Reasons for using nursing cover

Vacancies - 37% Sick leave - 28% Annual leave - 10% Peak in workload - 10%

Although the average trust spent �2.5m on pool and agency staff in that year, some spent three times that amount.

On a typical day in the NHS, there are around 20,000 temporary nurses working - covering 10% of shifts.

Vacancies and sick leave account for two thirds of cover needed.

Expensive

Only two in five trusts have contracts with commercial agencies.

The rest book shifts on a more expensive "ad-hoc" basis.

If all trusts had contracts, the Audit Commission predicts the NHS could save around �20m per year.

It says arrangements for using NHS pool nurses should be better co-ordinated - nearly half of trusts have more than one group of nurses they call on.

Trusts should also carry out better pre-employment checks, and ensure temporary nurses have proper induction periods and can keep up to date with their training.

'Lessons to be learned'

Launching the report, Sir Andrew Foster, controller of the Audit Commission, said: "There is evidence the patient's contract is being broken, and if this area of using temporary nurses is growing, that chance increases.

Case study

An agency nurse who usually worked in nursing homes was assigned to A&E. When asked to take an ECG (heart trace) for a 70-year-old man who had chest pain, she failed to say she did not know how to do it, and was unable to resuscitate him when he had a heart attack and stopped breathing. She had to wait for assistance, and had not had basic life support training for over three years.

"We are not deprecating these nurses but this is a proven area of vulnerability."

He said the best way to reduce risks was to reduce the demand for temporary staff by attracting more permanent staff to the service.

Janet Graham. nurse manager at Luton and Dunstable Hospital, told the BBC she selected her temporary nurses carefully: "It's really important for our patients, who expect consistent continuous care.

"They don't want to wake up and think 'oh my goodness - there are nurses on duty this morning who don't know how to care for me'."

Josie Irwin, senior employment relations advisor at Royal College of Nursing, was on the advisory group that helped put the report together.

She told BBC News Online: "The report is not putting any particular blame on the bank or agency nurses, but saying very clearly that the way they are being deployed is manifestly making an impact on quality of care.

"It is a huge sum of money being spent on temporary staff, and that money - or whatever could be saved - could be spent on better pay, and better flexibility for permanent nursing staff."

Alistair Henderson, policy manager for the NHS Confederation, which represents trust mangers, admitted that some trusts needed to improve the arrangements for employing temporary staff, and added: "Clearly, there's not a trust around that does not want to cut its spending on temporary nursing staff.

"But if more nurses come back to the NHS, as we are beginning to see, the amount that is being spent on temporary staff will come down."

New agency

The Department of Health is in the process of setting up NHS Professionals, a NHS-run body to co-ordinate the way trusts arrange cover.

Health minister John Hutton said NHS Professionals would provide a more flexible working environment for existing staff, and should encourage others to return.

"It also allows the NHS to better guarantee quality of patient care."

The first 50 sites will start next month, with the scheme being rolled out across England by April 2003.