Examination of Witnesses (Questions 40-59)
DEPARTMENT OF
HEALTH
2 MARCH 2009
Q40 Mr Bacon: Do you still have the
active benefits realisation plan for Agenda for Change?
Mr Nicholson: The benefits realisation
plan is called ISIP.
Q41 Mr Bacon: And it is ongoing,
is it, or have you parked it?
Mr Nicholson: I think we have
finished that particular part of the process. We have now got
assimilation of most staff on Agenda for Change. We have dealt
with most of the issues in relation to Agenda for Change and we
will essentially be delivering the productivity improvements I
have described by using the tools that we have in the environment
we use now as the tariff.
Mr Griffin: Could I just add that
from a trust perspective it really makes much more sense to focus
on the total outputs, what the trust is trying to achieve, what
the service is trying to achieve, rather than trying to identify
specific elements and contributions to the overall thrust. Our
key objectives are to meet our waiting list targets, to meet the
four hours' wait target, to bring down MRSA and reduce our infections.
These are the big ticket issues to which Agenda for Change and
lots of the other Workforce changes have been an important contributor.
Q42 Mr Bacon: It might have been
better, if what you say is correct, not to have made such bold
assertions about Agenda for Change in the first place because
this report is littered with, wherever you look, in paragraph
2.16, for instance, "In order to assess whether Agenda for
Change has contributed to this £7.4 billion increase ..."—you
cannot even say whether it has, let alone the extent to which
it has; "The Department cannot demonstrate the contribution
that Agenda for Change has made to the achievement of the efficiency
programme", and so on and so forth; "The Department
did not put in place the necessary arrangements for trusts so
that it has got limited evidence to show what impact ...",
blah, blah, blah. Would it not have been better not to make a
series of sparkling assertions for what Agenda for Change was
going to deliver if you were not prepared to have in place at
the time the measures that were necessary to make sure you could
make them stack up?
Mr Nicholson: They were the best
assessments that could be made at the time in relation to the
impact of it. What I would say, having lived through this myself,
is that what I think the department did was listen very carefully
to what the service was saying, and what the service was saying
was, "Please do not have 20 different benefits realisation
programmes going on collecting data. Have one benefits realisation
programme which identifies both the total impact in terms of the
resources and also the total benefit in terms of the patient".
That is what the service said to us and I think they were absolutely
right.
Q43 Mr Mitchell: To a superficial
eye, which is mine, the Knowledge and Skills Framework looks more
important in the sense of improving quality of service, but it
seems to have taken a back seat to the review. Why is that?
Mr Nicholson: There is absolutely
no doubt that the focus of the attention was the implementation
of this massive programme. I am sure you understand. I do not
think there is anything quite like it on the planet in terms of
trying to change the terms and conditions of service of 1.1 million
people, all within a relatively short space of time.
Q44 Mr Mitchell: Why was it necessary
to get it through quickly? Why not do the two at the same time?
Mr Nicholson: I have implemented
job evaluation programmes and you probably know better than I
do that when you start evaluating someone's job and comparing
it with their colleagues' jobs that is an enormously difficult
and complicated and highly charged thing to do, so doing it for
that number of people was enormously difficult. One of the things
we learned from looking around at people who tried job evaluation,
not on the scale that we have done it but on a scale, was that
speed was of the essence. The longer you take to implement something
like the Agenda for Change where you are changing people's terms
and conditions the more complicated it gets, the more you get
involved in back pay, the more you get involved in all sorts of
interminable discussions. We felt it was right to do it quickly
and I think lessons have shown that.
Q45 Mr Mitchell: But knowledge and
skills were sacrificed?
Mr Nicholson: The implication
of that, of course, I think you are right, was that the focus
and attention on the Knowledge and Skills Framework was not given
equal weight when all of that was being implemented because the
drive was to get the numbers through, get the jobs evaluated and
get them through. I have to say we were slightly late on that.
In retrospect we might have done more, and you are absolutely
right: the Knowledge and Skills Framework is critical to driving
the changes through. I think what you will find in the report
and in reality is that the proportion of staff who had a Knowledge
and Skills Framework review stood at about 54% (as at Sept 2008).
Q46 Mr Mitchell: 54% had the framework
by September 2008.
Mr Nicholson: Okay.
Q47 Mr Mitchell: Why could you not
implement it, having got the main business through?
Mr Nicholson: It is proving more
difficult to do than perhaps the people who designed the thing
imagined.
Q48 Mr Mitchell: Is it more contentious?
Mr Nicholson: No, I do not think
it is more contentious. One of the things that you find about
the Knowledge and Skills Framework is that it is generally well
regarded by both managers and staff, certainly the staff side.
It is a very valuable mechanism with which to sit down with someone
and talk it through. I think there are issues about its complexity,
about how sometimes both managers and staff have found it more
complicated than perhaps it needs to be, and we are working on
that to simplify the arrangements, and sometimes how something
that might apply very well to a highly technical job does not
always apply so well to a more generalist job. We are learning
this as we go along. I do not know whether Mike wants to say anything
about the practicalities of it because I think it is important
for us to learn and King's have done pretty well, I think, as
far as that is concerned.
Mr Griffin: It is a big piece
of work to get it taken on board and every single manager, every
supervisor, has to get actively involved to work this around the
jobs in their particular areas of responsibility. Implementing
Agenda for Change by comparison involves a number of people but
not the same volumes of people that are required to get actively
involved with the Knowledge and Skills Framework. There is a big
investment in time resource by every manager to make it work.
What we have found is that one just has to keep behind and encourage
managers to put in the effort, to put in the training to develop
the programmes when they start. Once people have done that and
gone through the pain threshold they become very strong advocates
of it, and our experience is that once we build up a critical
mass of people who have done it we can get to a tipping point
where we can expect all other managers to achieve it too.
Ms Chapman: Can I just reinforce
that? There is one profession that has got to about an 82%[1]completion
rate and there is one region, I think it is the north east, that
has got to a 65% completion rate, so what we do know, working
with our Social Partnership Forum with employers, trade unions
and the department, is that by looking at those who are doing
it well we are getting those learnings out, so, exactly as Mike
describes, we are able to make sure that those who have to struggle
to do it as fast and as well as others get those learnings out
too, and that is getting good traction.
Q49 Mr Mitchell: Just seeing it from
the outside in Grimsby, it did seem a lot of trouble. There were
gradings and then a failure of some and an attempt to align them
all because different supervisors assess things very differently.
Do you have any figure for the actual costs of implementing the
programme as opposed the benefits in productivity or wages?
Mr Nicholson: The total costs
that are identified in the report here are difficult to get to
because in a sense what you have to do is say what would have
happened if we had not implemented it, so how would pay awards
have gone and all the rest of it. You can see from the report
in front of you that the National Audit Office have put a kind
of range of costs or savings around it.
Q50 Mr Mitchell: It is not savings
I am interested in. It is the costs of doing it and all the meetings
and all the assessments and all the consultations and all the
appeals.
Mr Griffin: In terms of the time
of lots of people involved in implementing it, it is difficult
to quantify what that opportunity cost was valued at, but the
payback for that investment was a terrific response in terms of
improved partnership working between managers and staff, and a
big feature of the implementation programme, a requirement which
paid dividends, was that staff should be actively involved in
the implementation process. That lesson of implementation has
been carried forward into the substance of the service, a re-designed
service and service development. That was the payback. Again,
it is difficult to quantify what the value of that is, but it
was more than worth the investment for the 12 or 18 months of
implementation.
Q51 Mr Mitchell: I can see the benefits
of it.
Ms Chapman: Can I just add one
other thing? I think there is some evidence to suggest that the
"do nothing" approach would have cost more than doing
something, particularly when you look at the rate of equal pay
claims.
Q52 Mr Mitchell: I do not argue with
that because it is a simplification of the system.
Ms Chapman: Exactly right.
Q53 Mr Mitchell: But in the sense
that you have got a more readily comprehensible, simpler system,
how far ahead is it going to need in order to change it because
some of the foundation trusts have not implemented it, and Southend,
for example, is not going to use it, so how are staff going to
be able to transfer in that situation?
Mr Nicholson: There is only one,
and I think the remarkable thing was that everyone worked across
the system to do it because there was an understanding across
the system of the value of having a comprehensive national system,
and there has been very little movement in practice from that
basic tenet. Even though we have got foundation trusts, other
parts of the United Kingdom have not got foundation trusts but
our coverage of Agenda for Change is greater than for any other
country in the UK.
Q54 Mr Mitchell: Paragraphs 3.25
and 3.26 say that some of them are going to have to bid higher
for staff or apply regional variations.
Mr Nicholson: There was always
what I think is called Annex K of the agreement, which sets out
within the agreement what are the flexibilities that organisations
have, and I think it is important that any system, particularly
a national system, has flexibility, so the ability to flex for
regional pay, the ability to look at the total package with holidays
and terms, seems to me perfectly reasonable flexibility. The point
of it is that first of all it has to be within its own framework;
it cannot step outside of it. Secondly, it has to be agreed with
local staff. It seems to me that those are positive things.
Q55 Mr Mitchell: Mr Bacon was fairly
suspicious of the productivity benefits you estimated initially.
Is not the honest truth that this was just put in to pretty it
up and get it accepted? I cannot see how it would have led to
productivity gains. How can you estimate them as precisely as
you did?
Mr Nicholson: I think we have
been round this one already. Nevertheless, it was the best estimate—
Q56 Mr Mitchell: But not the accusation
that it was just put in to make it look good.
Mr Nicholson:— that people
could make at the time. I am sure it is part of the business case.
Ms Chapman: Can I add one other
thing, which is that, remembering where we were before, which
was hundreds of pay scales and thousands of allowances, when you
look at the amounts of changes which are going to be required
to individual roles, given the visions that exist in each of the
regions, there will be changes. Those are big barriers to changing
roles when you have got a pay system that is that complex, and
so I think we have already seen that what it is doing is enabling
that change in a much more straightforward way. It is not the
barrier that it was before.
Q57 Mr Mitchell: Productivity in
the Health Service levelled out because you were employing fewer
staff and then it began to fall again so you employed more staff,
and that is the real driver of productivity, is it not? What does
drive productivity?
Ms Chapman: There is also the
ability that it gave us to put in different roles. For instance,
the assistant practitioner roles to support the registered nurse
and the advance practitioner roles did not exist before. This
was a system that enabled trusts to put those new roles in and
put them in within a framework that was coherent. Those are the
things which enabled far more thought around affordability as
well as practicality for the staff themselves.
Q58 Geraldine Smith: I do not want
you to spend too much on benefits realisation programmes and all
sorts of assessments to see how successful you have been with
Agenda for Change because if you do we will be telling you that
you wasting taxpayers' money because there are too many managers
in hospitals collecting figures all the time and not doing front-line
work. To me it is pretty straightforward. If you are looking at
simplifying the system that existed, and it was an absolute nightmare
when you looked at all the pay scales and all the other things,
as you have already said, and if you achieve that simplification
and if we do not have too many trades unionists knocking on our
doors going absolutely mad about what is going on and too many
members of the public complaining that things are going wrong,
then surely that is a measure of your success. I have heard very
little about Agenda for Change. I did go to one meeting where
unions were disagreeing about some of the job descriptions but
it was detail really that they had to sort out; it was not something
for politicians, so would you say so far it has gone fairly smoothly
and that you are in danger sometimes of over-analysing and over-assessing
things?
Mr Nicholson: As some of you will
know who may have been around when we did nurse grading in the
NHS some years ago, which was the exact opposite of that, we had
huge problems with trade unions, we had huge difficulties with
staff, we had literally thousands and thousands of appeals against
it, and it went on for years and years and really did distort
the relationship, I think, between the NHS and the nursing profession
over a period. This was, I think, a remarkable thing to have done,
to change the terms and conditions of service of 1.1 million people
and at the same time provide benefits, and we have shown how we
provided benefits when you add them to everything else. When we
got the level of satisfaction from the staff of the process that
we have, and we have had very few reviews overall when you think
of the number of people that have been through it, I think it
was a remarkable task that was done. When you look at an individual's
job and start comparing it with their colleagues' in the service,
the potential for getting it wrong is very significant. I think
we will, like in many of the pay modernisations, see really big
benefits coming over the next few years as we focus our attention
on both improving services but also in a time of financial constraint.
Mr Griffin: If I could add to
that, as well as the simplification, which was very real, I think
the real value has been that it has really started the process
of breaking down the silo mentality which existed previously.
It has enabled us to provide a common core way of evaluating jobs
and to start mixing and matching skills from across traditional
skills boundaries and, as Clare said, provide a series of core
composites which everybody's job is measured against—quality,
communications, et cetera, rather than each specialty being a
set of special requirements of the profession. It really is making
a major contribution to start bringing about an integrated workforce
to provide an integrated service. That is really the benefit and
it would not have been achievable had Agenda for Change not been
put in place.
Q59 Geraldine Smith: Do you feel
you reward people enough when they get involved in an issue though?
It is just a personal experience I have of visiting a local hospital
which is doing a lot of knee replacement surgery. They do it at
weekends, they do it right into the evenings and it has put a
lot of additional work onto the nursing staff because the ward
is full of people coming in and going and coming back from theatre.
They need a lot of care and attention, and those nurses were really
working flat out. Talking to one of them, she was complaining
that their morale was low. I was asking, "Why is that? Why
do you feel that way?". She said, "Everyone else is
getting something from these initiatives, the doctors who are
carrying out the surgery at weekends, but we are not getting anything
extra. We are just expected to do it". Would that be the
case or do you give incentives to people to take this on? At weekends
hospitals used to be very quiet, but my experience of this hospital
is that it is extremely busy, which is good because waiting lists
are going down and people are getting those operations.
Mr Nicholson: I do not know the
circumstances you have described. Every hospital negotiates things
slightly differently, but the whole purpose of the pay modernisation
was to make more sense of that kind of thing where you had literally
different grades of staff with completely different mechanisms
by which they got paid for extra work, from literally doing the
work at plain time right the way through to double time and almost
any gradation in the middle. Agenda for Change made that much
more simple, so there are four or five ways in which you can get
paid, and it is completely transparent so everyone knows what
everyone is getting. Similarly, the consultant contract was designed
in such a way as to make sure that with that extra time we needed
for consultants we were not in the place where we were paying
them spot rates that were negotiated locally, but that extra time
they used was part of the consultant contract and would be paid
accordingly. The intention was to get that in the right place.
Where I think it is sometimes slightly different, and Mike might
want to say something about this, is when you have managers involved.
When I say "managers", there are some quite senior nurse
managers who sometimes do not receive extra payments for working
out of hours in a way that others have done.
Mr Griffin: Yes, that can happen.
Somebody that is working on a shift system picks up a shift premium.
If they then come out of the shift system and take on a managerial
day job they lose the shift premium and they say, "I am not
materially better off". That is an issue and that applies
in every walk of life. The terms around Agenda for Change are
very much based around the spine of nurses' pay, so people harmonise
and coalesce around the nurses' pay and conditions, which is perhaps
why nurses might feel that they have got less than others, but
radiographers complained bitterly that they had lost their 35-hour
week and had to do a 37½-hour week as part of the equalisation.
One of the great benefits that nurses achieved was the increase
in clinical nurse roles and particularly the inception of the
nurse consultant role which has brought about a dramatic improvement
in services and has enhanced the profession of nursing enormously.
1 <ep<nh Note by witness: This figure
and the subsequent figure of 65% refer to staff having any form
of appraisal. The corresponding figures for a KSF review are 65%
and 47%-Staff Survey 2007 Back
| 
