Agency nurses: How will NI cut its dependence on private firms?
"Staff retention is nearly impossible... if we can't retain staff, how do you look after patients?"
Linda Smyth has been an NHS nurse for more than three decades but in recent years she has witnessed an exodus of staff towards private nursing agencies.
Nursing agencies often advertise much higher rates of pay and flexible, family-friendly hours.
Ms Smyth accepts temporary staff will always be needed to provide cover. 
But she is concerned that heavy reliance on agency nurses could affect patient welfare, as well as demoralising NHS staff working alongside them for less money.
ring of agency nurses cost Stormont's Department of Health almost £140m in the last financial year alone.
But in October, a crackdown on agency spending was announced, including a plan for a new system which will cap agency pay rates by February 2023.
Nursing unions have long argued public money should be used to improve pay and conditions of NHS nurses rather than being paid to private firms.
"We've all worked with an agency nurse that's less experienced but on more money," Ms Smyth told BBC News NI.
She is currently based in Belfast's Royal Victoria Hospital (RVH) and said the current NHS overtime system cannot compete with agency fees. 
"Nurses are leaving their staff posts and going to work for an agency... if someone was waving two bags of money under your nose, you would go as well."
Ms Smyth said NHS nurses were often grateful to have another pair of hands on busy wards, but admitted they were "resentful of the difference in the pay".
"They are all good nurses," she said.
"But they are there for a day and then they are gone.
"They don't get to know the patients. For example: 'There's John and he likes this.'  They don't have continuation of care every day."
week, BBC News NI reported on pressures in Northern Ireland's emergency departments and was advised that about 40% of emergency department shifts in the RVH were filled by agency staff. 
Despite attractive pay offers, Ms Smyth said she "loves" her job and is not tempted to go to an agency.
"I'll stay with the trust," she said, "because I believe in the NHS".
But she argues private firms are reaping the rewards of years of NHS investment in nursing skills.
"We train them, we mould them - then they leave and go to agencies. If we had a better rate of pay these agencies wouldn't have the grip they do on the health trusts," she said. 
"I'm no way saying they should pay the amount agencies are paying - we know there's no pot of gold here - but there should be a level playing field."
In October, Stormont's then-Health Minister Robin Swann acknowledged "overreliance" on agencies was having a negative impact on the NHS workforce and "putting additional pressures on them to support agency staff who are unfamiliar with systems and wards".
Just weeks before he left office, he set out a major plan to reform the system with the aim of substantially reducing expenditure on agency nurses.
re are three ways in which health trusts hire nurses to fill gaps in NHS rotas.
In October, the Department of Health revealed spending on off-contract agencies had almost quadrupled from pre-pandemic levels - rising from £27m in 2018/19 to £101m in the last financial year.
f on-contract agencies was much lower, totalling £38.4m in 2021/22.
At the time, Mr Swann announced a plan to "eliminate" off-contract spending, telling agencies they could "work with us on a contractual footing - or face an end to their income from the health service". 
One off-contract agency currently advertises a basic rate of £31 per hour for a registered nurse covering a weekday shift in Northern Ireland.
However, its pay rates rise to £98.50 per hour for a very senior nurse, in charge of a specialist unit like high dependency, if they work on a bank holiday.
gency concerned is believed to be one of the more expensive providers, but last year it supplied nurses to four of Northern Ireland's five health trusts. 
Department of Health is introducing a new system which will limit the amount of money health trusts can pay agencies to hire casual workers.
During the tendering process, the department is asking agencies to bid with their charge rate which should reflect the "total cost per hour to the trust for the service". 
"The total hourly charge rate bid must be within the capped limits and is to include worker's pay and all other financial obligations in relation to the employment of the agency worker," its spokesperson said.
union Unison supports the crackdown on agency spending but said it must be accompanied by NHS overtime pay rises and reforms in order to attract nurses to work anti-social hours.
Conor McCarthy from Unison said the reliance on agency staff over the past few years had "led to a very disillusioned workforce" and was "essentially privatising nursing from within".
"Some of them are very good, don't get me wrong," he said. 
"But there's a lot of agency staff that are just newly-qualified nurses who have chosen agencies as their substantive employer.
"As a result they're not as qualified as a lot of the more experienced staff with a high set of skills."
Mr McCarthy said younger, less-experienced agency nurses were often used to fill shifts during weekends and holidays which was not beneficial for patients.
But he also acknowledged that many experienced nurses now have "dual membership of both the NHS and agencies" because of private firms' higher pay rates.
"I see [NHS] nurses I know very well in the morning and then I see them in evening with an nursing agency uniform on," he said.
Unions have lobbied for the creation of a centralised "regional bank" system where all five health trusts can hire NHS staff for extra shifts, on improved overtime rates.
"It's safer for the patient and if nurses can also avail of an enhanced rate within that bank, then they'd be more than happy, Mr McCarthy said.
"And I do think it's definitely a game changer in reducing the cost in the health service of agencies and it's also, I believe, a game changer by way of enhancing recruitment and retention."
Department of Health said it recognised reform of the trusts' banks was "necessary to support the move away from agency usage" and that a new regional nursing bank is among measures under consideration.