The Agenda for Change (AfC) framework is the nationally agreed UK-wide package of pay, terms and conditions for all NHS staff other than very senior managers and medical staff (practice nurses and nurses working for non-NHS employers are not covered). AfC was introduced in December 2004 with the aim of creating a consistent and fair pay structure across different NHS occupations. The framework covers various aspects including pay scales (9 pay bands), career progression and working conditions (Buchanan et al, 2021). The NHS Terms and Conditions of Service Handbook sets out the conditions of employment and legal agreements that apply (NHS Employers, 2023). In Scotland the Management Steering Group (2024) addresses AfC in the NHS pay system for staff directly employed by NHS Health Boards.
Nurses in the NHS have been operating within the AfC framework for two decades and there have been significant changes within the profession over this period, yet AfC has remained largely unchanged. Initially, a set of national job profiles were agreed to assist in the process of matching posts to pay bands; staff were matched to a national job profile or their job was evaluated locally. The Job Evaluation Group, a subgroup of the NHS Staff Council, measures the skills, responsibilities and effort required for a job, allocating it to an AfC pay band.
AfC was designed to evaluate the job as opposed to the person in the role and to ensure equity between similar posts in different areas. Despite this aspiration, implementation has varied and some posts have been graded very differently from similar jobs elsewhere. Today, many of the job profiles used in the framework do not reflect the knowledge, responsibility and clinical skills that registered nurses exhibit on a daily basis. There is a need for improved pay rates and career pathways for experienced and advanced practice nurses. Band 1 was closed to new entrants in 2018, the overlapping pay points between bands were removed and automatic annual progression ceased. However, the AfC pay scale includes minimum periods before staff are eligible to move to higher pay points within each band.
Modernisation of the entire AfC framework is necessary to ensure that it can effectively support recruitment and retention. The broader policy emphasis in our NHS is to ‘build back better’ and to determine if the NHS pay system remains fit for purpose. The AfC framework needs to be adapted by governments across all four UK countries to take into account new roles, the technologies that are constantly being introduced and ways of working to remain relevant. Buchanan et al (2021) noted that the emerging divergence in the approaches of the four UK countries to NHS staff pay also deserves further discussion. Addressing variations within a unified system is causing tension, suggesting the need to explore a more decentralised pay system. More flexibility is needed, however, the principle of pay equity must be paramount across the board.
Any reform of the AfC framework must be done in a transparent way, engaging key stakeholders. Emphasis has to be on improvements to nurses' terms and conditions, changes to the pay spine with recognition of the increased responsibility and knowledge that come with promotion, and on making career development more attractive and rewarding. Improvements are needed to the overall job evaluation process that is the foundation of the Band 5 review and ensures consistent application across all NHS employers. It is imperative that nurses are at the centre of all that is done and the staff reward package must prioritise and recognise the importance of pay as a key motivator and retention factor.