The NHS needs you – and it has to work harder than ever to keep you

The number of employers in the NHS paying extra to attract or retain staff in England is falling.

Recruitment and retention incentives are a key part of Agenda for Change (AfC) pay contract, yet the NHS Pay Review Body (RB) says its use is either ‘static or diminishing’.

Picture credit: Daniel Mitchell

The RB, which this month published its recommendation for a 1% pay rise, attributed this drop-off not to diminishing need but to the necessity of making cuts.

In its 2016 report, the RB stated: ‘There is a fear of introducing payments that will be difficult to remove and of the potential impact on neighbouring trusts and health boards of staff moving from one to another.’

However, there is evidence that NHS organisations are using other local incentives to attract and retain staff, including relocation packages, ‘golden hellos’ and paying for training and development.

According to NHS Employers’ survey findings submitted to the RB, 99% of organisations have taken some form of local action to retain their nursing staff.

With pay rises of just 1% expected until at least 2020, the pressure is on employers to find innovative ways to keep their staff.

Unfilled posts

NHS Employers said the overall vacancy rate in English trusts is 10% and 88% of these are band 5 adult nursing posts.

In Scotland, three-month vacancy rates for nurses increased through the course of 2014 and 2015.

The RB report also revealed 7.5% of nurses in the NHS left in the year to April 2015 compared to 6.7% the previous year.

The RCN told the RB that nurses are choosing to leave their substantive posts to work agency shifts where they are given higher pay, flexibility and less pressure.

The RB investigated the possibility of the NHS using its funds to increase staff numbers rather than give a pay rise. This could have helped cut workplace stress, resulting in better patient outcomes, the RB said.

The report said: ‘We gave serious consideration to the case for a nil pay award this year, on the grounds that there would be more benefits if the available money were instead used to invest in workforce numbers to alleviate workload pressures.’

In the end, the pay body concluded this would have been ‘very difficult to justify’ when other workers in the public sector will be getting a 1% rise.

Although this notion of sacrificing a pay rise in favour of increasing staff numbers was rejected, it evokes a sense of déjà vu for Unite national officer for health Barrie Brown.

He says: ‘Health secretary Jeremy Hunt put that forward in 2014. But if trusts were given this money there would be no guarantees they would actually recruit these extra staff.’

Independent nursing workforce analyst Keith Hurst argues that depriving nurses of a pay rise in favour of recruiting extra staff could damage morale.

He says: ‘Even though inflation is low, nurses are struggling to make ends meet.’

Staff have to feel valued and the main factor influencing retention is workload

The RB report emphasised that most recruitment and retention problems are localised, and so are better suited to a local response. It called for each part of the UK to set up a national working group to identify innovative ways to reward and engage staff that are linked to high quality patient care, and for these insights to be shared.

It is likely the RB is referring to incentives such as creches, protected mealtimes for staff and flexible working patterns.


The trouble is that these types of initiatives are in short supply, according to Royal College of Midwives director for policy, employment relations and communications Jon Skewes.

He says: ‘One thing we know that works is flexible shifts and people choosing the days they want to work. That’s what you need when there are skill shortages – flexibility.

‘But this seems to have dropped off in the past ten years – it has almost gone. I think there is a perception that it’s difficult to roster staff.

‘But if you take that view, it brings a problem for staff with childcare duties or responsibilities for looking after an older relative.’

Mr Skewes argues that flexible working would be an important part of a rewards and incentives package to help recruit staff and then retain them.

Employers that do not give the option of job flexibility risk losing staff. Healthcare professionals will instead hire themselves out to agencies, in turn draining the NHS of money, he adds.

Jane Ball, a nurse and principal research fellow at the University of Southampton is an expert in recruitment and retention issues. She agrees with the RB that reward and incentive schemes need to be developed locally, and says this area of workforce planning has been neglected nationally.

‘When you study the experiences in other countries you realise that we are behind.

‘In Sweden nurses have a laundry and changing rooms. Uniforms are washed to a certain standard, and staff don’t wear uniforms outside. These are the sorts of things that would make the NHS a modern employer.’

But she cautions: ‘You don’t improve retention or patient outcomes just by engaging with staff. Staff have to feel satisfied at work, appreciated and valued. There are lots of things that contribute to that, but our research shows that the main factor influencing retention is manageable workload.’

Whatever approaches are used in future, the position of healthcare unions is clear; while incentive packages have their place there is no substitute for giving nurses a decent pay rise.

Unite’s Barrie Brown adds: ‘Over the past six years, staff have lost between 10% and 14% from pay in real terms. It’s fine to consider childcare facilities, for example, but it shouldn’t be an alternative to a reasonable pay deal.

‘Staff still have to pay their mortgages and their travel costs’.

Read the RB’s report at

Bonuses earned for bank shifts

A trust in the east of England introduced an incentive scheme as a response to the problem of difficult-to-fill shifts and to improve retention of nurses.

Northern Lincolnshire and Goole NHS Foundation Trust pays staff 25% extra for shifts in practice areas considered highly specialist including intensive care, emergency, neonatal intensive care and intensive therapy.

There is a bonus payment of £75 if a nurse agrees to work a shift at less than four hours’ notice. The idea is to help cut the amount the trust spends on agency staff.

Associate chief nurse for medicine Paul Kirton-Watson (pictured) says: ‘If we can use our own nurses for bank shifts instead of agency staff, we get consistency and continuity. We could have the same nurse on three days running instead of having three different agency nurses.’

He says in some weeks, hundreds of bank hours that in the past were worked by agency nurses are now undertaken by trust staff.

Mr Kirton-Watson believes the bonus scheme will encourage staff to remain at the trust to earn the higher rates, instead of leaving to join agencies.

‘It is acting as an incentive package for retention,’ he says.

The trust previously had a ‘baker’s dozen’ scheme, in which nurses would be paid for a 13th bank shift if they completed 12 within three months. But this proved difficult to achieve because of the short time period, and resulted in some nurses pushing themselves too hard to achieve the bonus, explains Mr Kirton-Watson.

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