NHS trusts in England spent about GBP 8.3 billion on nursing staff in 2004-05, with about GBP 790 million (or 9.4 per cent) of this spent on temporary nursing cover. The NAO report examines how trusts determine demand for temporary staff, the extent and costs of procurement and the impact of initiatives to improve performance quality and benchmark good practice. Overall, the report finds that whilst the NHS has successfully reduced its expenditure on temporary agency staff, the use of temporary staff still remains a key aspect of the ability of NHS trusts to be flexible in order to cover staff vacancies and absence through sickness and to meet fluctuations in activity levels. Many NHS trusts lack robust management information systems to help determine cost-effective staffing levels or to understand their real staffing needs. The report estimates that between GBP 38 million and GBP 85 million a year can be saved by better procurement of temporary nursing staff and better management of permanent nursing staff.