Another change agenda: Reflections on ‘Agenda for Change’

Abstract

This article presents research on nurses’ perceptions of the 2005 UK NHS reform ‘Agenda for Change’ (AfC) in order to identify lessons to inform future NHS policy development. Semi-structured interviews (n = 18) were conducted with NHS nurses who were in post prior to the reform and subsequently subjected to the policy reform. Interviews were undertaken by a single researcher and lasted between 40–60 minutes. Interviews were recorded and transcribed verbatim and thematic analysis was used to identify key concepts and findings. The article finds that each facet of the Agenda for Change was not perceived to have achieved the policy goals it intended to. The article concludes that repeated political re-organisation of the National Health Service (NHS) in England has been demoralising for hospital staff.

Keywords

Administrative organisation and structures central administration public sector reform personnel policies implementation public administration

Introduction

The UK appears to undergo continual change and is frequently subjected to large scale re-organisation (Hunter, 2011). Indeed, recently the NHS has experienced national structural change as the Health and Social Care Act (House of Commons, 2012) has been implemented. It is important to identify lessons and learn from historical change episodes to inform future NHS development and policy (Dixon and Alakeson, 2010). As such, this article investigates perceptions of the Agenda for Change (AfC) reform which was introduced in 2005. Specifically, the aim of the paper is to understand nurses’ perceptions of the NHS reform ‘Agenda for Change’ (AfC) and identify lessons to inform future NHS policy. Before describing the AfC reform specifically, this section will present a brief overview of the concepts of public policy making, and health policy and implementation.

Public policy making

Public policy can be described as a government proposal or decision pertaining to a social issue and the subsequent adoption and implementation of a specific strategy in order to address the problem (Anderson, 1975). In the existing literature, a number of interpretations of the process of public policy making have been offered. The dominant approaches include the rational model, the political system model and the policy cycle. The rational decision-making model identifies policy making as a balanced, objective and analytical problem-solving process (Lindblom and Woodhouse, 1993). The political system model considers policy making in conjunction with the environment and society, and describes a feedback loop between demands and policy decisions (Easton, 1965). The policy cycle describes a five-stage approach which includes agenda setting, formulation, adoption, implementation and evaluation has been proposed by Anderson and Sotir Hussey (2006). Other conceptualisations have presented a less structured representation such as the incrementalist model, or ‘muddling through’, which suggests that major changes occur through an evolutionary series of small steps (Lindblom, 1959), and the garbage can model which suggests that both order and disorder prevail, and agendas represent a mix of problems, solutions and politics (Cohen et al., 1972). Kingdon (1984) applied the reasoning underpinning this model to United States (US) federal policy making and developed the multiple streams framework which suggests that the chances that a policy will be adopted increase when the three streams of problem, policy and politics converge. Policy has also been considered as arguments, suggesting that reforms are presented as reasoned arguments developed through debate between state and societal actors (Juma and Clark, 1995) and as a social experiment (Greenberg et al., 2003) which involves iterative hypotheses being tested as a process of trial and error.

Of these models, the ‘rational model’ appears to be the most widely portrayed. This model assumes that policy makers approach issues in a linear fashion and follow three broad phases of identifying the agenda, making a decision, and implementing the decision. In recent years, the British government has given increasing emphasis to the notion of evidence-based policy (EBP). Indeed, the election of the Labour government in 1997 has been credited with revitalising interest in the role of evidence in the policy process (Solesbury, 2001; Nutley et al., 2002). However, it is worthy of note that recent evidence suggests that this is not representative of current practice by the UK Government (Hallsworth et al., 2011). Centrality of political power, administrative turnover and national mood have been identified as key factors which may influence policy making (Zahariadis and Christopher, 1995). Indeed, it is likely that some if not all of these factors were evident at the time of the introduction of AfC. Six months prior to the reform, a Conservative government succeeded the Labour government, which had served three consecutive terms. Studies of European policy making found that time constraints and other pressures could unduly enable a small group of policy officials to dominate processes and direct decisions towards their preferred outcomes (Zahariadis, 2008).

Health policy

Within public policy, health policy has been defined as authoritative statements of intent, usually asserted by governments on behalf of the public, with the aim of improving the health and welfare of the population (Lee and Mills, 1982: 28). Health policy is concerned with the social, organisational, economic and fiscal context within which it is to be implemented (Walt, 1994). Health policies may be generated in response to new knowledge, offered as a mechanism to address a public issue or problem, or in response to feedback. Health policy consists of a series of governmental decisions about what type of care is to be provided for the betterment of the health of the population, and how this will be done (Paton, 1996). Policy is often subject to reform and review, as it requires updating in light of political, sociological or economic changes. In developing health policy, ministers and senior managers are required to adopt a range of approaches to policy making and naturally adjust their strategy to the political, time and resource constraints of the given context (Smee, 2005). Like the policy process in general, the health policy process involves a wide and complex range of interests, actors and institutions. It follows that health policy is inextricably linked with power and politics and is thus constructed within certain pre-defined political parameters, which define the boundaries of what is, and is not, possible or acceptable (Bambra et al., 2005).

Policy implementation

The implementation of policy, whether legislative, guidance, or action based, is designed to instigate change. Policies generally seek to generate improvements in effectiveness, efficiency, administrative ease, legality, equity or other desirable outcomes. All improvements require change (Langley et al., 2009). However, the implementation of policy change has long been recognised as complex and challenging (Crosby, 1996). In general, there appears to be a demarcation between policy making and implementation. Grindle and Thomas (1991) have suggested that the divide between policy making and implementation can be ascribed to the divorce between the political sphere where decision makers tend to formulate policy and the administrative sphere where the implementation of policy is conducted. Policy implementation is the process of enacting the policy in practice and might be summarised as a deliberate set of actions or procedures directed towards achievement of goals and objectives articulated by the policy. However, it is common to observe a gap between what was planned and what actually occurred as a result of a policy (Buse et al., 2012; Glenngard and Maina, 2007; Hallsworth et al., 2011; Ham, 2009; Hunter and Killornan, 2004).

Agenda for change

Agenda for Change (AfC) was a sweeping modernisation agenda of the NHS described as the largest overhaul of NHS-wide pay, terms and conditions in more than 50 years (Buchan and Evans, 2007). Its objectives were to: improve the quality of patient care; assist new ways of working, achieve quality workforce organisation, improve retention, recruitment and morale of the NHS workforce, improve aspects of equal opportunity and diversity, and ensure equal pay for work of equal value (Department of Health [DoH], 2004). The reform entailed two main elements: new standardised pay scales and a mandatory annual personal development review (PDR), and was applied to all staff groups apart from doctors and dentists.

Prior to AfC, groups of NHS staff each had their own national pay scales; nurses were paid according to the Whitley pay system. This system included yearly salary increments; additionally, NHS Trusts could grant unique pay terms and conditions to recruit staff groups that were in shortage. This led to variation of entitlements in work leave, length of the working weeks, shift patterns and on-call arrangements (National Audit Office, 2009). The AfC reform sought to standardise pay scales by matching professional responsibilities to a list of explicit pay criteria (DoH, 2004). The Department of Health anticipated that correlating staff salaries directly with job duties, explicit skills and knowledge would lead to consistent and comparable remuneration in the NHS across staff groups and Trusts (DoH, 2004).

The second element of AfC was the introduction of compulsory annual PDR for all NHS staff. The purpose of the reviews is to provide clear and consistent objectives for the professional development of staff and to provide support from managers for skills and knowledge acquisition that is necessary for career development. The PDR includes a Personal Development Plan to be agreed jointly with the individual's manager and assessed against guidelines articulated in the knowledge and skills framework (KSF). The KSF was designed to be a rigorous method for identifying the development needs of staff and to aid their career progression (Buchan and Evans, 2007). It is based on generic competencies that have been developed, so they are appropriate for all non-medical NHS staff. There are six core dimensions to the basic competencies; communication; personal and people development; health, safety and security; service development; quality; and equality, diversity and rights. Most NHS staff professions have to demonstrate the ability to undertake at least two of these in order to meet the speciﬁc dimensions relevant to their job. There are also an additional 24 dimensions developed to cover requirements for specific NHS professions. Truss (2008) conducted research which explored the functions of PDRs within the public sector, including the NHS, and found that these were often perceived to be bureaucratic, cumbersome and a distraction from the ‘day job’ of participants. This study examines perceived quality and coherence of the AfC reform and the experiences of implementing AfC. Contextual issues which influenced the reforms are also explored.

Sampling and recruitment

Participants were included in the research if they were currently employed, full time on a permanent contract, in a nursing role, and had been prior to the introduction of AfC. Nursing roles included assistant nurses and registered nurses. A purposive sampling strategy was adopted. A sample with maximum variation in participant characteristics was sought, in order to identify the breadth and variety of views which existed on the topic (Creswell, 2007). Participants were recruited from a specialist hospital located in a Northern city of the UK. By virtue of being a specialist hospital, this site contained a higher number of nurses employed in a variety of job roles than tends to exist in general hospitals.

Potential participants were identified and initially approached by ward matrons at the hospital on behalf of the researcher. The researcher selected volunteers who were: men and women; those newly qualified and those nearing retirement when AfC was implemented; nurses from the lowest band (band 3) to the most senior nursing band (band 8); those working in a variety of different departments (intensive care, operating theatre, burns, paediatrics and others); nurses in different roles on the same pay bands (e.g. on band 6 participants had job roles such as day care nurse, staff nurse, senior matron); nurses who experienced the implementation of AfC in another Trust; and nurses who experienced the pay system preceding AfC, the Whitley pay system. Finally, participants who were on the same pay band were recruited from different wards. All participants were granted confidentiality and anonymity in reporting.

Interviews took place until data saturation, which was achieved at 18 interviews. Data saturation is when the same themes, issues, and topics consistently emerge among participants and nothing new is being added (Kelly, 1998; Seymour et al., 2010).

A breakdown of participants is included in Table 1.

Table 1.

Table of participant characteristics

Participant Number	AfC Band	Gender (M/F)	Age is over 40 years	Over 10 years of tenure at the Trust	Length of time of interview discussion (minutes)
1	Band 7	F	Yes	Yes	42
2	Band 8	F	Yes	Yes	46
3	Band 6	F	No	No	37
4	Band 6	F	Yes	No	41
5	Band 6	F	No	No	34
6	Band 6	F	No	No	41
7	Band 6	F	Yes	Yes	53
8	Band 6	F	Yes	Yes	55
9	Band 7	F	Yes	No	54
10	Band 7	F	Yes	Yes	40
11	Band 6	M	No	No	50
12	Band 7	F	Yes	Yes	58
13	Band 7	F	Yes	Yes	49
14	Band 8 a	F	Yes	Yes	39
15	Band 3	M	Yes	Yes	34
16	Band 5	F	No	Yes	52
17	Band 6	M	No	No	49
18	Band 7	F	Yes	Yes	57

Methods

The interviews were conducted face-to-face, lasted between 40 and 60 minutes, and were undertaken privately, at the hospital site, over a four-week period in March/April 2011. Interviews were semi-structured, following a schedule of open-ended questions to enable participants to talk freely and fully express themselves. A number of probes and follow-up questions were included to facilitate a conversational experience and for elaboration (Britten, 2007).

The interviews were audio recorded and transcribed. Transcripts were reviewed numerous times by the researchers. Analysis was by grounded theory (Glaser and Strauss, 1967; Strauss and Corbin, 1990). This is a process of organising a large amount of collected data into codes, and the codes then into themes, by a series of steps that compare and link passages of the interviews to successively greater degrees of summarisation. Data were openly coded to categorise key statements and the text was interrogated using a constant comparison approach to identify common categories (Bryman, 2008; Pope and Mays, 2000).

Following grounded theory, coding of the transcripts was undertaken alongside the conduct of interviews and data collection stopped once the ‘data saturation point’ (when there is a redundancy of information in codes) was identified (Bowen, 2008). Initially codes were aligned with the topics in the interview guide. As subsequent data were collected, new information was added in an ongoing manner to further develop the codes (Bowen, 2008). In this manner, the analysis and data were iteratively examined and reviewed in order to develop the categories through merging, dividing and refining codes. Fewer new codes emerged with each successive transcript, guiding the researcher in identifying the point of data saturation.

Results

Participants described a range of factors which contributed to their perceptions and experience of AfC. This section presents four themes which influenced the introduction and operationalisation of the reforms. These are: perceived aims of AfC; implementation; organisational context and the wider political and economic context.

Perceived aims of AfC

Participants were all aware of AfC and there was broad agreement between participants about the perceived purpose of AfC. This was described as to review individual roles and responsibilities in order to categorise them into pay bands which could be homogenised on a national scale:

What it did was try to standardize pay, terms and conditions across a range of different professions and staff groups within the NHS. So that we got a common pay spine and [ … ] so that you could also make sure people were being assessed on their performance in a more standardized way. (ID5)

However, participants were less certain about stimulus for AfC, advising that they were ‘never really clear on why it was introduced’ (ID7). None of the participants identified an explicit reason for the introduction of the initiative or as to why the reform was required, and the majority appeared content with the previous organisation advising: ‘I don't think it was necessary to change it’ (ID10). Participants were sceptical about the benefits of the reforms, and advised that they ‘don't think patient care delivery has changed at all’ (ID9).

Despite their lack of support for AfC the majority of participants indicated a passive acceptance of the reforms stating ‘it’s a case of, this is happening, you've got to do it so it was implemented and that was it’ (ID2). This suggests that participants were familiar with a top-down manner of policy implementation and did not consider themselves in a position to discuss or challenge the reforms. A minority of participants suggested the motivation for the introduction of AfC was ‘purely financial’ (ID1). The concept of financial pressure influencing the reforms is further discussed in the section on banding, and the economy.

Implementation of AfC

The implementation of AfC was described with respect to three main aspects: new band classification, benefits and responsibility, and the knowledge skills framework (KSF).

New band classification

The majority of participants considered that AfC had failed in its objective to introduce fair and consistent pay bandings across nursing, advising that there had been widespread disparities in terms of job roles, experience and responsibilities between professions and between Trusts. Nursing job descriptions were to be compared to national profiles and allocated to similar AfC pay bands. However, this process was deemed subjective and, in practice, Trusts undertaking job evaluations arrived at inconsistent bands, resulting in national pay discrepancies. Consequently, this led to resentment in the workplace, as nurses with markedly different degrees of work responsibilities, skills or job experience were allocated to the same band:

Some people were doing the same job and got banded differently, and that led to, well conflict really, at the end of the day. I'm doing the same job as you and you've got a higher band than me, I'm not speaking to you anymore. (ID16)

It also transpired that the majority of participants did not have their job individually evaluated, which appears at odds with the intentions of the reform to review roles and responsibilities and classify jobs accordingly. Rather, participants reported that many jobs were banded based on the previous pay grades of the staff employed in those roles:

[Grade] Ds were banded at five and [grade] E and Fs were banded at six. (ID2)

Although an appeals procedure was embedded in AfC, participants did not perceive the opportunity to negotiate their band once this had been allocated: ‘basically it was very much you were given it and you signed it and that was it, there wasn’t any opportunity to object’ (ID13). There was a perception that many roles were being downgraded, and participants reported fears among the nursing workforce that cutbacks would lead to their roles being re-evaluated and being revised to a lower paid band:

Some nurses who are band 6 here might be worried because they think we could theoretically be downgraded [ … ]I think they are aware that job cuts, that people are cutting back, there’s jobs that are being re-evaluated and downgraded. (ID9)

Benefits and responsibility

The only advantages which participants attributed to the implementation of AfC were a marginal increase in the basic rate of pay, and in annual leave entitlement. However, these benefits did not appear to be particularly sought after by staff, who reported that neither holidays nor small increases in salary were influential motivating factors; rather they suggested that a manageable workload was more of a concern than pay:

I don’t think anybody expects megabucks in nursing [ … ] I think it's more down to workload and whether you can do your job properly. (ID17)

Concerns were raised that following the transition from old grades to new AfC bands, participants were expected to take on higher levels of responsibility than were previously associated with that level. This was reported in generalities, but also below with specific reference to supervising a shift. The implication of increasing the amount of responsibility held by more junior members of staff is discussed later with reference to workload. What is notable with respect to pay was this increased responsibility was not compensated by any financial remuneration and was identified as having a negative effect on staff morale:

[ … ] for example- on the old system it used to be E grade staff nurses that could take charge of a shift and initially it was band sixes but we sort of phased it now where if - there is usually a band six on a shift- but if there isn't they expect the band five to do it now [ … ] I think it’s something that probably is having a bit of a negative effect on morale at the moment because people are being given more responsibility but without any sort of reward. (ID7)

The revisions to pay and responsibility generated through AfC were also cited as causing tensions related to personnel status and teamwork. The nature of the revisions in one Trust resulted in a junior sister being allocated the same band as a staff nurse. A junior sister is a more senior role than a staff nurse, and her position and status would be indicated by a different uniform. A junior sister was expected to hold more responsibility and classifying this role at the same band as a nurse, whilst maintaining the differentiation in uniform and job title, was noted to create tensions:

I think what struck me was the old F grade who was now getting, the junior sister, was now a band six in a sister’s uniform being paid the same as a senior staff nurse in a senior staff nurse uniform- that was more relevant than pay. (ID1)

Nurses reported that there had been a decrease in staff morale, following the process of job evaluation. They advised where previously staff had worked effectively to support each other in teams, that individuals had become fearful about protecting their jobs, creating a competitive and unpleasant atmosphere.

I did witness a very, morale was very low when I came back from maternity leave but it seemed like everybody was very twitchy and very scared for their job and, suddenly became quite competitive, whereas before there was very much a team ethos and everybody looking after everybody else, it almost became, like everyone was being competitive, it wasn't a nice atmosphere. (ID 18)

This perception of a divide was reiterated with respect to national level organisations and participants reported feeling betrayed by the introduction of AfC as it was not perceived to bring benefits or improvements for the nursing workforce. Frustration at this betrayal was directed towards the Royal College of Nursing (RCN), which is the profession’s largest union, and the government. Further, participants reported that many of the decisions were made without their engagement and imposed upon them, in a top-down manner:

I felt that it was like a kind of betrayal really, [ … ] the government and the RCN, these were the people that are supposed to be making things better, and yet they didn't and it's just a case of, again, somebody imposing something on you that you’ve really got no choice about. (ID15)

Knowledge and skills framework

A KSF was introduced as part of AfC, to aid and accompany annual PDR. However, participants reported that their PDR process had not changed, although it was now mandatory that these occurred annually. Participants were not overly enthusiastic when describing it, but conceded that it had the potential to be helpful. Ultimately, it appeared that the KSF had not standardised the process of appraisals, and individuals appeared to vary in the extent to which they opted to apply this framework:

KSF, the framework that we were working towards, to be honest it’s become quite a problematic framework and quite tedious really … (we’ve) not been particularly working within the framework to be honest. (ID17)

The KSF was described by most participants to be complex, overly time consuming and impracticable for the nursing workforce. The framework was considered too prescriptive, not tailored to an individual’s needs, and time consuming. There was a widespread belief, across all levels of staff, that the KSF was unmanageable in the amount of paperwork that it required to be completed prior to and during an appraisal.

Organisational context

The context of the nursing workforce and the NHS in general evidently influenced the perceptions of the impact of AfC. Two particular issues are identified here, which are rising workload and workplace stress, and increased performance management.

Workload and stress

A significant concern raised by both newly qualified staff and senior, more experienced, staff was related to increasing workloads which were becoming overwhelming and causing workplace stress to rise. The following quotation illustrates a newly qualified nurse being required to operate outside the responsibilities of her role and manage a ward. This was reported as in response to staff shortages and sickness. Undertaking these additional responsibilities was not recognised formally or compensated with financial remuneration, which was considered unfair practice.

[ … ] sometimes there isn't necessarily a lot of choice, like I was a newly qualified band five, well I’d been qualified a year and I was taking charge of the ward which wasn't sort of in my role to be doing, but because of staff shortages and sickness and that was just the way it was and I used to do it quite a lot but don’t, didn't ever get paid or recognised the fact that I was doing something that actually really band six and very senior band fives should be doing, so you know, I think that's quite unfair. (ID16)

A notable contributing factor to this rise in workplace stress was that the Trust was now operating with more junior staff. Further, junior members of staff were expected to take on more responsibility. This created increased pressure on the wards for senior staff who were taking on responsibility for supervising junior levels of staff. This is described in the following quotation:

We had an influx of quite junior staff obviously because of financial reasons, and so suddenly we were running with more sick children on a very diluted workforce and suddenly as a band seven you're suddenly finding yourself in charge of 18 very sick children and some quite junior staff, plus as well we didn't have enough doctors, and so you’re finding on night shift you were the most senior person there [ … ] it was very, very stressful. So I think everybody, everybody felt that, definitely. (ID18)

Although nurses consistently advised that they would stay beyond the end of their shift, or act beyond their defined role in order to deliver the best patient care, this was now becoming a substantial strain. The number of instances where there was an expectation on staff to work above and beyond scheduled hours or duties was noted to have increased, and this was noted to be taking a toll on nurses’ work–life balance:

[ … ] it’s got worse and I think, because the thing is you might only be staying like half an hour to 45 minutes late after work but when that’s like three or four times a week and you're never getting that back then actually it's quite a lot.(ID16)

Participants raised concerns about the long-term negative consequences of increased overtime, and expected that it would become unmanageable for nurses to continue to work through breaks and extended days. They suggested this may lead to an ultimatum whereby they consider leaving their role:

[ … ] the frustration then builds in where they try and do something about it, you know start and say, I’m overworked, I can’t stay, I can't keep not having breaks, I can't keep working later than my shift for no pay, do I really need this? (ID9)

Performance management targets

Alongside the AfC reforms, a number of other performance management targets had been recently introduced to the NHS. These were described as contributing to rising workforce pressure; the most frequently mentioned target was for 18-week waiting lists, but others included numbers of inpatient admissions, target for maximum four hour A&E waits, and the amount of days a patient spends on a ward until they are discharged. Participants portrayed nursing as a profession that was driven by patient-centred care, and indicated limited buy-in to targets and numbers which they associated with a management discipline.

I think naturally as a group of people (nurses) we are a bit, targets, that’s not our interest, it's more patient driven [ … ] turnaround times and bums on seats, numbers through doors, I think it goes against the grain of nursing staff in general. (ID1)

Participants described a lack of engagement with performance management initiatives, and indicated that there was limited nursing input in the development and generation of targets. Rather, they described that decisions would be made in isolation by senior management and subsequently communicated to nursing staff on the wards. This describes a top-down model of management, and it appeared to contribute to a sense of resentment associated with performance management targets.

I think sometimes they work on a need to know basis and they tell you what they want you to know when they want you to know it rather than telling you when it's in its infancy. So they’ll go away and develop it with people that are holding the purse strings if you like, and then they’ll come back and tell the junior level, junior staff or the shop floor staff as they tend to see them. What they need to know when it's about to happen. (ID11)

Political and economic environment

Participants also described how factors which are external to the organisation affected the implementation of AfC and may have contributed to how they perceived the initiative. These were the national economy and changes in government.

Economic climate

The recent economic downturn and fiscal deficits in NHS Trusts was identified as a contributing factor to increasing workplace stress. Participants acknowledged that NHS funding had been reduced and thus the service could not continue to operate in the manner it had: ‘this Trust alone has to save so much every year’ (ID10). Declining budget revenues resulted in Trusts seeking to reduce costs by employing fewer nurses, which resulted in the same workload being shared among a smaller number of people and consequently contributed to work pressure.

People know that there is less funding for the NHS so something has to give within that system…you have to meet the same service needs but by costing, you know in a cheaper way which generally means head count. (ID1)

The organisational context was directly impacted by the austere financial climate, and this is evidenced by the Trust constantly discussing compulsory redundancies. The issue was also discussed on national media, and so participants were constantly aware of the need and pressure for NHS cuts. This insecure and unpredictable environment was noted to negatively impact staff morale, and heighten fears about job security, including for relatively new posts:

The current financial climate it's very obviously on the government level and on the Trust level, we’re feeling it, we are aware of it, so, yes, I’m scared for my job, a new job now and I've only had for 8 months. (ID18)

Politically driven restructuring

Nurses reported that the political election cycle and subsequent changes of government were associated with restructuring, and noted that this unsettled the workforce and they became demoralised as they anticipated that everything would change again. This appears to indicate weariness with perpetual politically driven change.

I'll tell you something that really gets people- nurses is government, the government changes, ‘oh what’s going to happen now?’ You know? -everything is going to change again and I think that influence is quite unsettling and demoralising. (ID1)

Others confirmed that change in the government party had a negative impact on morale, and highlighted a disparity between political manifesto and post-election actions, noting that the government had promised not to decimate the NHS, and then proceeded with recent reforms which were considered unsettling.

It's had an effect on morale, overall there is quite an unrest especially since new government’s gone in and they said they weren't going to decimate the NHS and they are doing exactly the opposite so it's made people very unsettled. (ID11)

Discussion and implications for policy

In general, it was apparent that while staff were broadly aware of the purpose of AfC, the motivation and rationale underpinning the introduction of new banding was not well communicated or understood. Well-articulated aims and underpinning rationale of policy changes are more likely to generate consensus and support from credible actors. This is in line with recommendations from other research (Boydell and Lander, 2011; Hurst, 2010).

Participants did not consider the process of the job evaluation for new bands to be sufficiently rigorous, and attributed this as the determinant for the widespread discrepancies and dissatisfaction with the new pay structure. The marginal increases in salary and in annual leave were not highly sought after or valued by nurses. Early stage engagement with those affected by the policy is likely to lead to increased support of the policy. Further, it has been suggested by others that this will help generate a sense of ownership and improve motivation and cooperation in implementing policy change (Gifford et al., 2012). The KSF element of AfC was described as poorly implemented and administratively burdensome. For nurses who are predominantly engaged with practical, ‘hands on’ work, the administration to support PDRs was perceived to be particularly burdensome. The impact of administrative tasks and paperwork as detracting from core function has been observed in relation to other policy changes (McCafferty et al., 2012; Naylor and Goodwin, 2010).

Following the introduction of AfC, participants described increased workloads, responsibilities, and stress, which appeared to be further exacerbated by the introduction of performance management targets. Additional challenges were attributed to the economic downturn, and politically driven change in line with government election cycles. Policy makers should be aware of, and account for, the political and economic environment in which policy will be implemented. In particular, frequent policy initiatives in line with government election cycles were described as disruptive and should be managed more coherently. Bambra et al. (2005) has advocated for a greater consideration of the political science of health.

Limitations

This research has been subject to two main limitations of limited sample size and use of volunteers. Ideally, a sample that has a similar proportionate number of nurses possessing relevant research characteristics as that in the ‘population’ NHS nurse workforce would have been recruited for this research, in order to enhance generalisability (Creswell, 2007). However, to achieve this, it would be necessary to sample all the factors that make the results generalisable. There is regional variation in the speed and manner of the implementation of AfC (Ball and Pike, 2006) and it may be that satisfaction with AfC varies considerably between NHS Trusts. By conducting the interview at one Trust, the differences in nurses’ experiences of implementation of AfC at different sites is likely to be missed. To have a selection criterion that could produce generalisable results, it would be important to conduct interviews with nurses in different types of Trusts, in different locations in the UK. This was a task beyond the scope of this study.

The disadvantage of using volunteers is that there is no guarantee that their opinions represent those of other nurses (Fossey et al., 2002). The sample of volunteers from which participants are chosen might under-represent or over-represent particular groups in the nursing workforce. Possible causes for misrepresentation might include: some wards or nursing roles being more busy than others; no convenient time for some nurses to take part, particularly those who work a shift during unsociable hours (evening and weekends) or those who work part time in the community; some nurses might not trust the intentions of the research and some might have a particular grievance with the organisation. These influences are quite typical when using volunteers (Bryman, 2008).

Conclusion

In general, AfC reform was not perceived to have achieved its aims which included: improving the quality of patient care, generating new ways of working, achieving high quality workforce organisation, improving retention, recruitment and morale of the NHS workforce, improving aspects of equal opportunity and diversity, and ensuring equal pay for work of equal value. Participants questioned the rationale for introducing the reform and consequently demonstrated limited buy-in to AfC. Nurses indicated keen interest in demonstrable improvements in patient care, which they did not perceive AfC to have achieved. In contrast, the received benefits of marginal increase in basic rate of pay and in annual leave entitlement were not highly valued by nursing staff. A high number of nurses reported rising levels of work-related stress, related to increasing workloads. Further, the process of ‘banding’ nurses to new pay grades was described as inconsistent and perceived to be unfair which contributed to increased tensions between nursing staff. Finally, the reforms were perceived to be politically driven, and the frequent re-organisation of the NHS in this manner was described as demoralising.

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