The Real Cost of Empty Positions: Understanding the Financial Impact of Healthcare Vacancies
An unfilled nursing post doesn't save you the salary. It costs you multiples of it.
NHS providers spent an estimated £8.3 billion on temporary staffing in 2024/25, down from nearly £10 billion the previous year. Before the pandemic, that figure was £5.8 billion. Three-quarters of the spend went on bank workers, with the remainder on agency staff - often at rates significantly above substantive pay.
The government has rightly targeted this spending. Health Secretary Wes Streeting ordered trusts to reduce agency spending by at least 30% and has set an ambition to eliminate agency use altogether by the end of the government’s term of office. NHS England: Further action to reduce NHS spending on temporary agency staffing
NHS England reported that agency staffing accounted for £2.1 billion, or 2.3% of the total NHS pay bill, in 2024/25, below the 3.2% target of £2.6 billion. This represented a £451 million reduction compared with the previous year. NHS England: Performance Report 2024/25
At A24 Group, we work with healthcare facilities across the UK and South Africa to manage staffing costs without compromising care. Understanding the true cost of vacancies is the first step.
The Direct Financial Costs
The most visible cost of a vacancy is the agency premium. NHS England sets maximum hourly price caps for agency workers, with these rates calculated using substantive pay as a baseline and accounting for additional costs including holiday pay, employer National Insurance contributions, pension contributions and an agency fee.
Overtime for existing staff compounds the expense. When a ward is short, remaining nurses work additional hours - at enhanced rates. Overtime isn't just more expensive per hour; it's less productive per hour because fatigued staff work more slowly and make more errors.
Administrative costs rise too. Every vacancy generates recruitment activity: advertising, shortlisting, interviewing, compliance checking, and onboarding. If the first recruitment round fails - and in healthcare, it often does - the cycle repeats.
For a single registered nurse vacancy that remains unfilled for six months, the combined cost of agency cover, overtime, recruitment, and administrative burden can reach tens of thousands of pounds. Multiply that across the hundreds of vacancies a typical NHS trust carries, and the financial impact is substantial.
The Hidden Costs
Financial accounts capture agency spend and overtime. They don't capture the full cost of vacancies.
Staff morale deteriorates when teams are chronically understaffed. The remaining workforce absorbs additional duties, misses breaks, and feels unsupported. The NHS Staff Survey consistently shows that understaffing drives dissatisfaction, stress, and intention to leave. When experienced staff resign because of workload pressure, you lose their institutional knowledge, their mentoring capacity, and the investment you made in their development - and you create another vacancy.
This attrition cycle is the most expensive consequence of unfilled positions. It's self-reinforcing: vacancies create workload pressure, which creates more vacancies.
Patient outcomes are directly affected. A UNISON survey of more than 1,400 shifts across 42 hospital sites found that staff reported insufficient staffing to deliver safe care on 69% of shifts, up from 63% in 2023. A serious safety “red flag” event occurred on 67% of shifts considered insufficiently staffed, compared with 16% of shifts where staffing was considered sufficient.
The cost of a clinical incident - in patient harm, litigation, regulatory scrutiny, and reputational damage - dwarfs the cost of adequate staffing.
The Opportunity Cost
Every pound spent on reactive agency cover is a pound not spent on improvement. Trusts facing persistent vacancies divert management attention from quality improvement, service development, and digital transformation to firefighting staffing gaps.
NHS Providers reported that nine in ten trust leaders were scaling back or considering scaling back services in 2025 due to financial pressures. Over three-quarters were cutting or considering cutting clinical posts. The staffing crisis isn't just costly - it constrains an organisation's ability to develop.
The South African Perspective
In South Africa, the dynamics differ but the principle holds. Public healthcare facilities lose an average of 5,900 doctors and nurses per year through resignations, according to parliamentary data. Below-market salaries, poor working conditions, and limited career progression drive professionals towards the private sector or overseas - with over 23,400 South African health professionals now working in the UK, New Zealand, the US, and Australia.
The cost of these departures is borne by the patients who remain: longer waiting times, reduced access, and poorer outcomes. For facilities partnering with A24 Group's Ambition24hours division, strategic temporary staffing provides a bridge - maintaining service continuity while longer-term retention strategies take effect.
Calculating Your True Vacancy Cost
To understand what vacancies actually cost your organisation, consider the following: direct agency and overtime spend to cover the vacant post; recruitment costs (advertising, agency fees, interview time, compliance processing); productivity loss from remaining staff absorbing additional workload; sickness absence costs driven by overwork and stress; training and induction costs when a replacement is eventually hired; and the risk-adjusted cost of potential safety incidents on understaffed shifts.
Most healthcare organisations underestimate this total because the costs are distributed across multiple budget lines and some are invisible to standard financial reporting.
Reducing the Cost Without Compromising Care
The solution isn't to eliminate temporary staffing - it's to use it intelligently within a broader workforce strategy.
Build a strong internal bank before relying on external agencies. NHS Professionals displaced over £680 million of external agency fees last year by strengthening trust bank services.
When you need agency support, use compliant, framework-approved medical staffing agencies that provide pre-vetted, qualified professionals at agreed rates. A24 Group operates on approved NHS frameworks and supplies staff who meet all compliance requirements - reducing the risk of overspend and non-compliance.
Invest in retention. Every substantive member of staff you keep is an agency placement you don't need to make. The return on investment from flexible working policies, professional development, and wellbeing support far exceeds the cost of implementing them.
Plan ahead. Predictable demand - elective lists, seasonal pressures, maternity cover - should be staffed in advance, not reactively. A24 Group works with facilities to forecast demand and pre-book qualified professionals, reducing last-minute premium costs.
Act on the Numbers
The real cost of empty positions isn't a theoretical exercise. It's hitting your budget, your team, and your patients right now. Understanding that cost - and addressing it with a strategic, compliant approach to workforce planning - is one of the most impactful decisions healthcare leaders can make in 2026.
Ready to take control of your staffing costs? Contact A24 Group to discuss how our medical staffing solutions deliver quality, compliance, and value.