHS England recognised that the investigation had identified a gap in the PSIRF guidance and that, as this was in the process of being reviewed, there was an opportunity to engage with agencies and include reference to this group in the guidance.

HSSIB makes the following safety recommendation

Safety recommendation R/2024/020:

HSSIB recommends that NHS England includes guidance on engaging temporary staff in learning responses within their 'engaging and involving patients, families and staff following a patient safety incident'. This should be developed in collaboration with providers of temporary staff to the NHS to help assist healthcare providers being able to fully investigate incidents from a systems perspective, enabling learning that can improve patient care.

2.3 Investigation processes

An investigator speaks to a doctor holding a tablet device.

Evidence collection

2.3.1 The investigation was told by patient safety teams that it was generally more challenging to collect evidence from agency staff than from bank staff. This was said to be because of the closer relationship trusts had with bank staff, and because bank staff were often deployed more regularly than agency staff, leading to better team integration. Trusts told the investigation that when information about an incident was received back from agencies it could to be in the form of a “brief” and sometimes “defensive” statement from the staff member. The investigation was told that in such situations there was usually no opportunity to interview the staff member to further explore why an incident had occurred. The investigation was told of attempts to elicit further information following receipt of a statement and how this could be a lengthy process and may not be fruitful. It was clear that the use of a systems approach in these investigations was hampered because it was not possible to get a full picture of the circumstances of an incident.

2.3.2 The PSIRF recommends a ‘move away from a reliance on documentation and written statements to listening to the views of those affected through interviews and discussions’ (NHS England, 2023c). The techniques referred to in the PSIRF guidance represent a cognitive interview technique which is designed to ‘improve the recall of accurate and reliable information from an interviewee’ (Centre for Research and Evidence on Security Threats, 2016).

2.3.3 One trust told the investigation that it had found doing interviews with staff rather than using written statements to gather information about a patient safety incident made the process quicker, although this was in relation to all staff rather than specific to temporary staff. The trust explained that a 30-minute interview enabled it to explore an incident fully, while a statement could need several follow-up questions to get to the same level of detail. The trust said that where possible it interviewed temporary staff also and enabled their full accounts to form part of the investigation process.

2.3.4 The investigation acknowledges that there are financial considerations when considering how to engage temporary staff in investigation processes. While substantive staff would usually be interviewed during working hours, it may not be possible to interview a temporary staff member during a working shift. This is because, as reflected by the fact of their deployment, they may be needed to deliver care, or they may have no further shifts booked with the trust. Considerations around pay for involvement in investigation processes are outside of the scope of this investigation, but it is acknowledged that this is a factor which would require discussions and agreement.

2.3.5 The investigation found that most trusts had not considered how they might complete interviews with temporary staff and (as at 2.2.16) agencies had limited knowledge of PSIRF, or its move towards this method of evidence collection.

HSSIB makes the following safety observation

Safety observation O/2024/019:

Agencies providing temporary staff to the NHS can improve patient safety by facilitating the involvement of temporary staff in investigation processes, including interviews. This is to enable the investigation of patient safety incidents in line with the Patient Safety Incident Response Framework.

Dissemination of learning

2.3.6 Of the 30 reports analysed, 18 did not describe that the findings had been shared with the temporary staff involved in the incident, and a further 7 were unclear about whether there had been such feedback. Similarly, the investigation was told by agencies and by agency staff that they were not routinely told the outcomes of investigations. This included where a temporary staff member had been “blocked” from working at a trust pending the findings of the investigation. In such circumstances the outcome of the investigation often had to be “chased up” in order to clarify whether the staff member was able to return to work at the trust.

2.3.7 Two trusts told the investigation that they routinely fed back the findings from relevant investigations to temporary staff via agencies. Other trusts did not have such processes in place and one trust told the investigation that such feedback would only likely happen if the temporary staff member “happened to be at the team meeting where it was shared”.

2.3.8 One trust had recognised that wider learning from incidents which was made available to substantive staff was inaccessible to temporary staff because it was only available on the trust’s intranet. To mitigate this, the trust had taken the step of displaying learning on notice boards on the wards so that it was accessible to all staff working there, while recognising the limitations of disseminating learning in this way.

2.3.9 The investigation found that the feedback to temporary staff of learning from incidents in which they were involved was variable and there were limited processes in place to support this. The investigation also acknowledges that there may be benefit in agencies being aware of learning from incidents their workers are involved in so that they can be supported with any development needs and wider learning.

A tired surgeon sits on the floor of a hospital corridor with their head hanging down.

Staff support

2.3.10 During the investigation it became apparent that support mechanisms for staff involved in incidents varied depending on whether they were substantive staff or temporary staff. It has been recognised that ‘work-related exposure to trauma, including remote exposure’ (indirect exposure) is associated with the development of post-traumatic stress disorder (National Institute for Health and Care Excellence, 2018) and moral injury (Shay, 2014). Additionally, staff wellbeing concerns can have a significant impact on teamworking and patient safety because of the way they affect individual staff (Healthcare Safety Investigation Branch, 2023).

2.3.11 In recognition of the importance of staff wellbeing, NHS England has been working with the Care Quality Commission (CQC) to integrate this into the assessment framework as a ‘measurable quality indicator’ (NHS England, 2023d). This would ensure that the systems of support in place would be reviewed as part of any CQC inspection.

2.3.12 The investigation was told that there were processes in place to support substantive staff who had been involved in an incident, often through debriefs, peer support and, if needed, psychological support. The need to support those involved in incidents, including staff, is well recognised and this forms part of the PSIRF guidance (NHS England, 2022a).

2.3.13 In some trusts this support was extended to those temporary staff who were longstanding – such as bank staff who had worked for the trust for a long time – or those on ‘long lines’ agency contracts (that is, agency staff booked for a series of shifts). The investigation was told by patient safety teams that short-term temporary staff were not routinely offered support by a trust following their involvement in an incident. It was explained that there were various reasons for this including:

  • substantive staff were not aware that temporary staff could be included in trust support
  • temporary staff were no longer working at the trust
  • access to support resources was through systems that were not available to temporary staff, such as the trust’s intranet.

Inequality of access to support was identified in the Healthcare Safety Investigation Branch investigation report ‘Support for staff following patient safety incidents’ (Healthcare Safety Investigation Branch, 2021), which stated that ‘staff on rotational jobs or in locum positions had less access to support’.

2.3.14 The investigation was told that some individual trust staff were keen to ensure that agency colleagues were supported and tried to ensure that when requests were made for statements a wellbeing check was also done. However, they did not receive feedback about how the staff member was and were unsure of what support was in place via the agency for the staff member who had been involved in the incident.

2.3.15 The investigation heard of the expectation of several patient safety teams that agencies had systems in place to support temporary staff involved in incidents. However, the investigation engaged with agencies providing temporary staff to the NHS under the framework agreements that did not provide support for staff involved in incidents. They explained that this was not something they would expect to offer as an employment agency and that they would expect trusts to include temporary staff in their offers of support. The investigation was told by agency staff that they did not feel well supported by agencies when they had been involved in incidents but that they did not expect such support as the agency/worker relationship was a business one.

2.3.16 From the evidence gathered in this investigation it is clear that there is no standard approach to the support of temporary staff who are involved in patient safety incidents.

HSSIB makes the following safety recommendation

Safety recommendation R/2024/021:

HSSIB recommends that NHS England updates the agency worker framework agreement criteria to explicitly require framework agreements to adhere to the staff support principles of the NHS England Patient Safety Incident Response Framework. This will improve patient safety as there is a recognised link between staff having wellbeing concerns and the delivery of patient care.

2.4 Next steps

2.4.1 This investigation report is intended to support learning for improvement in patient safety and staff wellbeing. Healthcare providers can use the findings from this investigation as prompts to help them consider how they involve temporary staff in patient safety investigations:

  • How do you ensure that temporary staff are aware of how to record patient safety incidents?
  • If an incident takes place, how do you ensure that temporary staff are able to record it?
  • How do you engage temporary staff in a learning response?
  • Do you have processes in place so you can conduct interviews with temporary staff?
  • Can you work with employment agencies to create agreed methods of including temporary staff in learning responses through your contractual arrangements?
  • How do you ensure that learning is fed back to those staff involved, including temporary staff?

2.4.2 The investigation will continue to explore challenges for temporary staff in providing safe care. Further work will focus on how temporary staff are integrated into teams, including induction, access to digital systems and integration into the culture of the workplace. If you would like to share your experience or have information that may be relevant, please contact enquiries@hssib.org.uk.

3. References

Centre for Research and Evidence on Security Threats (2016) The cognitive interview. Available at https://crestresearch.ac.uk/resources/crest-guide-cognitive-interview/ (Accessed 23 November 2023).

Department of Health (2000) An organisation with a memory. Available at https://webarchive.nationalarchives.gov.uk/ukgwa/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4065086.pdf (Accessed 23 November 2023).

General Medical Council (2018) What our data tells us about locum doctors. Available at https://www.gmc-uk.org/-/media/documents/what-our-data-tells-us-about-locum-doctors_pdf-74371150.pdf (Accessed 23 November 2023).

Health and Safety Executive (2004) Investigating accidents and incidents. Available at https://www.hse.gov.uk/pubns/hsg245.pdf (Accessed 3 December 2023).

Healthcare Safety Investigation Branch (2021) Support for staff following patient safety incidents. Available at https://www.hssib.org.uk/patient-safety-investigations/support-for-staff-following-patient-safety-incidents/ (Accessed 23 November 2023).

Healthcare Safety Investigation Branch (2023) Interim bulletin 3. Harm caused by delays in transferring patients to the right place of care. Available at https://hssib-ovd42x6f-media.s3.amazonaws.com/production-assets/documents/hsib-interim-bulletin-3-harm-caused-by-delays-in-transferring-patients.pdf (Accessed 23 November 2023).

HM Government (2003) The Conduct of Employment Agencies and Employment Businesses Regulations 2003. Available from The Conduct of Employment Agencies and Employment Businesses Regulations 2003 (legislation.gov.uk). (Accessed 23 November 2023).

National Institute for Health and Care Excellence (2018) Post-traumatic stress disorder [NG116]. Available at https://www.nice.org.uk/guidance/ng116 (Accessed 23 November 2023).

NHS England (2015) Serious Incident Framework. Available at https://www.england.nhs.uk/wp-content/uploads/2020/08/serious-incidnt-framwrk.pdf (Accessed 23 November 2023).

NHS England (2018) Supporting locums and doctors in short-term placements: a practical guide for doctors in these roles. Available at https://www.england.nhs.uk/wp-content/uploads/2018/10/supporting_locums_doctors.pdf (Accessed 23 November 2023).

NHS England (2022a) Patient Safety Incident Response Framework supporting guidance. Engaging and involving patients, families and staff following a patient safety incident. Available at https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-2.-Engaging-and-involving...-v1-FINAL.pdf (Accessed 23 November 2023).

NHS England (2022b) Patient Safety Incident Response Framework. Available at https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-1.-PSIRF-v1-FINAL.pdf (Accessed 23 November 2023).

NHS England (2023a) Agency rules. Available at https://www.england.nhs.uk/wp-content/uploads/2023/04/Agency-rules-changes-for-2023-to-2024.pdf (Accessed 25 November 2023).

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4. Appendix

Investigation approach

To identify topics for investigation within the workforce and patient safety theme, the investigation reviewed intelligence from service and professional regulators, national reports, the Parliamentary Health and Social Care Select Committee, academia and research. Discussions also took place with a large number of national stakeholders to understand their emerging concerns in this area. As a result of this work four investigations were launched in June 2023 looking at temporary staff, the digital environment, prioritising patient care, and skill mix and integration.

A search of the Strategic Executive Information System (StEIS) (where all serious incidents are reported) was undertaken to identify trends in incidents which have involved temporary staff. This identified 55 reports which referred to bank/agency/locum staff in their description. Trusts (25 acute trusts and 15 mental health trusts) were contacted for copies of these reports and 30 were made available, all of which followed the Serious Incident Framework. Four reports were removed from the analysis as the involvement of bank/agency/locum staff was incidental and no findings or actions related to their involvement.

The reports were coded, using inductive coding (where codes are derived from the data rather than the data being categorised into predetermined codes), by one investigator and the coding reviewed by another investigator to ensure, as far as possible, that there was a consistent approach. The investigators undertaking the coding had different professional backgrounds which allowed for different perspectives of the data to be considered. Any differences in the coding were discussed by the investigators before the final coding was agreed.

The investigation developed 53 codes to categorise elements of the data in the reports. Common themes were identified from the coding of the reports, which spanned both acute trust and mental health trust reports.

The investigation recognises that there are limitations in the methodology used, due to the varied way in which incidents are reported in StEIS and the number of reports reviewed. However, the identified themes were verified through engagement with stakeholders at both national and provider level to triangulate the evidence.

Evidence gathering

The investigation undertook site visits at three trusts (two acute and one mental health) and engaged with a variety of staff, including ward managers and patient safety and governance teams, to explore the identified trends. The investigation also engaged with six further trusts (three mental health and three acute trusts), agencies, bank staff providers and representative organisations for both primary and secondary care. Semi-structured interviews were conducted guided by the System Engineering Initiative for Patient Safety (SEIPS) framework.

Stakeholder engagement and consultation

The investigation engaged with stakeholders to gather evidence; this also enabled checking for factual accuracy and overall sense-checking. The stakeholders contributed to the development of the safety recommendations and safety observation based on the evidence gathered.

Investigation stakeholders
National organisations Other organisations
NHS England Observations at two acute
trusts and one mental health trust
Care Quality Commission Discussions with three further
acute trusts and three mental health trusts
Parliamentary and Health
Service Ombudsman
Bank staff providers
Nursing and Midwifery Council Employment agencies
General Medical Council Professor and Academics in Health Policy and Management
British Medical Association
NHS Employers
The Recruitment and Employment
Confederation
The Employment Agency Standards
Inspectorate