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Contents

1. Message from the CNO
Chief Nursing Officer Sarah Mullally on what the HR in the NHS Plan means for nursing and midwifery leaders and their staff.

2. HR in the NHS Plan - an overview

3. Pay modernisation: Agenda for Change
Agenda for Change aims to build a fairer, simpler pay structure that supports new ways of working and the move to 24-hour, seven-day services. Now that the settlement for NHS funding for the next three years and beyond is clear it is expected that the final part of the negotiations can be completed more quickly.

4. New roles and new territory for nurses - how is it working in practice?
Increased demands on the NHS over the next few years cannot be met solely by improvements in staff recruitment and retention. For nurses and midwives this means working more flexibly, even adopting roles traditionally within the territory of GPs and junior doctors.

5. Leading questions
While the new HR strategy shines the spotlight on developing strong leadership, some 23,000 nurses and midwives have already been through the Leading Empowered Organisations course. But, as one senior nurse reports, being a better leader isn't about becoming someone else - it's about honing the skills you use every day.

6. Taking decisions together
How managers in a Midland's trust are abandoning solo problem solving in favour of involving and empowering staff.

Message from the CNO

Chief Nursing Officer Sarah Mullally on what the HR in the NHS Plan means for nursing and midwifery leaders and their staff.

As I travel across the country I see nurses and midwives working hard to deliver The NHS Plan; beginning to work more flexibly and develop new roles. It isn't always easy and the results are not always instant, but great progress is already being made.

Now, with the launch of the new HR in the NHS Plan, there's a renewed focus for nurses, midwives, their managers and indeed the whole of the NHS on becoming the sort of organisation that truly recognises, develops and rewards the skills we need to deliver better patient care.

The strategy builds on the two major workforce objectives of The NHS Plan:

• to substantially increase the number of NHS staff
• to redesign jobs around patients' needs.

What the strategy does for the first time is provide a very specific focus on the people who work for the NHS. This document is for all staff in the NHS, not just for HR or personnel managers - it's especially important for nurse leaders who have a responsibility for managing and developing their staff. It is a framework for attracting and retaining staff by creating an environment in which people want to work. It shows how, in a much more systematic way, we can provide the knowledge and skills people need to deliver better patient care.

But what does this mean for nursing and midwifery leaders? The new HR strategy certainly reinforces opportunities to develop and improve your own skills, leadership potential and career paths.

Through a broad range of HR leadership development programmes nurse leaders will have opportunities to develop their people management skills - motivating, developing and rewarding staff in the clinical team. The strategy promotes closer working relationships between HR professionals and clinical practitioners. Nurses and midwives clearly demonstrate the direct benefit of effective leadership on the quality of patient care. Now, leaders have a unique and important contribution to make to organisational development ensuring that NHS services are truly patient centred.

But it also reinforces our responsibility and role in supporting our staff locally as they too develop new skills and begin to work in increasingly broader and more flexible roles.

The strategy outlines good work already going on and plans future action to ensure staff have rewarding careers where they are paid fairly for the work they do.

There are excellent opportunities for nurses and midwives to develop their skills and knowledge through lifelong learning and the NHS University so they can take on new roles that will increase job satisfaction.

A national job evaluation programme ensures equal pay for work of equal value, creating greater chances for higher pay.

The strategy also recognises that you need other kinds of support, such as childcare provision, to help you balance a rewarding career with life outside work.

The HR strategy is vital in making the vision of a successful patient-centred health service a reality. It's not just a matter for the very top levels of nurse managers. The strategy is crucial for anyone who leads a team in the NHS.

Making the NHS a better place to work at all levels in order to achieve better care for patients is everyone's business.

Sarah Mullally
Chief Nursing Officer
July 2002

HR in the NHS Plan - an overview

The NHS Plan set two major and challenging workforce objectives - a significant increase in staff numbers and a major redesign of jobs.

Increasing the number of NHS staff is key to improving patient care and the Government has set a challenging target that there will be 35,000 more nurses and midwives by 2008 than in 2001. Delivering these targets will require a concerted effort both nationally and locally

The Changing Workforce Programme has been established to modernise the way services are delivered. It aims to ensure jobs are redesigned around the needs of patients while at the same time creating greater job satisfaction for staff and attracting different groups of workers into the NHS.

There are 13 pilot sites testing job redesign and looking at the difficulties associated with developing new ways of working.

Extending the roles of nurses, midwives and health visitors also includes the establishment of a new consultant role - so far more than 700 posts have been agreed out of the 1,000 promised by 2004.

Delivering the HR in the NHS Plan is based on four pillars which are outlined here.

Pillar one - making the NHS a model employer

The NHS aims to offer all the things you would expect from a ' model employer' :

• excellent working conditions
• the ability to balance life in and outside work
• job security
• lifelong learning
• fair pay
• career prospects
• team working
• staff involvement in decision making
• good communications.

All NHS trusts have now pledged their commitment to the Improving Working Lives standard. That means they now have to prove they are creating well-managed, flexible working environments that support staff and promote their welfare and development.

A raft of other initiatives, such as the Positively Diverse programme, the NHS childcare strategy and the Flexible Careers programme, are also helping make the NHS a model employer.

Pillar two - ensuring the NHS provides a model career through the skills escalator

The modernised NHS will have more staff, working in different ways and will offer services designed around patients' needs.

Underpinning that aim is the skills escalator. Staff are encouraged to renew and extend their skills and knowledge through lifelong learning so they can move up the escalator, while some of the workload and job roles pass down the escalator to ensure greater efficiency. Staff at all levels can benefit from the new opportunities and challenges on offer.

Working with the skills escalator is the Agenda for Change pay modernisation framework which will mean higher pay for most NHS staff and a much simpler pay system so that staff are paid for the job that they do rather than the grade that they hold.

The pay framework is underpinned by a national job evaluation system ensuring equal pay for work of equal value.

An NHS University will be established by 2003 to help provide more and integrated education and training. It will offer learning opportunities for all - from literacy and numeracy courses to postgraduate education and leadership development.

Pillar three - improving staff morale

Most staff in the health service work hard and well beyond the call of duty, but the national media often paints a picture of low morale and extensive failures. Staff morale is a complex issue and the measures outlined in the HR in the NHS Plan should help to improve morale - becoming a model employer will have a positive effect, as will a new pay system, involving people in decisions that affect them and the care they provide, better communications and improved access to education and development.

We will also work with NHS organisations and professional bodies and individual staff to express publicly all that is good about the NHS, without glossing over the things that are wrong.

Pillar four - building people management skills

High-quality patient care can only be delivered by NHS organisations with strong leadership and clear strategies to support and develop their workforce.

The delivery of high-quality healthcare in the NHS requires all managers, not just HR managers, to be involved in crucial human resources issues and to appreciate their importance in building the modern NHS.

• To view the full HR in the NHS Plan document click here

Pay modernisation: Agenda for Change

NHS pay modernisation under Agenda for Change means that nurses, midwives and health visitors will be helped to break down the barriers to flexible working and to create new patient centred roles.

Agenda for Change aims to build a fairer, simpler pay structure that supports new ways of working and the move to 24-hour, seven-day services.

Chief Nursing Officer Sarah Mullally said: "Pay modernisation is all about encouraging people to develop new skills and to take on new responsibilities. The new pay system will provide clearer career progression and will provide extra rewards for nurses and midwives who contribute to service modernisation."

The current pay system has hundreds of separate pay scales and grades that impose artificial ceilings. The new system will contain fewer grade boundaries helping nurses to progress as they develop their skills and roles.

The system will be underpinned by a national job evaluation framework, which is important in helping managers to design and grade new and extended roles and evaluate them consistently in the workplace.

The framework will be delivered in partnership with trade unions to ensure fair pay across all NHS organisations. It will provide consistent conditions of service.

Negotiations are going well and much good work has been done in developing proposals for the final agreement. The aim is to complete this work as soon as possible. Now that the settlement for NHS funding for the next three years and beyond is clear it is expected that the final part of the negotiations can be completed more quickly. Following consultation by staff organisations, this should enable the Department of Health to begin the process of implementation before the end of the financial year.

John Humphreys is director of employment relations at the Royal College of Nursing and is the RCN's lead negotiator on pay modernisation. He said: "We are committed to the talks and now have initial proposals that will give us the basis for the new system, but there's still a lot of hard work to be done if we are to conclude negotiations this summer.

"Nurses are a very important part of the workforce and they are looking to us and the Government to come up with a product that will properly reward them and address the long-standing recruitment and retention problems.

"There's a lot riding on these talks and that can't be under emphasised.

"Once negotiations are concluded, there will be an initial testing phase in 'early implementer' sites to check whether the new system does begin to release the expected benefits for staff, patients and employers without unexpected consequences for costs or capacity."

Andrew Foster, director of human resources for the Department of Health, said: "Agenda for Change will have three big benefits for nurses.

"Firstly it will provide a fair basis for setting pay rates for jobs, taking into account the required levels of knowledge, skills, effort and responsibility.

"Secondly it will offer better pay progression by reducing the number of grades and career ceilings.

"Thirdly it will support career progression by introducing a new knowledge and skills framework to encourage development at all levels."

Mr Foster added: "Agenda for Change is the key to releasing and rewarding the enormous potential for nursing in a modernised NHS."

New roles and new territory for nurses and midwives - how is it working in practice?

Plans to extend the roles of nurses, midwives and health visitors are well underway and more than 700 new nurse and midwife consultant posts have been agreed out of the 1,000 promised by 2004.

There is also a commitment to appoint 250 new allied health professional consultants by 2004. 

But modernising jobs is also about identifying new skill mixes. The Changing Workforce Programme is helping to develop new roles, expanding the depth and breadth of jobs and shaping tasks and skills around particular client needs. 

The programme is currently running 13 pilots to test redesigned jobs -  including nurses working as major practitioners in accident and emergency (A&E) - and trialing a new approach to handling chronic disease.

Alice O'Neill, workforce designer of the programme, said: "It is taking nurses into new kinds of territory in terms of their practice and new skills.

"The major practitioner works within the front of house where they are assessing the patient and working with the doctor in developing diagnosis. While not yet making the diagnosis themselves, they are part and parcel of what junior doctors would normally do.

"We are also developing a chronic disease practitioner - a nurse or other professional looking after a group of patients, through sickness and health, both inside and outside the hospital, so they are managed in a more holistic and patient-centred way," added Alice.

Sue Pemberton, a cardiac rehabilitation sister, is helping pilot the chronic disease practitioner role at the Central Middlesex Hospital in London. She is handling the long-term care of heart failure patients.

"Before, I was focused on preventing another cardiac event, on patient education," Sue explained.

"Now I am much more pro-active. I am focusing on optimisation of their drugs, making sure they are seen by the right people outside hospital and trying to increase their self-management. 

"Pharmacologically, it's a lot more responsible. I can recommend drug treatment variations."

Sue is also examining professional barriers that prevent her being more actively involved in managing patients, such as not being able to order ultra-scan or x-rays. 

"I am all in favour of this expansion of my role because, as nurses, we do tend to see the patient more often and there is continuity for them with a familiar face."

Sister Joyce Robinson is trialing the job of a chronic pulmonary practitioner at the Central Middlesex.

"My role is supporting  patients in the home over a long period. It is a role that was previously filled by their GP," she said.

"I have had to learn a lot more about the conditions that I am treating, the equipment used and how to interpret information.

"At the same time I am learning  new skills and enhancing those I already have. If I want to branch out, I now have the ability and skills I will need."

• To find out more about the Changing Workforce Programme click here.

Leading questions

The new HR strategy makes clear that strong leadership and robust strategies to support and develop the workforce are at the centre of improving care in the NHS.

The Leadership Centre - now 18 months old and incorporating the National Nursing Leadership programme - has already put 23,000 nurses and midwives through the Leading Empowered Organisations (LEO) course.

The centre also has more than 1,000 clinical leaders from 96 NHS trusts on the Royal College of Nursing leaders programme and is running an e-learning pilot with thousands of nurses participating on-line.

Professor Jean Faugier, programme director, believes that good leadership is absolutely crucial for a successful human resources strategy in the NHS.

"All we have in the NHS is human capital; we deliver our interventions through people. If we don't invest in those people, develop them and enable them to take the lead themselves, then we are failing as leaders."

Prof Faugier adds that by encouraging staff, patients benefit too.

"In a business where you deliver care, if you don't invest in the staff, respect them and show that you value them, you cannot expect them to value the patient. In terms of an HR strategy, that has got to be top of the agenda."

Dickon Weir-Hughes, chief nurse and deputy chief executive at the Royal Marsden Hospital in London, added that, for senior nurses, developing leadership ability is about honing existing skills.

"The senior leadership courses are about assertiveness, making your voice heard, networking and how to work your way round an organisation.

"I use those skills every day in almost everything I do and they help me judge the different demands I face".

"The nurse director role is multi-faceted," added Mr Weir-Hughes. "You have to be able to prioritise and deliver what is really key to the organisation while delivering a heavy office agenda and remaining high-profile to the nursing staff."

He believes the roles of ward sister and charge nurse are crucial to a hospital's success.

"These are the people who are really going to make a difference," he said.

"Hopefully we have moved away from the idea of ward managers and people in suits wandering around, and have returned to a time where the role of the ward sister is key."

He praised the LEO programme as "feisty" and said it had been useful for a lot of people.

"There are some interesting concepts around leadership which don't relate to other organisations, particularly the 'servant leader'.

"That's about people with a more altruistic view who are interested in leadership in terms of  improving patient care rather than because it's going to get their name in lights.  That's what leadership in the NHS is about."

Taking decisions together

Partnership between staff and management is an essential part of a modernised health service.

HR in the NHS Plan recognises that staff should be involved in decisions that affect them and patients. The NHS is now looking to introduce a package of policies involving partnership and communications between employers and staff.

Staff in the Midlands have already seen the benefit. An effective consultation scheme has been introduced among the 1,700 staff at the former Wolverhampton Healthcare NHS Trust, now Wolverhampton City Primary Care Trust.

Lesley Francis, the trust's human resources director at the time, said: "We really will not deliver the NHS Plan without engaging frontline staff".

"We invested heavily in communications, which must underpin any kind of engagement - real two-way communications".

"Working with groups of staff, we looked at issues such as how to make flexible working a reality. Ward staff, for instance, looked at their rota patterns and each one ended up with something different. That was challenging for us, but it was certainly empowering for them in deciding their own shift patterns."

She believes one of the big challenges is about how people behave as leaders and managers.

"As managers we are traditionally taught to problem solve on our own and have the answers. You have to forget that with staff engagement. Don't have pre-conceived answers, start with a blank sheet of paper and go to the staff. That takes a very brave manager because it's undoing all our training."

While there is a challenge for managers, however, there's also a challenge for the unions.

"The traditional approach has been: 'Here's the problem, let's give it to management', added Lesley.

"But the partnership approach changes that to: 'Let's work this through together, taking responsibility to work through the options and do it a different way'."

John Brown, the trust's staff-side chair, said relations with management had been poor.

"Much of the problem was a lack of communication. Management talked at staff, rather than to them. We looked at that and talked about flexibility and leadership styles, about having good listening skills, being approachable and sensitive and showing that you are bothered."

With the aid of a £32,500 grant from the Department of Trade and Industry's Partnership at Work Fund, and matching funding from Unison, they first asked an outside consultant to assess their situation. They then ran training sessions for all sides that led to the development of a problem solving tool.

The tool is based on five simple stages to identify and clarify a problem. It then engages the views of all those who may be affected by the issue, with a final stage to share the success or learn from the failure of that solution.

Several issues have been successfully tackled since the system was adopted a year ago. "None are desperately significant on their own," John concedes, "but they do matter. There is a deep sense of ownership. You want it to work because you are part of it."

When the new PCT was established staff were consulted. "We were appreciative that, from the very beginning, we were involved in putting our structure together," said John. "That would not have happened five or six years ago."

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copyright: © | published: July, 2002