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Modernisation: why use the NHS Knowledge and Skills Framework?

As part of Agenda for Change, the NHS Knowledge and Skills Framework was described as "the jewel in the crown" or "the icing on the cake". Many years on, do you think this is really the case in your organisation?

Kate Oultram
Unite Health Sector National Organiser
Prestwich, Manchester

Can you recall the first days of Agenda for Change? There was real excitement about the NHS Knowledge and Skills Framework (KSF) – it was the one part of Agenda for Change that trade unions and staff-side representatives were counting on to make all the upheaval, modernisation, job evaluation and changes to terms and conditions worthwhile.1 The potential benefits of applying the KSF are:

  • Everyone knows where they are, what happens next, and why.
  • Resources are used wisely, and not wasted – things are "right first time".
  • Learning and personal development planning cycles are in place for everyone, with clear objectives and equity across all staff groups.
  • Multidisciplinary teams learn and work well together.
  • Patient care improves, with evidence to show this.
  • Organisations plan for existing and future workforce.
  • Staff stay, feel valued, and recruitment and retention (turnover) are at sensible levels.

So – is this happening?

Partnership working
What does this really mean? It is supposed to be the essence of modernising the service with organisations, employers and trade unions working together. How do they do it where you work? It's certainly not modern, or helpful, to revert to the traditional "banging the table" style of industrial relations.

Working relationships between employers and trade unions can be effective when there is recognition of partners having equal, legitimate points of view, even if they sometimes disagree. The power within the relationship should be balanced, with decision-making and problem-solving resulting from mature discussion between all the partners.

Where managers and staff have introduced the KSF within their organisations together, it has worked well. Union learning representatives and staff-side KSF leads have demonstrated real talent, at very different levels from their day job. They have developed outlines, trained colleagues, been involved in rolling out the programmes, supporting less confident staff, and contributed in trust- or board-level meetings. Some examples of successful partnerships involving Unite members were given in Amicus Health magazine in 2006.2

There are some excellent case studies giving examples of using the KSF on the NHS Employers' website ( – well worth a look.3

Things haven't gone to plan if HR departments or individual managers have written KSF outlines for staff, and simply requested that they sign them. The only way to capture real examples of application required in a role is to ask the people with that job, and their managers, to agree what goes into the outline.

Useful outlines held in the "national library" on the electronic "e-KSF" (, are ones that actually mention the job, the trust, department or service; for instance, some early midwifery outlines didn't even refer to mothers or babies!4

The three stages of your job
When you are new in a role it is useful to know what is expected of you, and what you need to learn for the first time, or perhaps to learn to do more effectively.

During the first year in a post, before the "Foundation Gateway", the KSF helps you to understand what you need to do immediately, and how you will contribute to the team.
After 12 months, you and your manager can talk about your potential, and what further support and learning you will need in the future. You will be feeling more comfortable and confident about your knowledge and skills. The KSF outline should then make it clear where you need to develop towards
full competence.

Your personal development review won't need to focus on what you and your manager know you can do well already, nor does it need to be long and uncomfortable. It is a guide for reinforcing and enhancing your skills – indicating areas to concentrate on over the next few months.

Further learning can supplement what you have done already; examples are reading, "e-learning", CDs or DVDs, working with a mentor or coach, shadowing colleagues, or joining a discussion group. You'll be applying your skills, and looking forward to new opportunities to learn more, not just in a formal classroom setting.

The time may come when individuals feel that they are growing beyond their current job. If this applies to you, your manager can discuss with you whether you can pass on your knowledge and experience to colleagues, broaden your own role to include more team-based responsibility, prepare for promotion, or think about moving into a different area of service. Sometimes this is called "career counselling".

The "Second Gateway", near the top of each pay band, is an opportunity for everyone to take stock. Managers who have experienced, competent team members feel more confident about delegating tasks day to day, giving staff a more interesting part to play. This also frees up time for those in leadership roles to take on more strategic or organisational jobs themselves, since they have KSF development reviews and outlines too!

Can't get you out of my head!
The question is, how do we extract all the latent knowledge, skills and experience from the people who really understand their role, how it fits into the organisation and benefits patients and colleagues, and somehow transfer it to newer, less experienced staff?

One of the most neglected – yet essential – activities an organisation needs to do is "succession planning". With a clear set of KSF outlines for different roles, from bottom to top within a service, and across the organisation, it is much easier to see who needs to do what, how they can learn to do it, and where the ultimate talent lies within the workforce.
The KSF helps us to:

  • Use people's time and energy, budgets, the environment, and physical "things" wisely, without waste.
  • Improve skills for service need and patient care, (like new technology, treatments or processes).
  • Manage change – the "shape" of the organisation, the population, economics.
  • Effective "talent management" – recruitment and retention of our stars!
  • Make sense of how everyone's role fits into achieving targets.
  • Share excellent practice and knowledge, using existing or new networks.

How does this fit in with everything else expected of us?
It shouldn't be:

  • Duplication of effort.
  • Just "something else people have to do".

If you are working towards an NVQ, a degree, or higher qualification, there is no doubt that formal training and education underpin your practice. However, the KSF isn't about gaining academic or vocational qualifications; it describes the practical skills and knowledge needed in a specific NHS job.

As a member of a key healthcare profession, you will be expected to do your own continuing professional development (CPD). The KSF should be one way to support this. You are reflecting on your own learning, translating it into what you do at work, how you share with (or learn from) colleagues, and you'll be considering future learning in your development plan.

You should not need to do two completely separate pieces of work, or have different portfolios of achievement – there should be sensible overlap if KSF evidence is relevant to your role and practice; for example, if it supports registration, or revalidation.

The learning you undergo should all count towards, and supplement, what you actually do. The Greater Manchester Allied Healthcare Professionals and Healthcare Science CPD group came up with the following "wish list" of skills they felt they needed to develop:

  • Leadership.
  • Motivation and involvement of staff.
  • Dealing with rapid change.
  • Presentation and facilitation skills.
  • Time management.
  • Cost-benefit analysis and financial management.
  • Business case planning.
  • Influencing decision-makers, commissioners, and stakeholders.

This list directly maps easily onto the dimensions of the framework shown in Box 1. All these need to be held somewhere within the organisational "suite" of outlines to build both leadership and operational skills for future demands on the service.

Targets, objectives and goals: where do I fit in?
Each organisation will have targets required by the government (for example, through the Department of Health or regional Strategic Health Authority), or regulatory bodies. This is where funding or legislation will be applied. These objectives should filter down through service areas to department and teams, and will end up with individuals.

If people are not working on what meets objectives or targets, then either "priorities" are not vital to the service, or you could conclude that staff are not doing what is really required day to day. Either way, hard workers are wasting their time, or budget spending is not going where it is needed! Examples of this might be infection control, waiting times, staff involvement, public sector spending, care for different groups, eg, children or older people, or specialised treatment for cancer, mental health issues. It is a long list!

If everyone has some responsibility in meeting these targets, from the staff through to managers and up to the chief executive, it makes sense to ensure that these are clearly included across the full range of KSF outlines for each role, at each level (or in each appropriate payband) and across the local health economy.

A number of different healthcare professionals are involved in the treatment of one patient, so their KSF dimensions should reflect the different responsibilities they hold, at the correct level. The examples of application should also include mention of the other departments they work with or use. No health sector department operates in isolation when providing a service to patients and their families. The KSF helps us to be clearer about how to join everything up.

[[Box 1 KSF]]

A risky business!
Where there are capacity and capability issues around providing care, then there are risks to running services effectively.

An excellent article by Tamsin Snow in the Nursing Standard affirms that organisations need to make sure that time is given to holding appraisals (or KSF reviews).5 The article states, "Almost half of NHS staff are missing out on career development scheme". This makes it clear that nursing colleagues need to be supported and prepared for keeping up with service pressures. It is short-term thinking to ignore time spent on developing and supporting staff, or on learning opportunities.

Who is at risk? Is it you or your staff, or even a patient? Vulnerable areas may be:

  • Groups that don't have professional bodies/CPD.
  • Union members without learning representatives.
  • Any department with one or more of the following:
    - Staffing or resourcing problems, work backlogs,       no backfill.
    - High turnover, high sickness absence levels.
    - Large numbers of part-time or agency workers.
    - Unsupported managers, no training budget.
  • Traditional nonparticipators in learning.
  • Trusts or health boards without robust monitoring mechanisms, or where KSF isn't "recognised".

Organisations that have harnessed the talent of union learning representatives, KSF and CPD leads, training and education professionals and external support mechanisms, and used the KSF review to pin down priorities for staff and their teams, have taken an important step to reduce, or manage, potential risks.

Beg, steal or borrow!
If you have good things going on because you are supported by using the KSF to help underpin service demands, then build on this. Find out what other colleagues are doing – take a look at those case studies mentioned above on the NHS Employers' website. The recent National Audit Office report recommendations suggest that the KSF is the only way for the benefits of Agenda for Change to be realised!6

Last year, Ann Keen, as Parliamentary Under Secretary for Health, urged all trusts to have a named board member responsible for making sure that the KSF was implemented and used properly.7 Find out who this person is, or talk to your KSF leads – there should be a management lead and one from the
staff side.

What next?
If you are interested in your own or others' development, find out about becoming a union learning representative – you'll support colleagues, make sure your professional group get learning opportunities, and help less confident staff make the most of the
KSF review.

Your manager may well be wondering when they are going to have their own review, or meet their targets around staff developments. Your organisation may not be able to collect robust data to support workforce planning, equality or patient-protection legislation, or Investors in People. If your organisation or department hasn't been using the KSF, persuade colleagues to ask for their KSF reviews or some refresher training, ie, create a groundswell of awareness. It is, after all, your contractual right, and if the best part of modernising the health service is ignored, we have to ask – how can it happen?

1. Department of Health (DH). The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London: DH; 2004. Available from:
2. Oultram K. Is a little knowledge a dangerous thing? Amicus Health 2006:3.
3. NHS Employers. KSF Case Studies. Available from:
4. e-KSF. NHS Knowledge and Skills Framework: Online Tool Kit. Available from:
5. Snow T. This year's challenge: maintaining quality care under a tight budget. Nurs Stand 2009;23(18):12–3.
6. Department of Health (DH), National Audit Office. Pay Modernisation in England: Agenda for Change. London: Stationery Office; 2009.   
7. Department of Health (DH). Letter from Ann Keen, Parliamentary Under Secretary for State for Health; 2008. Available from: