Discrimination stops temporary workers speaking up about safety concerns

The findings were identified during an investigation we carried out looking at the integration of temporary staff into healthcare providers. During our investigation, we heard the discrimination experienced by temporary workers is due to their work status and sometimes due to their ethnicity. As well as having a negative impact on their wellbeing, our report states that temporary workers’ experience of discrimination and barriers to speaking up may mean they do not share patient safety concerns, and therefore mitigations to safety risks may not be put in place.

Throughout the course of our investigation we carried out site visits and engaged with NHS trusts, providers of bank staff, agencies that supply staff to the NHS, substantive (permanent) NHS staff, bank and agency staff, and a range of national stakeholders. Agencies told HSSIB that because of the culture that can exist within healthcare providers, temporary staff can feel vulnerable about raising concerns.

Temporary staff told the investigation that raising concerns can lead to them being seen as a “troublemaker”, potentially resulting in them being “blacklisted” from working at the provider. They also described feeling unwelcome, not part of the team and “disposable” while working in the NHS. They had been told "we don’t need you" when having been deployed and substantive staff sticking together, not providing them with support and, on occasion, not passing on important clinical information or answering questions.

Generalisations about temporary staff

The investigation spoke to a number of national organisations and the report states they ‘all agreed that certain elements of the NHS are currently unable to function safely without the use of temporary staff.’ However, we also heard a common perception from national stakeholders and substantive staff (NHS frontline and senior management) that the knowledge, skills and attitudes of some temporary workers could put patient safety at risk. Temporary staff and agencies acknowledged that, as with substantive staff, skills, knowledge etc. varies and both groups shared concerns that some staff in the NHS made generalisations that temporary staff provided poorer care to patients. During site visits, we also heard comments suggesting these generalisations were being made across different organisations

The report emphasises that staff from ethnic minority backgrounds face known barriers to speaking up. Status as a temporary worker then adds an additional challenge to raising concerns. The investigation was told by some that they had experienced discrimination on the grounds of race from both patients and staff members. This was also reflected in the 2023 NHS bank only staff survey results. The investigation observed that some staff accepted such behaviours as the norm saying “that is just the way it is.”

The NHS Race and Health Observatory told the investigation that workers from ethnic minority backgrounds are less likely to speak up as they are more likely to experience “harsher consequences” if they do. This was also described by the National Guardian’s Office. Both organisations said there was a high number of people from ethnic minority backgrounds employed as temporary workers, which is supported by NHS data. The Race and Health Observatory expressed to HSSIB that temporary staff were seen as “other” due to not being part of the core team. This, coupled with experiencing racist behaviour may mean they do not feel ‘psychologically safe’ to raise concerns.

Striving to improve relationships

While the investigation found evidence of a negative culture in relation to temporary staff, it also heard of trusts striving to improve relationships. Initiatives included a local temporary staff survey to understand their experience, and a celebration event for bank staff.

The investigation also heard from some temporary workers who felt integrated into teams and were viewed as part of the substantive workforce. They had commonly worked a number of shifts on the same ward, and this had enabled them to demonstrate their abilities to the wider team.

As well as examining organisational culture in relation to temporary workers, the investigation looked at how temporary staff are allocated to teams and the processes for staff induction and orientation.

Safety recommendation

The report concludes with one safety recommendation to the National Guardian’s Office. Building on the work they have done for other staff groups, we have recommended they work with relevant groups and individuals to identify all the barriers that prevent temporary staff from speaking up and develop ways to address those barriers. The aim of the recommendation is to help all workers to contribute to patient safety improvements without fear of reprisal.

In a previous report on this topic published in March 2024, HSSIB made two safety recommendations to NHS England aimed at increasing the engagement of and support for temporary staff.