'Riding the bumpy seas': or the impact of the Knowledge Skills Framework component of the Agenda for Change initiative on staff in intermediate care settings

This paper explores the compatibility of the recently modernized NHS pay structure, ‘‘Agenda for Change’’ (AfC) with the workforce flexibilities arising within intermediate care services in the NHS in England. The findings reported here were an unanticipated outcome of a larger, Department of Health (England) study which explored the impact of workforce flexibility on the costs and outcomes of older peoples’ community-based services. The research coincided with the introduction of AfC, and, as such pay modernization was a strongly emergent theme from focus groups that involved 11 teams as part of the larger study. In principle, it appears that both intermediate care and AfC should support the concepts of interprofessional working, blurring of role boundaries and role substitution, however the findings from this study suggest otherwise. In particular, intermediate care was described as a largely non-hierarchical service structure where staff roles expand horizontally to take on a broad plethora of generic tasks. In contrast, AfC promotes a hierarchical framework for career progression that recognizes and rewards defined skills, expertise and responsibility. From this perspective, AfC was seen to reward specialization rather than skill sharing, and had difficulty differentiating between and rewarding staff with broad generalist roles.