Knowledge and skills take on a new dimension: the NHS Agenda for Change
Competencies underpin the ambitious Agenda for Change in the NHS, where 1.3 million healthcare staff are covered by a new Knowledge and Skills Framework. John Warner reports.
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Key Points The NHS Knowledge and Skills Framework:
Focus
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Following the collective agreement of NHS unions in November 2004, an Agenda for Change programme sets out the national terms and conditions of service for about 1.3 million NHS staff. Alternative agreements cover doctors, dentists and some very senior managers. The Agenda for Change programme and associated developments represent the largest initiatives of their kind in the world. Since 1 December 2004, the programme has been rolled out to strategic health authorities nationally. It aims to achieve equality of pay by replacing numerous legacy pay scales and service conditions, and supersedes all previous local contracts. All NHS authorities were due to be assimilated into the Agenda for Change by the end of September 2005.
Knowledge and Skills Framework
As part of the Agenda for Change, the NHS has launched a significant programme to raise quality standards and service levels through the systematic development of its huge workforce. Tens of thousands of staff, employed in an extensive range of roles, from domestics and porters, care assistants and nurses, to assistant directors of finance, are being included in a competency framework that is known as the NHS Knowledge and Skills Framework (KSF). The introduction of the KSF and the other elements that accompany it is a massive undertaking that has few, if any, parallels elsewhere.
The stated purpose of the KSF is to:
- facilitate the development of health services so that they better meet the needs of users and the public through investing in the development of all members of NHS staff;
- support the effective learning and development of individuals and teams;
- support the development of individuals in the post in which they are employed, so that they can be effective at work; and
- promote equality for, and diversity of, all staff.
The KSF was created by the Department of Health with input from a network of working parties representing different interests, including management, trade unions and professional bodies. Trials of the KSF were conducted at pilot sites and revised versions were prepared; the current one being rolled out is the seventh version. In view of the large numbers of employees involved, representatives from different strategic health authorities were trained by staff from the Modernisation Agency, a division of the Department of Health. The roll out and implementation of the KSF is continuing to be monitored and evaluated by the NHS's staff council to ensure that it remains appropriate for its purposes.
West Yorkshire example
The West Yorkshire Strategic Health Authority (WYSHA) is typical of the authorities that are overseeing the implementation of the KSF. In the area covered by the authority, there are numerous NHS organisations, including: the Workforce Development Confederation; 15 primary care trusts; two mental health trusts and learning disability trusts; five acute trusts; a care trust; and an ambulance trust. To illustrate the large numbers of employees involved, the Leeds Teaching Hospital Trust alone has about 15,000 staff. Across the country, and not just in West Yorkshire, the health trusts are usually the largest employers in their area.
We spoke to the West Yorkshire Workforce Development Confederation's project manager Christine Scaife to get an insight into the implementation of the KSF in West Yorkshire.
"Training was carried out in Birmingham for six representatives from trusts in my area. Similar numbers also attended from other areas of the country. Our training equipped us to train colleagues on the details of the KSF," Scaife explains. "On our return, we carried out a series of training sessions for staff across West Yorkshire, who in turn shared their knowledge using Modernisation Agency training materials."
Consistent, comprehensive and explicit
The KSF applies to one of the largest groups of employees in the UK, and aims to ensure better links between education and development, and career and pay progression. It is intended to be the single source of consistent, comprehensive and explicit descriptions of the knowledge and skills required to perform NHS roles, and is forming the basis of performance reviews and individual development planning. In view of the broad range of roles that the framework covers, and to make it a useful tool in reviews and development, systems are being put in place to ensure the appropriate identification of job descriptions. These are known as KSF Outlines, and specify the knowledge and skills, and their levels, necessary for a job. The aim is that KSF Outlines will have been prepared for all employees by October 2005.
"There are Agenda
for Change project teams in every NHS organisation in the UK working on
implementing the Knowledge and Skills Framework," Scaife
says. "In our case, as we're part of West Yorkshire Strategic Health Authority,
we have a remit to make sure that our own staff become
familiar with the framework and we also assist and train people in NHS trusts
throughout
The KSF does not set out how employees should behave, but provides the skills and knowledge that are required to carry out roles effectively and provide a quality service. Hence, when individual performance is assessed, it is based on how well the skills and knowledge have been applied on a day-to-day basis. This means that the emphasis of the framework is not on the manner in which objectives are achieved, but focuses more on the outcomes.
Setting out the dimensions
The KSF is made up of 30 "dimensions" covering the broad range of functions in the NHS. Six of the dimensions are core to all roles:
1. Communication.
2. Personal and people development.
3. Health, safety and security.
4. Service improvement.
5. Quality.
6. Equality and diversity.
The other 24 dimensions apply to some jobs, but not others, and are grouped together in four clusters of similar elements:
Health and wellbeing
- Promotion of health and wellbeing, and prevention of adverse effects to health and wellbeing.
- Assessment and care planning to meet health and wellbeing needs.
- Protection of health and wellbeing.
- Enablement to address health and wellbeing needs.
- Provision of care to meet health and wellbeing needs.
- Assessment and treatment planning.
- Interventions and treatment.
- Biomedical investigation and intervention.
- Equipment and devices to meet health and wellbeing needs.
- Products to meet health and wellbeing needs.
Estates and facilities
- Systems, vehicles and equipment.
- Environments and buildings.
- Transport and logistics.
Information and knowledge
- Information processing.
- Information collection and analysis.
- Knowledge and information resources.
General
- Learning and development.
- Development and innovation.
- Procurement and commissioning.
- Financial management.
- Services and project management.
- People management.
- Capacity and capability.
- Public relations and marketing.
None of the dimensions is regarded as being on a higher level than any other and, in various combinations depending on the role, all are seen as necessary for the operation of the NHS. However, to provide differentiation, each dimension is split into four levels and each is given a descriptor. For example, the core dimension "Communication" has the following descriptors:
- Level 1 - Communicate with a limited range of people on day-to-day matters.
- Level 2 - Communicate with a range of people on a range of matters.
- Level 3 - Develop and maintain communication with people about difficult matters and/or in difficult situations.
- Level 4 - Develop and maintain communication with people on complex matters, issues and ideas and/or in complex situations.
Further details of three levels of the "Communication" core dimension can be found in the accompanying document extract.
To illustrate the way in which different roles have different combinations of dimensions, the role of a nurse would have the six core dimensions and a selection from the "Health and wellbeing" cluster. Depending on the nurse's role, not all the dimensions in the cluster may be included. To determine those that apply, the dimensions have "indicators". These are statements that provide a description of the type of work that the dimension is expected to cover.
Also, depending on their specific role, the nurse may be covered by dimensions that are drawn from others elsewhere in the framework, for example those that are grouped under the "Information and knowledge" cluster, such as "Information collection and analysis" and "Knowledge and information resources". Including the six core dimensions, most nurses' roles have about 12 dimensions in total. A similar pattern applies to non-nursing roles, and the selection of their non-core dimensions is determined by the nature of the job.
KSF briefings are taking place to ensure employees are familiar with the KSF dimensions, the levels and the indicators. Responsibility for preparing KSF Outlines - the new-style job descriptions - is being taken by line managers who work in partnership with the employee, or representative groups of employees where there are many staff working to the same job description, such as large groups of nurses. The aim of this consultation is to receive staff input and suggestions and ensure that it is "done with them, rather than to them".
Personal development reviews
To keep up the momentum of the Agenda for Change programme, and once the KSF Outlines have been prepared and agreed with employees, personal development reviews will be conducted. Reviewing the performance of individuals is nothing new for the NHS: appraisal has always formed an important part of the way in which it operates. As before, the new form of review will take place between an employee and their line manager, but performance assessment will now be made against the dimensions set out in the KSF for the role and their relevant levels. The first round of revised performance reviews is due to be completed with all staff by October 2006.
To ensure consistency, the WYSHA ensures that all managers responsible for carrying out performance reviews with staff are fully trained in the personal development review process. "Staff are reviewed against the KSF dimensions, and if there are areas that indicate a training need then that's included in the personal development plan," Scaife explains. "Part of our role at the WYWDC is to commission education and training from universities and a number of other providers, for example, nurse and dental nurse training. But we also have our own in-house training programmes, as do all of our trusts. The NHS is a learning organisation and the KSF is a commitment to annual development reviews and to the development of all staff."
Pay and the link to development reviews
The KSF has not been introduced to determine the pay band (there are eight altogether) on which a post is placed; this is the role of the job evaluation and matching system within the Agenda for Change. The intention is that the KSF will be used to inform an employee's development within the pay bands.
Pay progression usually takes the form of an annual increment within a pay band; however, at some points, known as "gateways", decisions are made about pay progression and individual development needs. Employees do not automatically qualify for transition through the pay bands; they have to apply for posts, and jobs are advertised and are open to competition. For each pay band, there are two "gateways": the Foundation Gateway, which is reached about 12 months after an individual is appointed to a new post and its pay band; and the Final Gateway, which is encountered towards the top end of a pay band.
Personal development reviews are undertaken annually using the KSF's dimensions and levels. The reviews are intended to ensure that the individual is meeting the demands of the post and that they are applying their knowledge and skills consistently. At the gateways, or if concerns have been raised about significant weaknesses at other points, the outcome of a review could, in the extreme, be that pay progression is deferred until such times as the necessary development has been successfully undertaken.
However, a policy of "no surprises" exists so that individuals who are not meeting the appropriate level of knowledge and skills for a post are well aware of this in advance of the gateway review. Responsibility for this rests with the reviewing line manager, and action plans are drawn up to remedy any outstanding development issues before progression is deferred.
Development
review process
"Compared with what's been in place previously, the KSF is far more objective. You know where the goalposts are and what you're trying to achieve," Scaife says. "People know what knowledge and skills are required for a job, so they can see if they've any gaps and can ask for appropriate training to meet their needs."
The development review process is seen as requiring a partnership between the employee and their reviewing line manager (or someone delegated to the role who is sufficiently competent and has the authority to arrange learning opportunities). The process follows a cycle (see the diagram):
- a review of how employees are currently applying their knowledge and skills in response to the demands of their role and the identification of any learning needs;
- the preparation of a personal development plan until the time of the next review;
- implementation of the learning and development plan, with support from the line manager who makes regular checks on progress; and
- evaluation of the learning input and a consideration of how it has been applied in day-to-day work.
Because each employee has different strengths, development plans are specific to the individual. Even though groups of employees may have similar roles, they are unlikely to have similar personal development plans. One of the essential commitments for the line manager, as part of the learning partnership, is to check regularly on the progress being made by each of their staff and the contribution that newly acquired skills and knowledge are making to their work.
"All NHS organisations are trying to ensure that all jobs are evaluated and everybody has a job Outline," Scaife explains. "We're really in the thick of it, but to help we've computer-based tools, one to assist with job evaluations and another, the 'e-ksf', to help with KSF outlines."
Through the use of a common framework, the KSF is seen as providing organisations with the means of conducting a consistent audit of the knowledge and skills of individuals and of their workforces as a whole. This can help in areas such as planning learning programmes, effective deployment of staff and in determining the capability of teams. It is hoped that this will improve services to users and the public through consistent and effective staff development, and will help in recruitment and selection processes by giving clarity to the requirements of a role.
Implementation
With so many employees, strategic health authorities, and trusts, the task of rolling out the KSF and the systems that are being put in place alongside it represents a major undertaking, not only for the WYSHA, but for every other strategic health authority in the UK. The priorities for implementing the framework and the review processes are identified as covering 12 areas:
1. Familiarise all staff with the KSF/development review and the impact they will have.
2. Prepare all job outlines.
3. Develop the knowledge and skills of staff so that they can participate effectively in development reviews.
4. Develop managers' knowledge and skills in handling reviews and in supporting employee development.
5. Determine what training managers need to ensure equality and diversity in the development-review process.
6. Manage the transition from any competencies currently in place to the KSF, and implement revised career and pay progression processes.
7. Link the KSF and the development-review process into current appraisal systems and business planning cycles.
8. Review all existing policies and procedures, for example induction and maternity leave, in the light of the KSF.
9. Devise systems for monitoring and reviewing progression decisions.
10. Devise systems and structures to support staff development equitably.
11. Introduce learning and development structures for individuals and teams that are "balanced" with available resources.
12. Monitor the implementation of the KSF and development reviews to ensure effectiveness and equity.
"Once we've finished the implementation and the KSF beds in, then we'll be able to judge how successful it is proving to be," Scaife says. "The best thing about the whole Agenda for Change, and not just the Knowledge and Skills Framework, is that it's being rolled out as a partnership between management and staff organisations which is helping to change that working relationship."
One early myth that built up about the KSF is being addressed. There was a suggestion, probably as a result of enthusiastic press reports, that the framework could allow an employee to begin work as a porter and eventually become the chief executive. This is not the case; all jobs still have to be applied for competitively if staff are to pass through the gateways.
However, the KSF is assisting by putting a focus on the development that is necessary for career progression. Eventually, everybody will have access to the KSF Outlines for any post and be able to discover what knowledge and skills are required for the role, thereby making them better informed about progression requirements. Once an individual has demonstrated that they have achieved this through the personal-development process, there is no reason, technically, why career progression should not take place through merit - including a porter becoming the chief executive.
