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1. Background and Nature of the Research

1.1 Introduction

This report was commissioned by the Society and College of Radiographers (SCoR) to identify the effects of Agenda for Change (AfC) on career progression on the radiographic workforce in England and Wales. The situation in these two countries appeared relatively similar in that AfC was implemented at a similar time and under similar conditions. Scotland and Northern Ireland were excluded from the study since the implementation of AfC in those countries was quite different to England and Wales, and therefore results may not be comparable. Due to the larger number of employees per employer in Scotland, AfC was introduced there over a longer timescale. Northern Ireland is at an earlier stage of AfC implementation, and it is likely that the experiences and attitudes of participants there would differ from those elsewhere in the United Kingdom. Therefore, this survey concentrated on the views of radiographers, assistant practitioners and healthcare assistants (HCAs) across the spectrum of clinical imaging and radiotherapy in England and Wales. It is recognised that in the future it may be appropriate to carry out similar research among staff in Scotland and Northern Ireland.

The work was completed by a team of researchers from the School of Health and Emergency at the University of Hertfordshire, the Institute for Employment Studies and the Oxford Radcliffe Hospitals NHS Trust.

1.2 Background

Until 2004 radiographers, along with some other groups of National Health Service (NHS) staff had their pay and conditions determined through negotiations between management and trade union representatives through a Whitley Council framework. The framework was cumbersome (White and Hutchinson, 1996) and did not reward staff who wished to develop a clinical career rather than follow a management pathway. Although the road to modernising pay and conditions in NHS trusts began in the 1990s when trusts were allowed to establish their own pay arrangements, fewer than twenty five NHS trusts did so (Corby, 2003). AfC set out a modernised pay system designed to ensure fair pay and a clearer system for career progression, with a common pay spine with bandings from 1 to 9 (DH undated). Implementation of AfC would initially include the undertaking of job evaluations, and later the introduction of the NHS Knowledge and Skills Framework (KSF) (Department of Health (DH), 2004a) in order to determine the banding to which individuals should be allocated. With the three core elements of AfC identified as job evaluation, harmonised terms and conditions, and the KSF, the over-riding principle was that staff would be paid on the basis of the work they undertook and the skills and knowledge they applied in their post (DH, 2004a). 

Whitley Council terms and conditions were therefore to be replaced by a pay banding system linked to the newly-developed KSF.  The Department of Health (2004b), through AfC, aimed to standardise roles and working conditions, improve recruitment, retention and morale, and help achieve a high quality workforce capable of delivering higher standards of patient care. Since AfC was implemented, the Department of Health has claimed that it has ‘dramatically simplified the process of designing new ways of working and the establishment of extended roles’ (DH undated).

Prior to AfC the College of Radiographers had introduced the Career Progression Framework (CPF) in 2002 in an attempt to provide a clear progression pathway for radiographers and ensure continuous improvement in patient services (CoR 2002). While there is evidence that the CPF has been adopted by a number of centres this is far from being universal (Price et al, 2009). In principle, the CPF should be compatible with both AfC and the KSF as they have similar intentions and, together, AfC and the KSF should provide the means by which the CPF is expedited. However, AfC did not have an easy introduction in radiography in spite of a promise for many of pay rises of up to 15% (Hutton 2005). There were concerns over increased working hours (AfC required radiographers to accede to a gradual increase in working hours from 35 to 37.5 hours a week), inconsistencies with job evaluations, confusion over on-call arrangements and, of particular interest given the focus of the this research, scepticism over whether AfC would facilitate professional development or improve retention (Anon, 2004). 

Five years on from the introduction of AfC among NHS early implementers, and four years on for the majority, it is now timely to assess the impact that AfC has had on career progression in the radiographic workforce and to evaluate whether it has lived up to its original intended benefits or whether initial suspicions were justified.

1.3 Aims of the Research

The aims of the project were to investigate the effects of Agenda for Change on the radiographic workforce within the following three career impact categories:

  1. Career development expectations
  2. Career progression opportunities
  3. Barriers to and incentives for career progression

The radiographic workforce consists of radiographers, assistant practitioners and healthcare assistants in diagnostic imaging and radiotherapy.

1.4 Report Structure

A multi-method approach was adopted to meet the requirements of the project: a literature review was undertaken followed by interviews with key stakeholders, a survey of the radiographic workforce, and finally, follow-up interviews with volunteers who had responded to the survey.

The literature review explored issues and consequences of AfC as a whole and its impact on career progression. It is reported in Chapter 2. The findings from telephone interviews conducted with individuals identified as key stakeholders are presented in Chapter 3, with  key stakeholders being identified because of their role and experiences of AfC, either immediately prior to its introduction and/or during its implementation and/or its current operation. 

Chapter 4 reports the outcomes from the survey of radiographers, assistant practitioners and healthcare assistants. This was a cross-sectional survey by means of an online questionnaire. The survey was open to the radiographic workforce in the NHS in England and Wales.

Chapter 5 discusses issues arising from the report and Chapter 6 presents conclusions and recommendations to the SCoR on the effects of AfC on career progression.

The work was undertaken from November 2008 to May 2009 as agreed with the SCoR. The research provides for the first time a comprehensive report on the impact of AfC and the NHSKSF on career progression informed by the views and experiences of the radiographic workforce in England and Wales. 

1.5 Method of investigation

1.5.1 Literature review

Although our recent research scoping of radiographic practice (Price et al 2009) has made us aware of many of the main issues currently viewed as affecting career progression within radiography, the programme of work started with a review of the recent literature relating to career progression under AfC within health professions to ensure that all current research was available to the research team to inform the design of the questionnaire instrument.

1.5.2 Interviews with key stakeholders

Ethical approval for the interviews and online survey was obtained from the School of Health and Emergency Professions Ethics Committee, University of Hertfordshire. A series of telephone interviews were conducted with a number of key stakeholders who were identified as having expert or specialist knowledge of AfC and its influence on the radiographic profession due to the role they held at the time of its implementation or due to their current role. These included past presidents, industrial relations officers from the SoR, society representatives from early implementer sites, and consultant radiographers. Their views helped inform the questionnaire design and allowed some comparison of staff opinion towards AfC in relation to career progression opportunities at the time of implementation with current opinion. 

1.5.3 Survey

The cross-sectional survey was devised using the Bristol Online Survey (BOS) service which allows development, deployment and analysis of surveys via the Web. A full copy of the survey can be found in Appendix 1.

The survey was open to the whole of the NHS-based radiographic workforce in England and Wales in order to maximise the likelihood of obtaining a representative sample. Staff working in the independent sector were excluded from the survey since they are not bound by AfC terms and conditions. NHS staff practising in Scotland and Northern Ireland were also excluded, due to differences in AfC implentation. Articles publicising the study and how to access it were featured in issues of ‘Synergy News’, ‘RAD’ magazine, and ‘Toptalk’, an e-mail newsletter for radiography leaders. In addition, fliers were distributed at two national conferences held in December and January.

The online survey was available at http://sdu-surveys.herts.ac.uk/effect-of-afc and was “live” between 4pm on 20th January 2009 and midnight on 28th February 2009. Online responses totalled 2339.  Paper copies were supplied with a pre-paid return envelope on request.  Completed paper questionnaires returned no later than Monday 2nd March 2009 were included in the survey. There were 75 requests for paper copies and 34 were returned. For ease and consistency of analysis, these 34 responses were entered by hand into the online survey dataset by a member of the research team. Total responses for analysis were 2373.

1.5.3.1 Materials and questionnaire design

The survey comprised five sections and 44 questions in total requiring a mixture of ‘tick-box’ and free text responses. It was straightforward to complete and allowed individuals to give free text responses where they wished. All questions were optional in order to maximise the number of submitted responses. Participants had the option of completing the survey in one visit or they could save their responses, log-out, and return to complete it at a later date. Section 1 requested demographic information. Section 2 explored participants’ current role and AfC banding, and previous grade if practising prior to the implementation of AfC. Information on whether participants perceived their current grade as fair and details on any appeals they may have undergone was also requested. Section 3 investigated career progression and development and asked participants about recent appraisals and the KSF. Section 4 focused on the experience of new graduate practitioners in terms of career expectations and likely progression in relation to Annex T. Section 5 asked participants about how their attitude towards AfC may have changed over time by providing an opportunity to cast a theoretical vote. It also sought any final comments which they may not have had the chance to express earlier in the survey and invited people to supply an email address if they were willing for a member of the research team to contact them again for greater detail.

1.5.3.2 Method of analysis

Descriptive statistics were used to identify trends and patterns amongst staff in relation to a range of key variables including their AfC pay banding, role, and location. In addition, inferential statistics were performed to explore any significant differences between attitudes and experiences of staff in terms of length of time qualified and between those who had entered the profession pre- and post-AfC. 

All free text responses to key questions were read, analysed and themed, thus providing a means of quantifying the qualitative data. To strengthen internal consistency, the themes were double checked by different members of the research team.

1.5.4 Follow-up interviews

All free text comments submitted in response to the final question (’Additional comments’) were read and interpreted by members of the research team. The majority of additional comments echoed those which had been made at earlier stages in the questionnaire, and required no further investigation. However, based on the nature of some specific comments, seven participants who provided email addresses were invited to take part in follow-up interviews conducted by telephone. Four accepted. Consent was obtained on acknowledgement of the invitation to contribute further and on provision of a contact telephone number to a member of the research team. Clarity was required on some themes highlighted in the survey including the perceived advantages of AfC over Whitley Council terms and conditions, and inequity both amongst radiographers and when compared to other health professions in terms of career progression under AfC.

Details of the findings from both the telephone interviews and survey are presented in chapters three and four.

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