With a lack of focus on underlying behaviours, Agenda for Change cannot deliver long-term results, says Phil Kenmore

The recent King’s Fund report on Agenda for Change, Realising the Benefits, has re-ignited the debate about whether the implementation of Agenda for Change has delivered real benefits for patients, bearing in mind its very significant costs.

Similar criticism could be leveled at the implementation of the new GP and consultant contracts, both of which, some would argue, have seen significant pay increases for debatable service improvements.

Pay reform on the huge scale of the NHS is immensely difficult to negotiate and implement and is an achievement in itself that merits recognition. However, as the King’s Fund points out, merely achieving implementation can become an end in itself – defeating the object of undertaking the reform in the first place.

The real problem with Agenda for Change - as at times with so much of the NHS - is a focus on processes and skills rather than underlying behaviours. Paying people more does not fundamentally change behaviour or organisational culture – which is what the NHS needs if it is to reinvent itself as a 21st-century public service.

Increasing pay and benefits will enhance motivation in the short term. It can also address a legacy of underpaying against the wider market, and it may allow the harmonisation of terms and conditions and ensure equal pay. All of these are genuine benefits of pay reform in their own right, and many major employers in industry - and elsewhere in the public sector - will be rightly envious of what the NHS has achieved.

What this does not change, however, is the way the NHS actually works or thinks. There is a need to overcome the paternalistic attitude the service can sometimes take towards patients. In addition, reform needs to be driven by culture, rather than structure and processes.

Agenda for Change attempted to achieve some of this by linking progression at the top end of the pay bands to progress against the knowledge and skills framework.

On paper this is a good idea - actively growing expertise, skills and knowledge in return for more reward. But the framework is missing any real content that is linked to fundamental behaviours, and more importantly, the NHS still lacks an effective individual and collective performance management system, which takes into account the behavioural change it wants and needs.

Agenda for Change is being criticised for not providing sufficient benefits, but in reality the scheme was never likely to be able to deliver the following critical improvements:

  • greater efficiency or throughput of patients - resulting in reduced waiting times;
  • a more customer-focused service - one that puts the needs of the individual above convenience, the historical practices of the organisation, professional interests and staff;
  • a service that drives learning and quality improvement as a fundamental element of its everyday existence;
  • an organisation that fundamentally values input from the communities it serves and orientates its services towards them, rather than to government demands.

Pay reform, while essential, was a very blunt instrument to drive what is fundamentally a cultural and behavioural change. To achieve this, it would need to be aligned with effective performance management processes and linked to clarity over the new behaviours and culture required to deliver a 21st-century service.

Ultimately, service needs to function in a consumerist society for people who now consider themselves customers and expect as a minimum personal, flexible and consistently high-quality services.

Some leading foundation trusts are beginning to tackle this cultural change by refocusing their strategy on customer experiences and what this means for both their core business and their brand.

These trusts can then drive their own pay and performance management reforms – moving beyond Agenda for Change – to not only create greater flexibility for how they reward individuals and teams, but also make an explicit link between overall reward, organisational objectives and the behaviours required to deliver them.

It is this next evolution of the reward and performance management framework that the NHS needs to realise. Until this happens, the service will continue to struggle to shift the way that its workforce thinks and behaves, and as a result, how services are fundamentally designed and delivered.