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2. Literature Review

2.1. Introduction

AfC introduced a modified system of career progression and conditions of work for all directly-employed NHS staff, except those covered by the Doctors’ and Dentists’ Pay Review Body and some senior managers. This represented the first major overhaul since the adoption of Whitley Council conditions in 1948. The AfC system was applied to twelve “early implementer” sites(1) for evaluation in the Spring of 2003 and then rolled out across the whole of the NHS in England and Wales from October 2004 to December 2006. Nurses had already been subject to a review of clinical grades, from April 1988, which resulted in a system of grades A to I and had generated a large number of appeals. These grades would be incorporated within the new NHS-wide AfC system.

NHS Employers (2006) remarked that AfC was designed to support a cultural shift in health provision, based on a highly flexible workforce, with reduced demarcation between teams and with staff in possession of transferable skills developed along the patient or care pathway. They saw AfC as providing a set of high-level workforce tools, “beyond being simply a new pay system”. The main role for the graduate healthcare professional would be to “facilitate, educate, enable and lead others to develop healthcare, whilst carrying out those tasks that they alone cannot do, such as more complex assessments and interventions”. AfC, as announced by the Department of Health (2002), also embraced several key aspects of practical working conditions: job evaluation and basic pay; career progression linked to the KSF; enhanced pay in high cost localities; recruitment and retention premia; revised working hours and overtime payments. However, chief amongst its provisions was the use of “job weight” to determine career band on a scale of 1 to 9, with job weight being calculated on the basis of the knowledge and skills required to do a job; the responsibilities involved; any physical, mental or emotional efforts expended and any extra demands imposed by the working environment. The job weighting was intended to allocate jobs to one of the nine common pay bands, with work of equal value receiving fair and equal pay. The Equal Pay Act, in 1970, had previously outlawed any pay discrepancies between male and female employees doing the same work and from 1984 was amended to cover work of “equal value”.

(1) James Paget Healthcare NHS Trust; Guy’s and St Thomas’ Hospital NHS Trust; City Hospitals Sunderland NHS Trust; Papworth Hospital NHS Trust; Aintree Hospitals NHS Trust; Avon and Wiltshire Mental Health Partnership NHS Trust; South West London and St George’s Mental Health NHS Trust; West Kent NHS and Social Care Trust; Herefordshire NHS Primary Care Trust; Central Cheshire Primary Care Trust; North East Ambulance Service NHS Trust; East Anglian Ambulance NHS Trust.

In conjunction with the calculation of job weightings under AfC there was a “pay uplift” worth 10% over three years, intended to cushion the transition to the new system. The transition period also brought about the creation of “job profiles” for standard NHS posts with common features, on a national basis, designed to ease the process of assigning staff to one of the new pay bands. The profiles were not intended to be descriptions or person specifications for individual jobs. They were loosely defined as “the outcomes of evaluations of jobs” and as “rationales for how national benchmark jobs evaluate as they do” (DH, 2004c). There was also a clear expectation that the new KSF would be integral in steering annual development reviews and personal development plans. It would permit staff to receive clear and consistent development objectives, plus development opportunities linked to identification of the extra knowledge and skills needed for career progression. Two “gateways” within each AfC career banding were introduced, in order to allow assessment of knowledge and skills prior to further progression.

Another aspect of the commonality which AfC sought to achieve was the phased implementation of a 37.5 hour working week for all staff, which brought about a decrease in hours for some, such as pharmacists, and an increase for others, such as radiographers. There was also a standardised annual leave entitlement. The Department of Health (2002) remarked that the new system “has been designed to ensure that as many staff as possible move to pay bands that provide a higher maximum pay than now, whilst ensuring a phased approach that is consistent with affordability.” The NHS Staff Council was established in 2003 to oversee the new national system and to replace the previous General Whitley Council and separate Whitley Councils.

The final agreement document (DH, 2004b), set out the wider-ranging aims of AfC, which included: quicker patient treatment and improved quality of care through identification of new ways of working; enhanced efficiency; improved staff retention, recruitment and morale through facilitation of career development; attainment of  the right workforce for the needs of the NHS; equal opportunity and diversity, especially in terms of career and training opportunities and working patterns that are responsive to family commitments. This would be facilitated by local partnerships. A twelve month period of “preceptorship” was confirmed for newly qualified staff directly entering band five, enabling accelerated progression through the first two pay points, subject to satisfactory performance. This was later developed into ‘Annex T’ of the AfC mechanisms.

The expectation was that allowances would be replaced by higher basic pay for the majority of staff, with extra discretionary awards being available for staff undertaking statutory regulatory duties outside those required by their job descriptions. There would be extra local allowances to enable employers to recruit in areas of special need and, where market forces dictated, enhanced pay (Annex H(2)) with a need for recruitment and retention premia being identified for dental nurses, biomedical scientists, pharmacists and new entry midwives, amongst others, but omitting nurses, radiographers and physiotherapists. In addition, under Annex K (DH, 2007) NHS Foundation Trusts and three star NHS organisations would be able to act independently with regard to specified “local freedoms” such as accelerated progression, alternative benefit packages, expenses, bonuses, recruitment and retention premia.

(2) Details of recruitment & retention premia are provided under Annex H  in the DH AfC Final Agreement document (2004) and under Annex J in the DH AfC service handbook (2007).

In addition, the agreement document announced that personal development plans would be implemented for all NHS staff, based on annual reviews set against the NHS KSF, by no later than October 2006. This would result in an annual documentary record of performance measured in terms of the KSF post outline. Where training and development needs were identified, the expectation was that employers would provide financial support and developmental time to staff, and would be unable to defer pay progression if they failed to do so.

In April 2003, a large turnout of 97,884 Royal College of Nursing members voted on the proposals, with 88% of the poll voting to accept the AfC proposals (Didovich, 2003). This result was paralleled in the same year by over 90% of midwives, 81% of UNISON members, and 86% of physiotherapists casting their votes in favour of AfC (CSP, 2009). By contrast a first ballot of radiographers returned a “yes” vote of only 49% (SoR, 2003), partly due to misgivings about increased working hours and reduction of on-call earnings. This result was emphasised more dramatically by a second ballot, in which only 17% of radiographers voted for AfC (SoR, 2004). Radiography was unique amongst the major health professions in its membership’s rejection of AfC. However the Society of Radiographers, following a lengthy period of negotiation, believed  that AfC would be applied to radiographers regardless of the membership vote. In view of this, the SoR determined to remain within the collective bargaining process, in order to ensure representation for radiographers (Paterson, 2005).

Since the inception of AfC, a number of studies have examined its impact on the NHS workforce. Their findings are analysed in the following sections of this chapter by topic aspect rather than date of publication. It should be noted that comparatively few of these published enquiries have considered the specific position of radiography staff.

2.2 Expectations of Agenda for Change

The Shadow Executive of the NHS Staff Council (2004), in a review of experience at early implementer sites for AfC, commented that beneficial developments would include: new roles, such as assistant practitioners in radiography; changing roles, for example in medical records; extended roles, including emergency care practitioners; improved team working through harmonisation of terms and conditions; new ways of working; improved recruitment and retention.

Agenda for Change however, received a mixed reception from members of the health professions. Walmsley (2003), reporting from a nursing perspective, noted that AfC would include the possibility for rewarding staff for the work they actually do, and should benefit nurse specialists, but would be threatened by funding shortages. He expressed a desire to see AfC as the “light at the end of the tunnel”, not “the lamp on the front of an oncoming train”. Many commentators were pre-occupied with pay and working conditions. Pollard (2003) remarked that although his initial impression had been that it was a “recipe for confusion” on repeated reading the package for nurses was coherent, fair and transparent. He felt that many nurses on low pay should benefit from the changes and welcomed the standardisation of other professions’ working hours to the 37.5 per week already undertaken by nurses.

Parish (2004), writing just prior to the national roll-out of AfC, commented that many national job profiles had not yet been created and that this was stalling the implementation process. He also found that the job evaluation process, requiring a 39 page questionnaire, had proved more time-consuming than expected, even at early implementer sites.  Nevertheless, he noted that UNISON and other trade unions were broadly in favour of AfC. The Chartered Society of Physiotherapy took the view that “although not perfect, Agenda for Change represented a considerable improvement on the old 'Whitley' system and was a good deal for physiotherapy, physiotherapists and physiotherapy assistants” (CSP, 2009).

However in 2003, Henderson reported that many radiographers were unhappy about the increase in working hours, but felt the AfC proposals represented the best that could be achieved by negotiation. He commented that radiographers who wanted to progress would have the opportunity to further themselves under AfC, while those who saw radiography as a job rather than a career would have fewer opportunities to progress. Harker (2005) expressed disappointment that most senior II radiographers at her local NHS trusts had been assimilated into band 5, despite having several years of post-qualification experience. The SoR (2005) stated that “Agenda for Change must facilitate accelerated career progression to enable radiographers to deliver the Government’s health agenda, and to secure the support of the profession”. The SoR also voiced the view that Annex T must apply to all newly qualified radiographers, permitting accelerated development in the first two years post-qualification and movement to band 6 within two years. This would require a period of preceptorship with appropriate support and funding, elevating skills and knowledge to that expected of a band 6 practitioner.

The general expectations and aspirations of allied health professionals, particularly with regard to recruitment and retention, were explored by Arnold et al (2006) in a large study for the University of Loughborough. They found that pay was not the salient motivational factor for most allied health professionals, although it was a significant one amongst reasons for leaving. This is pertinent, as AfC was largely conceived as a structure for pay re-organisation. Arnold et al (2006) also noted that the attitudes and perceptions of radiographers towards the NHS were more negative than those of other allied health professionals. However they also found that despite these negative attitudes, radiographers were more likely than other groups to remain in the NHS. The study further reported that amongst “stayers”, radiographers were less positive than any other AHP groups in terms of their perceptions of professional development within the NHS.

2.3 Transitions to Agenda for Change

Much of the published survey evidence on the transition to AfC relates to the nursing profession.  Ball and Pike (2006) in a postal study of 2,462 nurses, found that 55% felt AfC to be less fair than the previous system. Nearly two thirds (63%) felt that the transition to AfC was too slow and only 24% were satisfied with the way that AfC had been implemented in their organisation. However, 43% said that their employer had kept them well-informed about the transition to AfC. Nearly equal numbers of nurses, 40% and 41%, were satisfied or dissatisfied respectively with their AfC banding.

Ball and Pike (2006) also explored the views of NHS nurses on career banding. More than three quarters (77%) indicated that their job had been evaluated under AfC. Of these, just 3% provided positive comments while 19% felt that their band was too low, downgraded or failed to reflect their responsibilities, or was otherwise incorrect. Dissatisfied nursing respondents were most likely to have been placed into pay band 5 and commented that previous D or E grade staff had often been grouped together into this band, regardless of duties.

A further problem identified was the fact that the job evaluation process in many cases had failed to look at individuals and had focused instead on groups of nurses performing similar roles (Ball & Pike 2006).  Previous E grade nursing staff now on band 5 represented the largest dissatisfied group. The prior grades of band 5 staff were D (51%), E (44%), F (5%) and G (0.5%). The prior grades of band 6 staff were D (0.5%), E (9%), F (56%), G (28%) and H (7%).  Respondents who had been involved in implementing AfC in their organisations were more likely to have moved to relatively higher AfC bands than their colleagues who were not involved. Just over half (54%) of the nurses in the survey felt that their AfC banding was fair, while 40% did not. This compared with percentages of 45-47% who felt that their banding was not fair in previous RCN surveys prior to the advent of AfC. Only 31% of managers felt that their AfC banding was fair, while 75% of sisters/charge nurses were satisfied.

As part of an analysis conducted on behalf of the King’s Fund of professional groups included in NHS Staff Survey data for 2003-2006, Buchan and Evans (2007) noted a steady decline in staff perceptions that their work was valued by the employer, and in perceived standards of patient care, during the transition period to AfC. However, staff job satisfaction scores rose slightly over this period, although expressed intention to leave was unchanged. Buchan and Evans (2007) noted that the Department of Health had estimated that the transition changes would result in an immediate pay increase for over 90% of staff under AfC and commented that the majority of staff would receive substantial increases between 2004 and 2007.

The National Audit Office (2009), in a further examination of data from the 2006 NHS Staff Survey, noted that nurses and midwives were more likely to feel positive about AfC than other groups of staff in acute trusts, with 46% of nurses and 41% of staff as a whole regarding their re-banding as fair. Since nursing staff comprised a large proportion of the hospital workforce, the percentage of non-nursing staff who felt positive towards AfC in this survey was likely to be markedly less than 41%. The National Audit Office (2009) also reported that average earnings for nurses rose by 4.2% per year since 2004, while those for other staff groups rose by 5.8% per year. These increases placed financial pressures on the NHS.

The effect of the new AfC system on career progression and banding was followed with keen interest by NHS staff, as many hoped to benefit from the re-banding process, although some managers were apprehensive about the financial implications (MORI, 2006). Jenkins (2007) has commented that NHS staff who submitted job descriptions later in the evaluation process may have “benefited from the experience gained by others”. He reported that in Wales, a funding squeeze resulted in employers “pressing within job evaluation panels for lower and more affordable outcomes than would otherwise be merited”. Jenkins also commented that the “clustering” of job descriptions for staff undertaking similar roles, although not allowed for within AfC, may have offered an efficient solution for managers.

2.4 Opportunities for progression under Agenda for Change

The views of nursing staff towards career progression were also explored by Ball and Pike (2006) in an analysis of results from the 2005 and 2006 NHS Staff Surveys. This was the time period during which AfC was rolled out nationally. These findings are summarised in Table 1:

Table 1: Percentages of nurses agreeing with positively framed items regarding career progression during the period 2005-2006 (Ball and Pike, 2006)

   NHS 2005  NHS 2006
Opportunities for nurses to advance their careers have improved  58%  35%
I have a good chance to get ahead in nursing  37% 18%
Career prospects in nursing are NOT becoming less attractive  33% 16%
It will NOT be difficult for me to progress from my current grade  29%  15%
I DO know where my career in nursing is going  44%  33%
I can determine the way my career develops  57% 47%
I am NOT in a dead end job  73% 64%
I am interested in career progression 66%  60%
I know what I want to do in the future my career  55%  52%
There is open dialogue about my career with my manager  45%  42%

The table demonstrates that nurses became more negative in their views of likely personal career progression during the implementation period for AfC, with changes in positive framed attitudes ranging from minus 23% for career opportunities to minus 3% for open dialogue with managers. Ball and Pike (2006) also found that nurses working in trusts with a financial deficit were much less likely to respond positively to career progression items. For example, 69% of nurses in trusts where there was a deficit agreed with the statement that career prospects in nursing are becoming less attractive compared to only 53% in trusts that did not have a deficit.

Buchan and Evans (2007) felt that the main “losers” under AfC had been bands 4 and 5 administrative and clerical staff, while the big “winners” had been senior clinical nursing and senior allied health professional staff. Ancillary grades appeared to have done relatively well, by moving across to a new system with a lengthened pay scale and improved career progression. Cox, Grimshaw, Carroll and McBride (2008) found that new career opportunities existed for band 2 healthcare assistants to progress to bands 3 and 4 via NVQ level 2 and /or 3 awards and foundation degrees.

Regular staff appraisal is a key part of the AfC and should provide opportunities for staff progression. The National NHS Staff Survey for 2007 (The Healthcare Commission, 2008) found that 61% of staff had received an appraisal or performance review in the previous 12 months. This was not significantly different from the proportions of staff who had done so in 2006 (58%) and 2005 (60%), suggesting that the AfC had little or no impact on rates of staff appraisal in the NHS. In the 2007 survey, 41% of respondents said that they had received a KSF development review, while the remaining 20% had received some other type of appraisal. About half (53%) of those who had received an appraisal felt that it would help them improve how they did their job, while 76% said that it had provided clear work objectives. The National Audit Office (2009) found that the percentage of staff who had received a KSF development review had risen to 53% by September 2008, following a letter to all health organisations from the Parliamentary Under Secretary for Health Services on this topic. MORI (2006) in a qualitative survey of union members working within the NHS, including nurses and allied health professionals, found that there was uncertainty about KSF and how it would work in practice. There was a view that KSF had not been well-communicated and that it might create staff expectations that were unrealistic in the face of funding shortages. The National Audit Office (2009) has since commented that some managers and staff view the KSF as complex and burdensome.

Additional training forms an essential part of banding progression under AfC, linked to KSF-led development plans. The National NHS Staff Survey for 2007 (The Healthcare Commission, 2008), in a survey of 156,000 employees, found that 94% had taken part in at least one employer-led training, learning or development activity during the past 12 months. While this level was virtually unchanged from 2005 and 2006 (both 95%), a decrease in attendance on taught courses and an increase in on-line training was also observed. Furthermore, only 50% of staff stated that they had received the training that was identified in their personal development plan in 2007, compared with 53% in 2006 and 56% in 2005, suggesting that if anything, rates of training are falling under AfC. The percentage of staff saying that their line manager had supported them in accessing this training also fell over the period 2005-2007 from 68% to 59%.

2.5 Barriers to progression under Agenda for Change

Use of staff appraisals based upon the KSF forms a key part of AfC implementation and should facilitate career progression. However the available evidence indicates that this process has been tentative. Buchan and Evans (2007), in their analysis of NHS staff survey data for the King’s Fund, found that 67% of staff had a full KSF job outline, 33% had a KSF personal development plan and 27% had received a development review using KSF. Ball and Pike (2006), in their survey of nurses, found that only 29% of respondents had a completed KSF outline for their post, while 23% said that their outline was in progress. Nearly four in ten (37%) did not have an outline. Progress had been greater in community settings than in hospitals. Of those staff that had a completed KSF outline for their post, 75% said it was linked to their personal development plan and 54% indicated that they had been involved jointly with their employer in developing it. Comments centred on perceptions that KSF was time-consuming to implement and that many line managers did not understand it. Nearly a fifth (19%) felt the KSF was a waste of time, but more (46%) did not agree with this view.

Cox et al (2008) cautioned that in some trusts, healthcare assistants were not always being promoted after obtaining extra qualifications, due to lack of available on-site posts at the higher band. This created dissatisfaction amongst staff and contradicts the aim of AfC to recognise and reward increased skill levels as they are attained and utilised, rather than requiring individuals to wait for more senior staff to leave before moving into higher graded posts. In practice therefore staff may need to be geographically mobile in order to obtain the advancement opportunities available upon the “skills escalator”. Kelly, Piper and Nightingale (2008) have commented on funding constraints that may restrict the numbers of advanced and consultant radiography practitioners reaching the top of the escalator. Price et al (2009) noted that AfC was seen by some radiography managers as a step towards establishing advanced and practitioner posts, while others reported that funding shortages prevented them from providing band 7 status for experienced staff even though their role justified it.

Bogg et al (2005) found that a lack of training opportunities was the highest reported barrier to career progression amongst allied health professionals in the past and the second highest reported barrier to career progression in the future. Probst and Griffiths (2008), in a qualitative study, discovered that therapeutic radiographers found their continuing professional development (CPD) time restricted by work pressures, although good management could alleviate this and free up staff for training. The therapeutic radiographers also commented that they needed to be very “self-driven” in order to gain time off for CPD. Miller, Price and Vosper (2008), in a survey of radiography managers, found variations in the perceived availability and quality of training provision across the UK, together with a strong demand for training for some extended role activities. There were many examples of “in-house” courses which offered an alternative to university attendance, some being accredited and others not.  Some respondents in the study expressed concerns about unaccredited courses and the extent to which they equipped individuals for extended role activities. Price et al (2009) noted an association between AfC banding and the possession of postgraduate qualifications in radiography, although it was not clear to what extent banding was driven by these awards. The focus group research undertaken within the same study indicated that it is not easy for radiography practitioners to access the relevant masters' level courses to help them advance through the CPF.

2.6 Working patterns, gender, ethnicity and age

Some evidence suggests that perceived barriers to career progression, such as gender, age, ethnicity and part-time status, have not been vanquished by AfC.

2.6.1 Working patterns

Bogg et al (2005) in a qualitative study of allied health professionals undertaken as part of the “Breaking Barriers in the Workplace Project” discovered that family commitments and part-time working patterns were the main perceived barriers to career progression amongst female AHP staff. They also found a “continuing tradition of the low professional profile of AHPs, when compared to other female dominated professions such as nursing”. The majority of AHPs interviewed expressed a wish to remain clinically focused within their careers. Opportunities for progression however, were often limited to managerial roles and there was a need for more clinical specialist and consultant positions. However the interviewees were positive about the availability of training opportunities in the NHS compared with other organisations, particularly for CPD. A quantitative element of the same project by Bogg et al reported that 48% of AHPs reported a lack of opportunities for career progression, with proportionally more senior grade AHPs expressing this view.

Bogg, Pontin, Gibbons and Sartain (2007) in a questionnaire survey of 420 physiotherapists, found that two-thirds (63%) of respondents felt that the NHS could learn from other organisations in terms of effective methods of developing diversity and career progression. The same authors, in a study of 396 occupational therapists (Bogg, Pontin, Gibbons and Sartain, 2006), discovered that almost one third (32%) had experienced barriers to career progression, including lack of training opportunities, personal commitments and equality issues.

2.6.2 Gender and ethnicity

A recent study by Thompson and Horan (2009), based on analysis of pay data from the 2004 and 2007 NHS Earnings Surveys commented that “there did not appear to have been systematic bias due to gender or ethnicity”. However male AHPs appeared to have done rather less well under AfC than their female colleagues, receiving a mean 14.9% pay increase, rather less than the 17.2% mean pay increase received by female staff. The mean pay of male AHPs in 2007 (£28,100) was also rather less than the mean pay of female AHPs (£29,300). These gender differences were more marked in the case of unqualified AHPs. Here the mean pay increase was 13.7% for male staff and 18.2% for female staff. Thompson and Horan found that qualified AHP staff did rather less well than registered nurses in terms of increased pay over the period, with a mean increase of 16.9% compared with 19.5% for the nurses. Unqualified AHP staff fared slightly better, receiving a 17.5% mean increase.

Other studies have examined career progression under AfC in the context of demographics such as age, gender, ethnicity and locality. Wray et al (2007), in an interview survey of nurses and midwives, found that many staff aged over fifty years experienced difficulties in gaining access to training opportunities. Some felt that they had been well rewarded under AfC, although others said that their experience was not as well regarded as paper qualifications. However, the National NHS Staff Survey for 2007 (The Healthcare Commission, 2008) reported that only 2% of staff over fifty felt discriminated against on the basis of age.  In fact, there is evidence that younger staff feel more dissatisfied with the NHS as an employer than older staff. Bogg et al (2005) found that a high proportion (64%) of AHP staff aged twenty one to twenty five stated that they would not be working in the NHS in five years time. 

Buchan and Evans (2007) reported that a higher number of women than men in acute trusts had thought that their AfC banding was fair, with nearly a half (44%) of women compared to just under a third (31%) of men believing that the band they had been assigned was fair. However, a slightly larger proportion of women employees (just over a third, 36%) compared to male employees , (just under a third, 32%) felt their banding to be unfair. A recent claim for sex discrimination under AfC, which alleged that male support workers were overpaid relative to female colleagues, failed in an Employment Tribunal hearing (Staines, 2009). However the National NHS Staff Survey for 2007 (The Healthcare Commission, 2008), reported that 2% of men but less than 1% of women felt discriminated against on the grounds of their gender. Bogg et al (2007) found that more male physiotherapists than female physiotherapists regarded gender as a barrier to their own career progression.

Black and minority ethnic staff may be more likely to believe they have been poorly treated under AfC (Buchan and Evans, 2007). Only 26% of black and minority ethnic staff regarded their AfC banding as fair, compared to 43% of white staff, with a further 30% of black and minority ethnic staff being unsure whether their banding was fair, compared to just 13% of white staff. Bogg et al (2007) noted that 72% of physiotherapists from non-white backgrounds agreed with the statement “minority groups do experience barriers to career progression”, while the Healthcare Commission (2008) found that 12% of black and ethnic minority staff across the NHS felt discriminated against on the basis of ethnicity.

Regional variations

Buchan and Evans (2007) in their analysis of NHS Staff Survey results on behalf of the King’s Fund, reported only minor regional variations in the perceived successful implementation of AfC. These are displayed in Table 2 below:

Table 2: Variations in the perceived implementation of AfC by English health region (Buchan and Evans, 2007)

English Region
Percentage of staff who thought that their banding was fair Percentage of staff receiving a new job outline Percentage of staff reporting a successful implementation of AfC Percentage of staff reporting increased responsibility
East Midlands 42% 73% 22% 21%
Eastern 41% 71% 25% 19%
London 37% 71% 28% 25%
North East 43% 77% 22% 22%
North West 43% 75% 24% 23%
South Central 42% 71% 25% 20%
South East Coast 42% 75% 27% 20%
South West 41% 74% 24% 19%
West Midlands 44% 73% 25% 21%
Yorkshire and Humber 38% 69% 18% 18%

The most striking aspect of this breakdown of national figures is the consistency across regions. Across England, fewer than half of all staff believed that the AfC band they were assigned had been fair, and, across regions, there was only a few percentage points difference in this proportion. London had the lowest proportion of staff saying this (37%) and the West Midlands had the highest (44%). Similarly, only around a quarter of respondents across England felt that implementation had been successful, with the highest proportion being seen in London (28%) and the lowest proportion saying this in Yorkshire and Humber (18%). Buchan and Evans (2007) also found some differences in their comparisons between different types of NHS trust in the implementation of AfC. In acute teaching trusts, only 20% of staff felt that that AfC had been successfully implemented, while 28% did so in small acute trusts and 32% in specialist trusts. In acute teaching trusts only 37% of staff felt that their AfC banding was fair, compared with 44% in small acute trusts and 43% in specialist trusts.

2.8 Other developments since the introduction of Agenda for Change

The recent increase in the number of foundation trusts within the NHS has brought about more capacity for autonomy with regard to AfC in response to specific local needs. Arguably, this has potential for influencing career progression among healthcare workers through the design of new ways of working and through offering alternative terms and conditions. The National Audit Office (2009) noted that as of January 2009 there were 169 acute trusts in England, 82 of which had foundation status. They also commented that the changing situation in the NHS could make the national AfC system redundant should trusts opt for local terms and conditions of service. They reported that one foundation trust had declined to introduce the KSF, and another was planning to move away from it. However The National Audit Office (2009) expressed the view that AfC would remain an important reference point for trusts in the changing NHS landscape.

2.9 Summary

AfC was the greatest overhaul of pay and conditions since the inception of the NHS. It was designed to introduce equity, facilitate career progression for healthcare staff, and improve patient services. Due primarily to an increase in working hours, a large proportion of radiographers were antagonistic towards AfC from the start and, unlike other healthcare professions, voted against it. However, the literature reveals that dissatisfaction with AfC has been widespread within the NHS and not confined to radiographers as a staff group. Much of the dissatisfaction appears to derive from individuals having been assigned to bands lower than anticipated. In addition, there are differences between the different groupings within the workforce: women workers appear more likely to have felt that their banding following AfC was fair than do male workers, while workers from ethnic minority backgrounds are far more likely to feel that their banding was unfair than are white workers. Across the country, though, there are few differences in the proportions of workers who feel that AfC was poorly implemented, with around three-quarters of staff believing that AfC was not successfully implemented. Although AfC aims to reward clinical expertise, some studies indicate that a lack of vacancies and funding continue to prevent career progression.


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