Direct Engagement Efficiency

London North West University Healthcare NHS Trust

statistics for a direct engagement case study
overview for direct engagement case study


As LNWH’s managed service provider, Medacs Healthcare identified DE as an area that could generate significant savings and efficiencies – and reduce risks associated with tax legislation and compliance.

Only 54% of locum doctors were being processed via the trust’s direct engagement model and less than 31% of AHPs. The Medacs Healthcare team calculated that the use of non-DE-compliant umbrella workers was costing the trust over £80,000 per month.

Umbrella workers are contracted and paid through third party umbrella companies. As these types of locum workers are not VAT registered, VAT savings of up to £8 per hour are lost and responsibility for their tax obligations lies with the trust, creating risk.

Additional risks were also apparent as 25% of bookings were off-contract workers, not subject to the same stringent compliance checks.


London North West needed a rapid reduction in umbrella workers to increase DE efficiency to the agreed target of 80% and mitigate the identified risks but knew implementing the required steps would be challenging.

If the critical culture change could not be adopted by all parties and the current methods of recording spend continued, there could be an adverse impact on fill rates.

Medacs Healthcare had also encountered issues on a similar project at a neighbouring trust, where doctors would only agree to change their pay type if rates were escalated.

If regular locum doctors could not be moved under the direct engagement model, there could also be a corresponding impact on the continuity of care delivered by the trust, as new workers would need to be brought in to replace them.

male doctors outside hospital
male doctors talking


A comprehensive project control plan was created, specifically designed to avoid any impact on operations, with clear roles and responsibilities for escalating identified issues and a detailed risk register. It was tightly managed and jointly implemented in eight weeks, with the Medacs Healthcare team working in true partnership with key trust stakeholders.

Communications were thorough and led by the trust, including comprehensive FAQs for doctors, supply chain partners and off-contract agencies to support change management, with a clear cut-off date for non-compliance. Sharing successes achieved at other trusts also helped to convince key stakeholders that the project goals were achievable, and it could be delivered with no perceivable impact on overall fill rates.

In just four months, the DE-efficient hours filled had more than doubled, well exceeding the 80% target. Current DE-compliance is now 100% for AHPs and 95% for doctors. Total cost savings since project launch are currently £349,408 and the trust now has the highest rate of DE-compliance in their region.


  • Direct Engagement compliance of 100% for AHPs and 95% for doctors, the highest in the region
  • Cost savings of £349,409 in just four months
  • 15% increase in fill rates, with a corresponding increase in the quality of care provided, with on-contract workers subject to more stringent compliance
  • Improved management information and rate management with 100% adherence to AHP rate caps and extremely high adherence to the pan-London rate caps for doctors (97% core, 100% unsocial)
  • More efficient booking processes with last-minute changes auto cascaded to the supply chain, so agencies are more accurately focused on filling true demand
  • Reduced compliance risk, with consistently higher quality standards for all locum bookings in line with framework specifications
  • Continuity of care preserved with the retention of existing workers

Medacs Healthcare has boosted our direct engagement throughput to 100%, generating significant savings for our Trust in less than four months, reducing risk and uplifting fill rates. We now have a much more efficient operation and the highest rate of DE-compliance in our region.

London North West University Healthcare NHS Trust , HR Director

Direct engagement of agency staff has been a key issue in North West London. One of the priorities we have is to make sure that DE-compliance is high to maximise savings. A forecast of the impact of this project was developed, making some assumptions on the improvements in process compliance and the savings that would be generated. Based on data from the last two months, these assumptions have been massively exceeded. The team have managed to move to almost complete compliance in two months rather than five – this will generate significant additional in-year savings. This approach will now be shared across North West London.

North West London STP , Workforce Transformation Lead

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