Scotland’s NHS is under immense pressure. In 2023–24, the service spent £358 million on agency and locum staff. A figure, while slightly down from its peak, remains 45% higher than it was five years ago in real terms¹.
This spending designed to plug short-term staffing gaps isn’t creating long-term solutions. It’s not building a workforce. It’s not improving staff morale. And most of all, it’s not sustainable.
What Scotland lacks is not funding — it is a plan. This vision, developed independently by the author, proposes one possible approach to achieving NHS workforce sustainability within existing budget limits.
A Cost-Neutral Strategy for Rebuilding the NHS Workforce
It is a practical, financially grounded vision for how Scotland could transition away from dependency on expensive short-term staffing and toward a more resilient, sustainable NHS workforce.
At its heart is a simple premise – redirecting existing agency/locum spending into permanent staff recruitment and training without any additional government spending.
Key Assumptions
This vision is based on reasonable and publicly reported figures:
- Agency and locum staff typically cost the NHS around £100,000 per role per year²
- An equivalent permanent NHS Nurse or Doctor costs around £45,000 per year including pension and employer contributions³
- Training a nurse or doctor is estimated at £120,000 over three years⁴
- A £5,000 conversion bonus is factored in to support agency staff returning to NHS contracts
- The model assumes phased implementation beginning in 2026, with agency use declining each year
Projected 5-Year Impact (2026–2030)
In 2026, the model assumes agency costs would be reduced by 15%, saving approximately £54 million, with 800 new NHS staff beginning training and 400 agency staff converting to permanent roles. The cost of training and bonuses that year would total around £34 million, fully covered by savings.
By 2027, agency costs fall by a further 15%, freeing £108 million. The model anticipates 1,300 new staff trained, 600 conversions, and a reform cost of £55 million; again, cost neutral.
By 2028–2030, agency spend continues to decline annually; down to £90 million by 2030 while recruitment and conversion efforts increase.
Long-Term Outcomes by 2030
- 7,900 new NHS professionals trained
- 3,600 agency and locum staff returned to public contracts
- £0 in new public spending required
Why This Vision Matters
Audit Scotland has warned that NHS Scotland is becoming financially unsustainable without serious reform. However, reform does not need to mean cuts! It can mean smarter choices – rooted in fairness, efficiency, and realism.
This vision shows how Scotland can:
- Protect care
- Support staff
- Reduce waste
- Rebuild trust
It is not about grand slogans. It is about getting serious with what we already have.
Conclusion
Scotland is spending the money. The question is whether it is spending it wisely!
This vision demonstrates that with discipline, purpose, and political courage, it is possible to turn short-term firefighting into long term workforce renewal. All while living within the current NHS budget.
References:
1. Audit Scotland, NHS in Scotland 2024, page 16
2. Nuffield Trust, Pay and Cost of Agency Staffing, 2023
3. NHS Employers – Agenda for Change Pay Scales, 2024
4. Scottish Government, Nursing and Midwifery Student Bursary Scheme
5. Audit Scotland, NHS in Scotland 2024
* Tanvir Ahmad is a Scottish Liberal Democrat Parliamentary Candidate with over 20 years of experience in telecommunications. A former Royal Navy Reservist and Youth Centre Manager, he brings a solutions-first, community-led approach to public service.
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25 Comments
I have some insight in this field and I’m afraid the reason that agency staff have to be employed is due to the difficulties in getting people to apply for permanent positions. Vacancies that remain unfilled, despite the posts being advertised, have to be covered by agency staff. And, to be clear, the reason that these agency staff do not apply for permanent positions is that they often don’t even live in Scotland but fly in from London and elsewhere to take short-term agency work, attracted by the higher pay.
So the solution, unfortunately, is money – more money so that wages for those posts in the NHS that are hard to fill can be more competitive with other sectors. In addition, there probably needs to be a ‘remoteness weighting allowance’ to make it more attractive for NHS staff to be willing to move to harder to fill positions in more remote parts of the country…again, requiring more money.
Thank you for a most interesting article.
What is to stop paying N.H. S. staff decent attractive pay and making sure that they enjoy their work (mostly) without raising taxes for regular citizens, some 20 to 30% cannot afford to feed their children decently?
It’s nice to see an attempt to not just suggest a policy but think through in detail how it could be implemented and how much it would cost.
But @Mike Peters your well argued point was exactly my first thought on reading the article. How on Earth do you stop nurses from refusing permanent jobs if they know they can get more money through agency work! I would also like to know why it costs £120K to train each nurse. That sounds extraordinarily high for a 3 years of teaching (considering for example that Universities charge about £10K per year in tuition fees). I also do not see how a Doctor can cost just £45k/year total when salary alone can be up to £100K/year.
If these kinds of queries can be resolved, then @Tanvir this looks like a good basis for an idea to help the NHS.
@Steve: Can you please supply a source for your claim that 20-30% of NHS staff cannot afford to feed their children?
@ Simon R,
“Can you please supply a source for your claim that 20-30% of NHS staff cannot afford to feed their children?”
You forgot the word “decently” on the end of your quote btw.
I’m surprised that you’re sufficiently surprised by this figure that you want to challenge it. It’s generally accepted that about 30% of children are living in poverty, so a claim of 20-30% for all NHS staff seems slightly on the low side, if anything.
This report by the TUC focuses on “key workers”. The figure given here is 40%
https://www.credit-connect.co.uk/news/two-fifths-of-children-in-key-worker-households-are-living-below-the-breadline/
@Peter: Thanks for the link, but that doesn’t really help because it doesn’t define either what they consider to be a key worker, or what definition of poverty they are using. Most discussions of poverty seem to use the (IMO, idiotic) definition of ‘60% of median income’, so the best guess has to be, that’s the definition they are probably using. , Unfortunately 60% of median income is actually a measure of inequality amongst the bottom 50% of the population, not a measure of actual poverty, and gives no meaningful information about deprivation, or things like ability or otherwise to buy ‘decent’ food. So without more info, I don’t think that article, for all it’s evocative headlines, tells us much.
@Peter Martin @ Simon R
Interest article that describes ‘living in poverty’ as living ‘below the breadline’. Of course, the definition of poverty used today is not related to whether or not people are starving, (which below the breadline used to mean), but is just a measure of relative income (with those below 60% of median income counting as ‘in poverty’.)
Ironically, when the definition of poverty is ‘below 60% of median income’, an easy way to reduce the rate of poverty is for the government to reduce the incomes of those around medium income – not what I would want to see, but reducing medium incomes would mean that less people would be below 60% of that lower median income, so numbers defined as living in poverty would be reduced!
In response to the request for child hunger in the U. K. information, made by Simon R., here is but one website:
https://www.barnardos.org.uk/news/quarter-parents-britain-struggle-provide-enough-food-their-children#:~:text=A%20quarter%20of%20parents%20%2825%25%2
The next article indicates the seriousness of the problem and its appalling consequences:
https://www.taxresearch.org.uk/Blog/2025/04/17/we-are-living-in-a-fucked-up-world/
@Peter Martin There is a big difference between your “about 30% of children are living in poverty” and Steve’s “20 to 30% cannot afford to feed their children decently”. The 30% of poorest children of NHS workers are probably the dependants of less than 10% of NHS workers.
@Peter Martin: That £34.4k p.a is median equivalised disposable income, so it’s after tax and NI and adjusted (downwards) for household size.
Tanvir Ahmad,
Firstly, it is disappointing that you haven’t responded to any of the comments in the one and a half days this has been up on LDV.
Secondly, you haven’t provided any evidence that paying an agency or locum member of staff an extra £5,000 would mean that that person would take on their agency or locum position as a permanent member of staff. Do you have any research to the reasons why so many people prefer to work as agency or locum staff?
Even if the £5,000 was an increase to the normal salary point of the agency or locum member of staff and so would carry forward into future years I don’t believe it would be enough of an incentive. If you have any evidence that it would be, please present it.
Wouldn’t a percentage increased salary be a better inducement so the more an agency or locum member of staff earned, the more the inducement would be?
Thirdly, is your mathematics correct?
In 2026 400 people are induced to move to permanent work and according to your figures this saves £70,000 each (120k-45k-5k). 70k x 400 = £28m.
You say that 800 people would start training, but this would cost £40,000 each (120k/3) 800 x 40k = £32m.
In 2027 you only have 200 ‘conversions’ 70k x 200 = £14m, but you still manage to have a further 700 people entering training 700 x 40k = £28.
(Continued) Then after five years you have 3600 ‘conversions’, which is 720 per year, which is much higher than your previous figures. Plus 7900 trained professionals, which can’t be correct because one fifth will be at the end of their first term of their first year, one fifth will be at the end of their first term of their second year, and one fifth will be at the end of their first term of their third year. Two-fifths of 7900 is 3160, but in the first two years you only have 1500 people starting their training.
Fourthly, it takes between 10 to 14 years to train as a doctor (https://www.healthcareers.nhs.uk/explore-roles/doctors/training-doctor).
@Steve: Thanks for the links. The Barnardos one is informative and does seem to confirm. It quotes polling in which 25% of parents, when asked, said they had struggled to feed their children. That is very sad and definitely a cause for concern – although with the proviso that the question seems to leave it up to individual perception what ‘struggle’ means, and it may well mean occasionally, not regularly.
That doesn’t necessarily reflect on NHS salaries though since there’s no data on what work those people are doing, and it’s a reasonable guess that the people most likely to face financial difficulties and therefore be the ones self-reporting struggling are single parent families and families where no-one is working. It’s probably not significantly, people working as doctors and nurses!
Simon. What we have in the UK and across the West is a significant Children’s obesity issue. This will manifest itself through the Health in years to come. Ultimately the responsibility lies with parents in regards to healthy eating & excersise. If my children were not fit enough to engage in school sports or had poor dental hygiene – that is a parental failing of myself and my Husbands , not the States.
Simon R. asks, ” Can you please supply a source for your claim that 20-30% of NHS staff cannot afford to feed their children ?”………… Simon, it’s not difficult to find it if you look for it :
‘The Nursing Times’ carried the following item as long ago as 12 January, 2023 :
“Nurses make up more than 10% of the staff currently using food banks provided by NHS charities to cope with economic hardship, according to a survey.
The survey found that at six NHS trusts and health boards alone, nearly 5,000 NHS staff, of whom 550 were nurses, were making monthly use of the food banks run by charities that support NHS trusts and health boards.
This adds to the evidence that many nurses across the UK are living in poverty, as new Royal College of Nursing president Sheila Sobrany told the Nursing Times last month, when she said nurses were “really struggling” right now, both financially due to the cost-of-living crisis and pay levels, and emotionally due to the pressures in the system and short staffing.
A previous survey carried out by charity Cavell Nurses’ Trust in January 2022 found that 30% of nurses had difficulty paying for food, and that 14% were relying on food banks”.
@Thelma Davies
“What we have in the UK and across the West is a significant Children’s obesity issue. …… If my children were not fit enough to engage in school sports or had poor dental hygiene – that is a parental failing of myself and my Husbands , not the States.”
I perceive that cheap food isn’t necessarily good quality food – in terms of nutritional value, sugar content etc.
Suppose a child is being ‘brought up’ by parents who themselves were fed on such food in childhood. Isn’t it possible that when such a child becomes a parent they might continue with similar food habits – through not knowling any better?
How do you prevent children from becoming bad parents?
@David Raw
The use of food banks does not mean that the users are ‘struggling to buy food’ – it means that they are struggling to pay for all the things they believe they need and, rather than cut back on other things, access free stuff from a food bank. I don’t blame them for this, but food bank use is not as simple as just due to an inability to pay for food.
@ Mike Peters As the former Chair of a Trussell Trust Food Bank, thank you for telling me that, “food bank use is not as simple as just due to an inability to pay for food”.
In response I’d advise you that I happen to know that access to a food bank is not a simple matter, nor is it a blank cheque.
Might it be that the N. H. S. in Scotland and far too many children are suffering from the following?
1) The delusion the H. M. G. expenditure should be matched by tax receipts
2) A tax set up which favours the wealthy to the cost of the not wealthy
3) Promoted delusions that taxation must not be altered in any way which alters 2
4) Governmental tolerance/connivance at harmful foods being promoted and marketed
5 Ditto serious long term harming to future citizens/workers whose parents cannot afford enough healthy food
https://www.taxresearch.org.uk/Blog/2025/04/11/its-time-labour-saved-the-children/
https://www.taxresearch.org.uk/Blog/2025/04/14/the-uk-tax-system-is-deeply-regressive-when-gains-are-taken-into-account/
https://www.taxresearch.org.uk/Blog/2025/04/19/saving-the-nhs/
https://www.taxresearch.org.uk/Blog/2024/11/17/obesity-has-a-simple-cause-the-food-industry-is-poisoning-us/
@ Steve Trevethan As a resident of Scotland for the last twenty years, and as a successful and grateful recipient of treatment by NHS Scotland for hip surgery, a transplant and skin cancer, I can assure you, none of the above in your comment.
As a former Cabinet member in a Scottish local authority, in my experience Scottish children tend to be a pretty bright lot on the whole and the vast majority don’t suffer from the delusions or expertise indicated by you…….. nor, I believe, do most children in England, Wales or Northern Ireland.
My response to the latest comment of David Raw is that I too am a resident in Scotland where I also find the health service to be outstanding, as well as being so communicative and cheerful. This cheerfulness also applies to the Scots where I live. Their politeness to children is impressive.
Scotland is doing much better than England in addressing child poverty.
“The Scottish Government is spending millions in trying to mitigate the U. K.drive to impoverish children and families such as housing support and the Scottish Child Payment. That contributes to child poverty in Scotland now being significantly lower than England, 31% compared to 24%. But with the limited powers it has, the Scottish Government cannot hope to deal with the root causes of the problem.” [Article below]
https://www.believeinscotland.org/the_uk_worst_in_the_world_for_growth_in_child_poverty_an_independent_scotland_could_do_better
@David Raw
I have no doubt that you understand that use of food banks is not just due to inability to buy food. Unfortunately, I encounter many people who don’t get it. Part of this is reinforced by the number of times we are informed that people are having to choose between ‘eating and heating’….when these are seldom their only choices people have for cutting when they find they are spending more than their income.
@ Mike Peters “Unfortunately, I encounter many people who don’t get it.”
I’m sure you’re well capable of putting them right if you really want to, Mike.
Some information on Food Banks:
https://www.stylist.co.uk/food-drink/myths-about-food-banks-busted/849173
Despite the increase in need many still follow the Tory response to poverty..
Three years ago Rachel MacLean said, “Those struggling should protect themselves better – whether that is by taking on more hours or moving to a better paid job” whilst
George Eustice suggested such people should just, “Switch to value brands to make ends meet…”
Why is it that those who have more than enough seem to believe that they know how to economise far better than those who have no choice?
“Why is it that those who have more than enough seem to believe that they know how to economise far better than those who have no choice?”
Perhaps those who have more than enough now have never had to economise? So have no idea what they are talking about?