Andrew Foster, whose most recent healthcare job was as chair of Manx Care, has died after a short illness, Health Service Journal reports.
His past NHS roles included being chair (1996-2001) and then chief executive (2007-19) at Wrightington, Wigan and Leigh Hospitals FT; director of workforce for the Department of Health (2001-6); and workforce lead for the NHS Confederation.
The tributes, both on Twitter and in the comments under the HSJ news story, refer to Andrew's effectiveness, humanity and kindness. They are absolutely right. Andrew was the real deal: a values-based leader, and a very genuine guy.
We first met when he was DH director of workforce. Andrew picked up the phone to me, having read an editorial that I wrote in British Journal of Healthcare Management mentioning him: he wanted to be sure that I'd understood the workforce policy in question properly.
This was the first of many excellent conversations. You never forgot that you were dealing with a seriously sharp and innovative mind, but any chat with Andrew was always full of laughter as well.
Andrew brought a real showmanship to his DH job, always arrriving spectacularly for his keynote speech to the annual 'HR In The NHS' conference. (On one occasion, this was arriving by motorbike; on another, he double-somersaulted onto the stage).
He was also an operator: you don't get to be NHS director of workforce without that (or at least, you used not to). But Andrew was motivated by people. He liked them, and cared about them, and set standards for them. They motivated him, and he motivated them right back.
And as the longstanding success with staff morale and organisational performance that he oversaw during his 12-year stint as chief executive at WWL showed, 'The Wigan Way' worked. They remained a national top performer, even as the 2010s austerity impacts dragged well-run trusts down.
When I got the opportunity to do some communications work with him at WWL, I got to see him making repeated unscheduled tours round the hospital. He knew his staff by name, and they knew him. The positive atmosphere there wasn't faked: it isn't really fakeable anywhere, if you bother to do a bit of looking.
'Values-based leadership' wasn't rhetoric for Andrew Foster. He proved that an organisation can look after its staff (but not baby them: 'The Wigan Way' had lots on values and personal responsibility); and, by being an excellent employer, deliver high-quality access and safer care.
I'm lucky to have known Andrew. His family and friends will feel his loss hard. The NHS could do with a major dose of his vision and values in 2023.
Below are the texts of a few interviews that we did. Andrew's last interview with his local paper before he left as WWL chief executive is also well worth reading, as is the Manx Care tribute.
Health Management 2004
Andrew Foster – HR with attitude (and humour)
by Andy Cowper
Andrew Foster has a good anecdote about an encounter at Heathrow Airport, and he tells it well. While waiting for a flight, he was approached by a woman doing market research, and agreed to answer her questions. Her first question was ‘Are you responsible for managing people in your organisation?’ – Foster replied in the affirmative. Her second question was ‘how many?’ - Foster looked her in the eye and said, “You won’t believe me if I tell you the truth”.
As director of human resources in the NHS, Foster is ultimately responsible for almost 1.3 million staff. Under the current modernisation programme, he is in charge of one of the biggest and highest-profile recruitment drives in the developed world. He is a man with quite a big job.
More to his credit, then, that Foster remains one of the most popular and dynamic NHS conference speakers (whose on-stage arrivals at the ‘HR in the NHS’ conference have ranged from double-somersaults, motivational bellowing at delegates and arriving on the back of a motorbike).
Foster is also as unaffected by the Department of Health’s media handling as it’s possible to be. The usual ‘we’ll get back to you (not really)’ approach does not sit well with his direct and candid approach. In short, an interview with him tends to be more of a pleasure than a chore.
Previously, he chaired an NHS trust, and was then Human Resources Policy Director for the NHS Confederation. This background has served him well as he approaches the range of challenges around the workforce expansion and reform.
Refreshingly, Foster is upfront about the scale of the task ahead in growing the NHS workforce: he warns of the difficulties in “getting more staff at a 29-year low point for unemployment, and our existing workforce is ageing and retiring in ever greater numbers (also, the NHS hasn't got a great media image)”. He is, however, proud of his record and careful to defend the successes achieved so far.
In what seems an allusion to the writings of T. E. Lawrence, he refers to “the Four Pillars of Delivery … (that) the NHS should be a model employer (with Improving Working Lives); offer a model career (with the skills escalator – a tool to plot the acquisition of new skills through a career); improve morale; and improve quality of people management”. Foster points out that these have been taken on board in the majority of NHS trusts.
Foster is also quick to indicate the new challenges ahead as the NHS moves towards more patient-centred care – evidently, not a ‘zero sum’ in HR terms, whether in training staff to work differently, alter their skill mix or simply get new staff. “personalised care, if I can summarise it, doesn’t just mean just having an efficient service: it means putting patients in charge of their own care – and that means a very different relationship between staff and patients.”
He is aware of the new challenges posed in The NHS Improvement Plan, which promises lower waiting times overall and makes new and firm commitments in the area of diagnostics: “that’s a radical change in terms of access, with implications for further increasing the capacity of the workforce. Particularly in some of the bottleneck areas – to get diagnostics down to a short period of time, we’re going to have to do hundreds of thousands more scoping and imaging procedures, and that will have a huge knock-on effect on the workforce”. If the slogan from The NHS Plan and HR In The NHS Plan was ‘more staff, working differently’, Foster jokes that the aims of The NHS Improvement Plan now means ‘MANY more staff, working differently’.
Foster describes The European Working Time Directive as “a huge Sword of Damocles hanging over the NHS for the past few years, and I think the HR function can take credit for an initial remarkable success in compliance. I don’t rule out problems occurring over the next few months, but the doom-mongers who said 30% of services would fall down were obviously way off.”
The negotiations of the new GP contract and consultants contracts, while conducted by the NHS Confederation, happened on his watch. In future, these negotiations will be in the hands of the new NHS Employers’ Organisation subsidiary of the NHS Confederation – a body whose creation he lobbied for while he worked at the Confederation.
He accepts that the protracted and frequently acrimonious nature of the negotiations was far from ideal. Looking back on them, Foster says, “It’s a matter of regret to me that the negotiations with the consultants’ contract were quite acrimonious. I know that those over the GMS contract were much less acrimonious, and the NHS Confederation team did in the main conduct them in a very non-adversarial fashion. I think that a lot of the tensions were between the GP community and the GP negotiating team, rather than between negotiating teams, and I’m sure the EO will want to continue to work in that style”.
He adds the piquant comment that “The BMA conducted a study of both sets of negotiations, and I think it will be looking to conduct future negotiations in a much more consensual manner.”
He was equally unimpressed by recent claims in a report from the BMA that there are dangers of consultants resigning en masse over the provisions for pay progression in the new contract, calling it “nonsense … peculiar logic ... an inexplicable piece of scaremongering”. Foster points out that under the new contracts’ incremental pay scale, consultants move through an increment in waves over the next few years (but then going on for over twenty years).
He continues, “the BMA report claimed that as they moved through the first wave, lots of consultants will suddenly be prone to retire. To me, there is no logic in that. The old system had a sort of increment, but in practice most people reached the top of the six points very early on (usually within six years), and there is no wave of retirements under that contract. Under the new contract, full pay progression to the top of the scale is supposed to take 23 years.
"So why someone should suddenly retire after just one increment doesn’t make sense. The new contract actually incentivises people to stay longer – the longer they stay, the higher the benefits they get.”
He admits that the implementation of Agenda For Change pay reform for other NHS staff has been slightly delayed, but contends that “when negotiations for AFC were concluded, we intended to start the national roll-out on 1st October 2004. Subject to ballot, it will now start of 1 December 2004 and will be back-dated, so it’s moved just 2 months.
"In the context of the largest and most complicated pay reform that the world has probably ever known (with involving 1.2 million staff, 600 jobs, 17 trades unions and currently some 1,500 pages of terms and conditions), to turn that into a completely new systems with 2 months delay is not bad.”
He cites as one influence the nursing pay regarding exercise of the 1990s. “It poured an awful lot of money into wages, resulted in an awful lot of unhappiness, was very unwieldy in its implementations and didn’t deliver the desired results. But it did teach us that you can’t introduce a major pay scheme for all staff without testing it, so we designated a dozen pilot sites.
"When they reported back in July, the message vast majority had worked very well apart from one bit – the unsocial hours, where there had been changes of ability to get staff to work evenings and weekends and cost over-runs. So by virtue of having tested it, we were able to delete that section.”
He is also keen to point out that Agenda For Change is ‘locked in’ to foundation trusts, but does not rule out the option for their pay schemes to work additionally to AFC. “If foundation trusts want to and have the resources, they can operate bits of a pay scheme that are over and above AFC, for example systems of team bonuses or other types of reward scheme – but these would be in addition to AFC, not instead of it.”
The picture he sees going forwards is broadly positive. “We’ve got a really good track record in workforce expansion, in terms of international recruitment, in bringing people back into the workforce after career breaks and in in increasing training places. So expansion will continue to be the name of the game, and I’m confident that we can do that”.
British Journal of Healthcare Management 2004
Andrew Foster interview
by Andy Cowper
Where do you see the HR agenda at present, relative to where it should be?
In headline terms, three years ago we produced the HR in the NHS Plan - a workforce strategy for the NHS, with the slogan "More staff working differently". Both parts of the slogan are hard things to do: getting more staff at a 29-year low point for unemployment, and our existing workforce is ageing and retiring in ever greater numbers (also, the NHS hasn't got a great media image). Flexibility is about meeting the changing technology and the different demographic needs.
So, how do we do that? We had the strategy with what we called the Four Pillars of Delivery, saying the NHS should be a model employer (with Improving Working Lives); offer a model career (with the skills escalator, which you'll have seen); improve morale; and improve quality of people management.
That Four Pillars approach has been generally adopted in most trusts in their workforce planning. Since that was published in 2002, a huge amount has changed, with foundation trusts and different employment status. StBoP has changed the relationship between Whitehall and the front line and PCTs.
There have also been a range of new visions in the NHS Improvement Plan, all of which have major impact on the workforce. Reducing total waiting time to 18 weeks by 2008 means we need an awful lot more capacity. Payment by results has meant that a lot of trusts who are in excess reference costs will have to bring them down and the most likely way they'll do that is in their biggest area of costs - the workforce.
So there is the productivity issue there. We've got the National Programme for IT, which is going to make working with IT a way of life for NHS staff.
There is plurality of provision: the Secretary of State has said that by 2008, 15% of NHS care will be provided in the private sector. That’s going to be very different culturally for staff, working in or alongside the private sector.
And we’ve got the concept of personalised care, which if I can summarise it, doesn’t just mean just having an efficient service: it means putting patients in charge of their own care – and that means a very different relationship between staff and patients.
All of these big themes have come along since HR In The NHS Plan, and we’ve now got to adjust our workforce strategy over the next three to four years to deliver the NHS Improvement Plan.
The NHS Improvement Plan was in many ways a restatement of The NHS Plan and Shifting The Balance Of Power. The continued reductions of waiting times was implied in those documents – do you see much in the NHS Improvement Plan that is new for the HR agenda?
You could almost characterise The NHS Plan as being about improving patient experience. You could also argue that we are further refining that improvement in the NHS Improvement Plan. The NHS Plan said that by 2008 inpatient waiting would be down to 3 months and outpatient waiting down to 13 weeks, but there was nothing specified in between – so no time limit was proposed for diagnostic functions.
So that’s a radical change in terms of access, with implications for further increasing the capacity of the workforce. Particularly in some of the bottleneck areas – to get diagnostics down to a short period of time, we’re going to have to do hundreds of thousands more scoping and imaging procedures, and that will have a huge knock-on effect on the workforce.
So it’s ‘many more staff, working differently’. But the cultural aspects of working in and alongside the private sector will be very different for NHS staff, as will putting the patient in charge. It will be like the changes to the utility industries when they were privatised in the 1980s and 90s – they became fantastically customer-driven organisations. I’m, not saying the NHS is anything like as bad as BT or British Gas were, but it’s a massive cultural change.
The revised GP contract makes a lot of excellence payments to GPs for things they should arguably have been doing anyway, and the payments are largely validated by their peers. Do you think this is helping redefine the relationship between patients and the workforce?
The contract itself is a radical approach to trying to pay people for quality. If you take a simple phrase like ‘pay people for quality’, the task for the negotiations was to turn that into something that made sense in reality. The quality and outcomes framework is, I think, one of the most enlightened arrangements that anyone, anywhere has introduced for the payment of primary care services.
I’m sure there are areas where anyone can pick holes and say that it should have covered and doesn’t, but it’s taken the most important and prevalent disease areas, and set up quality frameworks. You’re right in saying that many of them should have been achieved already, but there was no mechanism for making sure they were being achieved. What we also know is that the variation in quality in primary care has been very high indeed, so this creates a huge incentive to level quality – to level it up to what independent experts regard as being the gold standard. People from around the world are looking to see if this contract works as well as we hope it will, and the signs so far are pretty encouraging.
So the contract can be seen as ‘outing’ variations in clinical performance?
Whatever we do in the NHS, if you spread the range of performance, and try to raise the level of performance to the top quartile, you’d crack almost every problem: money, waiting, quality, whatever. This is a device precisely to do that. If it works, it’ll be an enormous achievement. Many people are picking at details, but you’ve got to see the bigger picture of raising standards.
At what point will you be able to assess the new GP contract’s success?
We’ll know some of that at the end of this financial year because we’ll have the quality measurements for every practice so that’s how the payments will be triggered. They’ve had to say at the start of the year the level that they are aspiring to with the quality framework. They get paid for 1/3 of that up front (only 1/3 to avoid the risk of overpayment), and then we calculate the balance at the end of the year.
But this contract is a living document, which is going to be reviewed on a regular basis to ensure it keeps to the highest level of evidence-based best practice.
What is the Department’s perspective on out-of-hours GP provision?
PCTs have been given the responsibility for ensuring that there is high-quality, continuing out-of-hours service. That does not mean it’s been provided in the way it historically has. In any part of the country, you’re going to have a mixture of GP services, nursing services, A&E, minor injuries units, drop-in centres and NHS direct. Obviously that’s been a fairly dis-co-ordinated system in the past.
Now PCTs know that this is their responsibility, and they are very clearly focused on not allowing systems to change until they have new arrangements in place that will work not just as well but a great deal better than out-of-hours services in the past. I read some of the GP press, and hear lots of worries and concerns.
We go back each time to the mentioned localities’ PCTs and say, “I’m sure you’ve got this under control”, and we get very strong messages of reassurance from the PCTs. I’m sure that there will be problems in some parts of the country, but we believe this transition will be handled well.
Does the over-extension and subsequent collapse in profits of a company like Nestor Healthcare in the out-of hours market send out any signals, or have implications for the new mixed economy of provision?
I think we’ve got a very collaborative approach, in both primary and secondary care, with the private sector which has grown very substantially in the last few years. There are a series of contracting discussions taking place around extra capacity at present.
My understanding in the case of Nestor is that they went out on a bit of a limb and ended up getting it wrong. Maybe that was how you worked in the old world – taking a punt, but I would have thought that a bit of collaboration and working together in the new world would be a better way of avoiding getting it wrong.
The consultants’ contract has been a slightly thornier rose that might have been expected. Where are the negotiations up to at present?
Currently, 95% of consultants who expressed an interest in taking up new contracts have now received their job plan offers. Of that 95%, just under 70% have accepted and around 5% have decided not to pursue it.
When over the past few months we’ve tracked the progress of job plan offers, there’s been a time lag of about seven weeks before responses. We expect the implementation process to be substantially completed by October. Some places (including where clinical academics are involved) started later.
So the back is broken on the implementation side. The real task now is to realise the benefits under the contract, and we hear anecdotally that organisations’ problems are concerns about cost.
They find that they are contracting to buy more programmed activity than our central models predicted, but the benefits are that now getting exactly what was intended – a much clearer and more transparent framework about who does what and when, and a much better ability to programme the work of consultants alongside those of other staff for the whole of their working week – not just for fixed sessions as with the previous contract.
I think the real next stage is that in the new contract, pay progression is linked to achievement of objectives. All the evidence we have about what really makes a difference in employment relations is an annual appraisal, as part of which objectives are set and reviewed.
That’s the biggest tool for changing behaviour and that’s the part of the contract which now needs to steam ahead and be implemented. I think if you got a consultant signed up to local objectives and taking responsibility for them, then you’ve got the best possible result out of the contract.
What is the current timetable for the job reviews?
The timescale for appraisals should be starting around January-February of 2005. The Department and the BMA will both be issuing guidance shortly, and we’re talking to each other make sure it’s all as similar as possible.
Helpfully, the BMA have already said that one of the main objectives of this first round of reviews should take the opportunity to reduce the number of programmed activities that consultants have, which we’ve always intended it to do: the contract should be used to reduce workload.
Is there any truth in the recent BMA report that consultants are going to resign from the NHS en masse fairly soon?
It’s nonsense. The logic of the BMA report was most peculiar. Under the new contracts’ incremental pay scale, as consultants move through an increment in waves over the next few years (but then going on for over twenty years).
The BMA report claimed that as they moved through the first wave, lots of consultants will suddenly be prone to retire. To me, there is no logic in that. The old system had a sort of increment, but in practice most people reached the top of the six points very early on (usually within six years), and there is no wave of retirements under that contract. Under the new contract, full pay progression to the top of the scale is supposed to take 23 years.
So why someone should suddenly retire after just one increment doesn’t make sense. Additionally, under the NHS pension scheme, to get the maximum pension, you’ve got to work 40 years. So the new contract actually incentivises people to stay longer – the longer they stay, the higher the benefits they get. It was an inexplicable piece of scaremongering, I think.
Ever since I’ve been working in HR in the NHS, people have been telling me that consultants are retiring younger and younger; but if you look at the returns from NHS pension scheme, it’s not true. The average consultant now retires at around 62, and as long as our records go back, they’ve been retiring around 62. There’s a lot of myth around, which is not reflected by the facts.
Agenda For Change has been delayed – what is the latest timescale?
There wasn’t an original timescale for the negotiations, thought they did go on for longer than anyone expected. When they were concluded, we intended to start the national roll-out on 1st October 2004. Subject to ballot, it will now start of 1 December 2004 and will be back-dated, so it’s moved just 2 months. In the context of the largest and most complicated pay reform that the world has probably ever known (with involving 1.2 million staff, 600 jobs, 17 trades unions and currently some 1,500 pages of terms and conditions), to turn that into a completely new systems with 2 months delay is not bad.
One of the great pleasures of pay reforms in the NHS over the last few decades was of course the nursing pay regarding exercise. It poured an awful lot of money into wages, resulted in an awful lot of unhappiness, was very unwieldy in its implementations and didn’t deliver the desired results.
But it did teach us that you can’t introduce a major pay scheme for all staff without testing it, so we designated a dozen pilot sites, and they reported back in July. And the message broadly speaking was that the vast majority had worked very well apart from one bit – the unsocial hours, where there had been changes of ability to get staff to work evenings and weekends and cost over-runs. So by virtue of having tested it, we were able to delete that section. And we can say that it’s been very fully tested.
One very positive piece of feedback is that at local levels, it’s driven a level of partnership working locally between staff, unions and management that there’s never been before. I’m delighted at this, and hope it will play out nationally, because it will turn out to be one of the biggest benefits to delivering service modernisation.
Have you been doing some research into the greater partnership working?
We’ve written up some of the AFC stories and have some ‘top tips’ to pass on from the people who’ve actually experienced it chief executives, HR directors and finance directors.
What’s the latest news on terms and conditions for staff in foundation trusts?
Agenda for Change is locked in to foundation trusts – staff have got it when they’ve started, or are committed to taking it on. That was part of the commitment made to the NHS national unions. So there will be a national pay scheme for staff.
If foundation trusts want to and have the resources, they can operate bits of a pay scheme that are over and above AFC, for example systems of team bonuses or other types of reward scheme – but these would be in addition to AFC, not instead of it.
How will Payment By Results influence the HR agenda, given that the national tariff system may not successfully compensate for the differences in cost of producing health care in the north and south of the UK?
Arrangements are in place to take account of regional differences (case mix adjustments and costs) are technical issues which I assume they’ve got right. What it means for HR is in the many trusts whose reference costs are higher than they need to be.
To get the costs down, given that pay is the biggest element of cost, they will have to get costs down by having a more productive workforce. So some of the skills escalator stuff and productivity trackers we’ve been promoting become tremendously important for such trusts.
I think the advantage the NHS has is that we are still in the expansionary cycle, so we’re not talking about cutting jobs here. The NHS is growing and it needs more capacity, but it needs to improve staff productivity.
How is the pruning of your infamous ‘Christmas tree’-shaped NHS workforce going?
Variations between trusts’ workforces, and particular sections of the workforce, are important. If you look at radiography, where there’s a national shortage of consultants, the Christmas tree is very top-heavy with consultants and under them a band of radiographers in band 5, and under them assistant radiographers. But it wouldn’t look anything like a Christmas tree because you’ve got gaps at levels six to eight, and nothing much at levels one, two and three.
So they are using the Christmas tree methodology and the changing workforce programme to define extended roles of practitioners at all levels of the Christmas tree.
So you get advance support workers – people who are assistants taking on work previously done by radiographers. And you’ll get advanced practitioners – radiographers taking on extra work previously done by consultants.
So that Christmas tree will in time become more diamond-shaped. It’s a great tool for looking at your workforce skill mix and seeing where the opportunities lie.
Given that diagnostics is a potential bottleneck, do you think that outsourcing overseas (to India etc) may be a solution?
I thought that had been ruled out, at least in the short term. I’m not saying that it’s either technically or legally impossible, but all our efforts are about increasing the UK workforce capacity to do that and I understand at present that it’s not regarded as a feasible solution.
Patients are to be ushered to choice by their PCTs. For primary care to hold on to more health pounds, they will have to do more that might in former times have gone to hospitals. Are you sure that the HR systems, with the new GP contract and Agenda For Change are flexible enough that this can be achieved?
Yes. Agenda For Change provides a common pay system, which I think will become increasingly attractive even in GMS practices: even though they’re not mandated to do it, I think they will find it works best for them. They will find that the language of AFC and the ‘Christmas Tree’ a huge advantage in delivering their work more efficiently.
The key thing is more flexibility. At present, it’s incredibly hard to give staff new responsibilities, because what should they then earn? With AFC it’s perfectly adapted to this - you just need a job description, a person specification, put it through the job evaluation tool and that applies it to a relevant pay band.
The AFC pilots have used the system to get early benefits, particularly with these emerging intermediate roles between primary and secondary care. They use the system to design new roles to meet their needs.
One comment being made about the National Programme for IT is around training budgets. The Harvard Business Review has run various articles which suggest that to get best value for every dollar spent on new equipment, you need to spend three or four dollars on training. The NPfIT is spending £2.8 billion a year, largely spoken for on equipment. Do you think HR budgets will cover this?
I am aware that we have a huge training programme ahead of us, one of the things we’ve got to adjust the original HR in The NHS Plan to address. Agenda For Change can be quite useful here: we can define a set of competencies around IT and intall them into every job plan, so it becomes part of the basic job description.
I might dispute the 1:4 ratio for spending, but I take the point and our directorate is working closely with NPfIT to anticipate and begin to design the training programmes that are going to be needed for almost every member of staff. It will be a completely different way of working
Do you think the training will be provided in house?
Given the size of the NHS, it’ll have to be done in-house, and there’s no substitute for on-site learning, but I’m sure it will either be procured or kitemarked nationally. An awful lot of IT training is going to be needed.
What qualities will the new Chief Executive of the NHS Employers’ Organisation need?
They’ll need to be able to work in partnership across a wide range of professional organisations. As well as representing employers, they will be working with trades unions and professional bodies within a mandate set by government.
They’ll need a great deal of knowledge about the workforce agenda, personal qualities of integrity, a partnership style of working and a great deal of judgement. They sit amid government, employers and trades unions.
Will the alleged acrimony which surrounded the GP and consultants’ contract negotiations be a recurring problem for the EO?
It’s a matter of regret to me that the negotiations with the consultants’ contract were quite acrimonious. I know that those over the GMS contract were much less acrimonious, and the NHS Confederation team did in the main conduct them in a very non-adversarial fashion. What of course happened is that there was a lot of tension once it starts getting out among GPs themselves. They got quite angry with their negotiating teams, and effectively the GP community, and obviously there was the Black Wednesday when the Carr-Hill formula fell apart.
So I think that a lot of the tensions were between the GP community and the GP negotiating team, rather than between negotiating teams, and I’m sure the EO will want to continue to work in that style.
The BMA conducted a study of both sets of negotiations, and I think it will be looking to conduct future negotiations in a much more consensual manner.
How do you think the HR picture will look in eighteen months’ time?
We’ve got a really good track record in workforce expansion, in terms of international recruitment, in bringing people back into the workforce after career breaks and in in increasing training places. So expansion will continue to be the name of the game, and I’m confident that we can do that.
The European Working Time Directive has been a huge Sword of Damocles hanging over the NHS for the past few years, and I think the HR function can take credit for an initial remarkable success in compliance. I don’t rule out problems occurring over the next few months, but the doom-mongers who said 30% of services would fall down were obviously way off.
Pay reforms are a huge task – the consultant contract has largely now been cracked, but that was only 30,000 people: with Agenda For Change, we’ve got 1.2 million people. We are not assuming that implementation will be complete until around September 2005. So that is going to be by far the biggest task.
But HR is not an end in itself: we’re doing Agenda For Change to improve access and patient care, and reduce costs to tariff. Also, if you take the model employer side, which is crucial with the workforce expansion and retention we need, then our recent staff survey gives some good messages. We found that 73% of staff were satisfied with their job – a higher figure than you’d get in other sectors. But it’s not all rosy.
There were alarmingly high levels of harassment and bullying – 28% of staff experienced these. A significant number of staff having witnessed clinical errors. And while we’re pleased that about 50% have had good appraisals, it means the other 50% haven’t.
So the staff survey gave us quite a few ticks, but set out areas where we have more to do. For me, though, the 73% job satisfaction score is a real sign that HR departments around the country have been implementing this model employer dealing with the real issues that concern staff – child care arrangements, flexible working and of course the NHS pension scheme, which is one to die for, it’s so good.
The other thing you see everywhere is the explosion of the new roles, triaging physiotherapists, nurse therapists, and nurse endoscopists.
There was some fuss a while back about the NHS recruitment website, and whether the big print classified advertising publications would accept adverts mentioning it. Is that going to be one of the first choice ports of call for people looking to extend their career?
Our e-recruitment project, which has been successfully tested in a few areas, is going to be the first point of call in due course. If we hadn’t done it ourselves, someone else would have done it pretty quickly.
And I can see the pain it’s going to cause to print-driven advertising, and therefore some of the resistance to it. It’s bound to happen – it’s just a question of how quickly and who owns it.
Health Director 2006
Crusading and somersaulting for delivery
Andrew Foster, Director of Human Resources in the NHS, explains “HR with attitude”
Interview by Andy Cowper, editor, Health Director
Where is Human Resources in the NHS up to now, in relation to where you wanted it to be when you joined in April 2001?
We are making real progress, though there’s still a long way to go - and the real lodestone and criteria by which success will be seen is in two parts: 1. having more staff; and 2. having staff working differently.
As regards more staff, nearly 60,000 people joined the NHS in each of the last two years - and this has been a low period of UK unemployment in context of the past 27 years.
As for working differently, we are getting there but not yet doing enough – to be of real benefit, we have to increase productivity. There are huge variations in productivity: it means the NHS working both more efficiently and more effectively. It’s a key task to facilitate general management to increase productivity, while still motivating staff.
Other than making the HSJ and Nursing Times classified advertising departments very profitable, how much have ‘The NHS Plan’ and ‘Shifting the Balance of Power’ reforms improved a) patient care and b) staff’s working lives?
On patient care, the productivity I mentioned is about reducing waiting, making systems more efficient and not duplicating things with patients.
I’m most proud of Agenda For Change – in that jobs are not defined by title, but what staff do for patients.The ways forward here are in knowledge and skills frameworks.
The ‘Old NHS’ viewed patients with scepticism as they received a free good – changing this attitude is central to the modernisation agenda.As for working lives for staff, our Improving Working Lives initiative is now in year four, as an evidence-based analysis of what improves things for staff. It covers flexible working; work–home balance; opportunities for career progression; staff involvement in decision-making; and a range of good policies from anti-racism to bullying.
This scheme has independent inspection teams, who meet random panels of staff and ask them about NHS as an employer.
Annually, increasingly exacting standards will drive the NHS up to being a model employer. Compared to any other employer, the NHS is good on flexible working, child-care, and terms and conditions. Its pension scheme is profoundly enviable
You clearly feel that the HR function is not only central to reform, but heroic. In your speech to the conference, you emphasised the new ‘balanced scorecard’ idea (which is being consulted on now). What are the main areas where you are looking for new thinking?
The world has a collective scepticism on HR. My main job in the NHS is to prove that it can be heroic and can make a real difference, using evidence - which is very compelling. Increasing productivity and the measurement of gain is absolutlely right.
The NHS Confederation is gradually assuming significant parts of the DoH / NHS HR function in negotiating the GP and consulatants’ contracts – and now pensions. Is it right that a QUANGO should do this?
When I was NHS Confederation HR Director I argued that this is what they should do, and miraculously now it has become government policy!
We are now in discussion about me transferring some of my functions to them, and saying from Department of Health to the NHS Confederation, ‘here are the resources: you have now to take responsibility for the outcome of negotiations’.
The GMS negotiations have produced a brilliant system, but one with much detail which needs ongoing attention. Arguably, it’s as complex as it needed to be – but that complexity presents a lot of risks.
What demographic modelling is undertaken to ensure the NHS workforce of the future fits our population profile, as well as the future ways of practicing medicine?
I think we’ve made some progress in this area, but not enough. The demographics of the NHS workforce need to represent the communities it serves. In Birmingham and Bradford, trusts are striving and doing well, but as a whole we need to make more progress.
Medical school intake, which sets the tone is still largely a white, Anglo-Saxon university-educated and public-school world – where a 'good' education makes you a good doctor (I acknowledge that doctors need a good intellectual understanding).
A high degree of consensus is emerging – the Royal College of Nursing has always been enlightened on this, and the other Royal Colleges really are getting there. Like many NHS policies, it’s great in theory but implementation is the challenge. Last year, we launched the ‘HR in The NHS Plan’. That’s the roadmap – this, and future years, are about delivery
Taking a cynical viewpoint, where do you rate NHS Professionals on a scale between a desire to cut agency staff bills and potential restraint of trade?
If you draw a line from Gloucester in the west to Clacton in the east, above that line, NHS Professionals is about better use of IT; improving collaboration between organisations; and getting better agency staff. You can include Cornwall, Somerset and Dorset in that area.
As for London, Avon, the Thames Valley and Brighton, the NHS is on a curve of having two workforces: core NHS staff, and agency staff earning up to twice as much and who are more committed to themselves than to the NHS. It’s clearly unacceptable to have such a discreperancy among staff working alongside one another
If that trend continued, the south-east and Avon would have a non-NHS workforce, which is clearly unacceptable.
So in those areas, NHS Professionals is about reversing that trend. It is not to stop agency staff, but to change to them being supplementary to the NHS workforce.
Will The NHS Plan succeed within the set lifetimes to above 60% of its targets?
I can’t put figures on it in that way. I think it will succeed in its essence of removing waiting as an essential part of the NHS. It will substantially improve patient experience, as it will lead to more patient-sensitive services and jobs.
And in my area of capacity, yes, I think it will succeed
Tell us briefly about ‘HR with attitude’?
You can have a series of intellectual arguments about changing ways of working, but that’s all very well until someone drives it home. Like Semmewlweis on handwashing back in the 18th century, there can be as powerful an argument as possible - but it didn’t penetrate.
t’s the same with HR – it is only by getting the best out of the workforce that makes the difference. You can’t just send out a letter about it – you have to have ‘in-your-face-ness’. The old-school of HR has got to change, and is changing.
British Journal of Healthcare Management, 2006
Andrew Foster interview, British Journal of Healthcare Management, May 2006
The outgoing DH workforce director on benefits and risks of the new contracts; on losing posts; and on the DH’s former board losing the plot
Interview by Andy Cowper
Andrew Foster is director of workforce at the Department of Health. At the end of April 2006, he is moving to be director of HR and OD at Blackpool, Fylde and Wyre Hospitals NHS Trust.
Looking back at NHS workforce issues over the past six years, as one of the key authors of The NHS Plan, how do you think it has gone?
It’s a narrative with a happy start and middle, nearly a happy end and a little bit of bitterness to follow.
Think back to the heady days of 2000: the Chancellor agrees a big funding growth for the NHS. Alan Milburn says that with the funding must come reform, and embarks on the astonishing process of producing The NHS Plan (DH 2000) including a massive consultation of staff, the public and stakeholders.
I was involved on the Workforce Modernisation Action Team which was one of six stakeholder groups which contributed. When The NHS Plan came out there was great enthusiasm, and I think that was the last time almost everyone in health was singing from same hymn sheet.
The NHS Plan opens with the 10 things the public most wanted to see : number one is “more staff, better paid”. It’s ironic to contrast that with the recent headlines and furore about staff numbers and pay, but that was the vision.
The chapter on workforce set out stretching targets on numbers, but it also demanded reforms. We had to lose 1940s ways of working, and needed a more flexible workforce, with more patient-centred care. To be an attractive ‘model’ employer, we also had to care for staff better, in areas like childcare, flexible working and staff involvement.
Following The NHS Plan, I generated The HR In The NHS Plan – the NHS’s first-ever workforce strategy (it is in itself bizarre that the biggest employer in the Europe had never before had a workforce strategy, which was all about ‘more staff working differently’.
I’m very proud that from March’s payroll data, 99% of staff are now being paid under Agenda For Change, and after only 6 of the 10 years of The NHS Plan, we’ve delivered. I’m really proud of the model employers’ strategy, the skills escalator, pay reform and other things we’ve done.
Does the shedding of 8,000 jobs in the NHS look like panicky management, or more staff working differently?
A couple of crucial points here. Firstly, these are not job losses – as in, they’re not real people losing jobs. With one or two exceptions, this is post losses: organisations planning to reduce size, either in natural wasteage (retirements, etc) or in eschewing use of temporary or agency nurses. There has been a tiny handful of actual compulsory redundancies, and a tinier still proportion of clinical staff made redundant.
Secondly, this has to be seen in the context of an NHS workforce that is still expanding fast. At the recent HR In The NHS Conference, I announced that in the year to September 2005, NHS workforce had expanded by 34,000. In a workforce of 1.4 million, the current plans for cuts are the slightest foot on the brakes.
Having said that, there are signs of one thing that we’ve been trying to improve for ages that is not going well – the integration of workforce planning with financial planning.
In North Staffordshire NHS Hospitals Trust, for example, which has just announced 1,000 job losses, the Trust actually expanded its workforce by nearly 300 in the first quarter of last year, so yes, there we are looking at hundreds of real job losses: that is one case.
But we must remember that over 30,000 jobs were gained in the whole year from September 2004 to September 2005, and over the previous three years, job gains have averaged 50,000 each year.
How much of this is about unsophisticated integration of financial planning with workforce planning?
A lot of it is about lack of integration of workforce planning with the rest of planning.
We have said for ages that supporting Local Development Plans should integrate workforce planning with the rest of organisations’ planning. At the beginning of last year, we got financial, activity and workforce data returns. The first draft last year showed a 6% increase in workforce numbers, which proved that at local levels, no-one was linking workforce plans to financial plans.
So the proof is that year-start plans of 6% have translated into year-end plan of less than 2%, and the year-start plans bore no relationship to the financial environment.
That shows how planning is not currently linked in with money at all. We responded by producing a revised HR strategy document last December, A National Framework To Support Local Workforce Strategy Development (DH 2005), promoting the issue of integrated planning.
So which bit of the system wasn’t listening to you about integrating workforce planning with financial planning?
It wasn’t one particular bit – it was a failure of the system to work together. Managers were concentrating madly on activity planning to hit waiting list targets. The same was true in financial planning to get financial balance, and also in workforce planning. Far too often, those three have not spoken to each other.
The NHS has had over-riding access-based objectives, and every organisation now has to plan the needed capacity to get down to the 18 weeks maximum waiting target by 2008. Well, NHS capacity is about beds and people. I hope we’ll see must stronger integration in workforce planning this year.
Are the post losses a sign of contestability in action?
I don’t think so – I think it is just a sign of not-brilliant planning. The extent to which the private sector is out there competing with NHS is very small, so don’t think this is the cause at all.
What is being done about blatant obstructionism of local medical teams against Independent Sector Treatment Centres (ISTCs)’ imported doctors, as highlighted in the recent BBC2 ‘Sweeney Investigates’ programme?
Protectionism, you mean?
Wave 1 of the ISTC programme went very fast, and with few constraints barring the additionality rules (that ISTC providers can’t use NHS staff, so they had to recruit from overseas). ISTCs have met with lot of hostility from NHS organisations and clinicians, who have seen a lot of the ways they formerly earned money declining.
We think that the ‘waiting list industry’ has declined by 75%. Anecdotally, one chief executive told me that his waiting list spending has gone down from £6-7 million a year to below £1 million.
Behaviour change that has resulted from ISTCs has affected the self-interest of lots of people. So lots of criticism of ISTCs has come under the banner of quality. I’m not aware of any evidence that ISTCs’ quality overall is lower than that in the NHS.
Professor Aidan Halligan, NHS Director of Clinical Governance, wrote in our last issue that “any suggestion of real reform has been a deceit: working patterns, practice and customs are at the heart of many capacity issues, and have never been challenged”. Do you agree with him?
What I’d say to Aidan is “Go to any NHS organisation you like and ask them ‘now, as compared to 6 years ago, how many non-medical staff are prescribing?
“How many jobs that were formerly done by doctors (e.g radiologists) are now being done by non-doctors (e.g. radiographers)? How many new nurse practitioners, or healthcare assistants do you have?” There’s been an explosion of task delegation, with jobs built around the generic needs of patients, stroke / diabetes nurse. Go to any trust, Aidan, and audit their workforce flexibility now versus how it was six years ago."
Your aim was ‘more staff, working differently’. But haven’t we just gone from more staff working the same to less staff?
Look at the increases in workforce numbers over recent years: 2002 - 58,000, 2003 - 58,000, 2004 - 48,000 and 2005 - 34,000. What we’re seeing now is significant growth beginning to taper off.
So staff reductions of 8,000 (or 13,000 if you believe the RCN figures) are small in comparison to growth of 198,000. Some trusts are still recruiting, especially primary care and community care with the new GMS contract.
I think we’ve got pretty close to equilibrium in numbers. I see staff working differently all the time, and the skills escalator strategy and career framework have made it clear how staff need to train if they want to progress.
The other issue underneath this is productivity, which is notably hard to measure. Alan Maynard argues in your pages and elsewhere that there have been no increases in productivity.
The recent ONS report said that there was in fact a 2% increase in NHS productivity, but some of this can only be measured in quality. Statins prevent heart disease, consume the drugs bill and lower the number of finished consultant episodes as the need for surgical interventions is reduced. So technically, this death prevention reduces NHS productivity.
The NHS Modernisation Agency’s 10 High-Impact Changes (MA 2004) are now being thoroughly implemented everywhere, and productivity gains like those outlined in the 10 high-impact changes are the name of the game.
What do you make of the decision to close the Modernisation Agency?
I think it was a terrible mistake. In its early stage, the MA had a mixed reputation, but in its final 18 months began to produce excellent work like the 10 High-Impact Changes. The NHS Institute has learned lessons from the MA, and has concentrated on being a resource, not a ‘doer’ of change.
So there’s a link to High-Impact Productivity Changes just launched by the Institute. The 10 High-Impact Changes can make fantastic differences to organisations. I doubt we’re going to re-create the MA, though.
Was the Modernisation Agency ‘doing change’ to front-line organisations a mistake?
No, I don’t think so at all. In A&E, their system redesign brought 98% target to meet-ability. The MA was of its time: it was needed to get organisations beyond a ‘tipping point’.
We’ve decided to do things in a different way now. But with decisions like that, I have this mental image of a horse and cart, where the cart isn’t going fast enough - so we kill the horse.
By that, do you mean the Modernisation Agency?
And the NHSU, and others such as Workforce Development Confederations. Bodies are designed to fill a gap in the system, then we get impatient that they aren’t delivering fast enough,so we get rid of them!
What have been the big successes of Agenda For Change?
Agenda For Change (AFC) set out with four objectives. The first was equal pay-proofing, and it’s an equal pay-proof system. At end of 1990s, NHS was losing serious tribunal cases on equal pay. Now we have AFC, hundreds of millions of pounds that the NHS would have lost in tribunal or legal claims now won’t be lost.
The second, if we go back to 2000, was about expanding investment in pay, so the NHS would be more likely to recruit and retain staff. Vacancy rates are currently the lowest for years, so we’ve largely achieved this.
The third was that under the old pay system, pay review bodies constantly tinkered, but then put additional ‘uplifts’ on top which cost 0.5% to 1 %. So in the last few years, there’s been a single deal and no uplifts, improving our ability to plan financially.
The fourth was about productivity gains: this is the most difficult to prove, in part as we’ve only just finished AFC and in part because it’s hard to separate AFC productivity improvements from those accruing from service redesign and IT, but I’m sure that flexible working under AFC and new roles will contribute more to productivity.
What have been the big challenges of Agenda For Change?
The real challenge is just getting organisations using it.
At one extreme, you might get organisations that get the last person under old system onto AFC, and then heave a sigh of relief thinking it’s finished - but they don’t use it to redesign jobs and services.
AFC can be used to maximise improvement, to redesign jobs, introduce flexibility, and to use the knowledge and skills framework as a driving force to get the right types of knowledge, skills and behaviour into organisations.
Unless trusts maximise Agenda For Change, I worry that there will have been a billion-pound investment into higher pay, not more flexibility.
That is the criticism some have levelled at AFC, but it’s in the hands of the critics themselves to use AFC to redesign services.
I cannot implement AFC across the whole NHS. It’s not down to me, to Whitehall or even to the local chief executive: it’s down to local teams at ward and practice level.
Do you think that the message about using Agenda For Change to alter services and delivery has got across? Many people perceive it as ‘just HR’.
The HR community has got it, and we have also tried to get chief executives and finance community on board. With competing pressures, it's always hard to get the attention you want.
Even when it involves spending billions?
Yes. We have committed to this spending, but let’s use it to effect, not just sit there grumbling about it.
Is Sir Ian Carruthers right to say that financial problems are “an opportunity”, and would you be taking such an opportunity to run HR at a trust in the south of England?
The trust I am going to faces substantial financial challenges and a recurrent deficit. So I’ll be in that boat!
I know what Ian means: when the ship has a burning deck, behaviours can change. When you’re in financial trouble, you’ll either change or downsize, and most trusts will prefer to change.
There are ingrained working practices that haven’t changed for decades, so yes, we need to redesign services.
You’re agreeing with what Aidan Halligan said there …
I am, in the sense that I agree that more reform is needed.
Has the consultants’ contract been unfairly maligned?
Yes, in my view. The sting has somewhat gone out of it now, but last year people were saying that the overspend was going to be hundreds of millions. When we got actual return, the overspend was £90 million and indications are that this figure is reducing lower as the number of consultants’ Programmed Activities goes down.
The consultants’ contract gives managers two levers: one is better planning of the working week, which has been grasped and has offered more transparency.
Where I think we’ve failed is in the area of agreeing annual objectives with consultants. Some research literature suggests that agreeing objectives is the most powerful management tool, and it’s just not being used.
Mark Britnell, chief executive of University Hospitals Birmingham Foundation Trust, asked for a show of hands at a recent conference by delegates who were setting their consultants objectives, and there weren’t many hands raised. There have been exaggerations over cost, but the consultants’ contract can be much more fully implemented by local NHS trusts.
Are GPs worth £250,000 a year?
I don’t think they are, and hardly any are actually earning that. What you do see is a practice earning £250,000 net of costs.
Typical GP pay per head is around £100,000 and it’s more for those at the top end of league table, but they are being paid to provide better care, as part of the right move towards better care closer to home
What have been the cost over-runs of Agenda For Change and the GP and consultants’ contracts?
With AFC, it’s too early to know categorically. Our evidence from testing it with 36,000 live people made us confident that we would fit the pay envelope. Our sample part-way through the year showed an overspend of about £120 million in the direct pay bill and potentially another £100 million on cover for annual leave.
At the moment, anecdotal reports are going back to a smaller figure. Leeds report implementing AFC within the financial envelope. So we’re cautiously saying its over-spend is just over £100 million, which with a non-medical total pay bill of over £30 billion, is like landing a supertanker on a sixpence: it’s pretty damn close.
The cost of over-run of the consultants’ contracts was £90 million more than expected.in 2004-05, but much less than this in 2005-06 And the overspend on the new GMS contract was £300 million.
Other than a very thick skin, what qualities are going to be needed in the next chief executive of the NHS?
I think the next one needs to be a visionary leader who understands the NHS’s people and culture of values, who gets the best out of them using that understanding and who sees that so doing is good for them, for staff and for the organisation.
Should the chief executive of the NHS and permanent secretary to the Department of Health have ever been the same job, and should they be the same now?
This is an interesting question, but not anything like the most important of issues at present. Each model has advantages and disadvantages.
I thought combining the two in 2001 was a good idea, to get the NHS and DH closer together. Whatever result comes out, the chief executive of the NHS will be the more important role.
What things do you wish that you had done differently?
There were countless problems with the negotiations over the consultants’ contract: hard negotiations with a difficult and adversarial person on the other side of the table – by which I mean Alan Milburn, the Secretary of State, not the BMA! That, by the way, is a joke.
What we wanted in the consultants’ contract, we got - but the route to getting it was tortuous.
I’d like to have connected more with chief executives too. I think I’ve been well able to connect with the HR community, but I’ve had less success than I’d have liked getting the HR story across to chief executives and general managers.
What did the McKinsey report say?
I don’t know because I wasn’t there at the presentation, but the word is that it was deeply critical of a DH which had lost control of its relationship with the NHS, of finances, and of the system reform agenda (and of explaining it).
The report found that the DH board had basically completely shot itself in the foot. It was very critical of a dysfunctional department and board (one thing that pleased me was that they noted as a criticism that the workforce director had not been on the board. As you know, that oversight was rectified as a result).
Beyond that, the rest is speculation.
Why was no-one willing to speak out about the increasingly dysfunctional relationships within the top team, and between Sir Nigel Crisp and ministers?
It’s not the case that nobody did anything, but there was a very painful 12 months with a rising chorus of criticism of the DH from the NHS and stakeholder bodies.
The former chief executive’s response to that criticism for a long time was, if there are problem in the NHS, then they’re the result of poor management. So the two groups who should have been working more closely together than anyone were polarised.
And that’s not to mention the decision to redesign the senior management structure, which deeply destabilised those holding the system together. It’s been a little bit like working in the bunker for several months.
What I welcome is Sir Ian Carruthers coming into post and saying, we must stop the corrosive behaviours and blaming. The ways in which Sir Ian now works internally with Hugh Taylor have led to a huge sigh of relief, albeit there are still a hell of lot of challenges ahead.
A National Framework To Support Local Workforce Strategy Development (2005) DH Workforce Directorate, Leeds. Gateway Ref 5811.
HR In The NHS Plan: more staff working differently (2002) Department of Health, London. Gateway ref 2002
The NHS Plan: a plan for investment, a plan for reform (2000) Department of Health, London. CM3487
10 High-Impact Changes (2004). NHS Modernisation Agency Gateway 3483. www.wise.nhs.uk/cmsWISE/HIC